Health is not possible without mental health, and quality mental health care cannot be achieved without culturally and linguistically relevant services. These are the two principles that guide the work of the Center of Excellence for Cultural Competence at New York State Psychiatric Institute (“the Center”). The impetus for the creation of the Center was the review of the status of mental health in New York State performed by the NYS Standing Committee on Mental Health, Mental Retardation, and Developmental Disabilities. Under the leadership of its Chairman, Hon. State Assemblyman Peter M. Rivera, the committee undertook a comprehensive review of the mental health delivery system in New York State. Not surprisingly, the Committee’s report released in 2002, titled Broken Promises, Broken Lives: A Report On the Status of the Mental Health Delivery System in New York State, reached the following conclusion: “The current system of service delivery was not meeting the needs of the citizens of the state. As a result, thousands of mentally ill persons have suffered indignities and abuse, and hundreds of others have succumbed to untimely deaths due to a dysfunctional mental health system.”
The follow-up work performed by the Subcommittee on Underserved Populations led to the passing of Assembly bill A01612 to create two centers, one at Nathan Kline Institute in Orangeburg, New York and the other at the New York State Psychiatric Institute in Manhattan. Both were funded in November, 2007.
Among the demographic factors that influenced the passing of this bill was the growing proportion of New York residents (and of the US population as a whole) who belong to a racial, ethnic, and linguistic group that is underserved by the health care system. While this population shift is most evident in the state’s urban centers, rural communities are equally impacted. A longstanding injustice affecting ethnic, racial, and linguistic underserved groups in New York State (regardless of urban or rural location) is the persisting level of disparity in the care of both physical and mental health. In fact, the gap appears to be widening between non-Latino white Americans and other groups with respect to several indices of health care access, quality, and outcome.
The increasing number of unmet physical health needs of individuals receiving treatment for chronic mental disorders, also defined as serious mental illnesses (SMI), is one byproduct of this demographic shift. As a result of the marked morbidity and mortality associated with physical illness, ethnic/racial and linguistic minority individuals coping with SMI are one of the most vulnerable underserved populations in New York State. Even without taking into account the effect of SMI, African American and Latino communities are at higher risk of obesity, diabetes, hypertension, and other adverse physical conditions than non-Latino white communities. Across all ethnic/racial and linguistic groups, the presence of SMI worsens the risk of inadequate detection of physical health problems in mental health settings, frequently the predominant source of general health care for the SMI community. However, when their illness is detected, ethnically and linguistically underserved groups with SMI experience a lower likelihood of receiving guideline-concordant care. This increases the already-elevated risk of adverse outcomes, resulting in higher rates of disability and premature death among African Americans and Latinos in New York State relative to white New Yorkers. Since people with SMI die on average 25 years earlier than the general population, it is clear that chronic mental illness compounds already existing racial/ethnic disparities, resulting in a true health crisis among ethnically, racially, and linguistically underserved persons with SMI.
Although shifting demographics have contributed to increasing health disparities throughout all of New York, census estimates indicate that Northern Manhattan has one of the highest concentrations of ethnically/racially and linguistically underserved individuals in the state. Approximately 72% of residents in Washington Heights and Inwood are of Latino origin and 20% are African American; over 90% of the Latino community are first-generation migrants, frequently with limited English fluency. In Harlem, 67% of community members are African American –including a substantial community of African and Haitian immigrants– 20% are Latino, and 3% Asian. These demographics have created challenges for delivering culturally and linguistically competent care in Northern Manhattan. This region also has one of the highest concentrations of poverty in the City, which contributes to the disparity between need and service capacity.
As a result of the high number of immigrants residing in Northern Manhattan, inattention to language and cultural factors constitutes a serious barrier to the delivery of adequate mental and physical health care to persons who are monolingual in Spanish, French, or Haitian Creole. Health care providers and mental health advocates who are committed to a paradigm of cultural and linguistic competence try to convey to patients and family members that they are not alone. This cultural engagement is an opportunity to build solidarity and a sense of community with stigmatized individuals and families experiencing mental illness. The challenge is to ensure that this message of hope transcends cultural and linguistic barriers and creates an environment that is truly conducive to recovery and that addresses both physical and mental wellbeing.
The Center is committed to the integration of mental health and physical health care for illnesses such as heart disease, hypertension, diabetes, and other obesity-related conditions that frequently co-occur with mental illness. In order to address this integration in a culturally competent way, it is critical to explore culturally adaptable models of service integration and public health promotion so that consumers, families, and providers can work together to transcend cultural and linguistic barriers and empower diverse consumers to make healthy choices. In order to develop such a model, the Center is engaging in a five-phase community outreach project centered in Northern Manhattan that will develop culturally competent, person-centered best practices for delivering physical health care to SMI patients. This project is being conducted in collaboration with diverse community stakeholders, including consumers, family members, care providers, faith-based leaders, and community residents. We have started this work with the community surrounding our base at the New York State Psychiatric Institute in Northern Manhattan and will then expand from there into a statewide initiative.
The five-phase project will start to address the gaps in the physical health care of underserved patients with SMI by outreaching to several mental health clinics in our surrounding neighborhood, including consumers, staff members, and other stakeholders. The first phase of the project is a program needs assessment, involving an initial evaluation of 6 mental health clinics across Northern Manhattan. The goals of this phase are to engage community stakeholders, explore existing programs related to physical health care, and start to develop alternative models for integrated physical and mental health services. During the second phase we will work with the programs, clinics, and community members to collaboratively choose interventions to enhance culturally competent management of physical health problems in a way that addresses patients’ needs. Jointly with all stakeholders, we will then conduct the third phase, which consists of a more thorough baseline evaluation of each clinic. We will assess information on cultural competence of existing services, detection/ management of physical health problems, patient engagement, self-management of lifestyle choices that affect health—such as diet, exercise, and smoking—and patient outcomes. During the fourth phase the research team will assist each mental health clinic to implement the intervention they have chosen. Finally, the fifth phase consists of a post-intervention assessment, which will be used to assess the intervention’s impact and sustainability. During all five phases the Center research team will employ a mix of qualitative and quantitative research methods, which have become the standard methodology for studies of this sort. A mix of surveys, participant observation, individual interviews, and focus groups will be used.
Throughout the whole research process the Center will engage consumers and their families, providers, and other key helpers (such as their faith-based community) through person-centered approaches that employ self-management models. We also recognize the importance of strengthening support networks in order to help the person through his/her recovery process. Ultimately, the Center’s goal is to work together with the person and his/her recovery team to develop a sustainable programmatic infrastructure that embeds culturally competent best practices for physical health care into his/her existing network of mental health services.
The staff of the Center of Excellence for Cultural Competence at New York State Psychiatric Institute also contributed to the publishing of this article.