Consumer-Driven Standards and Guidelines in Managed Mental Health for Populations of African Descent

Annotated Bibliography

A. Basic Materials

1. Managed Behavioral Healthcare

Review of the literature did not disclose any current bibliographies that focus on core competencies needed for mental health service delivery to African Americans. Of the existing bibliographies that were reviewed, there were no articles, books, reports, or studies reported that focus specifically on African Americans or the competencies needed to provide quality services in managed care. This absence of attention in the literature is not a recent phenomena. African Americans with mental illness have rarely been the subject of specific research attention in relationship to previous health care plans, policies, or workforce competencies. Where research projects in these areas have been conducted generally, there has been a noted absence of African Americans identified in the populations sampled. Clearly, there is a significant gap in the literature in this area that has the potential for decreasing the quality of service provided to this population.

2. Training Professionals to Work with African Americans with Psychiatric Disabilities

The literature review did not reveal any bibliographies / publications specifically focused on training mental health providers to work effectively with African American populations in a managed care environment or in other healthcare plans. As will be noted in this report, published materials found tend to approach mental health care of African Americans from the standpoint of the relationship between race and treatment. This relationship has been addressed more recently under the general heading of cultural competency. This literature will be identified in the materials that follow.


B. General Workforce Competencies

A number of published articles were identified that focus on the skills and competencies needed for service delivery to individuals with severe mental illness. These are found in the materials produced by other members of the CMHS project, and are not included in this report. Consistent with the findings from other areas, there is a major gap in the literature in this area extending from the late 1970's to 1996. The following materials provide relatively broad direction for this area.

1. Cultural Competency

Comas-Diaz, L., & Griffith, E.E.(Eds.).(1988). Clinical Guidelines in Cross-Cultural Mental Health. New York: John Wiley Co.

Cross, T.L., Bazron, B.J., Dennis, K.W., & Issacs, M.R.(1992). Towards a Culturally Competent System of Care. Washington, D.C: CASSP Technical Assistance Center.

Chunn, J., Dunston, P.J., & Ross-Sheriff, F.(Eds.). (1983). Mental Health and People of Color: Curriculum Development and Change. Washington D.C: Howard University Press.

This is a compilation of articles that address curriculum issues in what was then termed the four core mental health disciplines: psychology, social work, psychiatry and psychiatric nursing. The authors apply these four curriculum areas to Black, Asian, Native American and Hispanic populations.

Deas-Nesmith, D., & McLeod-Bryand, S.(1992). Psychiatric Deinstitutionalization and Its Cultural Insensitivity: Consequences and Recommendations for the Future. Journal of the National Medical Association. Vol. 84, No. 12. 1036-1040.

This article focuses on the heretofore unexplored area of how deinstitutionalization impacts racial minorities. Of importance in the article is the juxtaposition made with efforts in the state of Ohio to address the byproducts of this national policy through culturally competent approaches.

Gary, L.E.(Ed.). (1978). Mental Health: A Challenge to the Black Community. Philadelphia: Dorrance & Co.

This book is consistent with the genre of articles that were published in the latter years of the 1970's. It includes conceptualization, policy, disorders, community strengths, service delivery systems, research (generally) and workforce considerations. While the articles are dated, some of the materials here are helpful for conceptualizing the dilemmas and challenges of providing services to African Americans in a managed care environment. A number of the individual articles cited in this anthology will be annotated in other sections of this bibliography.

Gary, L.E. & Weave, G.D.(1991). A Multidisciplinary National Conference on Clinical Training and Services for Mentally Ill Ethnic Minorities. Conference Proceedings. Washington D.C: Howard University Press.

Hanley, J.(Ed.). (1996). African American Behavioral Health Workforce Conference. Conference Proceedings. Atlanta: September 6-9, 1995.

The proceedings report on the first conference that focused on the training role, responsibility, opportunity, history and barriers facing historically black colleges and universities in meeting the human resource crisis associated with behavioral healthcare. The conference participants sought to identify the successful component of clinical training programs and curricula across disciplines that address the issues related to mental health of African Americans. Discipline specific plans were developed to assist universities interested in developing or expanding their curriculum. The conference also developed an outline of a strategic plan for increasing both the number of processional training programs within historically black colleges and universities but also the content of the curriculum within these programs. Individual presentations from colleges and universities that have developed successful training programs were made.

Leigh, W.A.(1994). Implications of Health Care Reform for Black Americans. Journal of Health Care for the Poor and Underserved. Vol. 5, No. 1. 17-32.

This article compares and contrasts the various health care reform options and plans proposed (by President Clinton and the U.S. Congress) prior to 1993, and the potential impact each of these plans would have on African American populations. The author provides an excellent overview of the insurance status of the African American population and how this status will not be changed substantially under a managed care health plan. Leigh concludes the analysis by proposing a series of policy options for insuring greater equity for the African American population.

Lu, F.G.(1996, April). Getting to Cultural Competence: Guidelines and Resources. Behavioral Healthcare Tomorrow. 49-51.

Orlandi, M.A., Weton, R., & Epstein, L.G.(1992). Cultural Competence for Evaluators: A Guide for Alcohol and Other Drug Abuse Prevention Practitioners working with Ethnic/ Racial Communities. Washington D.C: U.S. Government Printing Office.

Ruiz, D.(1990). Handbook of Mental Health and Mental Disorders Among Black Americans. New York: Greenwood Press.

