Substance Abuse and Mental Health Services Administration
Center for Mental Health Services
Child, Adolescent and Family Branch
Creating a Vision for Cultural and Linguistic Competence: An Essential Element of Systems Transformation
Working Group Session Proceedings
February 28 – March 1, 2005
Submitted by:
Barbara J. Bazron, Ph. D.
April 11, 2005
Revised:
May 9, 2005
INTRODUCTION
One of the major findings of Mental Health: A Report of the Surgeon General (2001) was that mental health disparities are inextricably linked to race, culture and ethnicity. People of color, as well as members of other population groups including but not limited to gay, lesbian, bisexual and transgender (GLBT) people, have less access to, and availability of mental health services. Some of the barriers to care include mistrust, fear of treatment, racism and discrimination, the geographical location of services and differences in language and communications. However, the report notes that even when services are available, members of these groups tend to receive a poorer quality of care that does not meet their unique needs.
The findings from the Surgeon General’s report were further supported in the President New Freedom Commission on Mental Health Report (2003). As a result, addressing disparities in mental health treatment was established as one of the main goals of the New Freedom Initiative (NFI) which recommends a fundamental transformation of the Nation’s approach to mental health. NFI mandates providing necessary services and supports to enable all Americans with disabilities, including people of color and other minority groups, to live, work, learn and participate fully in their homes and communities. In response to this mandate, the Child, Adolescent and Family Branch (CAFB) established the delivery of culturally and linguistically competent services as a priority for the Branch, its partners and systems of care communities.
The CAFB conducted a planning meeting February 28-March 1, 2005 at the SAMHSA Headquarters in Rockville, Maryland to create a consistent vision for cultural and linguistic competence for the CAFB, its partners and systems of care communities. The objectives of the meeting were to (1) establish concrete priorities and outcomes for policy development and service provision that support the delivery of culturally and linguistically competent practices; (2) develop a work plan to identify and produce specific products that operationalize the concept of cultural and linguistic competence; and (3) develop structures and processes that support effective communication and coordination of product development and implementation processes across all contractors and technical assistance providers.
Fifty-two individuals from the field attended this session (See Appendix ). Participants included members of the major racial and ethnic groups within our country—American Indian or Alaska Native, Asian, Black of African American, Native Hawaiian or Other Pacific Islander and White. The group included mental health practitioners, researchers, policy-makers, academicians, family members, youth, representatives from the systems of care communities, communications experts, mental health consultants, leaders from family organizations and organizations representing the interests of groups of color, the CAFB Branch Chief and other CAFB officials.
A comprehensive input process was used to develop the design and agenda for the meeting. Specific strategies were employed to maximize the engagement of potential participants. Interviews were conducted prior to the meeting to gather input from a sample of participants regarding the current status of the field and to identify the major areas of focus for the action planning process. Informal conversations were also held prior to the meeting with representatives from the Branch and participants to obtain input regarding the meeting format and to identify materials that could be included in the participant packet. In addition, the draft meeting design plan, which contained specific goals, objectives and outcomes of the session and a proposed agenda was reviewed by the CAFB’s Council for Coordination and Collaboration (CCC). Modifications in the design were made to incorporate the input received from the CCC.
FORMAT OF THE DOCUMENT
This document has been organized into three sections and an appendix. A brief description of what is contained within each section follows.
Section I: Current Status of the Field
The field of mental health has been making efforts to implement culturally and linguistically competent systems of care for over 15 years. This section captures the discussion regarding the degree to which progress has been made in this area. It also highlights some of the challenges identified, which must be addressed to support the implementation of an action plan to operationalize the concept of cultural and linguistic competence.
Section II: Work Group Proceedings
Work groups were conducted using the World Café technique, a collaborative thinking strategy, to address the five areas of focus for the CAFB Cultural and Linguistic Competence Work Plan. The work groups were (1) workforce development/education and training (2) research and knowledge development (3) practice (4) policy development and administration and (5) developing public and political will to support culturally and linguistically competent practices. The recommendations generated through World Café discussions are included in this section.
