Hogg Foundation for Mental Health

Case Study: Working with African American Communities

June 1, 2008

By Elisabeth Kristof

Cultural beliefs, economic status, personal history – all can greatly impact a person's ability to successfully manage a mental health condition and access appropriate treatment.

While specialized treatment methods, known as evidence-based practices (EBPs), have proven successful for treating white mental health consumers, they remain largely untested in treating people of color.

In addition, people in populations of color have less access to mental health treatment than their Caucasian counterparts, according to the Surgeon General's Report on Mental Health, the Institute of Medicine, and the President's New Freedom Commission on Mental Health.

Mental health services can be adapted to successfully serve people of diverse cultures and ethnicities, said Rick Ybarra, program officer of the Hogg Foundation for Mental Health, and Sonya Mosley, project manager of Lena Pope Home, Inc. in Fort Worth.

In 2006 the foundation launched a three-year initiative to adapt EBPs for people of different cultures and ethnicities. The foundation awarded grants totaling more than $3 million to five Texas entities, including Lena Pope Home.

"Selecting grantees was a competitive process," said Ybarra. "These organizations really demonstrated they understood what cultural competency was all about."

The project has two goals – to increase the availability of effective mental health services for people of color in Texas and to increase knowledge about culturally adapting EBPs for use by mental health professionals and researchers.

"There's not a lot of information on this," said Ybarra. "We want to learn what works and what doesn't, to contribute to the literature so providers around the country can learn how to deliver evidence-based mental health treatments to diverse communities in a culturally responsive and linguistically appropriate manner and hopefully replicate lessons learned from the project."

Ybarra and Mosley said the initiative's findings to date show that, to achieve success, EBPs must be adapted to meet the needs of diverse consumer groups, rather than uniformly applied across populations.

"EBPs must be inviting in content, relevant to the culture you're trying to engage and validated by constant community feedback," said Ybarra. "Most importantly, to reach these communities we must reduce the cultural stigma of mental health conditions."

Lena Pope Home used funds from the foundation to adapt the Defiant Child EBP model to African American children with attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD).

Past research proved the Defiant Child model effective; however, less than three percent of that research focused on African American families, said Mosley. Lena Pope Home is changing that by applying the model to consumers in two predominantly African American, low-income communities in Tarrant County.

The grantee first adapted the model by creating a parent advisory board of five to six parents of children with ADHD and ODD in the community. The board meets with staff monthly to discuss cultural differences, marketing techniques and challenges in navigating the mental health system. "They continuously help us mold this program," said Mosley.

Lena Pope Home implemented changes to the original treatment model based on the board's recommendations, such as condensing parent worksheets for convenience, modeling behavior for parents, and making literature welcoming to consumers. Staff also visits participants' homes to increase access to services.

Staff found that working with church organizations and local businesses was the most effective way to get information to the community and increase acceptance of mental health services.

Communication with the board also gave staff a deeper understanding of cultural differences in the population. "We talked, for example, about the community's strong beliefs around medication," said Mosley. "We learned families felt medication and psychiatrists were designed to poison the child."

To address these issues, Lena Pope Home provides psychiatric services and education to families. "For our community, having access to a psychiatrist is like moving a mountain," said Mosley. "We made that available for clients."

Tensions between teachers and parents became clear during the project. "Families have so much frustration with the school system," said Mosley. "They feel teachers don't understand their kids and are too critical of them."

One of the most significant adaptations was instituting meetings between parents and teachers facilitated by a Lena Pope Home representative to open the lines of communication.

Mosley said the most important realization she and her colleagues came to was how to empower parents to deal with their children and with other people. "We realized there's no one way to serve African Americans," said Mosley. "But there are ways to treat families with respect, regardless of ethnicity or origin."

Lena Pope Home already has served 120 parents and 127 children through the program and has set a goal of serving 92 more families in the next year. The grantee is working with an independent project evaluator contracted by the foundation to evaluate project data collected during the grant period.

Other providers nationwide are eager to learn from the project's results once enough data is collected, said Ybarra. "We believe what we learn from the five grant sites will impact how we customize and deliver effective treatment to diverse populations," he said.

Research has made one element clear, said Ybarra: providers must be mindful not to stereotype. "They must look at people as individuals, shaped by unique personal histories and life experiences," he said. "They must learn about them through interaction, not generalization."

The biggest issue for providers to be aware of is simply that differences exist, said Majosé Carrasco, director of the National Alliance for Mental Illness Multi-cultural Action Center. "The key is not only to realize that a consumer's culture influences every step of the treatment process, but also to realize that, as a provider, your culture is just as influential."

Addressing the cultural gap between providers and consumers would allow populations of color greater access to care and improve the quality of that care, said Carrasco. "Improvements in cultural competency will result in more people staying in treatment and continuing to work toward their recovery."