This work represents a comprehensive treatment of the social, structural, and cultural issues that impact mental health treatment of African Americans. This holistic approach examines a broad range of psychological stressors and their impact on mental health status of this population. The perspectives of social workers, psychologists, sociologists, psychiatrists and mental health administrators are incorporated in a multidisciplinary manner. The data on which a number of the articles were based had been drawn from studies conducted in the early 1980's.

Sanchez, A.M.(Ed.). (1996). Developing Culturally Competent State Mental Health Delivery Systems for Ethnically Diverse Adults with Serious Mental Illness. Draft Monograph. Boulder: WICHE.

This is a very comprehensive effort to identify the detailed elements in a culturally competent public delivery system. The most recent (August, 1996) draft provides an excellent overview of the conceptualization of a culturally competent public system of services and the linkages and implications to managed care. Of value as well is an extensive bibliography that covers issues across a number of racial and ethnic groups.

Tarpley, M.(Ed.) (1996). Mental Health Research and People of Color: Defining an Agenda for the Year 2000 and Beyond. Conference Proceedings. Worcester: October 13, 1995.

This set of proceedings had not arrived at the time this summary report was completed. These materials will be included in the summary at a later time.

Yee, T.T.(1993). General Principles for designing and developing culturally competent programs. San Francisco: Department of Public Health, Division of Mental Health and Substance Abuse.

2. Race and Diagnosis

Flaskerud, J.H., & Hu, L.(1992). Relationship of Ethnicity to Psychiatric Diagnosis. Journal of Nervous and Mental Disease. 180(5), 296-303.

Garretson, D.J.(1993). Psychological Misdiagnosis of African Americans. Journal of Multicultural Counseling and Development. 21, 119-126.

This article addresses the accuracy of psychological and psychiatric diagnosis of African Americans dating back to slavery. African Americans primarily took care of their mentally ill relatives at home because of (1) a lack of private and public facilities and (2) because of the extreme stigma attached to mental illness in the African American community. The author contends that poor data collection and reporting were major obstacles to accessibility and utilization of services by African Americans. The author also elaborates on several reasons for possible misdiagnosis: (1) social and cultural distance, (2) the diagnostic process, (3) continuation of stereotypes of African American psychopathology, and (4) cultural differences in values and life stressors. Clinicians must take into consideration the psychosocial values, racial and cultural dimensions, and the experiences of the African American consumer.

Jones, B., & Gray, B.(1986). Problems in Diagnosing Schizophrenia and Affective Disorders Among Blacks. Hospital and Community Psychiatry. 37(1), 61-65.

This article reviews the problem in diagnosing and distinguishing between schizophrenia, major affective disorders and specific problems related to diagnosis of these conditions in African American populations. The article suggests that African Americans are misdiagnosed more frequently than European Americans and receive inappropriate treatment. The problems in diagnosis have been attributed to: (1) thought content, (2) disorder of thought process, and (3) cultural distance between the patient and the clinician. The authors suggest that more attention be focused on cultural and racial differences of African American patients.

Lawson, W.B., Heplar, N., Holladay, J., & Cuffel, B. (1994) Race as a Factor in Inpatient and Outpatient Admissions and Diagnosis. Hospital and Community Psychiatry. 45(1), 72-74.

In this article the authors review the relationship between race and inpatient and outpatient admissions and diagnosis. Data presented shows that African Americans are hospitalized more often than other populations and more frequently diagnosed with schizophrenia. The data also confirms that African American populations are more frequently involuntarily committed to psychiatric hospitals. Differences in diagnosis have been attributed to misdiagnosis, failure to appreciate cultural differences in the presentation of symptoms and differences in the actual prevalence of rates of mental disorders. The authors draw two major conclusions: additional studies are needed to examine and explore these relationships more extensively and there are implications for training and educations of professionals who conduct assessments.

Williams, D.H.(1986). The Epidemiology of Mental Illness in Afro-Americans. Hospital and Community Psychiatry. 37(1), 42-49.

3. Treatment Issues and African Americans

Allen-Meares, P., & Burman, S.(1995). The Endangerment of African American Men: An Appeal for Social Work Action. Washington D.C: NASW, Inc.

This article gives informative data regarding African American men and examines the role the mental health practitioner should play in providing services to this population. It addresses institutional racism, the African American family, and policy issues related to African Americans. The authors suggest that mental health professionals must address life stresses, discriminatory practices, economic disparity, as well as other key issues. Professionals need to develop program strategies that strengthen social support networks and resources in the communities. The authors propose what is termed a model of activism as the vehicle for producing change in the status of African American men.

Bennett, M.(1988). African American Women, Poverty and Mental Health: A Social Essay. Chicago: Haworth Press, Inc.

This article examines the relationship between poverty in African American women and mental illness. The author proposes that intractable poverty contributes to the onset of mental illness. Furthermore, the author contends that lower end jobs in the labor market and public assistance are the primary sources of income and support for African American women with mental illness. To alter these circumstances, the author proposes that extensive mental health education programs are needed and must be geared towards changing the overall behaviors and attitudes of the women towards poverty. Bennet contends that it is important to also focus on changes in the political, economic, and social circumstances associated with poverty in this population.

Bui, Khanh-Van, T., & Takeuchi, D.T.(1992). Ethnic Minority Adolescents and the Use of Community Mental Health care Services. American Journal of Community Psychology. 20(4), 403-416.

The focus of this article was on determining the extent to which there were differences in the utilization of community mental health facilities by adolescents by race and ethnicity. When the data set on youth were compared and contrasted in the period between 1983 and 1988, it was shown that African American youth were disproportionately represented. In addition, African American youth were more likely to remain in treatment longer than other youth. Bui and Takeuchi note that there were significant differences in the socio- demographic profile of the youths by race. Black youths were more often from economically poor environments and were likely to have been referred by social agencies.