Section III: Proposed Action Plan to Implement the Vision of a Culturally and Linguistically Competent System of Care
At the conclusion of the café sessions a “Town Meeting” was conducted to synthesize the work completed by the work groups and to develop recommendations for the proposed Action Plan. A list of the specific action steps recommended by the Town Meeting participants to implement the vision of a culturally and linguistically competent system of care can be found in this section. It should be noted that the action steps are not listed in priority order.
Appendices
The appendices contain the meeting agenda, preparation materials and a list of the participants. In addition, participants were asked to bring materials to the meeting that they felt represented examples of how cultural and linguistic competence is currently being operationalized in the field. These materials are also included in this section of the document.
SECTION I: STATUS OF THE FIELD
Nine (9) interviews were conducted with a selected group of participants to gather information regarding their perceptions of the current status of the field. An attempt was made to interview individuals with varying perspectives regarding cultural and linguistic competence. Informants included individuals responsible for providing leadership to major organizations that provide technical assistance to system of care sites on the development and implementation of cultural and linguistic approaches to policy development and service delivery; researchers from the field; representatives from former and current system of care sites and service providers. A telephone conference call was also conducted with the Latino Steering Committee to gather input from their unique perspective. The results of this data collection effort were analyzed, summarized and presented at the planning meeting.
A series of key questions were posed to the informants through the interviews to gather information regarding the current status of the field. They were (1) What is the current status of the field? (2) What issues must be addressed to support cultural and linguistic competence? (3) What are the perceived gaps in service strategies? A summary of their responses is presented below.
Current Status of the Field
The majority of those interviewed felt that there has been little movement in the field since the document Towards a Culturally Competent System of Care (1989) was developed despite the number of resources available to support cultural and linguistic competence. It was stated that although this document provides a framework for cultural competence there is still only limited understanding of how this construct can be operationalized. In some instances in which strategies for operationalization have been developed, but they have not been widely disseminated to the field.
The field is still grappling with the skills needed to provide culturally competent services. As one respondent noted, “…been there…heard about it, but don’t have the skills.” Respondents repeatedly indicated that a collective and concerted effort is needed to address this issue. Research needs to be conducted to identify the types of service strategies that increase access, improve engagement and retention and result in positive treatment outcomes for people of color and other minority populations. Once this information is gathered, technical assistance and training should be systematically made available to help policy makers and practitioners develop the skills necessary to provide culturally and linguistically appropriate services.
One respondent stated that generic models of technical assistance on cultural and linguistic competence are being used that promote the principles of cultural competence without providing frameworks that are tailored to meet the specific needs of different cultural groups. It was felt that technical assistance providers should offer information, tools and strategies to the field to support the implementation of culturally specific approaches to cultural and linguistic competence.
Another critical issue raised was that evaluation, research and other activities to test implementation models and standards of practice have not been conducted. For example, the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS) were finalized in 2000, yet little or no effort has been made to evaluate their effectiveness or to ensure that they are systematically implemented and enforced.
Several respondents indicated that there is a lack of Latino voices in the development of systems of care. More specifically, it was felt that Latinos were not being given sufficient resources to develop and implement Latino-specific intervention and treatment strategies.
Several organizations were highlighted as making contributions to the field. It was noted that the National Center for Cultural Competence has been a leader in the field. The National Alliance of Multi-Ethnic Behavioral Health Associations (NAMBHA) was viewed a valuable resource for moving cultural and linguistic competence forward.
Almost everyone interviewed agreed with the sentiments of one respondent, “I don’t want to talk anymore. I want to do!”
Issues that must be addressed to Support Cultural and Linguistic Competence
A wide array of issues was raised regarding the implementation of culturally and linguistically competent practices. The major concern among interviewees was how to operationalize this concept. The question raised repeatedly was, “What do culturally and linguistically competent practices look like in the field?” Participants felt that the core competencies required for cultural and linguistic competence needed to be identified and described.
Several of the respondents stated that there is a lack of clarity or buy-in regarding the words used to discuss this concept. “Cultural competence”, “cultural and linguistic competence”, “cultural diversity”, “cultural responsiveness”, and “disparities” represent some of the terms currently being used. It was noted that these terms are often used interchangeably. This has resulted in confusion in the field and has impeded the ability to effectively brand the concept. Participants felt that the field needed to come to consensus regarding the words to be used to identify this concept and the related definition of those terms.
