Culture and Behavioral Health Service Delivery:

An Analysis of Focus Group Findings

July 2009

Developed by the DMHAS Office of Multicultural Affairs in collaboration

with the Yale University Program for Recovery and Community Health
Executive Summary
Background. This report summarizes focus group findings conducted as part of a DMHAS
Office of Multicultural Affairs Health Disparities Initiative. Findings are based on focus groups
that were conducted around the state of Connecticut during an 18 month period in 2007 and
2008. Focus groups explored people’s experiences with care and the ways in which their
cultural beliefs and values were, and were not, incorporated through out the care process. In
all, 25 focus groups were conducted across the state with African American, Latino American,
White American, Asian American, Youth, LGBTQ (lesbian, gay, bi-sexual, transgender, and
queer) individuals, and culturally mixed groups.

Method. To begin the data analysis process, Consumer Research and Evaluation Network
(CREN) members participated in a day-long, qualitative data analysis training. Following this
training, five data analysis teams, comprised of PRCH faculty and staff and CREN members,
were formed with each team analyzing one or more of the focus group types. Teams met
between 3-5 times to analyze their group’s transcripts and then all five teams met to identify
primary themes across all transcripts.

Results. Qualitative data analysis revealed eight overarching themes across the seven focus
group types. Themes address both general clinical care, as well as cultural competence-
related areas.

Theme #1: Positive Experiences with Care: Across many focus groups, participants reported
satisfaction with services and positive feelings about care. Participants discussed feeling
listened to and understood by their clinicians, and many reported that they were “getting
things done.” A prominent sub-theme identified was that many respondents who reported
satisfaction with care reported receiving services from ethnically and or culturally similar
programs or providers. There were also instances in which participants not seen by ethnically
similar providers also reported positive experiences with care.

Theme #2: Bridges and Barriers to Trust. In all focus groups, participants discussed a variety
of factors that either fostered or impeded the development of trust and a positive working
relationship with providers. A lack of confidentiality was one such factor. Respondents raised
concerns about information discussed being shared with other providers or being used
against them. Also impeding the development of trust, several respondents discussed some
providers being too strict with rules and this communicating that they do not really want to
help them. Respondents in this and other focus groups noted that provider willingness to
bend the rules -even a little-would help to establish trust and communicate a willingness to be
helpful. In turn, this would contribute to respondents opening up with providers and sharing
more in sessions. Respondents discussed ethnic similarity as one factor that facilitated the
development of trust.

Theme #3: Things “Left at the Door” or Not Discussed in Treatment. Many respondents
talked about not leaving anything at the door as a means of getting help and getting better. In
a majority of focus groups, however, respondents reported leaving a variety of issues “at the
door” and not discussing them with providers. For many, not discussing certain topics was
directly related to the previous theme of trust and the degree to which respondents felt
understood by their providers. This was particularly true for African American respondents

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who consistently reported that they did not discuss race or race related issues. Respondents
discussed a variety of additional issues that were not discussed in care.

Theme #4: Stereotyping and Negative Experiences with Care. Across most focus groups,
respondents reported a number of negative experiences with care in which they felt
stereotyped, disrespected, or dismissed by providers. Many respondents reported similar
experiences in broader society and some noted that hospitals and health care systems were
a microcosm of broader society, and given this, they were not surprised by their negative
care experiences. In addition to reports of feeling stereotyped and disrespected, respondents
discussed a range of experiences in which they felt care was not useful, providers were
disrespectful, their expressions of distress were misunderstood, they were not listened to, or
they felt invisible to providers

Theme #5: Language Issues/Barriers. Language barriers emerged as a prominent theme in

all focus groups conducted with individuals of Latino origin. Participants discussed
frustrations and difficulties they had participating in treatment when services were offered in
English only. Further, many noted that not being able to communicate with providers
contributed to feelings of isolation, loneliness, depression, anger, and, for many, resulted in
their feeling as if they were being “choked out of the system.”

Theme #6: Persistent Self-Advocacy as a Means of Getting Needs Met. Across all focus
groups, respondents discussed a number of experiences in which they exercised
persistence, voice, or self-advocacy as a means of facilitating their needs being met. For
many, the need to engage in self-advocacy emerged from situations in which they felt that
providers were not listening to them or they were pushing recommendations that were
different from what they wanted or felt they needed. Many stated that they believed that if
they expressed their needs consistently enough, and with intense emotion if necessary,
providers would eventually listen.

Theme #7: System Challenges/Barriers to Care. System challenges and barriers to care were
prominent themes that emerged in all focus groups. Respondents discussed a range of
experiences that they felt impeded their being able to receive effective care and address their
needs. Examples of such experiences include, 1) providers carrying heavy caseloads and
appearing burned out; 2) difficulties getting into detoxification programs due to not having
used enough; and 3) paperwork and administrative problems getting in the way of providers
being helpful.

Theme #8: Clinician and Agency Recommendations. In all focus groups, respondents offered
a range of recommendations that cluster in seven different areas including: 1) Connect with
community; 2) Develop peer-based services and supports; 3) Develop additional services
and supports; 4) Enhance direct care; 5) Offer more provider education and training; 6) Offer
more service user education and training; and 7) Enhance agency environment/physical.

Discussion and Implications. The findings discussed in this report highlight the complex
and dynamic role of race, ethnicity, and culture in the helping relationship and in the
development of services and systems that are responsive to the worldviews and values of
diverse groups. Eight overarching themes are discussed which summarize a range of
positive, as well as negative, care experiences. Further, it is important to note that many of
the negative experiences discussed exist within the context of similar themes in the broader
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cultural competence and multicultural health literature nationwide. Thus, themes that suggest
racism, bias, and discrimination are not unique to Connecticut; rather they mirror social
patterns that have challenged health care and U.S. culture in general for generations.
Nevertheless, the negative experiences discussed in this report represent an important call to
action. Needed are unique and creative interventions designed to enhance attention to
culture and service equity.

