For minorities and the poor in this country, the rates of access to and use of mental health care services remain far lower than those of majority whites.
At Clark University, Esteban Cardemil, Ph.D., and his team of undergraduate and graduate students in the Mental Health, Culture and Community Research Program are working to shine a light on the disparity faced by minority and economically disadvantaged groups in the United States.
An associate professor in the department of psychology, Cardemil is also editor of the Journal of Latina/o Psychology, a collaboration between the National Latino Psychological Association and APA.
Cardemil spoke with New England Psychologist’s Catherine Robertson Souter about the wide range of research his team conducts and the need to continue filling in pieces of a complex picture of disparity.
Q: Why is this field important and why now?
A: As you probably know, access to and utilization of mental healthcare services in the overall population is lower than what we want – something like only 40 percent who have a severe disorder receive adequate treatment for it.
But the numbers are consistently worse for people from low income and racial minority backgrounds despite the fact that we have known about these disparities in access to care for well over 20-30 years.
It seems pretty clear that our systems are not really well set up to understand and address the causes of those disparities.
Q: Beyond the system itself, are there also issues uniquely faced by recent immigrants because they are new to the system or may have various stigmas in their originating countries?
A: Absolutely. These things play significant roles in the disparities that we see. Some data suggests that even when you control for insurance levels, you still see disparities of care. So, yes, that tells us something else is going on around how people think about and use mental health services or choose not to.
Q: Do you see a difference in mental health care use between people who are first generation or immigrants and people who have been here longer? Minorities can, of course, include people who have been here for hundreds of years.
A: When we talk about cultural groups in this country, there are at least three different forces we need to keep in mind. One is cultural in the traditional sense of word: do people in different groups think about things differently? Do they think about mental illness as being caused by supernatural forces as opposed to biological forces, for instance? So, if you think about it that way, you may tend to seek services for symptoms from a religious provider.
A second piece we have to remember is that as a minority, there are things like discrimination and prejudice that you have to navigate here. Some things don’t change. Even if you have been a minority in this country for hundreds of years, you are still a minority. You are not part of the larger group.
The third piece is that, in this country, on average the per capita income for minority groups tends to be lower which also ties into lower use of health care and mental health care.
Those three things tend to pull together in ways that affect people seeking services. Yes, second and third generations tend to have less stigmatizing views about mental illness and mental health services than recent immigrants, but we still see significant differences.
Q: Is there more interest in this work right now?
A: I would say that the field of minority mental health has grown tremendously in the last 40 years. Then, as large-scale studies like the National Comorbidity Study have begun to show disparities in the receipt of mental health services, the specific issue of disparity has gotten a lot of attention in the last 15 years.
One of the amazing things about this country is that it is such a beacon for immigrants from across the world and there are all these opportunities to become connected with different communities that will change the story somewhat.
Q: What are you working on now?
A: We have a couple of projects taking place in our lab. One is related to questions of cultural values with regards to African American women. Another grad student is looking at stigma between first and second generation Chinese. Another is looking at transitions in care to outpatient services.
I have one group who is interested in some of the more recent Iraqi refugees. Their experiences sound familiar but are also different. We are becoming more attuned to the power of trauma in peoples’ lives.
Q: What are the biggest findings in your field?
A: The biggest implications from our work and others’ are that there are no magic bullets. We need to think systemically in interesting ways and also look at changes at a granular level.
We can talk about what therapists can do to better engage clients at the ground level and we can talk about what intervention developers can do to advance their work with the development and dissemination of evidence-based treatment, and we can talk about what community clinics can do to expand how they think about their work in terms of outreach and connections with other providers.
To be more specific, therapists can enhance their cultural competency to work with different cultural groups. Intervention developers need to do a better job thinking about the diversity of the population from the get-go when designing a study.
In terms of any institutions that are providing services, we need to think more broadly about forming rigorous collaborations between organizations that go beyond how we think about mental health services, like religious organizations.
As a concrete example, many people from different cultural backgrounds think about mental health services the way you or I may think about going to a doctor. I don’t go to the doctor week after week when I am feeling better.
We may need to think more flexibly about services we provide and how we can reach communities that have different models of working with our services.
Q: But what if they are not coming to your office? You know that various groups have come to your area but you are not seeing those people.
A: What is an amazing thing about this country is that when there is a new immigrant group, there will emerge a community of support for them driven by the individuals in that group or by people who are just grassroots people. Talk to those people and ask about the needs they are seeing.
Q: What else can you share about your field that people may not know?
A: One thing to emphasize is that, on one hand, there is so much we need to do as a field but, on the other hand, we should not get too discouraged.
We can say, “how can any one person do it all?” and the answer is, “you can’t.” But we can begin to challenge our assumptions. We can ask ourselves, “am I doing everything I can to create a welcoming space for this individual who comes in?” It may require more proactive preparation on our part.
By Catherine Robertson Souter