An analysis of interview data revealed that there are significant differences of opinion regarding the target population for culturally and linguistically competent services. It was noted that the definition of the target population for these types of services varies from organization to organization and between Federal agencies. At issue is how broad or narrow the target population should be defined? Some people felt that it should just include people of color, while other felt that the definition should be expanded to include other disenfranchised groups such as gay, lesbian, bisexual and transgender individuals (GLBT) and people from rural communities.
Another issue raised by almost all of the informants was whether a broad multicultural model for cultural and linguistic competence or culturally specific models should be utilized to operationalize this concept. There was no agreement or consensus on this issue among those interviewed.
Finally, the issue of collaboration among diverse groups was discussed at length. The majority of informants felt that there was no cross-group cohesion and that the spirit of collaboration does not exist. Others felt that while there was collaboration, the degree to which there is collaboration is really limited. It was stated that everyone is fighting for dollars. Additionally, some people are feeling disenfranchised. For example, it was mentioned that Latinos have not been well integrated in meetings.
Perceived Gaps in Service Strategies
The perceived gaps in services strategies identified through the interview process were:
- A lack of tools to incorporate the authentic voice of families of color in planning.
- The need for web-based training in critical areas such as intervention strategies, recruitment and hiring. This training should be followed up with technical assistance to the providers.
- The limited number of bilingual/bi-cultural people in the field. Resources are needed to hire such people at reasonable rates if this goal is to be achieved.
- The need for mechanisms to identify effective practice-based strategies that are easy to replicate, practical, low cost and adaptable.
- The existence of gaps in leadership at all levels of organizations to support cultural and linguistic competence.
- The need for a shared ownership of cultural competence. Some members of the majority culture do not feel comfortable owning it because they think that it is only a model for people of color.
- The need to develop and successfully implement strategies for confronting the “isms”, such as racism and sexism.
Recommendations for Advancing the Cultural and Linguistic Competence Agenda
The summary of the interview data was used to stimulate conversation among participants and to discuss the implications of these findings. The group engaged in a lively discussion of the findings and developed a list of recommendations that should be considered by CAFB to move the field forward. They were:
- Demystify cultural and linguistic competence by providing the field with information that describes practical strategies for implementing this concept.
- Involve families and youth of color in all aspects of policy development, planning, implementation and training related to the delivery of culturally and linguistically competent services.
- Develop and disseminate generic as well as culturally specific models to operationalize cultural and linguistic competence to the field.
- Identify, evaluate and disseminate cultural protocols to the field.
- Focus discussions that target difference with culture as the unit of intervention rather than engaging in discussions regarding which groups should be the target for culturally and linguistically competent service delivery.
- Develop and make skills-based training on effective culturally and linguistically competent approaches to policy development, program management, service provision and evaluation available to the field to support efforts to transform the children’s mental health system.
- Support the development of strategies to organize and coordinate technical assistance efforts across all Federal agencies and technical assistance providers.
- Support the evaluation of existing culturally and linguistically competent approaches for organizing and managing and delivering services through systems of care for children, youth with mental illness and their families to determine their efficacy.
- Conduct cost/benefit analyses to determine the financial impacts related to the delivery of culturally and linguistically competent services.
- Link cultural and linguistic competence to the reduction of health disparities.
SECTION II: World Café WORK GROUP PROCEEDINGS
Work groups were conducted using the World Café (Brown and The World Café Community, 2002) technique to address the five areas of focus for the CAFB Cultural and Linguistic Competence Work Plan. The World Café is a collaborative thinking strategy based upon the assumption that work group participants have within them the wisdom and creativity to confront even the most difficult challenge. In this planning session, participants had conversations on specific topics assigned to their work group within an informal café environment. Each person also had the opportunity to rotate to all of the other groups to add their ideas to those generated by their colleagues before they arrived. Thus, the development of the group’s final product was a result of iterative conversations held as participants rotated throughout the café.