Comas-Diaz, L.(1992). The Future of Psychotherapy with Ethnic Minorities. Psychotherapy. 29(2), 88-94.

Comas-Diaz, L., Geller, J.D., Melgoza, B., & Baker, R.(1982). Attitudes and expectations about mental health services among Hispanics and Afro Americans. Paper presented at the 90th Annual American Psychological Association, Washington D.C.

Comas-Diaz, L., & Greene, B.(Eds.). Women of Color and Mental Health. New York: Guilford Press.

Helms, J.E.(1986). Expanding racial identity theory to cover the counseling process. Journal of Counseling Psychology., 33(1), 62-64.

Jackson, G.G. (1976). The African genesis of the Black Perspective in Helping. Professional Psychology. 7, 292-308.

Jenkins, A.H.(1985). Attending to self-activity in the Afro-American client. Psychotherapy. 22, 335-341.

Jones, E.E.(1978). Effects of race on psychotherapy process and outcome: An exploratory investigation. Psychotherapy: Theory, Research and Practice. 15, 226-236.

Jones, E.E.(1982). Psychotherapists’ impressions of treatment outcome as a function of Race. Journal of Consulting and Clinical Psychology. 38, 722-731.

Jones, J.M. (1985). The sociopolitical context of clinical training in psychology: The ethnic minority case. Psychotherapy. 22 S, 453-456.

Neighbors, H.W., & Jackson, J.S.(1984). The use of formal and informal help: four patterns of illness behavior in the Black community. American Journal of Community Psychology. 12, 629-644.

Snowden, L.R., & Cheung, F.K.(1990). Use of inpatient mental health services by members of ethnic minority groups. American Psychologist. 45, 347-355.

Snowden, L.R., & Holschuh, J.(1992). Ethnic Differences in Emergency Psychiatric Care and Hospitalization in a Program for the Severely Mentally Ill. Community Mental Health Journal. 28(4), 281-291.

Solomon, P. (1987). Racial Factors in Mental Health Service Utilization. Psychosocial Rehabilitation Journal. 11(3), 3-12.


C. Discipline Orientations/Competencies

Sue, D., Arredondo, P., & McDavis, R.J.(1992). Multi-cultural counseling competencies and standards. Journal of Counseling and Development. 70, 447-486.

1. Psychiatry

Bell, C.C., Bland, I. J., Houston, E., & Jones, B.E.(1983). Curriculum Development and Implementation: Enhancement of Knowledge and Skills for the Psychiatric Treatment of Black Populations. In Chunn, J.C., Dunston, P.J. & Ross-Sheriff, F.(Eds.). Mental Health and People of Color: Curriculum Development and Change. Washington D.C: Howard University Press. 205-238.

Bell et al identifies the absence of knowledge of African American populations with mental illness as a critical problem in psychiatry training programs. They propose that curriculum needs to be modified to include content on African American culture and that research be conducted on this population to support alternative models of care. These authors conclude that there is a need to bring about fundamental change in psychiatry training. Although not extensive, the authors identify the content they believe needed in the curriculum as well as the strategies for successful change.

Butcher, R.O.(1993). Managed Care Now and Forever. Journal of the National Medical Association. 85(7). 505-507.

Butcher reports on a national conference of black health care professionals who examined the proposed changes in national health care policy in 1992. He proposed that numerous complex questions remain unaddressed about the impact of health reform on the African American population. Buthcer identified a number of these central issues: 1) access; 2) impact on the existing system of care; 3) changes in income of black health professionals; 4) a decline in opportunities for black professionals; 5) a decline in owner- ship and control of the health system by blacks; 6) deemphasis on prevention. The conference endorsed a recommendation that the nation provide 20% of all health care expenditures for prevention and health promotion. In addition, the conference endorsed the National Medical Association’s proposal for a single payer system and universal coverage. Of note, the conference called for the integration of health, social services and mental health service administration at the federal level.

Carter, J. (1986). Deinstitutionalization of Black Patients: An Apocalypse Now. Hospital and Community Psychiatry. 37(1), 78-79.

This article discusses briefly issues related to African Americans with mental illness. The author notes that African Americans are the largest minority group in America, and that chronically mentally ill African Americans are victims of neglect by society and mental health professionals. The article gives data regarding unemployment and poverty of the African American population. The author also discusses over reliance on public psychiatric hospitals, lack of community support systems, discriminatory zoning regulations that confine African American mentally ill patients to dilapidated inner cities, and stereotyping. The author suggests that we reexamine the methods for developing and implementing treatment programs for racial minorities.

Dawson, G.(1994). For African Americans Real Health Care Reform or Business as Usual. Journal of the National Medical Association. 86(12), 893-895.

Dawson raises a number of critical questions about the extent to which African American populations obtain the quality of health care needed, in the fee for service or managed care systems. He cites studies that show major disparities in access to life sustaining and life enhancing care in the Veterans Hospital system. He reports that in this setting, where cost is borne by government, there are significant inequities in the distribution of major cardiac procedures along racial lines. Dawson concludes that if African Americans are unable to obtain care in those settings were income is held neutral, he questions the extent to which blacks will fare under newer health care policies and plans in which cost reduction is a significant force. Dawson predicts that black patients will not fare as well under a managed care policy in which income disparities will combine with race. This brief article seems to capture and express a number of the major concerns within the African American community about managed care. The bibliography that accompanies the article is extensive and covers a number of issues more related to general health care than behavioral health. In his conclusions, Dawson places an emphasis on finding solutions that change the overall health care system and its supporting policies.

