The Need for Specialized Clinical Training in Mental Health Service Delivery to Latinos.
Research demonstrates the need for specialized clinical training to develop culturally sensitive therapists who can provide effective mental health treatment for Latinos and other ethnically diverse populations (De La Cancela & Guzman, 1991; Donahue & Thomas, 1998; O'Sullivan & Lasso, 1992). This paper proposes developing community-academic partnerships as one approach to help professionals develop cultural competent therapeutic skills.
There is a great need for mental health services and specialized training for Latino populations. Latinos constitute the second largest minority group in the United States. Of these approximately 63% identify themselves as Mexican American. As a group, their numbers are rapidly growing. It is projected that by the year 2010, if not sooner, they will surpass African Americans as the nation's largest minority group (WICHE, 1996).
Although Latinos are the nation's fastest growing ethnic minority population, studies show they have lower mental health utilization rates, higher dropout rates, and fewer average sessions than other ethnic groups (Gallo, 1993). Many researchers have taken this alarming under-utilization rate to be the result of therapists not being sensitive to the needs and culture of Latino clients.
Studies have been conducted that suggest that Latinos will utilize mental health services and will remain in therapy longer if they are treated in a mental health center in their community and by individuals who are aware of their culture (O'Sullivan and Lasso, 1992). Racism, poor treatment, and the perception that one is not understood may also increase these dropout rates.
Minority clients treated by culturally insensitive therapists are often over-pathologized because their cultural practices and worldviews do not fit into a Eurocentric psychological framework. Graduate student therapists who do not receive training in minority issues tend to be less aware of cultural factors that may affect treatment and are less adept in treating diverse populations.
Therefore, the question which must be addressed is "How can this problem be remedied at the preventive level within graduate programs in psychology?" Many clinical psychology graduate programs do not have specific training sites where students can receive specialized clinical training and supervision in working with ethnic minority clients. In the past decade, with changes in mainstream accrediting bodies requiring "cultural competency," there has been much more research in how cultural sensitivity can be achieved among professionals and students in training. The field of service learning has provided much valuable research on how to train students in providing culturally competent services to underserved minority groups.
Service-learning refers to experiential educational and research training which addresses social issues and community needs (Keys et al., 1999). This model provides students with the opportunities to apply classroom knowledge to community settings. Recent research has been conducted which demonstrates the link between service-learning and the development of cultural competency (Seifer, 1998; Flannery & Ward, 1999).
Service-learning has been shown to (1) increase students' interests and skills in working with minority communities; (2) increase students' understanding of cultural, community values, traditions, and customs; and (3) teach students to develop appropriate interventions and programs that incorporate culture and build on strengths. Finally, this approach provides experiential learning where students can learn in a minority community instead of congregating in traditional classrooms with others similar to themselves (Flannery & Ward, 1999).
In addition, service-learning provides a means by which students can train and learn to work with minority populations in a context that combines experiential, affective, and cognitive learning. For years, social learning theory has consistently demonstrated that this combination is the most effective means of learning (Bandura, 1977). A review of the psychological outcome research in the last decade has demonstrated effective change to be a result of cognitive and affective understanding as well as behavioral change (Bergin & Garfield, 1994). Service-learning combines these modalities and provides the context for training culturally competent professionals.
Given that most graduate psychology programs only have one formal academic course on ethnic minority issues, only a superficial, intellectual understanding of general multicultural issues is likely to result. As much of the psychological literature demonstrates, intellectual learning alone usually does not result in change without experiential learning and action (Bergin & Garfield, 1994).
When this formula is applied to multicultural graduate clinical training, the question that arises for me is "Why don't we combine the other elements of effective learning into a culturally competent training environment?"
This paper proposes a service-learning model for specialized clinical training in working with Latino populations. This model has been based on a Latino outreach training program at the University of Denver and on extensive research specific to Latino mental health, and is intended to serve as a model for other graduate training programs, to disseminate resources, and to inspire similar efforts.
This model would also apply to developing clinical outreach training programs in other minority communities; however, supporting research and evaluation guiding program development needs to be based on the target community and population served. The program described here is intended to decrease the problem of inadequate training in Denver's Latino neighborhoods by developing outreach community partnerships that will serve as training sites. This program will also serve to incorporate more multicultural educational experiences and greater diversity training.