Echoing themes in the recovery literature, findings suggest that, when asked, service users
know what works for them. This was well illustrated by the range of recommendations for
improving care offered by respondents. While all may not be feasible to implement now,
some likely represent low-hanging fruit that can be implemented with limited system effort or
costs. To further evolve and prioritize recommendations offered by respondents, it is
recommended that an Eliminating Disparities Subcommittee of the Multicultural Advisory
Council (MCAC) be formed. In addition to MCAC members, individuals invited to join this
subcommittee should include service users, direct care providers and relevant individuals
from the DMHAS executive leadership. Goals of this group should be to discuss the feasibility
of implementing these and other recommendations for improving care, in addition to
identifying individuals or departments responsible for advancing goals, identifying timeframes
and strategies for measuring success, etc.

Based on the findings discussed in this report additional recommendations include: 1)

offering ongoing cultural competence training and technical assistance for providers that
including service users in the training development and implementation process, 2) using
cultural assessments to reduce the impact of stereotyping, 3) enhancing peer services and
supports and 4) improving language assistance services.

Conclusion. DMHAS is to be commended on their willingness to ask difficult questions and

engage in self- reflection regarding the role of culture in the service delivery process.
Undertaking this evaluative work speaks to the state’s longstanding commitment to creating a
system of care that is responsive to the cultural values and needs of all individuals seeking
care. This same commitment will likely fuel next step efforts to build on system strengths and
improve the cultural responsiveness of care. Service users have offered an initial vision for
enhancing direct care and outcomes. Working in full partnership with service users, it is
imperative that recommendations offered are further developed and prioritized such that
interventions are aligned from personnel, policy, fiscal, and administrative perspectives.
Implementing new forums and formats for system planning and decision-making can help to
ensure translation of strategies for change to action. Further, continued self-evaluation and
the ongoing use of feedback loops can help to enhance the cultural responsiveness of care,
contributing to improvements in access, retention, engagement, service quality, and
outcomes for all individuals seeking care.

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Background
Inequities in access, service quality, and outcomes are pervasive and long standing for
individuals from diverse racial, ethnic, and cultural backgrounds. Discussing the omission of
culture in mental health, the 2003 New Freedom Commission Final Report noted that health
care systems have failed to incorporate the histories, traditions, beliefs, values, and language
systems of culturally diverse groups, resulting in their having to bear a greater disability burden.
As a result of these findings, the subsequent SAMHSA Federal Action Agenda and other federal
reports identify the elimination of health care disparities as a major goal for the future.

Increasing provider and system cultural competence is frequently cited as an important strategy
for eliminating disparities. DMHAS is committed to creating a transformed system of care that is
both recovery-oriented and responsive to the worldview, beliefs, and values of all individuals
seeking services. Through the work of the Office of Multicultural Affairs, a key goal of the state is
to increase provider, program, organizational, and system cultural competence as a means of
eliminating disparities. This report summarizes focus group findings conducted as part of a
DMHAS Office of Multicultural Affairs Health Disparities Initiative. Findings are based on focus
groups that were conducted around the state of Connecticut during an 18 month period in 2007
and 2008. Focus groups explored people’s experiences with care and the ways in which their
cultural beliefs and values were, and were not, incorporated through out the care process.
Findings from this report will be used to inform the update of the OMA Multicultural Best Practice
Guidelines.

Method
As a strategy for enhancing participation, culturally homogenous focus groups led by culturally
similar facilitators, where possible, were conducted. In all, 25 focus groups were conducted
across the state with African American, Latino American, White American, Asian American,
Youth, LGBTQ (lesbian, gay, bi-sexual, transgender, and queer) individuals, and culturally
mixed groups. Focus groups were 1-2 hours in length and were digitally recorded and
transcribed verbatim. Further, the focus groups with Latino Americans were conducted in
Spanish and were translated, transcribed, and analyzed in English. Five questions were used as
guides for focus group discussions (Table 1).

Table 1: Focus group questions

1) What’s it like to be an African American, Latino, Asian American, White American, or LGBTQ
individual?
a. What’s it like to be an (relevant group) in recovery?
2) How has your clinician been sensitive to your struggles as an (indicate relevant group)?
3) What can you not talk about with your clinician?
a. What do you leave at home because you think your clinician is not going to
understand?
b. What gets in the way of your clinician knowing you for who you really are?
4) If you came in and this place was more welcoming to you as a (indicate relevant group),
what would it be like?
a. If you could change things, what would you change?
b. What might prevent someone from coming here?
5) From where do you draw your strength? What helps you get through difficult days?
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 To begin the data analysis process, Consumer Research and Evaluation Network (CREN)
members participated in a day-long, qualitative data analysis training. Following this training,
five data analysis teams, comprised of PRCH faculty and staff and CREN members, were
formed with each team analyzing one or more of the focus group types. Teams met between 3-5
times to analyze their group’s transcripts and then all five teams met to identify primary themes
across all transcripts.

Results
Qualitative data analysis revealed eight overarching themes (Table 2) across the seven focus
group types that address both general clinical care, as well as cultural competence-related
areas. Within each of the major themes, a number of sub-themes were identified. Sub-themes
will be discussed within the presentation of each theme.

Table 2: Overarching focus group themes

1) Positive Experiences with Care
2) Barriers and Bridges to Trust
3) Things “Left at the Door” or Not Discussed in Treatment
4) Stereotyping and Negative Experiences with Care
5) Language Issues
6) Persistent Self-Advocacy As a Means of Getting Needs Met
7) System Challenges/Barriers to Care
8) Clinician and Provider Recommendations

Positive Experiences with Care

Across many focus groups, participants reported satisfaction with services and positive feelings
about care. Participants discussed feeling listened to and understood by their clinicians, and
many reported that they were “getting things done.” A prominent sub-theme identified within this
overarching theme is that many respondents who reported satisfaction with care reported
receiving services from ethnically and or culturally similar programs or providers. As noted by a
respondent who participated in a group for African American women:

And this group helps too, the leaders are Black and they understand us and we
understand them too. I like coming here. It’s peaceful and gives me more experience
talking to other people. I wish we could meet for two hours instead of once a week. They
help us get things done and so does my therapist. Like the other day I was crying
because I got laid off from my job and I told my therapist and she helped me find
another job the next day. I am very happy. It’s going to work out real good for me. I’ve
come a long way after getting clean. If it wasn’t for programs like this I’d be in the gutter
somewhere. But I’ve got faith now and confidence. I can never go back to where I was
before.

