Mental Health Disparities,Treatment Engagement,and Attrition Among Racial/Ethnic Minorities with Severe Mental Illness: A Review

Mounting evidence indicates that there are mental health disparities in the United States that disadvantage racial/ethnic minorities in medical and mental health settings. Less is known, however, about how these findings apply to a particularly vulnerable population, individuals with severe mental illness (SMI). The aim of this paper is to (1) provide a critical review of the literature on racial/ethnic disparities in mental health care among individuals with SMI; (2) identify factors which may contribute to the observed disparities; and (3) generate recommendations on how best to address these disparities. Specifically, this article provides an in-depth review of sociocultural factors that may contribute to differences in treatment engagement and rates of attrition from treatment among racial/ethnic minorities with SMI who present at medical and mental health facilities. This review is followed by a discussion of specific strategies that may promote engagement in mental health services and therefore reduce racial/ethnic disparities in SMI.     

A Systematic Review of the Literature Exploring Illness Perceptions in Mental Health Utilising the Self-Regulation Model

Psychologists have utilised a range of social cognition models to understand variation in physical health and illness-related behaviours. The most widely studied model of illness perceptions has been the Self-Regulation Model (SRM, Leventhal, Nerenz, & Steele, 1984). The illness perceptions questionnaire (IPQ) and its revised version (IPQ-R) have been utilised to explore illness beliefs in physical health. This review examined 13 quantitative studies, which used the IPQ and IPQ-R in mental health in their exploration of illness perceptions in psychosis, bipolar disorder, eating disorders, depression and adolescents experiencing mood disorders. Across these studies the SRM illness dimensions were largely supported. Mental illnesses were commonly viewed as cyclical and chronic, with serious negative consequences. Perceptions regarding chronicity, controllability and negative consequences were associated with coping and help seeking, while engagement with services and help seeking were also related to illness coherence beliefs. Treatment adherence was linked to beliefs that treatment could control one’s illness. Whilst a major limitation of the reviewed studies was the use of cross-sectional designs, overall the applicability of the SRM to mental health was supported. The IPQ and IPQ-R were shown to be valuable measures of illness perceptions in mental health, offering implications for clinical practice.     

Mental health care for ethnic minority individuals and communities in the aftermath of disasters and mass violence

Findings from research on psychiatric epidemiology, disaster effects, discrepancies in service use, and cross-cultural psychology are reviewed to generate guidelines for culturally responsive postdisaster interventions. Ethnicity and culture influence mental health care at various points: on need for help; on availability and accessibility of help; on help-seeking comfort (stigma, mistrust), and on the probability that help is provided appropriately. There are aspects of disaster mental health practice that may ameliorate many of barriers that contribute to ethnic disparities in service use. It is proposed that interventions should give greater attention to socially engaged emotions and functioning. To promote disaster recovery, practitioners are advised to: assess community needs early and often; provide easily accessible services; work collaboratively and proactively to reduce stigma and mistrust and engage minorities in care; validate and normalize distress and help-seeking; value interdependence as well as independence as an appropriate developmental goal; promote community action; and advocate for, facilitate, or conduct treatment and evaluation research. Notwithstanding the pain and stress they cause, disasters create opportunities to de-stigmatize mental health needs and build trust between providers and minority communities.     

Parental socialization of mental health in Chinese American families: What parents say and do,and how youth make meaning

Parental mental health socialization is a process by which parents shape how youth develop and maintain beliefs, attitudes, and behaviors regarding mental health and help-seeking behaviors. Although culture shapes parental mental health socialization, few studies have examined specific parental socialization practices regarding mental health and help-seeking, especially as a culturally anchored process. Using a qualitative approach, this study explores youth-reported parental socialization of mental health within Chinese American families by examining focus group data from 69 Chinese American high school and college students. Findings revealed that youth received parental messages that conveyed culturally anchored conceptualizations of mental health that included stigmatized views of mental illness and perceptions of mental distress as not a legitimate problem. Parents responded to youth distress in culturally consonant ways: by encouraging culturally specific coping methods, dismissing or minimizing distress, or responding with silence. Youth engaged in the active interpretation of parental messages through cultural brokering, bridging the gap between their parents’ messages and mainstream notions of mental health and help-seeking. Overall, our findings point to the significant role of culture in parental mental health socialization in Chinese American families and the need to integrate culturally specific understandings of mental health into future interventions for Asian American youth.     

