When I was a psychiatric resident in the mid-1970’s, the idea of cultural issues in psychiatry was hardly on the radar screen of most clinicians, educators or administrators. Interviewing, diagnostic assessment, and treatment planning, let alone policy making, rarely considered cultural differences between the clinician and the patients and families. The neglect of the importance of these differences extended beyond issues of ethnicity to those including gender, sexual orientation and religious/spiritual beliefs among others. Now, twenty years later, many exciting and groundbreaking developments have occurred in both systems and clinical cultural competence. I am very happy to share a few of these with you.

Culturally competent services can be defined as a set of congruent behaviors, knowledge, skills, attitudes and policies that work effectively in cross-cultural situations between a system, agency, or the clinician and the patient/family. A culturally competent mental healthcare system acknowledges the importance of culture and incorporates this value into all three levels of care; the first two levels involve systems cultural competence, while the last one speaks to clinical cultural competence. To do this requires the assessment of cross-cultural relations, an understanding of the dynamics of cultural differences, the expansion of cultural knowledge and a commitment to adapt services to meet culturally unique needs. Culturally competent behavioral healthcare (including services for consumers who speak languages other than English) provides better access to more appropriate, effective care and the opportunity for improved outcomes. Those who use the term "cultural competence" have focused on the provision of services to ethnic minorities; a more sophisticated perspective would utilize a matrix that includes ethnicity, language, gender, age, country of origin, sexual orientation, religious/spiritual beliefs, social class and physical disabilities among other factors to assess consumers and their needs.

At the systems level of cultural competence, Federal Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Mental Health Services (CMHS) has developed key standards of care, which for the first time, give policy makers and administrators a comprehensive direction to guide services. In November 1998, SAMHSA Center for Mental Health Services (CMHS) put on its website Cultural Competence Standards in Managed Care Mental Health Services for Four Underserved/Underrepresented Racial/Ethnic Groups. (The website is mentalhealth.org; search under cultural competence standards). It culminated a two and a half year process which started with convening four panels of mental health experts and consumers representing Blacks, Latinos, Asians and Native Americans, and led eventually to the final consensus document. The Western Interstate Commission for Higher Education (WICHE) coordinated this landmark effort. The system standards cover these areas: cultural competence planning, governance, benefit design, prevention, education, outreach, quality monitoring and improvement, decision support and management information systems, human resource development. The clinical standards include: access and service authorization, triage and assessment, care planning, plan of treatment, treatment services, discharge planning, case management, communications styles and cross-cultural linguistic and communication support, self help and provider competencies. For each standards section, there are also implementation guidelines, recommended performance indicators and recommended outcomes.

The SAMHSA CMHS has also released Cultural Competence Performance Measures for Managed Behavioral Healthcare Programs. Developed by the New York State Office of Mental Health, it is a state-of-the-art document that utilized a comprehensive literature search, focus groups of multi-ethnic consumers and an experts panel. For the first time, very specific measures are set forth to assess concretely the following domains of care across all three levels (system, agency, clinician): needs assessment, information exchange, services, human resources, policies/plan and outcomes. Harriett McCombs, Ph.D., at CMHS, has spearheaded the development of these two essential documents in systems cultural competence.

Other recent developments at the Federal level include the Office of Minority Health Cultural and Linguistic Standards for Healthcare (OMHRC.gov/clas), the NIMH Strategic Plan to Reduce Health Disparities (NIH.gov/about/HD/strategicplan.pdf), and the upcoming Surgeon General Report on Ethnic Minorities and Mental Health (surgeongeneral.gov).

At the clinical level of cultural competence, there has been an increasing level of awareness of the importance of cultural issues in clinical care. Three prominent practice guidelines from three mental health organizations that set an expectation of care in this area include: the American Psychiatric Association Practice Guidelines for Psychiatric Evaluation of Adults (American Journal of Psychiatry, November 1995), the American Psychological Association Guidelines for Providers of Psychological Services to Ethnic, Linguistic and Culturally Diverse Populations (American Psychologist, January 1993) and the American Counseling Association Multicultural Counseling Competencies and Standards. For example, the American Psychiatric Association guidelines acknowledge the importance of cultural competence in a section entitled "Considerations for Sociocultural Diversity":

Another important development has been that the DSM-IV has incorporated some of the recommendations of the National Institute of Mental Health Work Group on Diagnosis, Culture and Care for increasing cultural considerations in the diagnostic and formulation process. It includes an overview section in the introduction; age, gender and cultural considerations in the narrative description of 70 diagnostic categories; an Outline for Cultural Formulation; and a glossary of culture-bound syndromes. The Outline for Cultural Formulation is meant to supplement the multiaxial diagnostic assessment and to address difficulties that may be encountered by applying DSM-IV criteria in a multicultural environment. Five issues are identified: