Becoming a Culturally Competent Mental Health Provider: Working with Individuals From Marginalized Groups

The 2020 Census showcased what many of us had long suspected. The United States is becoming more racially, ethnically, and culturally diverse with each passing year. Yet the nation is still rife with many mental health disparities (preventable mental health differences) and the opportunity to attain optimal mental health is not available to many people in marginalized communities [1]. However, by becoming culturally competent providers, we can take real steps to increase mental health equity — where everyone has a fair opportunity to attain their full mental health potential and no one is disadvantaged [2]. The goal? To work toward mental health justice.

What is cultural competence in health care?

Health inequities are reflected in differences related to one’s length of life; quality of life; rates of disease, disability, and death; severity of disease; and access to treatment. According to the CDC, health equity is only achievable when all people are given a chance to attain their full health potential and “no one is disadvantaged from achieving this potential because of social position or other socially determined circumstances.”

For health equity to become a reality, health care providers must step up to the plate and recognize how important it is that we all strive to become culturally competent providers. Becoming a culturally competent provider means becoming skilled at working with all individuals, no matter the background.

Cultural competency is the ability to work effectively and compassionately with those who hold different values, beliefs, and behaviors from your own. It is not simply addressing differences based on race and ethnicity. To be fully culturally competent involves being a fully affirming provider — developing competence in working with LGBTQ+ individuals, those with language barriers who require the use of interpreters, people from rural areas, people who are incarcerated, and many other groups.

To become a culturally competent provider, one must acknowledge widespread inequities and privileges that exist — and recognize their impact. One must acknowledge that individuals in marginalized populations face greater challenges when it comes to both seeking and receiving mental health care. And one must adjust their daily work to better meet the needs of culturally diverse patients. By addressing these cultural differences, we may be able to reduce existing health disparities stemming from structural and institutional racism and discrimination.

Culturally competent providers in practice

A discussion of cultural competence must include a discussion of privilege. Each individual is going to have certain privileges and certain challenges based on different aspects of their identity. These privileges and challenges vary from person to person and vary depending on each social interaction.  

If you are a mental health professional, we encourage you to consider how your own biases and cultural uniqueness may impact how you provide mental health treatment and assessment. How do the following factors affect your communication style and ability to relate with each patient?

• Socioeconomic status
• Race
• Ethnicity
• Language
• Nationality
• Religion
• Gender identity
• Sex
• Sexual orientation
• Religion
• Geography
• Disability
• Age

Culturally competent care is affirmative care, validating and supporting the identity of each person you work with. Cultural competence involves honoring and celebrating one’s identity while validating experiences of oppression. This requires empathy and an understanding of each individual’s history, cultural context, and lived experiences. Your cultural upbringing and your patients’ cultural upbringing influence how you each interpret physical and mental health symptoms. Culture influences the relationships between providers and patients; expectations can and will differ. Some patients may be more or less willing to trust a provider and more or less willing to follow the recommended treatment plan. It’s important to keep this in mind.

Why become a culturally competent provider?

When we become culturally competent providers, we improve our skills so that we can

• Address racial bias in the moment
• Make more appropriate treatment recommendations for diverse individuals
• Integrate our knowledge and awareness of different cultural experiences
• Reduce perceived stigma
• Increase treatment seeking for those from marginalized communities
• Increase treatment duration
• Improve mental health outcomes

Culturally competent providers do not assume that a cultural group is homogenous. Instead, they see people as individuals and pause before assuming that a member of a group ascribes to certain beliefs or values simply because they are a member of that group. Becoming a culturally competent provider means having the ability to self-reflect on your own biases and beliefs and to be open minded with each person you work with.

Examples of culturally competent care

If you are working in the mental health field today, you probably recognize that many of the interventions in use today were developed based on work with white individuals. How do we know if these techniques work with people from other cultural groups? If we are to be culturally competent providers, we must adjust how we work with each patient in treatment. Some of the ways we may modify our work include

• Talking less (or talking more, depending on the person)
• Listening more
• Avoiding words like “we” or “us” (when working with people from marginalized groups that are different from you)
• Spending more time with patients (or keeping sessions shorter)
• Being more supportive
• Being more patient centered
• Taking careful notes of what occurs in sessions

It’s important to acknowledge that our patients are also going to bring their own biases into treatment. They may hold biases due to past negative encounters they’ve had or due to power differentials experienced in the room with you. Recognize that both your biases and your patients’ biases can impact transference and countertransference in the room. 

It’s not uncommon for mental health providers to experience microaggressions, harassment, intimidation, insults, or discrimination from patients. Should you experience this in session, take time to

• Assess your patient’s symptoms — could they be intoxicated, psychotic, or manic?
• Take steps to cultivate a therapeutic alliance
• Depersonalize the event
• Ensure that the environment is safe, particularly for trainees
• Promote values, education, and dialogue that support a culture of inclusion

By calling out and naming microaggressions, from peers and from patients, we can validate observed or reported experiences. 

Seven ways to improve cultural competence

Cultivating cultural competence skills can help to increase the quality of care we provide, support diverse treatment teams, and improve patient outcomes. This requires a lifelong commitment of evaluating and critiquing our relationship to power and how we address power imbalances between provider and patient. Are you willing?

1. Use humility to check your own beliefs and biases at the door. Give yourself grace as you notice your biases, challenge them, and decrease them. One easy way to check your own potential biases right now is to take the implicit bias test at Project Implicit.
2. When in doubt, always start with empathy. Take steps to understand how language, historical trauma, within-group diversity, reluctance or suspicion, and cultural beliefs impact the relationship between you and your patients.
3. Educate yourself on specific cultural groups in the U.S. by watching our webinar. We talk about specific challenges faced by specific racial and ethnic groups and discuss ways to work with rural, incarcerated and immigrant populations, and other socially disadvantaged groups.
4. Communication is key. Allow your patients to tell you their own unique stories, as you validate their uniqueness and resilience. Learn how to improve communication with patients from diverse cultural backgrounds, to help you make better informed decisions.
5. Consider whether you or others are intentionally or unintentionally committing microaggressions (hostile, negative, prejudiced, or derogatory slights directed to marginalized groups) to prevent unwanted outcomes and adverse events.
6. Do you see weaknesses in your organization that can be addressed with cultural competence training? One way to get started is to check out Think Cultural Health. This program promotes national standards for culturally and linguistically appropriate services (CLAS), aiming to improve health equity.
7. Cultural competency starts at the top. Is your organization staffed with leaders from diverse backgrounds? See how you can improve based on findings from this report from McKinsey.

Becoming a culturally competent mental health provider

Racial and ethnic minorities are less likely to seek mental health services and more likely to drop out of treatment early. A minority of physicians come from traditionally underrepresented racial and ethnic groups. Unconscious bias can result in lower quality of care and lower satisfaction rates related to care provided. 

We all have an ethical responsibility to work on our biases and address them in the treatment room. By eliminating mental health disparities, we can work toward mental health equity for all people, regardless of factors like race, socioeconomic status, gender, ethnicity, religion, or sexual orientation. 

This blog was based on our continuing education course, “Safe Spaces: Mental Health Care in Marginalized Populations,” presented by Avanti Bergquist, MD, MS, FAPA, DFAACAP.

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Related Reading

• BIPOC Mental Health Facts & Statistics
• BIPOC Mental Health Resources
• Providing Culturally-Affirming Mental Health Care
• Racial Justice and Healthcare Equity

Sources

[1] CDC: Health Disparities
[2] World Health Organization: Health Equity