Toward a Culturally Responsive Model of Mental Health Literacy: Facilitating Help‐Seeking Among East Asian Immigrants to North America

Studies have consistently found that East Asian immigrants in North America are less likely to use mental health services even when they experience levels of distress comparable to Euro‐Americans. Although cultural factors that may prevent East Asian immigrants from seeking mental health care have been identified, few studies have explored ways to foster appropriate help‐seeking and use of mental health services. Recent work on mental health literacy provides a potential framework for strategies to increase appropriate help‐seeking and use of services. This paper reviews the literature on help‐seeking for mental health problems among East Asian immigrants living in Western countries to critically assess the relevance of the mental health literacy approach as a framework for interventions to improve appropriate use of services. Modifications needed to develop a culturally responsive framework for mental health literacy are identified.     

Clinician competencies: Strengths and limitations for work with transgender and gender non-conforming (TGNC) clients

Individuals who identify as transgender or gender nonconforming (TGNC) face a number of health disparities compared to individuals who identify as cisgender (those who self-identify with the sex they were assigned at birth). For example, TGNC individuals experience heightened rates of clinical depression, anxiety, general psychological distress, suicidal ideation, and suicide attempts. Despite these troubling disparities, many TGNC individuals report hesitance to seek mental health services due to concerns regarding culturally insensitive or even overtly discriminatory services from providers. In addition to decreasing service utilization among TGNC populations, discriminatory services impair intervention effectiveness even when TGNC individuals persist in seeking mental health services. The American Psychological Association (APA) and the World Professional Association for Transgender Health (WPATH) provide guidelines for culturally competent work with TGNC clients; however, research indicates a profound lack of TGNC-specific training and resources among mental health care providers. To address this gap, the present investigation utilized a mixed-method design to assess training experiences, understanding of terminology, and TGNC competence among mental health care providers at various training levels. Participants were current mental health clinicians across the United States. Implications for improving reported and demonstrated weaknesses are discussed.     

Treatment Engagement with Caregivers of At-risk Children: Gaps in Research and Conceptualization

The high rates of dropping out and other engagement problems are significant concerns in the delivery of mental health and adjunct services to the families of at-risk children. Consequently, researchers have examined the correlates of attrition and have developed interventions to increase engagement and retention. However, the lack of a clear definition of engagement and gaps in theory about the relationship of engagement to other treatment processes hinder knowledge development. In this paper the behavioral and attitudinal aspects of engagement are disentangled. Current knowledge about treatment barriers and interventions to increase appointment keeping is summarized. A preliminary conceptualization of the engagement process is presented and research needs and practice implications are discussed.     

Racial Differences in Beliefs About the Effectiveness and Necessity of Mental Health Treatment

Members of racial/ethnic minority groups are less likely than Caucasians to access mental health services despite recent evidence of more favorable attitudes regarding treatment effectiveness. The present study explored this discrepancy by examining racial differences in beliefs about how the natural course and seriousness of mental illnesses relate to perceived treatment effectiveness. The analysis is based on a nationally representative sample of 583 Caucasian and 82 African American participants in a vignette experiment about people living with mental illness. While African Americans were more likely than Caucasians to believe that mental health professionals could help individuals with schizophrenia and major depression, they were also more likely to believe mental health problems would improve on their own. This belief was unrelated to beliefs about treatment effectiveness. These findings suggest that a belief in treatment effectiveness may not increase service utilization among African Americans who are more likely to believe treatment is unnecessary.     

Beyond stigma: Understanding the “inclined abstainers” in military behavioral health-care utilization

ABSTRACT

Low treatment utilization in Soldiers with combat-related Posttraumatic Stress Disorder (PTSD) is an ongoing issue. The critical concern is to better understand factors which prohibit a Soldier with PTSD who wants help from seeking treatment (an “inclined abstainer”). A total of 537 Active Duty Soldiers on a US Army post completed a brief survey comprising psychometrically validated measures of stigma, behavioral health treatment beliefs, resilience, PTSD symptoms, and treatment intentions. Health-care records were prospectively tracked for 12 months to determine the relation between survey answers and treatment utilization. Sixty-three percent of those who acknowledged having a mental health-related problem did not seek help within a one-year period. Greater severity of PTSD symptoms was associated with an increased likelihood of behavioral health engagement. Soldiers that were classified as “inclined abstainers” were also more likely to endorse negative beliefs about psychotherapy and report higher levels of resilience as compared to “inclined actors.” These results suggest that a treatment model of PTSD emphasizing self-efficacy and self-reliance, while addressing negative beliefs about psychotherapy, may help promote engagement of behavioral health services among Active Duty Soldiers.     