Each work groups was assigned one of the five areas of focus for the CAFB Cultural and Linguistic Competence Work Plan. They were (1) education and training (2) research and knowledge development (3) practice (4) policy development and administration and (5) developing public and political will to support culturally and linguistically competent practices.
Each of these groups was led by a Café Host, who was responsible for facilitating discussion among the work group and updating participants who rotated through the group and added their ideas to those of the original work group members. The Café Hosts and café discussion topics were:
- Raymond Crowel –Workforce Development/Education and Training
- Mario Hernandez – Research/Knowledge Development
- D.J. Ida – Practice
- Terry Cross- Policy Development/Administration
- José Soto – Developing Public and Political Will
At the conclusion of these sessions a “Town Meeting” was conducted to synthesize the work completed by the work groups. A summary of the discussions held in both the work groups and the Town Meeting follows.
Workforce Development/Education and Training
Workforce development was viewed as one of the most critical needs in the field to support a transformation agenda to operationalize cultural and linguistic competence. There are serious shortages of professional staff, particularly staff of color. Traditional training institutions are not producing enough people with skills and knowledge to support this new service delivery model. Curricula are outdated and there appears to be resistance to change within the academic environment. The work group recommended that CAFB investigate non-traditional approaches to curriculum development, training, and professional certification and licensure to address the critical shortage of providers.
Some of the specific strategies recommended for consideration by CAFB are:
- Develop targeted training on cultural and linguistic competence for supervisors, managers and program developers in the field. Specific training guides targeted at these populations should be developed and disseminated. Mandatory requirements or incentives for participation in training could be included as grant requirements to ensure that participants take advantage of learning opportunities.
- Develop model job descriptions and criteria that could be incorporated into performance evaluations. Provider standards developed by SAMHSA could be used as the starting point for identifying core competencies to be included in the job descriptions.
- Develop protocols that can be used by States to incorporate cultural and linguistic competency training as a continuing education requirement for licensure. For example, subsequent to the meeting the New Jersey legislature enacted legislation that requires physicians to receive training in cultural competency as a condition of licensure. This might be a model that can be extended to all mental health professionals and replicated in other states.
- Encourage the development of certification programs and licensure that give credit to individuals based upon their life experiences and knowledge of non-traditional approaches to mental health service delivery.
- Strengthen linkages between the provider community and Tribal Colleges, Hispanic Serving Institutions and Historically Black Colleges and Universities to expand and promote practicum and other training opportunities to students of color and other minority populations. This is one mechanism for increasing the number of people of color in the pipeline.
- Explore options for working with agencies responsible for accrediting undergraduate and graduate programs in mental health to strengthen requirements for curricula development and training in cultural and linguistic approaches.
- Explore options for working with professional associations such as American Psychological Association, Council for Social Work Education, American Psychiatric Association and the American Nursing Association to include cultural and linguistic training requirements in their accreditation standards for professional and faculty development programs.
- Prepare and disseminate examples of promising practices in curricula development and training. Some models that could be considered include the National Asian American Pacific Islander Mental Health Association curriculum designed to train clinicians in culturally competent practices; the John A Hartford Foundation Academic Geriatric and Training Program which is a model to train physicians, nurses, social workers and other health care providers to sustain curriculum changes in training programs for health professionals; and the North Carolina Public Academic Liaison Curriculum, Development and Training model in which families, youth and professionals co-teach courses on systems of care, interdisciplinary practices and clinical treatment.
- Ensure that cultural and linguistic competence is addressed by the Annapolis Coalition at their upcoming workforce development meeting and in on-going activities.
- Promote and encourage states to apply for Medicaid waivers to fund peer-to-peer support programs and family to family training and support activities as a vehicle to strengthen the array of service options and the numbers of providers of color.
- Establish mechanisms for refugees and immigrants of color, trained and certified in their countries of origin as mental health providers, to enter the field.
Research and Knowledge Development
Data are needed to support the value of cultural and linguistic competence yet little has been done to evaluate the efficacy of this approach or to adequately describe them. There is currently a lack of knowledge about what strategies are actually effective in improving treatment outcomes. Measures for evaluating effectiveness at all levels within the system must be identified and used to systematically gather data to support program improvements and link specific activities to outcomes.
