Racial-ethnic differences in access, diagnosis, and outcomes in public-sector inpatient mental health treatment.

This study investigated inequities in access, diagnosis, and treatment for African Americans and Hispanic Americans receiving treatment in northeast, public sector, inpatient mental health settings as part of a Department of Mental Health and Addiction Services Health Disparities Initiative. Data from 1,484 adults were obtained through a random extract of patients admitted to state inpatient facilities between 2002 and 2005. After controlling for demographic variables and symptom severity, logistic and linear regression showed that Hispanic Americans were significantly more likely to enter inpatient care through crisis/emergency sources and were significantly less likely to self-refer or come to inpatient care through other sources (e.g., family, outpatient). After admission, Hispanic Americans were more likely to be diagnosed with other psychotic disorders (e.g., schizoaffective disorder, delusional disorder), were less likely to receive an Axis II diagnosis at discharge, and had a shorter length of stay than non-Hispanic White Americans. African Americans were more likely than other groups to be diagnosed with schizophrenia, drug-related, and Cluster B diagnoses (discharge only), and they were less likely to be diagnosed with mood disorders and other nonpsychotic disorders. Although African Americans were more likely than other groups to come to inpatient units from numerous routes, including self-referral and referral from other sources (e.g., family, outpatient), they were more likely to terminate treatment against medical advice and displayed shorter length of stay despite receiving ratings of greater symptom severity at discharge. These findings highlight the need for policies, programs, and system interventions designed to eliminate disparities and improve the quality and cultural responsiveness of behavioral health services.

Seven essential strategies for promoting and sustaining systemic cultural competence.

Racial and ethnic disparities are disturbing facets of the American healthcare system that document the reality of unequal treatment. Research consistently shows that patients of color experience poorer quality of care and health outcomes contributing to increased risks and accelerated mortality rates relative to their white counterparts. While initially conceptualized as an approach for increasing the responsiveness of children's behavioral health care, cultural competence has been adopted as a key strategy for eliminating racial and ethnic health disparities across the healthcare system. However, cultural competence research and practices largely focus on improving provider competencies, while agency and system level approaches for meeting the service needs of diverse populations are given less attention. In this article we offer seven essential strategies for promoting and sustaining organizational and systemic cultural competence. These strategies are to: (1) Provide executive level support and accountability, (2) Foster patient, community and stakeholder participation and partnerships, (3) Conduct organizational cultural competence assessments, (4) Develop incremental and realistic cultural competence action plans, (5) Ensure linguistic competence, (6) Diversify, develop, and retain a culturally competent workforce, and (7) Develop an agency or system strategy for managing staff and patient grievances. For each strategy we offer several recommendations for implementation.

Racial-ethnic differences in referral source, diagnosis, and length of stay in inpatient substance abuse treatment.

OBJECTIVE: Racial-ethnic differences in referral source, diagnosis, and length of stay in substance abuse treatment were examined. METHODS: Data from 495 African Americans, 492 Hispanics, and 497 non-Hispanic whites were analyzed. RESULTS: Hispanics were less likely than whites to be referred by crisis services; African Americans were more likely than other groups to be referred from criminal justice settings. At admission Hispanics and African Americans were more likely to have a drug use disorder, and whites were more likely to have an alcohol use disorder. Both African Americans and Hispanics were more likely than whites to have a cluster B personality disorder diagnosis at discharge. African Americans had longer stays than other groups. CONCLUSIONS: The findings could be used to design interventions to reduce disparities in inpatient substance abuse treatment.

Applying stages of change models to recovery from serious mental illness: contributions and limitations.

Research on recovery has proliferated in recent years. Some investigators have advanced stages of change models that segment the overall process of recovery into discrete and sequential phases, through which a person progresses from being overwhelmed by mental illness to taking on an increasingly active role in understanding, managing and overcoming the impact of psychiatric disability. The authors review this body of literature, and reflect on the contributions and limitations of stages of change approaches to understanding mental health recovery. They conclude that stages of change models need to more accurately reflect the non-linear nature of recovery, the fact that processes are influenced by person-disorder-environment interactions, and the fact that the persons own motivations for change and decisions in this regard while of central importance are by no means exclusive factors in recovery, as they do not take into account sufficiently such issues as discrimination and the presence or absence of crucial resources and supports. A richer set of concepts is needed as we continue to deepen our understanding of the complex, dynamic and ongoing process of mental health recovery.

A clinical trial of peer-based culturally responsive person-centered care for psychosis for African Americans and Latinos.

BACKGROUND: Providing culturally competent and person-centered care is at the forefront of changing practices in behavioral health. Significant health disparities remain between people of color and whites in terms of care received in the mental health system. Peer services, or support provided by others who have experience in the behavioral health system, is a promising new avenue for helping those with behavioral health concerns move forward in their lives. PURPOSE: We describe a model of peer-based culturally competent person-centered care and treatment planning, informed by longstanding research on recovery from serious mental illness used in a randomized clinical trial conducted at two community mental health centers. METHODS: Participants all were Latino or African American with a current or past diagnosis within the psychotic disorders spectrum as this population is often underserved with limited access to culturally responsive, person-centered services. Study interventions were carried out in both an English-speaking and a Spanish-speaking outpatient program at each study center. Interventions included connecting individuals to their communities of choice and providing assistance in preparing for treatment planning meetings, all delivered by peer-service providers. Three points of evaluation, at baseline, 6 and 18 months, explored the impact of the interventions on areas such as community engagement, satisfaction with treatment, symptom distress, ethnic identity, personal empowerment, and quality of life. CONCLUSIONS: Lessons learned from implementation include making cultural modifications, the need for a longer engagement period with participants, and the tension between maintaining strict interventions while addressing the individual needs of participants in line with person-centered principles. The study is one of the first to rigorously test peer-supported interventions in implementing person-centered care within the context of public mental health systems.