In this program developed at the University of Denver, a community-academic partnership was established with Mi Casa Resource Center for Women, one of the primary community support providers in the Denver Latina community and La Clinica Tepeyac, a community medical center for monolingual Spanish-speaking Latino immigrants. These partnerships operate according to a collaborative, interdisciplinary fashion where graduate liaisons and university faculty work together with representatives from the community agency to assess their people's needs and work together to provide specialized and comprehensive services.
Research has demonstrated the necessity of specialized clinical training in developing culturally sensitive therapists who can tailor mental health treatment for Latino and ethnically diverse populations (O'Sullivan & Lasso, 1992; Acosta, Yamamoto, & Evans, 1982). Culturally-sensitive therapy includes providing ethnic minority groups with services consistent with their values, increasing cultural credibility, understanding issues relevant to the client, and incorporating the client's ethnic identity into the larger framework of the self (Gallo, 1993).
The lack of adequate clinical training and culturally-appropriate supervision in working with ethnic minority clients can result in therapists perpetuating negative cultural stereotypes, over-pathologizing the client, and providing ineffective and potentially harmful treatment.
It has been demonstrated through years of research that specialized clinical training with minority clients is necessary for the development of culturally-sensitive therapists who are competent in providing services and effective treatment to diverse populations (O'Sullivan & Lasso, 1992; Acosta, 1982). This problem has a long-term impact on several groups within the system: Clinical psychology graduate students and minority clients suffer as a result of lack of adequate training; therapists graduate without the skills in providing effective treatment to ethnic minority populations; and minority clients receive ineffective and potentially harmful treatment. Given our nation's increasingly diverse and multiethnic society, therapists need to have the skills and the training to provide effective mental health services to minority populations.
Building effective multicultural training programs, which produce culturally competent professionals, has been recently recognized in the strategic planning conference in 1995 on Latino behavioral health workforce development sponsored by the Western Interstate of Higher Education (WICHE). Conference speakers stressed the importance of cost, quality, access, and cultural competence in providing services to meet the Latino communities' mental health needs.
Community-academic partnerships may be established with many different types of community agencies such as, community resource centers, primary care and mental health clinics, schools, and churches. It is important for graduate clinical programs to form partnerships with these community agencies for a number of reasons: to provide access into the Latino community, to establish standards in working with Latino clients, and to meet the needs of the Latino community. Also, these partnerships provide students with essential training in working with Latino clients and even opportunities for future internships and jobs.
Cultural competence and an awareness of Latino culture and values are essential in working with Latino clients. Much of the professional literature encouraging cultural competency among mental health providers has been produced during the past three decades. Research suggests that services for Latinos and other underserved populations need to be of the highest quality in order to deal with the multitude of factors that contribute to their health care (Pumariega, 1995).
The importance of cultural factors influencing the delivery of health care is being addressed by mainstream accrediting bodies such as the American Psychological Association (APA), and the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). In fact, JCAHO requires that cultural factors affecting the delivery of healthcare be addressed in the assessment and treatment of clients (JCAHO, 1993).
For accreditation purposes, the American Psychological Association (APA) now requires doctoral students to take a course in multiculturalism and ethnic minority issues. Unfortunately, the APA has made only a few attempts, such as this requirement, to remedy the problem of lack of adequate training. As research suggests, however, simply having one required course in multiculturalism and having a limited exposure to minority clients without emphasis on specialized training is not enough for students to provide effective, culturally-sensitive treatment to minority clients (Ponterotto, 1998).
In the past decade, research has emphasized the need to provide specialized multicultural clinical training through university and community collaboration programs also known as service-learning (Moya, 1996; Pumariega, 1995). Service-learning refers to experiential, educational, and research training which address social issues and community needs (Keys et al., 1999).
Scholars have suggested one of the solutions for inadequate training is implementing community outreach teams (Flannery & Ward, 1999). However, as a number of Latino researchers suggest, implementing this sort of partnership would require specialized instruction, training, and supervision in advocacy and in ensuring cultural competency when working with Latino clients (Moya, 1996; Ponterotto, 1998). These authors also suggest that academic/community-training programs should also broaden their mental health conceptions to include problems having to do with welfare, housing, hospital clinics, and courts.