Harvard Law Review.(1995, May). The Impact of Managed Care on Doctors who Serve Poor and Minority Patients. Harvard Law Review. 108, 1625.

Lavizzo-Mourey, R., Clayton, L.A., Byrd, W.M., Johnson., G., & Richardson, D.(1996). The Perceptions of African American Physicians Concerning Their Treatment by Managed Care Organizations. Journal of the National Medical Association. 88(4), 210-214.

The focus of this article is on the potential impact of managed care on the careers of black physicians. The authors propose that as managed care plans increase, the number and proportion of black physicians holding managed care contracts will decrease. The need for a focus on this aspect of managed care is based on the prediction that a disproportionate number of African American lives will be covered under managed care because Medicaid programs are increasingly shifting towards this kind of health coverage. As this shift in Medicaid occurs, Lavizzo-Mourey et al expresses concerns that quality of care for African Americans will decline. To obtain data for their study, the authors administered a questions to a sample of 305 black physicians. Seventy-one percent of the sample reported having at least one managed care contract while an equal percentage reported losing patients to managed care plans when these physicians were not accepted as part of the network. Only 25% of the sample reported an overall decline in the number of patients in their practices. The major finding in this study was that 88% of the black physicians had been denied participation in a managed care network.

Loring, M., & Powell, B.(1988). Gender, Race and DSM-III: A study of the objectivity of psychiatric diagnostic behavior. Journal of Health and Social Behavior. 29, 1-22.

This paper examines whether the DSM-III provides objective criterial for mental health professionals evaluating clients based on sex and race. The authors used two case studies and surveyed 290 psychiatrists. They caution the reader that the results may be skewed given that only two studies were used. They also recognize that other factors about the psychiatrist may influence the diagnosis, such as private vs. Public practice, age, and years of service. The authors conclude by noting that eve with carefully designed standards, diagnosis is still a subjective undertaking.

Lu, F.(1995). American Psychiatric Association Practice Guidelines for Psychiatric Evaluation of Adults. Washington D.C: American Psychiatric Association.

These guidelines for assessing adults in psychiatric are make the point that during the psychiatric evaluation process, sociocultural and diversity characteristics and implications should be made. This is especially important when obtaining information from patients that includes personal history, using structured interviews, questionnaires, rating scales and conducting case formulations.

Moffic, H.S., Kendrick, E.A., Lomax, J.W. & Reid, K.(1987). Education in Cultural Psychiatry in the United States. Transcultural Psychiatric Research Review. 24, 167-187.

Pavkov, T.W., Lewis, D.A., & Lyons, J.S.(1989). Psychiatric Diagnoses and Racial Bias: An Empirical Investigation. Professional Psychology: Research and Practice.20(6), 364- 368.

This article examines the relationship between race and schizophrenic diagnosis of patients in several mental hospitals in Chicago. It notes that data collected by NIMH indicates there are major disparities in types of diagnoses by racial identity. The literature suggests that racial bias occurs within the institutions that treat persons with severe mental illness. This article states that regardless of type of care, evidence exists that African Americans are more likely than other Americans to be subjected to seclusion and restraints or both in treatment settings. The authors also acknowledge the lack of culturally relevant diagnostic instruments, as well as misinterpretations of symptoms. Training of professionals in large urban areas was also addressed. Results suggest that African Americans, as well as other minority groups, may be misdiagnosed and mistreated due to racial bias of the mental health professions.

Sabshin, M., Diesenhaus, H., & Wilkerson, R.(1970). Dimensions of Institutional Racism in Psychiatry. American Journal of Psychiatry. 127(6), 787-798.

Sabshin et al conceptualized the problem of race and service delivery as being within the ` domain of white psychiatrists to recognize and change. The authors concluded that systems of mental health care reflected the generalized perspectives on race and culture as found in the wider society. The key to change according to these authors is for the profession to look internally at its own practices, organization and training. A considerable proportion of the December 1970 issue of this journal was devoted to issues of racism within the professional of psychiatry.

Shader, R.I.(1982). Cultural Aspects of Psychiatric Training. In Albert Gaw (Ed.). Cross Cultural Psychiatry. Boston: John Wright, 187-197.

Spurlock, J. (1982). Cultural Aspects of Mental Health Care for Black Americans. In Albert Gaw (Ed.). Cross Cultural Psychiatry. Boston: John Wright, 163-178.

Thomas, A., & Sillen, S.(1972). Racism and Psychiatry. New York: Brunner/Mazel.

While not related specifically to managed care and African Americans, this work raised a number of significant questions about the racial context of professional training and education programs within universities. The authors propose that racist thinking is so significant a component of American culture that the mental health disciplines reflect similar thought that finds its expression in theory and practice.

Walton, T.M.(1994). Challenges for Health Professions in the Face of Health Care Market Reform. Journal of the National Medical Association. 87(4), 256-257.

Walton’s focus is primarily on the implications of health care reform on black physicians. He indicates that managed care presents unique challenges to black physicians for a number of related reasons: 1) minority physicians are concentrated in primary care areas of practice; 2) minority physicians infrequently practice in group settings; ) the patients seen by black physicians tend to be more often uninsured and underserved; 4) many black physicians are not board certified. Walton proposes that many of the processes employed in managed care arranges are at odds with the historical system of health care in the black community and are likely to increase the overall cost of providing services to this indigent population. Walton concludes that what is needed to provide quality services is an increase in cultural competency.