Evaluation methodologies must be designed that are culturally and linguistically appropriate. Traditional evaluation paradigms may not capture essential information required to assess the value of culturally and linguistically competent strategies. The workgroup supported the implementation of interactive, inclusive evaluation approaches, with families as real participants in research activities. Research efforts should be community-based and community-relevant. Communities as well as individuals and families receiving services should participate actively in all phases of research supported by CAFB. This includes the developing the research agenda, conducting research activity, interpreting data and determining how it might be used to improve service delivery.
Some of the specific strategies recommended to address these issues are:
- Conduct a series of meetings that include families, community representatives and researchers to develop a research agenda.
- Promote research in systems of care communities to study practice-based evidence as a strategy that leads to evidence-based practice.
- Host a meeting of Federal agency representatives to discuss relevant research being conducted and produce a compendium describing the findings of these efforts.
- Elevate the value of qualitative research in Request for Applications (RFA).
- “Package” research that informs decision-makers, families and youth about culturally and linguistically competent practices.
- Conduct a “Communications 101” training sessions for researcher on how to communicate research findings to families and the field.
- Support a national evaluation on culturally and linguistically competent practices.
- Include a specific requirement for culturally and linguistically competent evaluations in RFAs.
- Develop and implement SAMHSA benchmarks for culturally and linguistically competent services and outcome measures for mental health and primary care.
- Conduct research activities in the following areas:
- Describe methods of conducting cultural audits of organizations
- Identify positive outcomes across all levels of the organization
- Identify cultural and linguistic approaches that are cost effective and clinically effective as well as clinical practices that result in the reduction of disparities and improve health/economic outcomes
- Investigate the effectiveness of specific evidence based practices with difference ethnic/cultural groups. What works? What does not work?
- Identify the specific interventions that result in changes in practitioner behavior
- Translate and validating measurement instruments with different groups and languages
- Explore the relationship between an individual’s cultural context and his/her diagnosis
Practice
Culturally and linguistically competent practices were viewed as an essential element of systems transformation. Although there appears to be agreement that these types of services should be made available to children, youth and families within the mental health system, the details regarding what constitutes culturally and linguistically competent practices are unclear. Manualized descriptions of effective practices are not currently available to the majority of treatment professionals and others in the field. This limits the degree to which these practices can be replicated. There is a need to identify and collect information on techniques and strategies that work at every phase of the treatment process.
Information must be developed that clearly articulates how culturally and linguistically competent practices are different from or the same as “standard” practices. Once that data is generated, specific standards of practice need to be developed to ensure that minority populations receive appropriate services. The work group felt strongly that families and youth of color being served within the mental health system should be asked to identify the strategies they feel are most effective. This information should be the basis for the standards of culturally and linguistically competent practice.
Some of the specific strategies recommended to address these issues are:
- Establish a resource bank of information to support the implementation of culturally and linguistically competent approaches that is accessible by the field. This resource bank should include the following types of information: curricula; materials that describe clinical strategies/approaches; a list of consultants/cultural brokers; a list of trainers; information on upcoming training institutes and professional development events; and information on interpreters and translation services.
- Support the establishment of policies that improve practice through provider standards, licensing and accreditation.
- Develop protocols for outreach activities, developing cultural case records, conducting intakes and initial interviews, engagement activities, treatment and aftercare planning.
- Mandate the use of cultural formulation, as described in DSM-IV (2000), at all levels of assessment planning for systems of care communities.
- Compile information on promising ethnic-specific practices and encourage sites to adapt strategies for use with other groups.
- Expand the guidelines for site visit protocols to enhance the review of culturally and linguistic practices. This should include a description of what really happens during the therapeutic interaction from both the family/youth and provider perspectives and how service delivery approaches relate to the state’s cultural competency plan.
- Support the addition of cultural and linguistic competency review requirements in provider’s employee reviews.
- Provide training to individuals from systems of care sites, especially those using the treatment system, regarding obstacles/expectations related to service delivery that includes anticipatory guidance regarding how they can advocate for culturally and linguistically competent services.
- Take actions to integrate mental health services with primary health care within communities.