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Similarly, a respondent who sought services at an organization with a number of bilingual/
bicultural Latino American clinicians noted:

“[I feel] appreciative of the help that they have given us here in this clinic because
without it, I think that without this clinic we wouldn’t survive. It is very important in our
lives, well at least in mine. This clinic is very important in my life.”

Participants who were seen in ethnically or culturally specific programs reported a number of
specific factors that contributed to their positive experiences including feeling like they were
working in partnership with their clinicians to achieve goals, feeling like clinicians were “opening
doors” for them, feeling respected and cared about by their clinicians, believing that service
providers understood their cultural background, and feeling like they could talk about anything
with their providers. Addressing several of these areas, one respondent, seen by an ethnically
similar African American provider, noted:

I like the clinician I have now, because she treats me as a human being. I can talk to her
about anything, and I can see it that she is listening and that she is concerned. She
gives me feedback and whatnot and I can say things you can’t say to another one. I
mean, you can say things that you can’t say to another person, you know, not African-
American. So I try with my clinician, we’re real, real, real locked in. I’ve come here for
depression. I’ve had a lot of help and it’s been a while since I’ve been in that depressed
state, so I’m very thankful to God for these people, because I feel that I got the help I
needed.

While a majority of respondents seen by ethnically or culturally similar providers reported a

range of positive experiences with care, there were instances in which participants not seen by
ethnically similar providers also reported positive experiences with care. For instance, one
respondent of Latino origin reported satisfaction with services noting that his non-Hispanic
provider showed professionalism and worked hard to support his recovery:

In my case the therapist I have, I am not going to say names, is not Hispanic, because
she’s not like us Hispanics, but she does find the way, and all the means to try to find
an effective treatment for the persons she treats. I think that the same treatment of
cordiality that she gives me and the same way she finds to help me get better, I imagine
she gives to the rest. Because I cannot vote for the rest, but I think that, I am satisfied
and I think that although she is not Hispanic, she tries to give the maximum so that
people will recover. To me she is a tremendous professional in her profession.

Other respondents spoke positively of a White American psychiatrist who was highly sought
after and well liked by many service users of Cambodian descent. Respondents praised the
psychiatrist’s dedication, flexibility with time, willingness to make home visits, and his efforts to
learn about and understand their culture. This psychiatrist also visited a refugee camp in
Cambodia, so respondents discussed feeling comfortable talking about their experiences of
trauma under Communist rule, because this psychiatrist had “been there” and had seen some of
the places people described. Discussing their experiences of feeling listened to and understood,
a program staff person who was also a refugee camp survivor reported:

Yes, he understands their experience. Yes, from their point of view, because he went to
the [refugee] camp. Basically, he was at the house a long time ago where they were in
the camp and he understands where they’re coming from, what they have gone
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 through. And he listens instead of giving them, ‘Ok, here’s the medication. You can take
this. Here’s the medication, take that.’ He listens.

Bridges and Barriers to Trust

In all focus groups, participants discussed a variety of factors that either fostered or impeded the
development of trust and a positive working relationship with providers. A lack of confidentiality
was noted as one such factor. Respondents raised concerns about providers using information
discussed against them. As stated by one respondent:

Whether the clinician is Black or White – it don’t matter which color he is – first you
have to trust. And then you still won’t come clean because of what they put down in
your record. Whatever you say, they hold against you. So now you have to think, I want
to talk to this guy, but some things that I say he is going to hold it against me.

Respondents also raised concerns about personal information being shared in meetings with
other providers. Discussing this one participant said:

(Respondent) Can I say something about this questions you were just saying? I used to
go to another place for depression, and I had trouble with this counselor with something
very, very personal. She went and told the other counselor, and I could tell because of
the way they looked at me or I read their body language and how they would be like
smiling and stuff. I asked her if she had spoke about this. ‘Oh, we were just in a -‘ you
know, their meeting. Still I felt that she shouldn’t have even said it to them. That caused
me to - yeah, I wouldn’t tell any of these counselors, especially something personal,
personal. I wouldn’t do that.

(Moderator) You’re talking about the importance of trust?

(Respondent) Yeah, but then they go into their little meetings and discuss our cases,
even though it’s supposed to be kept confidential. I mean I feel when you say
confidential and you are on a one-on-one with somebody, it shouldn’t be brought up
with nobody else but you and that person….It’s a big thing when you say confidentiality.
Is it really going to be kept confidential?

Another respondent discussed a similar experience:

My clinician – I half-way trust her, but not trust her all the way because one time I
overmedicated myself and ended up in the hospital. When I got back in three weeks,
the whole staff knew about it. Everybody on the staff knew about it. ‘I heard you almost
died.’ It wasn’t even that far. It didn’t even go that far. By the time it got down to the next
person, it had gotten bigger and bigger and bigger, snowballed and snowballed.

Also impeding the development of trust, respondents discussed some providers being too strict
with rules and this communicating that they do not really want to help them. One respondent
told a poignant story of a situation in which he was sick and missed work because he had to go
to the hospital to get medicine for a sinus infection. The next day he woke up early to be able to
take his medicine and sign out to be able to make it to work by 7:00 am. However, when he

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went to the front desk his paperwork was not there so he could not leave. As reported by the
respondent:

So they called the Director and the Director called back and said, ‘Wait until seven.’ But
at seven I have to be at work. And I said, ‘well, whatever, let me call them to tell them
I’ll be late.’ When I called work they told me ‘Forget it, if you can’t be here by seven
forget about the job.’ It didn’t pay a lot. I had to take two buses and walk a half hour. I
would get there out of breath. Punch in at a minute to seven, but I wanted to make a
few dollars for when I get out of here. That Friday I was going to be on leave too. I had
put in for a request for some money that is mine, that is here being stored…. I had
planned to take my woman out to eat, to the movies, something really nice and when I
went to tell the Director he says, ‘No, we can’t give you that amount of money because
you are no longer working.’ So I got a little mad and said: ‘I lost my job because of you
guys and now you’re going to tell me you can’t give me the usual amount of money
today. But that’s my money and I lost my job because of negligence here. I was awake
at 4:30 a.m.’ I don’t earn a lot. It’s more of a sacrifice than money… Why this situation
happened I don’t know…We are human and make mistakes, but they can be so strict.

