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System Transformation Issues


Mental Health America (MHA) believes that it is essential that all aspects of wellness promotion and mental health and substance use disorder prevention, intervention, and treatment be reflective of the diversity of the communities being served and that mental health and substance abuse agencies strive to create and maintain environments that foster cultural humility,[1] which are culturally and linguistically responsive to the needs of all people.

A culturally and linguistically competent system not only incorporates skills, attitudes, and policies to ensure that it is effectively addressing the needs of people and families with diverse values, beliefs, and sexual orientations, in addition to backgrounds that vary by disability, race, ethnicity, religion, language, and socio-economic levels, but also works towards incorporating a culturally humble approach that focuses on mutual respect and ongoing introspection and learning. Cultural humility incorporates, “a lifelong commitment to self-evaluation and self-critique, to redressing imbalances in the patient-physician dynamic, and to developing mutually-beneficial and non-paternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations.”[2]

This requires a thorough understanding of the culture and language of people from diverse populations, including people of all ages, races, ethnicities, gender identities, sexual orientation, and people with disabilities. Special accommodations need to be made for communication in sign language and Braille. Mental Health America urges that planning and advisory councils and governing boards, staff and peer service workers of mental health and substance abuse treatment agencies all be chosen and trained to reflect and respect cultural and linguistic diversity as a basic civil right.[3] MHA urges a multifaceted, holistic approach to diversity which focuses on acceptance, inclusion and understanding of the needs of all communities.


Identification and treatment of mental health and substance use conditions requires a full understanding of the culture and language of the person and an ability to relate successfully to the person through culture and language. Thus, culture and language are indispensable means of communication, and when barriers exist, they must be addressed for prevention and treatment to be effective. This requires recruitment, resources, integrity, and sustained effort. Most importantly, cultural competence requires training and self-criticism to combat stereotypes, such as the legacy of racism and ethnic prejudice in America,[4] the condemnation of diverse sexual orientations in prior mental health diagnostic systems,[5] the ongoing impact of stigma for individuals with disabilities, [6] and other cultural biases and prejudices that still haunt us.

For LGBTQ teens and young people and families of color, the challenges of growing up are especially difficult. Stresses and confusion are pronounced in young people who are coming to terms with a stigmatized sexual orientation and considering coming out, as they are for racial and ethnic minorities seeking a positive role in American society. Studies show a strong correlation between gay, lesbian or bisexual sexual identity and the risk of suicide,[7] and increased prevalence of mental health problems.[8]

In its 2011 report, The Health of Lesbian, Gay, Bisexual and Transgender People,[9] The Institute of Medicine concluded that little is known to science about LGBTQ culture, and that: “While LGBT[Q] populations are [often] combined as a single entity for research and advocacy purposes, each is a distinct population group with its own specific health needs. Furthermore, the experiences of LGBT[Q] individuals are not uniform and are shaped by factors of race, ethnicity, socioeconomic status, geographical location, and age, any of which can have an effect on health-related concerns and needs.” Thus, according to the IOM, data on “sexual and gender minorities” should be included in the battery of demographic information that is collected in federally funded surveys, in the same way that race and ethnicity data are collected. In addition, data on sexual orientation and gender identity should be collected in electronic health records, like race and ethnicity.

Despite attempts to improve disparities in access to treatment, research show that racial and ethnic minority populations continue to face significant challenges in accessing any form of mental health or substance use treatment, let alone culturally sensitive treatment [10] Furthermore, there can be no doubt that and the criminal justice system disproportionally affects (and sometimes targets) racial and ethnic minorities further adding to disparity in care and barriers to recovery.[11] Culturally sensitive treatment programs should take into consideration unique cultural differences, including specialized care to consider diverse language needs, refugee or migrant status, and socio-economic circumstances in order to provide effective mental health and substance use treatment.[12],[13]

MHA believes that the best response is for all providers including MHA and its affiliates to embrace and integrate a multifaceted, holistic, approach to diversity which focuses on acceptance, inclusion and understanding of the needs of all communities.

This approach should help MHA and its affiliates to build community inclusion into the Before Stage 4 philosophy of early identification, intervention, and prevention focused on recovery as a goal. Awareness, engagement, education, outreach and integration endeavors will emphasize that diversity is comprehensive and inclusive of all populations, including subgroups and subsets that are oftentimes overlooked, such as LGBTQ people, people with disabilities, veterans, older adults, refugees, youth, and caregivers.