- Develop a “Promising Practices” document that describes how traditional native treatment practices align with Medicaid billing categories.
- Use CLAS Standards of practice as an accountability mechanism.
Policy Development and Administration
One of the challenges that currently exist in the field is how culturally and linguistically competent practices can be implemented. Both a political and an economic strategy are needed to overcome this challenge and build support for this conceptual framework. There is a need to ensure that standards for culturally and linguistically competent services are relevant to policy and decision-makers. This may require that the messages used to convey the value of this approach be changed or reframed in terms of the potential cost benefits related to the implementation of culturally and linguistically competent services. A social marking strategy may have to be developed to communicate this message effectively to policymakers so that they are willing to support the transformation agenda.
Historically fiscal policy and legal sanctions have driven practice in the United States. This has particularly been true for instances in which agencies or organizations have had to institute practices to address equal access issues for people of color or other minority populations. Therefore, it is not surprising that the Policy Development and Administration Work Group concluded that, in addition to the implementation of a social marketing strategy, mandates for state or local providers to implement policies to support culturally and linguistically competent practices must be tied to funding. This includes including mandates to support this approach in Medicare, Medicaid and Block grants. It was suggested that services rendered by natural supports including faith based providers, indigenous healers and cultural brokers should be approved for reimbursement. It was also noted that Title VI, which mandates language access, is not enforced. In addition, the work group recommended that a civil service category/classification be established for nontraditional family support personnel such as providers with culturally specific skills.
It was recognized that the CAFB does not have the authority to institute or change policy options such as those described above. However, it was recommended that the CAFB develop strategies to gather data to support the efficacy of culturally and linguistically competent services. This can provide the framework for a sound rationale that can be used to institute changes in policies promulgated at the Federal level.
It was recommended that the Center for Mental Health and the CAFB’s support cultural and linguistic competence in service delivery by requiring that states develop policies to enforce CLAS mandates. States should also be required to include a description of the measurable benchmarks related to the implementation of culturally and linguistically competent practices in their State Mental Health. It was suggested that the work done in California could be used as a national model. Incentives and penalties should be tied to progress on cultural and linguistic competence.
Some of the other recommendations developed for the CAFB’s consideration include:
- Policies developed by systems of care communities should be reviewed during site visits to ensure that they meet minimum cultural and linguistic competency standards. This review should be developed based upon an assessment of the community that includes data on the cultural needs of the population; service utilization; and the needs, resources strengths that match the cultural context of the population to be served.
- Collect, organize and disseminate samples of existing policies and standards related to interpreter/translation services and culturally competent service delivery.
- Collect and disseminate research data to drive policy change.
- Establish benchmarks for measuring progress that can be used at the state, local and practitioner level.
- Require that sites routinely conduct self-assessments and use those assessments for planning and evaluation.
- Assist sites in establishing accountability structures that include an evaluation of services by consumers and inclusion of performance measures in staff reviews.
- Require sites to produce a “report card” that describes the progress being made in the area of cultural and linguistic competence.
- Hold site leadership accountable for developing and implementing an affirmative action strategy to encourage hiring bilingual/bicultural staff, including cultural and linguistic competency requirements in job descriptions and making paid positions available for family members to support effective service delivery.
Developing Public and Political Will To Support Culturally And Linguistically Competent Practices
Malcolm Gladwell (2000) described the elements required to create a “tipping point” wherein a good idea spreads like an epidemic and is embraced by a critical mass of people who support the change or innovation proposed. One of the essential characteristics of this kind of idea is that they contain the “ stickiness factor” that grabs and holds the attention of people such that they are moved to action. Through this meeting, the CAFB is attempting to develop a tipping point in this country to support cultural and linguistic competence.
The Developing Public and Political Will Work Group suggested that a social marketing plan be developed and implemented to support cultural and linguistic competence. This social marketing plan would serve to create a cohesive voice that would support the emergence of a tipping point. The key recommendations related to the development of the proposed plan are:
- Identify target audiences beyond those who are already committed to the concept. Key people and organizations with the ability to influence policy and practice should be identified.
- Develop key messages tailored to the target audiences.
- Develop a case statement to support the value of cultural and linguistic practices.