Another respondent discussed a similar situation in which he was given a pass by his provider
to leave the facility to fill a medication prescription. The respondent noted that he went to the
place he usually did to fill his prescriptions, rather than the place that was indicated on the pass.
When he returned with his filled prescription, he was reprimanded for going to the wrong place
and his provider filled out paperwork for him to go 21 days without a pass as punishment for
going to the wrong place. Discussing how he felt about this situation the respondent stated:

So I got mad, but it’s like my friend here said, when you get mad you have to keep it all
inside and when I get to the room I explode like a balloon. I was thinking about it and
saying, ‘wow, this guy is wrong.’ How is he going to give me 21 days and tell another ‘I
sent him to one place and he went to another, you know?’ He should have said, ‘well, I
didn’t send you there. But you are showing me this as proof, so let’s leave it there and
it’s between us. But next time when I send you somewhere go there’.…He didn’t say,
‘you okay?’ or anything. He only said, ‘you didn’t go where I’d sent you.’ So I said,
‘wow, this guy isn’t here to help me then. He’s just here to bother me.’ But there are
times when I’ve needed him and he’s been there for me, you understand? But my point
is that that time I said, ‘oh no.’

Respondents in this and other focus groups noted that provider willingness to bend the rules -
even a little-would help to establish trust and communicate a willingness to be helpful. In turn,
this would contribute to respondents opening up with providers and sharing more in sessions.
Discussing the experience presented above one respondent commented:

It’s like my friend here says, he is professional and he is not going to stop being
professional in order to twist the rules a little. Not to do us harm, but to demonstrate
‘look, I’m going to do this for you’ and there he’d gain the trust of the person who
doesn’t speak up, with that he would open up with the counselor because he would say,
‘Wow, he did this for me. Well, I have this problem and I haven’t spoken to you about
this, but I now see you want to help me.’ If I see he wants to help me, I am going to
open up more to him.

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Finally, for many respondents ethnic similarity facilitated the development of trust, in addition to
a range of other positive care experiences as discussed in the previous theme. As noted by one
respondent:

I think there’s been a big change because when there’s a program that doesn’t have a
Hispanic counselor one feels deprived of saying what’s going on, but when there is a
Hispanic counselor you feel more trust in talking to him. An American isn’t going to treat
you the way a Hispanic is going to treat you, I don’t think.

Similarly, another respondent noted:

My clinician, by her being White, I can’t open up and tell her how the Black experience
goes, you know, how proud I am to be a Black man, how it feels to be in a Black man’s
shoes or a Black woman’s shoes, things like that. I can’t open up and tell her that, I
can’t….I don’t care how much I think I trust her, I can’t…So, I don’t trust her that way.

Things “Left at the Door” or Not Discussed in Treatment

Many respondents talked about not leaving anything at the door as a means of getting help and
getting better. Many talked about not being ashamed of anything that they had done and some
noted that if there were things that they were ashamed of, talking about these things could help
them to grow and feel better. As noted by one respondent:

I’m not leaving nothing on the bed because if there’s something that bad that I need to
leave on the bed, I mean, he might help me to get it off there. Do you know what I’m
saying? I haven’t done anything that bad enough that I needed to leave it on the bed.
Do you know what I’m saying? I believe that in order for me to continue to grow, I have
to let everything go and have trust in people.

In a majority of focus groups, however, many respondents reported leaving a variety of issues
“at the door” and not discussing them with providers. For many, not discussing certain topics
was directly related to the previous theme of trust and the degree to which respondents felt
understood by their providers. This was particularly true for African American respondents who
consistently reported that they did not discuss race or race related issues. As noted by one
respondent: “Well, in other words, you can talk to your therapist about a lot of things, but when it
comes to a race issue, than that’s taboo.” Many other respondents agreed and reported similar
experiences:

I never really discuss that with my clinician. I discuss more of how can we get things
done as far as my situation, as far as my housing, my social security, bills that needs to
be paid, how my depression is coming along. These are the things that we talk about.
As far as being African-American and race, we never really discuss that.

Another respondent stated that she does not discuss her struggles as an African American
woman, but also noted that for her there are other topics she is interested in addressing:

Well, I can actually say I don’t really discuss my African-American struggles with her. I
don’t - I mean, I want to talk about the abuse my father gave me when I come, not
necessarily that, you know, being Black, you do this or you do that. I don’t go into any
detail exactly about my African-American side of me.
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In one exchange, several respondents, with a hint of surprise, noted that they had never been
asked about racial issues or things going on in their community:

(Respondent) Excuse me. I don’t remember any of them ever asking that question, how
do it affect me as being an African-American or what’s going on in our community or
whatever. The subject never been -

(Respondent) Yeah, they never really ask you that question.

(Moderator) Is that a question that you would like to have been asked?

(Respondent) Yeah, well, I guess that -

(Respondent) Yeah.

(Respondent) Yeah, that’s where you could talk about some things that’s really, say,
going on with us or in our neighborhood, because we are involved in it. We are African
American. Yeah, it would have been a good question to ask when we have the group
meetings sometimes or whatever.

Many respondents reported that they did not believe that providers understood their
experiences. This contributed both to their not wanting to talk about them, and to their beliefs
that providers would not be able to help. Discussing these issues one respondent stated:

Let me just say something, right. I think they wouldn’t really understand, because they
don’t live in this community. They don’t live in the hood. I’m going to say the hood, the
ghetto or whatever. They don’t live where we live at. So a lot of things I can’t really talk
to them about, because they wouldn’t understand. I don’t live too far from here, but I
live in this neighborhood. For instance, I mean, there’s things that goes on in these
neighborhoods where we live at that they probably won’t see on a regular basis
compared to where they live at. If you live in the suburbs, you won’t see certain things
go on. That’s what I mean. It’s like we’re separated.

Respondents discussed a number of neighborhood and other experiences that they do not
discuss in treatment including violence and death of family members and young people, trying to
get away from drug dealers, how white police officers “beat our kids and get away with it”, gang
networks and experiences, being stereotyped and degraded when dealing with children’s
schools, experiences of prejudice and racism when dealing with court systems, healthcare
systems, employment, and other day-to-day experiences. Discussing how many of these areas
are not addressed in care one respondent stated:

I think the services are okay, right, but do they get to the core of the matter about how
things truly affect the community we live in? Not even a drop. Not even a drop in the
bucket.