Oil and water or oil and vinegar? Evidence-based medicine meets recovery.

With the increasing prominence of the notions of "recovery" and "recovery-oriented practice," practitioners, program managers, and system leaders are increasingly asking about the relationship between "evidence-based practices" and recovery. After reviewing the concepts of recovery from mental illness, being in recovery with a mental illness, recovery-oriented care, and evidence-based medicine, the authors argue for a complementary relationship between recovery and evidence-based practices. This relationship is neither simple nor straightforward, but results in a whole that is greater than the sum of its parts through which each element benefits from the influence of the other.

Remission and recovery in schizophrenia: practitioner and patient perspectives.

Schizophrenia remains a complex, dynamic, multi-dimensional, and poorly understood condition. Although the concept of heterogeneity in outcome has conceptually overturned the post Kraepelinian legacy of progressive deterioration, a number of factors appear to contribute to perpetuating a pessimistic attitude toward outcome within the field. These include the limited access people with schizophrenia have to effective interventions and the phenomenon of the "clinician's illusion," which refers to the tendency of practitioners to assume that patients remain seriously ill when outside of the clinical care settings in which they are typically seen. Longitudinal studies, however, continue to point to a large number of people who experience improvements in their condition over time. Pressure from patients and their families, who experience periods of symptomatic relief and enhanced functioning first-hand, has led to the introduction of such concepts as "remission" and being "in" recovery with schizophrenia, in addition to the conventional notion of recovering "from" schizophrenia. These developments are consistent with recent policy initiatives by the U.S. and other governments around the world and aim to re-orient research and clinical practice from a traditional focus on effecting cure to exploring ways to encourage and assist people with schizophrenia to live meaningful lives in the face of an enduring illness.

Beyond parallel play: Science befriending the art of method acting to advance healing relationships.

Research underscores the central role of factors in healing that appear to relate to the therapeutic relationship. These nonspecific or common factors and placebo effects are often overshadowed by an emphasis in the field on particular empirically supported therapies. Yet relationship variables account for a greater proportion of the variance in treatment outcomes than the technical intervention employed, representing a notable blind spot in our science and, by extension, our practice. As a consequence, clinical instruction in psychology and in the health professions more broadly generally lacks adequate specificity with respect to how to cultivate a healing relationship. Through the elaboration of several techniques derived from theatrical traditions, the authors propose that method acting and similar schools of drama provide a method for honing clinical skills in these areas that is amenable to empirical scrutiny. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Differential relationships of childhood abuse and neglect subtypes to PTSD symptom clusters among adolescent inpatients.

This article investigates whether childhood abuse and neglect subtypes (i.e., physical, sexual, and emotional abuse, and physical and emotional neglect) differentially predict the severity of individual posttraumatic stress disorder (PTSD) symptom clusters and overall posttraumatic stress. Eighty-nine patients admitted to the short-term adolescent treatment unit of a psychiatric hospital completed a battery of psychological assessments. Findings of multiple regression analyses showed that emotional and sexual abuse rather than physical abuse, emotional neglect, or physical neglect is related to individual symptom cluster severity and overall posttraumatic stress. Results suggested that a greater level of specificity is necessary when assessing child abuse and posttraumatic stress because each level provides more specific information about how to intervene to reduce the risk of negative outcomes.

Family of origin environments in two clinical samples of survivors of intra-familial, extra-familial, and both types of sexual abuse.

OBJECTIVE: It has been suggested that survivors of ongoing childhood sexual abuse (CSA) tend to have been reared in ineffective family environments that render them particularly vulnerable to maltreatment and which foster psychological difficulties beyond those accounted for solely by their abuse. If this conjecture is valid, one would expect that the family of origin environments of CSA survivors would be disturbed whether their abuser was intra-familial or extra-familial. To assess this hypothesis, two studies compared the childhood family of origin environments and supportive parenting characteristics of a clinical sample of women sexually abused by family members only (the intra-familial group), by non-family members only (the extra-familial group), and by both family and non-family members (the "both" group). METHOD: Study 1 compared the three groups (total N = 213) using the Family Environment Scale (FES). Study 2 compared groups (total N = 86) on the positive parenting scales of the Exposure to Abusive and Supportive Environments Parenting Inventory (EASE-PI). RESULTS: In Study 1, multivariate analyses indicated significant differences on the independence, cohesion, and conflict subscales of the FES. Pairwise comparisons revealed that the extra-familial group reported significantly higher levels of family independence and lower levels of conflict than the other two groups. In addition, the extra-familial group reported higher levels of cohesion than the intra-familial group. However, the effect sizes of these comparisons were extremely small. In Study 2, multivariate analyses revealed no group differences on the EASE-PI scales. CONCLUSIONS: Low effect sizes on the three significant FES scales, non-significance on the remaining seven FES scales, and non-significance on the EASE-PI scales suggest that there is considerable similarity in the family of origin environments of adult female CSA survivors seeking therapy regardless of whether their perpetrators were family members, non-family members, or both family and non-family members.