2. Psychiatric Rehabilitation

No reference materials were identified in this specialty area that pertained to African Americans with mental illness or the related issues of training standards or competencies..

3. Psychology

Bernal, M.E., & Padilla, A.M.(1982). Status of Minority Curriculum and Training in Clinical Psychology. American Psychologist. 37, 780-787.

Blount, R.L., Frank, N.C., & Calhoun, K.C.(1992). The Recruitment and Retention of Minority Students. The Clinical Psychologist. 45(1), 1-2.

Guzman, P.(1993). Guidelines for provides of psychological services to ethnic, linguistic and culturally diverse populations. Washington D.C: American Psychological Association.

The American Psychological Association’s Board of Ethnic Minority Affairs provides guidelines for mental health professionals to improve the quality of psychological services to ethnic and culturally diverse populations.

Lerner, B. (1972). Therapy in the Ghetto: Political Impotence and Personal Disintegration. Baltimore: Johns Hopkins University Press.

The author reports on five years of research within a community mental health center that provided services to low income black and Hispanic patients. Of value the author examines a series of characteristics of therapists believed to be positively correlated with outcome for low income clients.

Leung, P.(Ed.).(1990). Focus: Ethnic minority issues in psychology. The Journal of Training and Practice in Professional Psychology. 4. Entire Issue.

Myers, H.F.(1992). Overview and Historical Perspectives on Ethnic Minority Clinical Training in Psychology. The Clinical Psychologist. 45(1), 5-21.

Myers, H.R., Taylor, S., & Davila, J.(1992). The Recruitment and Training of Ethnic Minority Clinical Psychologists in a Multicultural Context: The UCLA Program. The Clinical Psychologist. 45(1), 23-33.

Myers, L. J.(1995). Culturally competent service outcomes assessment tools: Guidelines for upgrading quality assurance. Columbus: Ohio Department of Mental Health.

This handout identifies three levels of the service delivery system that must be established to create and sustain culturally competent managed health care outcomes: Administrative Performance Standards (i.e. nontraditional available options; diverse representation of staff; accessibility; diagnosis and treatment plans reviewed by culturally proficient peers; training; evaluating and monitoring cultural competence and accountability to the community). Clinical Performance Standards: (i.e., treatment based on clients cultural and value systems; cultural assessments; cultural competency training; consumer satisfaction surveys; culturally proficient interpreters). Financial Performance Standards: (i.e. most effective treatment is being sought and provided; access to treatment; training). The author states that cultural assessment instruments are currently being developed in areas of intake, diagnostic assessment, program evaluation and organization accountability. This is a most valuable resource document. When the materials discussed in the article are completed, this set of materials should help fill the gap in knowledge and information about what standards need to be developed to provide quality services to African American populations in both a managed care and fee for service environment.

Myers, H.F., & Wohlford, P., Guzman, L.P., & Echemendia, R.(Eds.) (1991). Ethnic Minority Perspectives on Clinical Training and Services in Psychology. Washington D.C: American Psychological Association.

Sabnani, H.B. & Ponterotto, J.G.(1992). Racial/ethnic minority-specific instrumentation in counseling research: A review, critique, and recommendations. Measurement and Evaluation in Counseling and Development. 24(4), 161-187.

This article reviews several instruments specifically conceived for use in ethnic, minority-focused psychological research. Scales and instruments include: 1) the African Self-Consciousness Scale; 2) the Cross-Cultural Counseling Inventory-Revised; 3) Modern Racism Scale; 4) Value-Oriented Scale; 5) the Racial Identity Attitude Scale; and 6) the Developmental Inventory of Black Consciousness. The article suggests that several of the scales are reliable for use with minority populations, but further research should be done to increase the reliability of each scale.

Wohlford, P., Myers, H.F., & Callan, J.(Eds.). (1995). Public Academic Linkages in Services, Research, and Training. Washington D.C: American Psychological Association.

4. Master’s Level Mental Health Service Providers

Hardy, K.V., & Laszloffy, T.A.(1992). Training racially sensitive family therapists: Contents, contact and context. Families in Society. 6. 364-370.

Johnson, S.(1990). Towards clarifying culture, race and ethnicity in the context of multicultural counseling. Journal of Multicultural Counseling and Development. 18(1), 41-50.

June, L.N.(1986). Enhancing the delivery of mental health and counseling services to black males: critical agency and provider responsibilities. Journal of Multicultural Counseling and Development. 1(1), 39-45.

These authors examine the various perspectives held historically about how to provide mental health treatment to African American populations. They then propose a model of effective service delivery based on a series of specific guidelines.

5. Nursing

Osborne, O., Carter, C., Pinkleton, N., and Richards, H. (1993). Development of African American Curriculum in Psychiatric and Mental Health Nursing. In Chunn, J.C., Dunston, P.J., & Ross-Sheriff, F. Mental Health and People of Color: Curriculum Development and Change. Washington D.C: Howard University Press, 335-376.

Osborne et al identifies and discusses the shortage of African Americans in psychiatric nursing circa 1972. In addition the authors provide a valuable list of the indicators of mental health in the African American population that they see as useful in providing direct services. Of particular merit is the listing of principles the authors believe are needed to undergird a curriculum that focuses on meeting the needs of African Americans with mental illness. Of note, very fee other articles were found that approach the issues of mental health care of African Americans and the relationship to nursing competencies.