Across all other focus groups, respondents discussed a variety of additional issues not
discussed including their sexual relationships, if one was raped or molested, if one had domestic
violence in their past, buying or selling drugs, what it feels like to experience language barriers,
and a range of LGBTQ issues. Many clients within both African American and Latino focus
11
groups noted that they were raised to believe ‘what happens at home; stays at home’ and
therefore, family matters were not appropriate to discuss. Further, many youth talked about not
wanting to open up and share personal information so as not to be left vulnerable, particularly
given the high staff and case manager turn over rates. Youth respondents noted that switching
providers so often was difficult for them and made them not want to open up to or rely on
providers who were likely to leave soon.

Stereotyping and Negative Experiences with Care

Across most focus groups, respondents reported a number of negative experiences with care in
which they felt stereotyped, disrespected, or dismissed by providers. Many respondents
reported similar experiences in broader society and some noted that hospitals and health care
systems were a microcosm of broader society, and given this, they were not surprised by their
negative care experiences. Discussing parallels between service systems and broader society
one respondent noted:

I’ve been here for seven years and I will say that this is a microcosm of our larger
society. You’re going to deal with racism in the larger society. You’re going to deal with
racism here…We live in a society where people are not equal. I mean, a large society is
not supposed to be racist, shouldn’t be racist, but it is.

Other respondents reported feeling quite surprised, even stunned, by their negative experiences
and many discussed a range of responses to the emotions stirred by these experiences,
including “stuffing” their feelings, getting mad, but not showing anger for fear of retaliation, going
to their room and “exploding like a balloon”, or working harder to not “be” the stereotype.
Respondents also speculated about possible reasons for their provider’s behavior, perhaps in
an effort to make sense of these unexpected experiences. Illustrating many of these sub-
themes, one person discussed a situation in which he was stereotyped for being in a gang as a
result of some of his grooming activities:

Yeah - very, very ignorant as far as cultural types of behaviors are concerned. One time
I had a do-rag - being Black you know what that means in grooming. Black men like to
take a shower and put Noxema on and wash their face and cleanse and exfoliate their
skin and then put oils in their hair and brush their hair before they go to bed or when
they wake up in the morning. It’s a process. One time I came for my MSE - my mental
status exam - and they all jumped back and they said: ‘Oh, my God, what’s this all
about?’ They were ready to arrest me. I had to hold in any type of hostility or emotion or
anger that I had. And they said, ‘What is that on? Are you in some type of gang? Are
you acting like those gangs out there - those Black guys in the gangs?’ I said: ‘No,
you’ve got it wrong.’ And I put my foot in my mouth, but what I said is true, and I’m glad
you’re here. I said, ‘You need to take some courses on African American culture and
behavior.’ And I went on to say: ‘When Black men groom, they always brush their hair,’
and they had this blank look on their face, like ‘What is he talking about? He’s got an
attitude.’ I went and took my do-rag off and brushed my hair, because I wanted the
waves in my hair. But it’s so ignorant. That’s why I use the word ignorant. And ignorant
is not a put down. They are uneducated about African American males - the way they
dress, their gait, their walk, the way they talk with their hands. They are very intimidated
- any type of aggressive activity -I’m an Alpha Black male - any type of aggression or
assertiveness is viewed as hostility.

12
Respondents discussed many similar situations in which they felt stereotyped by providers and
in the larger society. Many discussed how they believed that their charts “followed them around”
and this contributed to their being judged by their past and information written in their charts.
Discussing this, one respondent stated:

Get to know who I am not. They look at my report and that is all they see.

Many other participants talked about feeling marginalized in society and having multiple strikes
against them when applying for a job. As stated by one participant:

Strike one, to me, is being Black. Strike two is coming out of jail. So, strike three is
being Black, coming out of jail, and out of a program.

Another participant shared an experience in which she felt stereotyped as an African American
woman and betrayed by her provider. She reported that when her mother passed away she
relapsed after being clean for about a year. When she discussed her drinking again, her
provider, of fifteen years, asked her what she had to sell to use. While the provider did not
specify what she might have sold, the respondent noted that she was hurt by the question and
believed that the provider insinuated something negative – that she sold her body or her
furniture or something else to pay for alcohol. In discussing how she felt about this encounter
the respondent stated:

It did something to me, but I’m the type of person that I’ll stuff it. I won’t say nothing. But
it really did something to me, to the point that what I did was I talked about it with my
pastor and I prayed about it. I felt God moved her out of my life after all these - she
knew all three of my kids, even my two oldest children who are adults, since they were
small. My fifteen-year-old, she knew me before he was even born. She was my
therapist. And she turned around and made another statement that the only time I can
stay sober is if I’m on probation. She did that in front of everybody. I stuffed it. I didn’t
get indignant. I didn’t respond. I just took it, and it hurt me… I’ve been told, and I know
this is true because I’ve been praying about it and people have told me, that she lost
her sensitivity towards people. It’s just a job now. She has been here over twenty
something years, so that’s why she can make a statement like that. And not only was I
humiliated, but there were men in this room when she made them comments to me.
Somebody told me it’s just a job to her now. It’s just a paycheck. Her compassion is
gone.

In addition to reports of feeling stereotyped and disrespected, respondents discussed a range of

experiences in which they felt care was not useful, providers were disrespectful, their
expressions of distress were misunderstood, they were not listened to, or they felt invisible to
providers. For instance, many respondents of Latino origin discussed how common cultural
experiences or expressions of stress are often misunderstood, and how this contributed to their
feeling labeled and stigmatized. As noted by one respondent:

I think when you are referring to talking to the doctor and you tell the doctor, ‘doctor,
last night I saw my grandmother who died five years ago and she came to visit me’. For
us Hispanics that’s common, you know. A dream or something is not strange for us. But
the psychiatrist is going to say, ‘that person is hearing voices, is having hallucinations,
he’s psychotic, let’s send him to the hospital.’ Or they get incorrect diagnosis because
since it’s common in our culture it’s not strange to say it, but here the psychiatrist or
13
 social workers of other cultures are going to think, ‘oh, this person is hearing voices, is
having visions, is hallucinating.’