Parental Health and Children’s Functioning in Immigrant Families: Family Roles and Perceived Treatment at School

Although parents’ health condition is generally thought to be related to their involvement in their children’s functioning, the possible dynamics behind the scenes in school contexts with immigrant children has received little attention. This study examined the association between parents’ health condition and their children’s academic and behavioral functioning, as well as the mediation effects of parents’ school engagement and children’s perceived treatment at school among 607 immigrant families with 10- to 12-year-old children. Using structural equation modeling, the results indicated that parents’ poor health condition was associated with children’s increased behavioral problems. Parents’ school engagement fully mediated the association between parental health condition and children’s academic achievement and partially mediated the association between parental health condition and children’s behavior problems. Notably, higher levels of parents’ school engagement were associated with increased behavior problems, demonstrating a unique feature in these immigrant children’s developmental functioning. Higher levels of perceived harsh treatment by peers at school due to children’s immigrant identity were associated with these children’s greater risks of behavior problems. The results suggested what may lie behind the scenes in these children’s behavioral problems is that many of these children who act out and are brought to the school office for disciplinary issues may suffer from perceived discrimination and bad treatment by their peers. The findings provide important implications for researchers, healthcare practitioners, and educators seeking to understand this subpopulation and to design and implement family support and prevention programs for young adolescents from immigrant backgrounds.     

Latino Family Participation in Youth Mental Health Services: Treatment Retention,Engagement, and Response

Although researchers have identified a multitude of factors that contribute to family participation in mental health services, few studies have examined them specifically for Latino youth and their families in the U.S., a population that continues to experience significant disparities related to the availability, accessibility, and quality of mental health services. Latino youth and their families are at greater risk of dropping out of treatment prematurely and demonstrating poor treatment engagement, both of which have subsequent negative effects on treatment response outcomes. In order to help to guide efforts to improve the accessibility and quality of mental health services for Latino youth and their families, the current paper integrates modern conceptualization of family participation in youth mental health services and provides a summary of contextual factors within an ecological framework (Bronfenbrenner in The ecology of human development: experiments by nature and design, Harvard University Press, Cambridge, 1979). The current review aims to integrate empirical research on the impact of various contextual factors across multiple levels (i.e., culture, community, mental health system, family, parent/caregiver, and child/adolescent) on Latino family participation in youth mental health services, including treatment retention, engagement, and response. Clinical implications will be discussed, and an integrated, conceptual model will be presented. Not only does this model help to demonstrate the way in which existing literature is conceptually linked, but it also helps to highlight factors and underlying processes that health care providers, administrators, and policy makers must consider in working to improve mental health services for Latino youth and their families living in the U.S.     

Use of Technology to Provide Mental Health Care for Racial and Ethnic Minorities: Evidence,Promise, and Challenges

Mental health disparities among racial and ethnic minorities (R&EM) are well documented. Some of the variables driving these disparities are limited care availability, difficulty accessing services, and attitudinal barriers. Although no single approach will eliminate all these obstacles, the use of technology to provide mental health services represents a paradigmatic shift in care delivery that could reduce unmet mental health need. Despite increasing evidence supporting the feasibility and efficacy of behavioral intervention technologies (BITs), such evidence is more limited among R&EM. For BITs to truly reduce disparities in care, these interventions need to overcome common barriers to treatment that disproportionally affect R&EM. This article reviews the empirical support of different BIT modalities with R&EM. We then provide informed clinical recommendations for the use of BITs with these groups, as well as a case example illustrating these guidelines. We conclude this article by discussing future directions that can inform the development and refinement of BIT approaches for R&EM.     

Perceptions of the acceptability of parent training among Chinese immigrant parents: contributions of cultural factors and clinical need

Parent training (PT) is well established for reducing child externalizing problems; however, lower rates of engagement in PT among ethnic minority/immigrant families have been found. We assessed PT acceptability among Chinese immigrant parents and explored clinical and cultural factors that may be associated with acceptability. Participants were a community sample of 145 Chinese immigrant parents (84% mothers) between the ages of 32 and 65 years (M=43.3 years, SD=6.2) who had children (84 boys, 59 girls) between the ages of 4 and 17 years (M=10.7 years, SD=3.6). Results suggest that parents found positive reinforcement techniques significantly more acceptable, less problematic, and more likely to be supported by others than punishment-based techniques. Parents who endorsed the Chinese child-rearing value of shaming were less likely to find PT acceptable. Parents who reported greater dysfunction in parent-child interactions rated PT as more acceptable, and families with prior Child Protective Services (CPS) involvement rated PT as less acceptable. However, previous mental health treatment appears to bolster acceptability among parents with prior CPS involvement. Clinical implications for addressing barriers to PT engagement and future research directions are discussed.     