6. Social Work

Bush, J.A., Norton, D.G., Sanders, C.L., & Solomon, B.A.(1983). An Integrative Approach for the Inclusion of Content on Blacks in Social Work Education. In Chunn, J.C., Dunston, P.J., & Ross-Sheriff, F. Mental Health and People of Color: Curriculum Development and Change. Washington, D.C: Howard University Press. 97-126.

This article traces the lengthy effort within social work education to influence and amend the curriculum to include content generic to African Americans, but with a more specific focus on mental illness in this population. It is proposed that the most viable model for including such content is what is termed an integrative model. In this perspective, content on blacks with mental illness would be integrated throughout the curriculum rather than compacted into one course offering. The authors draw on a broad spectrum of other articles to develop a general framework of values, abilities, skills, attitudes, and competencies useful in working with African Americans with mental illness.

Dungee-Anderson, D., & Beckett, J.O.(1995). A Process Model for Multicultural Social Work Practice. The Journal of Contemporary Human Services. 459-466.

These authors provide the first three steps in an eight-step model that is designed to assist social workers increase the cultural competency of their clinical interventions. These three initial steps include acknowledging cultural differences, understanding the self, and knowledge of other cultures.

Harper, K.V., & Lantz, J.(1996). Cross Cultural Practice: Social Work with Diverse Populations. Chicago: Lyceum Books.

These two authors examine the relationship between the practice of social work and a series of diverse populations, differing by race, language, migratory status, ethnicity, residence, sexual orientation, gender, age, military service, and prior trauma. The authors attempt to help the reader to become more knowledgeable about diverse groups as the basis for providing culturally sensitive and specific services.

Jackson, V.(Ed.) (1996). Managed Care Resource Guides. Washington D.C: National Association of Social Work.

The focus of this work is on assisting the social work profession to understand managed care and the impact managed care is likely to have on practice in private and agency settings. The document does not specifically address issues related to African Americans and severe mental illness.

Lum, D.(1986). Social Work Practice with People of Color. Monterey: Brooks/Cole Publishing Co.

The author provides an excellent framework for conceptualizing cultural differences and utilizing these differences as the basis for developing and providing competency based services to people of color.

National Association of Social Workers.(1984). Standards for the Practice of Clinical Social Work. Washington D.C: NASW

A generic set of standards for guiding the clinical practice of social work. This work does not specifically address the issues in practice of clinical social work with African Americans with mental illness.

National Association of Social Workers.(1992). NASW Standards for Social Work Case Management. Washington D.C: NASW.

A very good guide for understanding how social workers conceptualize case management and the differences between this view and care management and case management in managed care plans. No specific focus on African Americans is noted herein.


D. Roles/Views of African American Consumers

No reference materials were found that address this area for African Americans.


E. Roles/Views of African American Families

Boyd-Franklin, N.(1989). Black Families in Therapy: A Multisystems Approach. New York: Guilford Press.

Lawson, W. B.(1986). Chronic Mental Illness and the Black Family. American Journal of Social Psychiatry. 6(1), 57-61.

Lawson proposes in this article that the role of the family generally has been neglected. He traces the history of blaming of families for the development of schizophrenia. In relationship to black families, Lawson indicates that these families have had to bear even greater burdens historically. Although Lawson’s article does not provide a perspective from the African American family about mental illness, it does give some directions for the content of therapeutic work with these families.

Pickett, S.A., Vraniak, D.A., Cook, J.A., & Cohler, B.J.(1993). Strength in Adversity: Blacks Bear Burden Better than Whites. Professional Psychology: Research and Practice. 24(4), 460-467.

The authors indicate that the research literature has principally focused on the adjustment and coping of white families with a severely mentally ill members, leaving out other racial and ethnic groups and how they have managed severe illness. The research that was conducted by the authors included determining the coping ability and self-esteem scores of both black and white families with severely mentally ill children. The findings suggest that black families had higher than expected levels of self worth and correspondingly lower rates of depression than white families. Although the study is not directly related to managed care issues or workforce competencies, this article helps shape the issues relative to the need for culturally sensitive models and how different groups respond to and manage illness.


F. Managed Care, African Americans and Mental Illness

Bluford, J.W.(1994). A Public Sector HMO in a Competitive Market: Ensuring Equity for the Poor. Journal of Health Care for the Poor and Underserved. 5(3), 192-199.

Center for Health Economics Research.(1993). Access to Health Care: Key Indicators for Policy. Princeton: Robert Wood Johnson Foundation.

An excellent resource for examining and comparing a series of health indicators for the American population as a whole. While the focus here is not specifically on managed behavioral health care or African Americans, the data are illustrative of the major disparities that exist in the general health area by race and social class. The charts and graphs included are excellent and in a number of instances show groups by race and social class.

Center for Vulnerable Populations.(1994). Health Reform and Vulnerable Populations. Spotlight. 2(1), 1-11.

This article discusses access to health care and the supportive services that are needed to maximize independent living for persons with special needs. It states that persons with disabilities account for significant expenditures in the health care system and that they tend to have lower incomes, much of which is used for health care. Many persons with disabilities rely on government programs for income and housing. The article suggest that more attention needs to be paid to the complex and multiple needs of these individual.

Davis, King E. (1996). Managed Care and People of Color: A Conceptual Framework. (Unpublished). Statewide Public Psychiatry Conference. Cleveland: Case Western Reserve Department of Psychiatry.

One of a series of presentations and papers delivered over the past two years that examines managed care through a socio-political and economic lens. Managed care is compared and contrasted with Medicaid and states rights as strategies designed to curb costs and increase the control and power of state governments. The article traces the history of states rights as a strategy and concludes that it offers no real guarantees of equitable distribution of access, quality, or outcomes to African American populations. Of import, as well the article examines the absence of African American input into the formulation of national health care policy.