Language Issues/Barriers

Language barriers emerged as a prominent theme in all focus groups conducted with individuals
of Latino origin. Participants discussed frustrations and difficulties they had participating in
treatment when services were offered in English only. Further, many noted that not being able to
communicate with providers contributed to feelings of isolation, loneliness, depression, anger,
and, for many, resulted in their feeling as if they were being “choked out of the system.” One
participant shared an experience that well summarized several of these themes:

When I was placed at the hospital for seven days that was horrible because here we
speak Spanish, but those seven days, I was in the hospital I spent 24 hours a day
sleeping because they gave us therapy, but it was all in English. So I would take a pill in
the morning and go to the room to sleep. I’d have breakfast and go to sleep at noon.
Then they’d call us for lunch and then I’d take another pill, so I slept 24 hours a day for
seven days. I wanted to go to therapy, but I felt I wanted to just leave because I wasn’t
doing anything so I slept all day. It’s not like here, I like it here because here we speak
Spanish all the time… Everyone spoke in English and I would try to speak with my little
English and they didn’t understand me. I would draw pictures so they would
understand. Even to ask for a fork they didn’t understand me so I had to draw a picture.
I just wanted to get out of there… So, I’m depressed, I’m sick, but I get more depressed
because it’s a barrier and they can’t help you.

Discussing a similar experience, another respondent noted feelings of embarrassment when

she tried to speak English:

Yeah, it felt like I was there like two months, but I was there like two weeks really. I
would get up in the morning and just thinking I would have to be in a group with
everyone speaking English, I would just lie down and feel sicker, but it was because of
that situation. But here it is very different, if I thought that the groups there were going
to understand me, oh my god, it would have been wonderful! But it’s true, it makes the
stay feel much longer and it could even make you more sick because you have that
anxiety that this or that is going to happen. One even feels embarrassed when you try
to speak up and if you saw that the Americans were laughing, you automatically
thought it was at you.

Expressing similar themes, another respondent noted that he would rather wait for services that
were offered in Spanish, because participating in services in English would be a waste of his
time that in the end could make him feel even worse. This participant stated:

I’m going to go in and leave worse than when I came in because they sent me to a
place I wasn’t helped. How am I going to get therapy in a program for the Chinese if I’m
not Chinese? I can’t go to a program where there’s only Chinese if I can’t understand
what they’re saying and they can’t understand me. It wouldn’t be good. If they told me,
‘We have this program’, I myself would reject it because I’m going to waste my time. I
would rather wait for a program where I can get involved and tell them,‘ I have this
problem. I have this emergency with my family or I have this situation, how can you

14
 help me? What are my benefits here, how can you help me? What does this program
give me so that I can come out doing well?’ If I don’t have the language, I can’t do it.

An additional sub-theme that emerged across interviews with individuals of Latino origin was the
preference not to use translators. Many respondents indicated that they did not like to use
translators because they did not want to share confidential information with a third person who
was not their provider. Others stated that while their preference was for their provider to be
Spanish speaking, if they had to use a translator, they wanted this person to be in session with
them, as opposed to using telephone translation services where there was no face to face
contact. Finally, other respondents noted that for them it was not enough for the provider or
translator to speak Spanish, but rather they wanted their provider to be both bilingual and
bicultural. Many discussed the importance of providers understanding their culture in order to be
able to help. Others noted that it was important for their provider to be bilingual and bicultural so
that they could identify with this person and so that they could express feelings that were difficult
to express in English. Discussing these sub-themes one respondent stated:

I’ve been 90 days without methadone now and thank God I haven’t had problems with
any other type of drug. And yes, groups have helped, but there are times I don’t
participate because the girls who run the program are American. I speak very good
English and I could identify with people speaking English, but there’s times I would like
to express in my own language and I’m not able to do this because I don’t have a
Hispanic clinician. Right now, I don’t have someone to identify with, with my culture and
my language. There are a lot of things I would like to express in my own language that I
cannot express in English.

Finally, several other less prominent sub-themes discussed by participants were their frustration
at individuals who were not fluent in Spanish being asked to translate, frustration at not being
able to understand providers who had strong accents, feelings that being in recovery was
difficult if one did not speak English, and feelings of pride and validation when seeing or working
with providers who were trying to learn Spanish.

Persistent Self Advocacy as a Means of Getting Needs Met

Across all focus groups, respondents discussed a number of experiences in which they
exercised persistence, voice, or self advocacy as a means of facilitating their needs being met.
For many, the need to engage in self advocacy emerged from situations in which they felt that
providers were not listening to them or they were pushing recommendations that were different
from what they wanted or felt they needed. For instance, one respondent discussed an
experience in which she was depressed and had physical health challenges, and her provider
only attended to her housing needs. This participant described feeling that her provider was
pushing her away by not addressing her emotional needs; leading her to state that she had to
get another provider:

I had a problem with living somewhere, and her first response was: ‘I’m going to get you
over there into the old WYMCA. After we get you situated with that, we’ll get you some
food stamps.’ She actually said: ‘That’s about the best I can do.’ She didn’t even want
to work with me on my problem, and she still works here. I see her. But I had to change
counselors because she wasn’t even trying to work with me. She didn’t want to deal
with the emotional problems. She figured that would solve it, I guess. I really felt that
she was just pushing me away. I was just another case to her, another Black woman in
15
 trouble… I just felt like once she found out what my situation was, she said: ‘Let me
solve it, get rid of her, and get somebody else.’ I only saw her maybe two times after
that, because I had to get another clinician. I was sitting here major depressed, and
she’s trying to tell me I had to go to someplace I don’t even know. That was just wrong,
so I got rid of her. I wasn’t going to at first, but another person told me: ‘Well, if you ain’t
happy with her, you’ve got to tell somebody.’ I only saw her maybe five times total, but
in that five times, we didn’t even talk about my problems in my opinion. We didn’t even
talk about them. She didn’t want to spend any time on them at all.