The case statement should include
- Treatment outcome and other data used to support the case.
- Information on the cost/benefit of providing these types of services.
- A description of the cost of not providing these services.
- A description of the mutual benefits that can be obtained by consumers and providers as a result of the provision of culturally and linguistically competent services.
- Develop keys message that emphasizes points of commonality among and across groups, minimizes racial/identity politics, and justify the relevance of this approach beyond mental health.
- Enlist the support of NAMBHA to address specific content issues to develop public/political will to support cultural and linguistic competence.
SECTION III: PROPOSED ACTION PLAN TO IMPLEMENT THE VISION OF A CULTURALLY AND LINGUISTICALLY COMPETENT SYSTEM OF CARE
At the conclusion of the café sessions a “Town Meeting” was conducted to synthesize the work completed by the café groups and to develop recommendations for the proposed Action Plan. A list of the specific action steps recommended by the Town Meeting participants to implement the vision of a culturally and linguistically competent system of care follows. Additional analysis and planning will be required to address these issues. It should be noted that the action steps are not listed in priority order.
- Establish a mechanism for coordinating the sharing of information, resources, best practices and other tools to ensure the development of effective strategies for addressing cultural and linguistically competence and the reduction of racial and ethnic disparities. The National Alliance of Multi-Ethnic Behavioral Health Associations (NAMBHA) was proposed as an organization that might fill this role.
- Develop and implement a social marketing plan to build the political will necessary to support the promulgation and enforcement of policies that support cultural and linguistic competence at the Federal, state and local level.
- Create a cultural and linguistic competence liaison function within the CAFB.
- Include language in RFAs mandating compliance with the CLAS and CMHS standards. Incentives and penalties should be included to support this requirement.
- Implement procedures to ensure the inclusion of families and youth in the development of research, technical assistance strategies and all aspects of service development, delivery and evaluation.
- Develop a research agenda and support research effort to determine the efficacy of culturally and linguistically competent practices. Specific studies should be conducted on the cost effectiveness and cost benefit of these approaches; evaluations of best practices; qualitative and descriptive studies on practice based evidence; and performance benchmarks.
- Collect, compile, evaluate and disseminate information on practical strategies being implemented in the field. This should include both generic and culture-specific approaches to service delivery.
- Develop “tool kits” for policy makers and program administrators that contain sample policies, social marketing strategies and data to support the development and implementation of culturally and linguistically competent services.
- Develop targeted training for supervisors, managers and supervisors in the field to ensure that there is systemic support for front line staff as they provide culturally and linguistically competent services. Families and youth should be included both in the curriculum development and training delivery process. Training should also be designed and provided to researchers to assist them in communicating their findings to the field.
- Establish consistent definitions and usage guidelines for the terms used to describe cultural and linguistic competence. This includes, but is not limited to “cultural competence”, “cultural sensitivity”, “cultural proficiency”, “disparities” and “linguistic competence”.
- Develop and implement a strategic plan for expanding the number of people of color and others with the skills necessary to provide culturally and linguistically competent services. The plan should include strategies for collaborating with certification and licensure bodies to adopt requirements for cultural and linguistic competence; working with academic institutions to strengthen graduate and undergraduate requirements for mental health programs; strengthening linkages between the provider community and Tribal Colleges, Hispanic Serving Institutions and Historically Black Colleges and Universities to expand and promote practicum and other training opportunities that might attract students of color and other minority populations to the field and supporting mentoring, coaching and cultural and linguistic competence training for the existing workforce.
It should be noted that the participants at this meeting reflected a range of perspectives and opinions on the work that needs to be completed to achieve cultural and linguistic competence and to eliminate racial and ethnic disparities. At the conclusion of the meeting, Dr. Gary Blau offered a summary statement that captured the shared vision of the group. It was that a culturally and linguistically competent mental health service delivery for children, youth and their families is one in which services are provided within a community, with a genuine understanding of each person’s culture, language and background, with each individual being treated with respect, compassion and fairness and grounded in practice that maximizes the full potential of the recipients of services and achieves positive outcomes. It is hoped that the work completed at this meeting will help the field realize this goal.
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