Call to Action

Unfortunately, many mental health systems and agencies, including those that serve highly diverse populations, continue to experience years of failure in addressing these concepts through non-specific plans and lack of vigorous outcome data collection. In order to improve the cultural sensitivity and responsiveness of mental health delivery systems, Mental Health America urges all organizations that provide mental health services including MHA and its affiliates to:

  • Have a formalized, written cultural and linguistic competency plan with clearly identified outcomes and ongoing accountability to improve diversity and assure cultural humility and competence that is reflective and respectful of the communities being served.
  • Appoint planning and advisory councils and governing boards with diverse and culturally and linguistically competent membership that is reflective and respectful of the communities being served.
  • Provide enrollment and educational materials in different languages and accessible formats that are responsive to the diversity and needs of the communities being served.
  • Pre-test the reader-friendliness of enrollment and education materials with focus groups composed of persons who are reflective of the cultural and linguistic diversity of the communities being served, including persons with visual, hearing and cognitive disabilities.
  • Measure the reader-friendliness of such materials in satisfaction surveys.
  • Ensure availability of providers with language skills that complement the languages used by the communities being served and provide needed linguistic support and translation services, including signing professionals as well as sign language services, to people in treatment and their families (at no cost to them), beginning at the point of entry into the system and throughout the course of care.
  • Develop and implement standards for recruitment and hiring of culturally and linguistically competent leadership and staff (including people with various disabilities, gender identities and sexual orientations, and linguistic and cultural capacities and understandings).
  • Develop care plans that are sensitive to and inclusive of cultural norms, traditions, and perspectives. Direct people in recovery and their families to treatment modalities that are accessible and culturally acceptable to them to ensure the likelihood of ongoing treatment collaboration (including, for example, sensitivity to religious beliefs and non-traditional families).
  • Have a regular quality-monitoring program with indicators that separately evaluate both the quality of services and the outcomes in serving diverse communities.
  • Provide regular cultural and linguistic competency training for leadership and providers.
  • Ensure that providers have an understanding of the cultural attitudes about healing systems held by the people in recovery whom they serve.
  • Ensure that providers have an understanding of the functional and environmental limitations, family dynamics, and sexual orientations and gender identities of the people in recovery whom they serve.
  • Ensure that providers are skilled in specialized assessment and treatment techniques to serve people in recovery with diverse ethnicities, functional abilities, sexual orientations, and gender identities.

Effective Period
The Mental Health America Board of Directors approved this Policy on March 5, 2016. It is reviewed as required by the Mental Health America Awareness, Engagement, and Education and Public Policy Committees.

Expiration: December 31, 2021


[1] Tervalon, M., & Murray-Garcia, J., “Cultural Humility Versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education, “Journal of Health Care for the Poor and Underserved, 9(2):117-25 (1998).

[2] Id.

[3] See MHA Position Statement 63, Participation on Boards

[4] Citations can only skim the surface, but a good starting point is Alva and Gunner Myrdal’s classic An American Dilemma: The Negro Problem and Modern Democracy (Harper & Bros, 1944) and the words of the Rev. Martin Luther King.

[5] In 1973, the weight of empirical data, coupled with changing social norms and the development of a politically active gay community in the United States, finally led the Board of Directors of the American Psychiatric Association to remove homosexuality from the Diagnostic and Statistical Manual of Mental Disorders (DSM). Some psychiatrists who fiercely opposed their action subsequently circulated a petition calling for a vote on the issue by the Association's membership. That vote was held in 1974, and the Board's decision was ratified.

[6] Corrigan, P.W. & Watson, A.C., “Understanding the Impact of Stigma on People with Mental Illness,” World Psychiatry. 1(1):16–20 (2002),

[7] Bolton, S. L., & Sareen, J., “Sexual Orientation and its Relation to Mental Disorders and Suicide Attempts: Findings from a Nationally Representative Sample,” Canadian Journal of Psychiatry/Revue Canadienne de Psychiatrie 56(1):35 (2011).

[8] Bostwick, W.B., Boyd, C.J., Hughes, T.L. & McCabe, S.E., “Dimensions of Sexual Orientation and the Prevalence of Mood and Anxiety Disorders in the United States,” American Journal of Public Health 100(3):468-475 (2010), doi: 10.2105/AJPH.2008.152942

[9] Institute of Medicine (The National Academies Press 2011)

[10] Garland, A. F., Lau, A. S., Yeh, M., McCabe, K. M., Hough, R. L., & Landsverk, J. A., “Racial And Ethnic Differences In Utilization Of Mental Health Services Among High-Risk Youths,” American Journal of Psychiatry 162(7):1336-43 (2005).

[11] In Position Statement 56, MHA acknowledged this shameful fact: “MHA recognizes the nation must acknowledge and address the forces that contribute to the disproportionately high involvement of persons from ethnic and racial minority communities in the criminal justice system. A system that continues to incarcerate so many people of color with inconsistent lengths of incarceration when compared to others is inherently unjust.” 

[12] Paniagua, F. A., & Yamada, A. M. (Eds.), Handbook of Multicultural Mental Health: Assessment and Treatment of Diverse Populations (Academic Press, 2013).

[13] Institute of Medicine, Unequal Treatment: What Healthcare Providers Need to Know about Racial and Ethnic Disparities in Healthcare (2002),