Many respondents discussed persistence in speaking up as an important component of

advocating for their needs. Many stated that they believed that if they expressed their needs
consistently enough, and with intense emotion if necessary, providers would eventually listen.
One respondent discussed a situation in which she wanted to be assigned to a new psychiatrist
because she felt insulted by the psychiatrist and because she felt that the psychiatrist was not
addressing her medication concerns. She discussed the importance of voice and how she was
not assigned a new psychiatrist until she “exploded and rebelled”:

I had to really explode and rebel. Then it happened. I finally got what I needed. They
finally got me another psychiatrist and I’m doing much better now. He’s a nice guy
and he’s got me on the right pills. I’m not aggravating nobody. I’m cool. I know what
works for me and what doesn’t. I’ve been on this road with this bipolar thing since I was
26 years old. If anybody could tell you anything, it’s me. Listen to me. All I want you to
do is listen. If you don’t listen because you know more than me, you got an education,
that ain’t going to work… It worked out and I’m doing fine now. All of us has a voice. If
we don’t voice our opinion and people keep doing what they’re doing to you, you’re not
going to graduate and go nowhere. Somebody’s going to hear that voice after a while, if
you keep voicing it. I’m happier when I have done something I know is right for me. I’m
not miserable like I used to be.

Respondents noted many similar situations in which they had to advocate for their needs to be
met. Further, some noted that at times they sensed that providers did not like their asking
questions or pushing for their needs, but because they were trying to advance their recovery,
they remained persistent. One respondent discussed a situation in which he felt that he had to
be persistent and ask questions so that he could make informed choices about his future as a
means of staying clean and rebuilding his life. This respondent indicated that he was tired of
“going in blind” and following recommendations without fully understanding how they would
benefit him. As he said:

A lot of people in here ain’t going to help me get my future out there in the world. I’ve
got to help myself before anybody else is going to help me. But if there’s anything good
that can be offered to me, I’m going for it, and I’m asking questions about it, and I’m not
going to stop until you answer my questions. I’m persistent. I’ve been persistent. I’m
going to continue to be persistent. But they don’t like that either…’I’ve already got my
job. I’m sitting here doing your paperwork.’ This is the attitude that I get. I don’t know
about the rest of them, but this is the attitude that I get. So what I do is instead of being
argumentative like I used to, I say: ’All right. You’re right, but I still want to know about
such and such, and such and such. Is this going to advance me, or is this going to help
me for the future, or is this going to help me out?’ Do you know what I mean? I’m a
statistic, man. Overall, we won the war, but we’re still fighting the battle. It’s hard. It’s
not easy. It’s hard. It is so hard, to the point to where I used to give up. I used to give up
16
 because I used to go numb the pain and say: ’Fuck it.’ Excuse my French, but this is
what I used to say. I used to say: ‘Fuck it. I’m going to go numb the pain, and just go sit
over here, and just go get high, and then I ain’t got to worry about it.’ But do you know
what I found out? Every time I kept doing that, I found myself back in jail doing the
same shit, going through the same motions, and I’m getting tired of that too. Do you
know what I mean? It’s getting old. It gets old. I be like, you know what, screw this,
man. From now on, if I’ve got to deal with something, I’m going to deal with it head-on,
just like a car crash. I’ve got to deal with it, and I’m going to ask questions. If I need to
know, I’m going to ask. And if you don’t like the fact that I’m going to ask you them
questions, then guess what? That’s going to be your problem, not mine. These are the
things that I want to know. I’m tired of going in blind. I’m tired of dealing with people
that’s not going to really help you. Do you know what I mean?

System Challenges/Barriers to Care

System challenges and barriers to care were prominent themes that emerged in all focus
groups. Respondents discussed a range of experiences that they felt impeded their being able
to receive effective care and address their needs. Several barriers were particularly salient
across focus groups and elicited numerous examples in which respondents noted how they
made it more difficult for them to get help. Some of these include: 1) providers carrying heavy
caseloads and appearing burned out; 2) respondents only being seen once a month and
wanting more regular appointments; 3) respondents only being seen in groups despite
requesting individual time; 4) feeling shuffled around; 5) difficulties getting into detoxification
programs due to not having used enough; 6) paperwork and administrative problems getting in
the way of helping respondents; 7) providers misunderstanding cultural expressions of distress;
8) experiencing poor follow through on the part of providers and case managers; 9) respondents
feeling controlled by too many rules; and 10) difficulties getting help with non-symptom related
needs. Addressing these and other systemic barriers to care, respondents described poignantly
a number of experiences in which they struggled to receive appropriate care. For instance, one
respondent described an experience in which she felt that she had no one to talk with and was
invisible to her providers, despite being seen by both a psychologist and a psychiatrist:

You know, if I would have had someone to talk to, I would never have committed my
crime. I was going out in (city name) for my outpatient psychiatric services. They would
say: ‘Are you okay?’ I’d tell them: ‘I’m fine’ They’d just say: ‘So you need a prescription?
Your doctor will write out the prescription.’ One month I would see the psychiatric doctor
and she would write out the prescription, and the next month I come back and see the
psychologist. I sit down and see the psychologist. He asks me how I’m doing. ‘How are
the children? Am I paying the rent? What have I been doing for the last month?’ I tell
him I’ve been getting ready to travel which I had been doing. I’d been paying the rent.
I’m doing fine. He’ll tell me: ‘How is your medication?’ I tell him the doctor gave me two
months supply. Then he’ll tell me to go to the front desk for my return appointment to
come back. That’s how it was going. And I didn’t have anybody to talk to. There were
only two African Americans going out to that clinic - me and another African American
lady. The African American people were going to (clinic name). And when I say about
psychiatric services, they had case management workers at (clinic name) - people that
would come out into the home to check on the people. Take them to the supermarket.
Take them clinic appointments. Make sure that they were taking medications. When the
weather is bad - snow days - make sure they get out to get their bills paid. Make sure
that they are doing well in the community. Make sure that they are eating. Make sure
17
 they are okay. I didn’t have anybody that could check on me. For ten months nobody
ever came and checked on me - not one time. I isolated myself in the apartment for ten
months. I was half eating. I was traveling. I was sick and confused - not taking my
medication. And by me going to see the doctors in (city name), they were so busy. You
would think they would’ve picked up on that, that I’m not making my medication.

(Moderator) You must have felt like you weren’t noticed at all.