De La Cancela & Guzman (1991) also emphasized the importance of training programs teaching psychologists to work in natural support systems such as community support agencies when working with Latino clients to impact client and community behavior. The APA emphasizes five crucial ingredients for the establishment of specialized multicultural clinical training programs (Myers, Wohlford, Guzman, & Echemendia, 1991): (a) commitment, (b) funding, (c) extensive outreach, (d) cultural diversity (in training curricula and recruitment of minority faculty and students), and (e) social support.
Only within the past few years have clinical psychology graduate programs begun to integrate cultural diversity training into the formal curricula and clinical training. A special feature section in the Community Psychologist entitled, "Cultural Competency in Community Research & Action," reviews a survey of all clinical psychology graduate programs where directors were asked what their programs did to promote cultural competence among their students and faculty (Cherniss, 1999). The response rate yielded twenty-one graduate clinical programs that responded to the survey. Out of these programs, diversity training usually consisted of encouraging students to take courses on race and ethnicity, and conducting research projects in minority communities. Some of these programs also offered symposia and have encouraged graduate students to teach undergraduate courses on diversity. However, as the survey reveals, few programs have gone beyond these basic approaches (Cherniss, 1999).
According to Cherniss (1999), only a very small percentage of programs have gone further to establish activities such as brown bag lunch discussions, colloquia, research groups, and speaker series. Even fewer programs use more experiential strategies (such as those used at Rutgers, the Chicago School of Professional Psychology, and the University of Waikato) to promote cultural competence in clinical training (1999). Of the graduate program directors who responded to the annual survey, none could report that their programs specifically addressed means to increase students' cultural competence with specific minority groups such as Latino clients. Recent literature suggests that researchers and clinicians often fail to achieve cultural competence with Latinos because of their lack of knowledge about diverse world views among Latinos, including religious, philosophical, and health beliefs (Zea & Murguia, 1999).
The pilot program at the University of Denver has been designed to improve multicultural training in a number of areas. First, the program will address the inadequate supply of specialized clinical specialists available for minority clients. In addition, graduate students will be better able to provide culturally competent mental health services to ethnic minority clients.
By having specialized training sites and more multicultural educational experiences, it is possible to increase recruitment and retain more minority graduate students in the program. In addition, when implemented, the Latino outreach program will also provide affordable mental health care to underserved Latino groups within the community.
In Colorado, research indicates that many of the social indicators of major mental health concerns of the Colorado Latino community (graduation rates, teen pregnancy, violence) can be more effectively addressed by programs which provide adequate access and culturally competent mental health services (Donahue & Thomas, 1998). It is important in the development of multicultural training programs that they be based on local research as well as community and program needs.
Unfortunately, finding therapists with specialized training in addressing minority patient needs is difficult because minorities are significantly unlikely to make use of mental health services in general. In fact, Latinos and Asians typically use mental health services the least of all ethnic groups (Sue, 1991).
Culturally diverse populations are unlikely to seek mental health services for a number of reasons: low socioeconomic status, limited presence of bicultural-bilingual staff, and lack of knowledge and accessibility to facilities (Sue, 1988). The development of such programs will eliminate the problems of training and service delivery by reaching into minority communities and delivering mental health services to multicultural agencies within those communities.
Studies have shown that therapists who participate in cultural sensitivity training and receive specialized supervision provide more effective treatment to ethnic minority populations (Munoz, 1996; O'Sullivan & Lasso, 1992; Lopez, 1989). Therefore, a crucial aspect of these training programs is clinical sensitivity training and supervision with a licensed psychologist with expertise in working with culturally diverse populations. Diversity training has been shown to significantly increase therapists' knowledge and sensitivity in dealing with low-income and minority patients (Acosta, 1984; De La Cancela & Guzman, 1991).
Given the current state of multicultural training, most graduate clinical training programs are in need of programs designed to increase the diversity of the client population, increase community access to the clinic, and provide mental health care to disadvantaged ethnic minority groups within the community.
Clinical training programs must be able to adapt and change in order to the meet the needs of our rapidly changing society. Service-learning applied to multicultural training provides solutions for the problem of inadequate training as well as needed services to Latino communities. This approach is comprehensive in client care as well as in training well-rounded professionals who are prepared to meet the needs of the growing Latino population.
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Theresa A. Salazar, M.A. Clinical Psychology, Psy. D Candidate. <email@example.com>. Jesse N. Valdez, Ph.D. Counseling Psychology, Assistant Professor. <firstname.lastname@example.org>.
Theresa A. Salazar, University of Denver, CO
Jesse N. Valdez, University of Denver, CO