Group Health Association of America.(1994). Understanding Managed Care: Introductory Program for New Managers in HMOs. Conference Proceedings. Chicago: GHAA.

This is an extensive review of the concept of managed care and its most critical elements from the perspective of a trade organization. In volume two there are a series of presentations made that focus on the implications of managed care for populations of color and for rural poor populations.

Glazer, W. M., & Morgenstern, H.(1993). The impact of utilization management on hospital length of stay and illness. Administration and Policy in Mental Health. 21(1), 41-49.

This article presents a model study to test the impact of utilization management in the behavioral health field. The authors suggest using randomization when conducting studies of utilization management and cost effectiveness. Utilization management is used to manage health care costs by influencing patient care decision making through a case-by-case assessment prior to providing services. The results suggest that utilization management may negatively impact on minority populations.

Horn, R. (1994). Managed Care: Implications for Underrepresented Physicians. Jourmal of Health Care for the Poor and Underserved. 5(3), 154-157.

Mental Health Statistics Improvement Program.(1995). Task Group on Enrollment and Encounter Data.

This report defines enrollment as the number of individuals covered or enrolled in a health plan. Encounter is defined as a face-to-face interaction between the enrollee and the provider. The purpose of the report is to offer a framework for the provision of management data such as 1) whether services are reaching the appropriate population; 2) what are the services and costs of data and 3) descriptions of the performance data.

The National Pharmaceutical Council.(1993). Ethnic and Racial Differences in Response to Medicines: Preserving Individualized Therapy in Managed Pharmaceutical Programs. . Pharmaceutical Medicine. 7, 139-165.

This article notes that genes in racial and ethnic groups may cause or create differences in reactions to medications. Due to standardization and uniformity, health plans have limited choices of medicines. Differences in medication are seen as representing some risks to the quality of care.

Phillips, J.N.(1994). Future Management Opportunities for Minorities in Managed Care. Journal of Health Care for the Poor and Underserved. 5(3), 247-251.

Randall, V.R.(1994). Impact of Managed Care Organizations on Ethnic Americans and Underserved Populations. Journal of Health Care for the Poor and Underserved. 5(3), 224-236.

Root, L.S.(1991). Cost controls on mental health services: Context and the role of the professional. Employee Assistance Quarterly. 7(2), 1-14.

This article maintains that pressures over the last ten years to control and cut costs in the general health environment have affected mental health care. Moreover, the author suggests that mental health services are very vulnerable to excess cost control measures. Often this emphasis on reduction of costs may mean that services are limited and individuals, groups, or populations may be excluded from needed services. To alter and reduce this possibility, Root proposes that mental health professionals must be active in taking a key leadership role in insuring that services continue to be provided where needed.

Smith, M.D.(1994). Managed Care and the Poor. Journal of Health Care for the Poor and Underserved. 5(3), 147-154.

Snowden, L.(1993). Emerging trends in the organizing and financing of human services: Unexamined consequences for ethnic and minority populations. American Journal of Community Psychology. 21(2), 1-12.

In this article, Snowden examines various organizational structures and various financial approaches as they help explain managed care. He maintains that ethnic status makes for increased vulnerability to service gaps, inefficiencies and fragmentation. He suggests that as efforts are made to reduce the utilization and cost of high users of services that the risks are greater for minorities often over-represented in this group. As new systems and policies for health care are formulated more attention needs to be devoted to the differential impact on minority populations.

WICHE.(1996). Standards for mental health services to Latino populations. West Link: Mental Health Developments in the Western States. 17(2), 12-15.

This article provides a list of standards which include cultural competency, planning, governance, benefit design, quality monitoring and improvement, and decision support and MIS. The article also lists clinical standards as well. These include access, triage and assessment, care planning, treatment services, case management and linguistic support. These standards were drafted by Latino mental health professionals. The document also lists several disadvantages of managed care for the Latino community including a lack of access and knowledge of how the system works, lack of advocates for access to services, lack of bilingual staff and providers, language barriers, fragmentation of the system and a lack of interest within the health care system. The document also lists several advantages of managed care to include its emphasis on consumer orientation, competition for the Medicaid dollar, flexibility of care option and access to early intervention and preventive care. The issues in this article, although discussed in the context of Latino Americans have general applicability to African American and other ethnic populations.

Weil, T.P.(1994). Managed Competition for the Poor: More Promise than Value? Journal of Health Care for the Poor and Underserved. 5(3), 158-169.

Whitlow, J.(1993). Is Managed Care the Answer for Blacks? Focus. 21(7), 5-6.

A brief overview of issues related to access to services by minority populations. The lack of access to needed services may contribute to an increase in cost of services overall. The author briefly addresses restrictions and benefits of managed care plans, as well as converting Medicaid users to other forms of managed care plans. The author notes that there is a need to carefully educate the African American community to new ways of responding to and preventing illness. It is predicted that managed care will have a negative impact on those health care facilities that have traditionally served the poor. There may be a corresponding negative impact on African American physicians and support staff who have been employed in these facilities, and who may not be accepted by managed care organizations.

Wilson, I.D.(1994). Increasing the Pool of Minority Providers. Journal of Health Care for the Poor and Underserved. 5(3), 260-268.


G. State and Local Governments and Managed Care for African Americans

Balderrame, C.H.(1995). Surfing the managed care tidal wave. Spokane: Washington State Mental Health Division.