Mental health attitudes among Middle Eastern/North African individuals in the United States

ABSTRACT

Middle Eastern/North African (MENA) individuals may have heightened risk for developing mental health problems due to unique cultural stressors. However, traditional cultural and religious practices and beliefs socialised within the family environment may reduce the likelihood of seeking mental health services. This qualitative study aimed to better understand the intersection of cultural, religious, and mental health attitudes among MENA individuals. Semi-structured telephone interviews were conducted with MENA adults who had received therapy services (N?=?13) and were analysed for emergent themes. Respondents reported lack of understanding of mental illness within their communities, and prominent levels of perceived and self-stigma. Families and religious practices/beliefs played an important role in responding to mental illness. Results suggest that incorporating psychoeducation and community awareness campaigns alongside religious services may help to reduce barriers to receiving mental health treatment.     

Being Examples to the Flock: The Role of Church Leaders and African American Families Seeking Mental Health Care Services

Within the context of Black churches, African American clergy have a significant role in the delivery of mental health care services for parishioners and their families. Working toward better linkages between faith-based communities and more formal mental health care could help to provide more culturally sensitive and timely mental health care for African American families. Using a salient part of an integrative model (Davey and Watson in Contemp Fam Ther 30:31–47, 2008), the roles Black church leaders have historically played for African American families seeking outside mental health care services are considered. We additionally provide an example of a recent collaborative partnership with a Black church that points toward some promising directions for future research and clinical collaborations between the field of couple and family therapy and the Black church community.     

Gathering Diverse Perspectives to Tackle “Wicked Problems”: Racial/Ethnic Disproportionality in Educational Placement

Among students receiving behavioral health and special education services, racial/ethnic minority students are consistently overrepresented in settings separate from general classrooms. Once separated, many young people struggle to improve academically and face significant difficulty upon trying to return to a general education setting. Given the complex, ongoing, and multifaceted nature of this challenge, racial/ethnic disproportionality can be identified as a “wicked problem,” for which solutions are not easily identified. Here, we describe our community-engaged research efforts, eliciting perspectives from relevant partners in an ongoing dialogue, to better integrate diverse stakeholders’ perspectives when attempting to address such disparities. We conducted focus groups and qualitative interviews with members of three stakeholder groups: community-serving organizations, individuals with lived experience of behavioral health conditions, and state-level policymakers, with a shared interest in addressing racial and ethnic disparities. Participant responses illustrated the “wickedness” of this problem and highlighted the need for additional supports for students, families, and school personnel, increased collaboration across relevant systems and agencies, and reduced barriers related to funding. Overall, this methodology bridged differing perspectives to develop, in concert with our partners, a shared language of the problem and a core set of issues to consider when seeking to effect change.     

Enhancing the Responsiveness of Family-Based CBT Through Culturally Informed Case Conceptualization and Treatment Planning

Family-based CBT has been shown to be effective in controlled settings for an array of youth mental health difficulties, yet disparities in treatment engagement and outcomes across culturally diverse groups remain. In practice, cultural minority families are less likely to reap the demonstrated benefits of supported programs. Although there have been tremendous advances in case conceptualization, leading models have largely ignored cultural factors, contributing to observed disparities. The present paper reviews recent advances in science-informed case conceptualization and highlights how such advances nonetheless have failed to provide guidance on systematically incorporating cultural formulation into assessment and treatment planning. We then build upon Christon et al. (2015) useful 5-stage model of science-based case conceptualization in an effort to move the field toward culturally informed case conceptualization. We highlight how leveraging cultural assessment—such as with the use of the Cultural Formulation Interview (CFI)—can facilitate the incorporation of cultural factors into each of the five stages of science-based case conceptualization. A case example is utilized to illustrate key opportunities for strategically incorporating relevant information gleaned from the CFI into culturally responsive care with youth and families.     

Comment on “The Self‐Care of Psychologists and Mental Health Professionals” (Dattilio, 2015)—Working With the Mentally Ill Is a Mental Health Hazard: What Can We Do About It?

It has been known for many decades that the risk of burnout, psychological distress, mental illness, or suicidal ideation is higher in mental health professionals (MHP) compared with many other professions and the general population; however, MHPs often disregard their own mental health for the sake of helping others, sometimes with fatal consequences. Paradoxically MHP tends to avoid seeking professional help for their own mental health issues. Apart from the serious risk to one's health that this poses, MHPs are now mandated to report any impairment that affects their ability to practice. The aim of this commentary is to emphasise the heightened risk of mental illness among MHP, and includes some risk factors associated with burnout, psychological distress, or mental illness in MHP. It explores some of the barriers to help seeking, including stigma, and highlights mindfulness as a self‐care strategy to prevent psychological distress and burnout. The commentary makes recommendations for inclusions into current psychology postgraduate as well as undergraduate curriculum. It concludes with recommendation for suitable support from professional bodies to help maintain good mental health and to help prevent mental illness among MHPs.