This article indicates that managed care appears to be an accepted national policy as evidenced by the growth of managed care plans in the states. In 1995, 68% of the states reported being involved in managed care plans. One area that is projected to be impacted at the state level as these plans are adopted will be the small community-based agencies that have traditionally provided the bulk of services to minority populations. The author suggests that there are clinical and administrative aspects of managed care that must be considered because of their relevancy to ethnic minorities. Community based organizations that serve minority populations will need to offer individualized care. These tailored services can enhance the quality of life of these populations in a managed care environment. Cultural bias places a significant burden on managed care policies need to provide quality service to minorities. The author indicates that there are few managed care experts in working with minority populations or providers who specialize in service design and delivery for these groups.

California Cultural Competency Task Force. Recommendations for the Medi-Cal Managed Care Program. Sacramento:

This document maintains that current health care systems in California do not overcome all barriers to access and cultural appropriateness for the many ethnic and cultural groups served in the system. A framework for addressing issues and concepts related to cultural competency is provided. This framework covers many dimensions including a definition of cultural competency, community linkages, demographic description of the catchment areas, service elements, recommended standards for data in operational managed care plans and others.

Of note, the concept of cultural competency promoted by this task force is that competency is a process that requires individuals and systems to increase respect for cultural diversity. This effort is designed to increase awareness, acceptance and valuing of diversity. The outcomes expected include more effective communication and the provision of services that are more appropriate and useful to various groups.

The primary recommended standards for data in operational managed care plans include 1) measurement of ethnic/racial demographics of the population served; 2) determination of the degree to which access and appropriate service utilization meets established standards of care, 3) identification of differences in enrollment and service utilization among population groups, and 4) measurement and comparison of outcomes by ethnic/racial groups. Additional data standards recommended include the classification of race and ethnicity that match true diversity of the populations; data classifications should match the level of literacy in the primary language of the catchment areas; data should be collected by catchment area and be inclusive of enrollments/disenrollments, utilization patterns, patient compliance and satisfaction information and statistical reports should include measures of dispersion as well as measures of central tendency.

California Mental Health Directors Association. Cultural Competency Goals, Strategies, and Standards for Mental Health Care to Ethnic Clients. Sacramento.

The Multiethnic Mental Health Consortium.(1986). Culturally Competent Approaches to Ohio Care. Position Paper II. Columbus: Ohio Department of Mental Health.

This paper provides a framework which includes demographic clusters which help customize interventions for ethnic minorities. The paper focuses on building therapeutic alliances with consumers and collaborating with other systems to decrease fragmentation of services.

Ohio Department of Mental Health.(1995). The relationship of managed care to cultural diversity. Working Paper. Columbus: Ohio Department of Mental Health.

This document suggests that managed care environments must develop interventions and strategies to address specific needs in order to minimize high cost services and maximize quality health delivery. The authors note that cultural competency is essential for this process because any services rendered may be inappropriate, ineffective and potentially damaging to the recipient. The document also suggests that awareness and knowledge of the consumer are important determinants of quality. The report proposes that as the level of cultural knowledge and competency of minority populations increases there is the potential for a decrease in the use of more costly services.

Randall, V.R.(1996). Section 1115 Medicaid Waivers: Critiquing the State Applications. Seaton Hall Law Review. 26, 1069.

San Francisco Department of Public Health.(1996). DMS Cultural Competency Self Assessment Questionnaire. San Francisco: Division of Mental Health and Substance Abuse Services.

The purpose of the questionnaire is to serve as a tool for organizations and programs to assess and review resources, capabilities and methods of providing services to racial, ethnic, and cultural minorities. The intent is to urge organizations and programs to do self studies to assess their ability to provide culturally competent services. The authors provide a definition of cultural competency: a collection of practice skills, attitudes, policies, and structures that enable systems to operate effectively in cross cultural situations.

Watson, S. (1993, June). Health Care in the Inner City: Asking the Right Question. North Carolina Law Review. 71. 1647.


Review of Standards and Competencies

This review of the literature, covering the period 1976-1996, did not disclose current materials that identify standards or core competencies for mental health service delivery to African American populations with serious mental illness. This finding holds for the more recent managed care environment as well as the fee for service model/policy that has been in use for decades. Of the existing bibliographies that were reviewed, there were no current articles, books, reports, or studies that focus on African Americans with serious mental illness and the competencies needed by providers in managed behavioral health care. Review of guidelines for care provided by managed care companies also did not reveal core competencies or standards to guide in the delivery of mental health services to this population.


Identified Gaps in Standards and Competencies

The most significant finding in this report is the paucity of literature that exists on African Americans with mental illness generally as well as the absence of standards, competencies, or guidelines that can be utilized in managed behavioral healthcare specifically. This absence of attention in the literature and the mental health field generally is the major gap that must be addressed if adequate standards are to be developed to guide curriculum, training, and services in managed behavioral healthcare for this population. The most significant indirect reference in the literature is to the value of cultural competency as the guiding model for service delivery to various populations.


Recommendations for Action:

  1. Center for Mental Health Service support a working national conference, in conjunction with the Historically Black Colleges and Universities Human Resource Development Project, to develop standards and competencies for service delivery to African Americans with serious mental illness;

  2. Encourage the associations of Black Nurses, Psychiatrists, Psychologists and Social Workers to participate in the development of standards and competencies for service delivery to African Americans with serious mental illness;

  3. Support the development of a national center/project that explores and conducts research on issues of mental health care services and policy as these impact African American populations and communities within managed behavioral healthcare;

  4. Utilize the standards and competencies for service delivery to African Americans as the basis for developing curriculum guidelines for the professions.