(Respondent) I wasn’t noticed at all. I don’t understand. If those people - they were just
different. They never had time. They had a caseload that was too heavy - too many
people. You sit down. They only give you a few minutes of time, and then they have to
prepare for the next person to come in for their appointment. You are only allowed so
many minutes. It wasn’t a healthy doctor/patient relationship.

Respondents discussed many similar such examples of having limited quality time with
providers. Some noted that on entering care they thought that they would be seen once a
week and were disappointed that they were often seen significantly less often. Many attributed
the limited time with providers to their being busy and having “heavy caseloads.” Some
individuals noted that they felt they were participating in self-help programs, because they did
not feel like they were getting help from their providers. Discussing several of these themes,
one respondent stated:

In another program, you would have a counselor, you would have a clinician, and you
would have a case worker. In this program you have a counselor…. But, whenever you
can catch him. If you had a problem, and you decided you wanted to get high, you
know what they’re going to tell you? ‘I’ll talk to you in a minute,’ or ‘I’ll be right back’
‘Hold on for one second, give me a half hour. I’ve got to’ - but it’s the fact that they put
us all with one counselor. They put all the black men with one counselor really. And he
don’t have time. So, you can’t pretty much blame it on him. So, like in here, this is
basically a self help program. If you are in here, and you are looking for some kind of
help or attention, forget it, you’re in the wrong spot.

Respondents discussed a number of additional barriers to care including the limited availability
of sober houses for individuals of Latino origin, limited availability of services and programs for
youth and LGBTQ individuals, and limited availability of services and supports in the community.
In addition, respondents, and particularly youth, reported feeling as though they were shuffled
around from provider to provider and this made it difficult to get help. Many discussed how at
times they had to wait several hours between appointments and this contributed to their feeling
that on some days they spent more time waiting to get help than actually getting help.
Discussing the experience of being shuffled around, a youth respondent stated:

I have been shuffled around a lot to different case managers. At this time I do not - one
of my problems is that I do not handle change very well. I am just not prepared for it.
When I am not prepared for it, it can bring my world crashing down, because I don’t
know what to do. I don’t know how to handle it. I don’t know how to express myself.
Yeah, that change is hard… If someone who is close to you, who you rely on and talk
to, and you can go to them with problems if you need someone to talk confidentially and
need advice. Then imagine that person disappears, and you have to build a whole new
- it is like trying to build a whole new family relationship with somebody else or a
friendship. It is hard. It is emotionally straining. You don’t have any guidance for a
18
 certain amount of time. When you do have that guidance, you are not sure that it is
something that you can completely trust in.

In addition to availability and continuity-related barriers, respondents discussed a number of

barriers related to accessing care. For instance, respondents discussed difficulties being
admitted to detox programs as a result of not being “high” or “strung out” enough. Addressing
these barriers, a peer counselor described an instance in which he recommended a client state
that he was using more than he actually was so that he could be admitted to detox:

Yeah, I ran into that predicament. There was a time that I called and said: ‘This guy’s
using 4 bags and he wants detox.’ You call and say the guy’s using 7 bags and they
say it’s not enough to get him in there. So you know, sometimes I have to tell the clients
you better say you’re doing 10 bags or more or they’re not going to take you.

Respondents discussed frustrations with having to use more drugs or alcohol at times or having
to “hit rock bottom” in order to be admitted to detox programs. Several respondents also
discussed disappointments with not being linked with more follow-up services and supports
following detox, and some noted that for them staying clean was difficult because most recovery
houses were located in high drug use neighborhoods.

Clinician and Agency Recommendations

In all focus groups, respondents offered a range of recommendations that cluster in seven
different areas.

1) Connect with community. Respondents offered a number of recommendations for increased

connection with community resources and supports. Recommendations highlight the need
for increased connection on the part of service delivery organizations, as well as consumers:
o Help people with transitioning to community life
o Do more with connecting people with community services and supports
o Give more information about events, other services, and supports in the community
o Build more partnerships with community agencies

2) Develop Peer Based Services and Supports. Several recommendations for developing
additional peer based services and supports were offered which suggested an interest in
greater consumer involvement in service provision, training, and system-related advisement
and decision making:
o Provide more opportunities for peers to help other peers; this makes people feel good
o Develop more peer run groups
o Involve peers more in training providers
o Develop more youth and consumer councils

3) Develop Additional Services and Supports. Respondents offered a range of

recommendations for direct care, as well as civic and recreational need areas:
o Hold more services in community centers and places other than mental health centers
o Hire more bilingual, bicultural providers
o Offer more language assistance services and supports
o Develop more services for specific cultural groups – sober houses for Latinos,
Women’s services, LGBTQ services, Youth services
o Offer art and music classes
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 o Organize more fun activities – trips to NYC, Boston, concerts, visiting other programs
with a similar focus
o Have community picnics, barbecues in parking lot of the center to give people more
information about services
o More detox services

4) Enhance Direct Care. Several recommendations for improving direct care and the provider-
client relationship were offered. Recommendations address a range of access, service
quality, cultural competence, and recovery areas:
o Get to know me as a person, don’t stereotype
o Ask about race and a person’s cultural background more
o Let people know you are interested in their cultural background; be willing to ask
questions to learn more
o Need to develop a plan with providers - 1 week, 1 month, 1 year, need to talk about
goals
o Programs and providers need to teach about recovery
o Offer more literature about recovery, finding jobs, or other general information so if
counselors are not available, you can still get the information you need
o Need to offer more individuals services/sessions – realize that not everyone is
appropriate for group
o More focus on everyday life, not just symptoms
o Allow for gift giving
o Make it easier for people who need detox to get in
o Explain confidentiality better
o Be willing to bend the rules a little
o Provide help with transportation
o Have more flexible hours and weekend appointments

5) Offer More Provider Education and Training. Recommendations for provider training were
offered in several areas:
o Providers need training to better understand the Black male experience
o Providers should take Spanish classes
o Providers need more training about culture and different communities
o Need training to help them better understand how different groups express their
feelings, stress, symptoms
o Need training on communication, listening, and professionalism

6) Offer Service User Education and Training. Respondents expressed interest in

participating in education and training programs in a variety of areas which they stated
would help with advancing their recovery and rebuilding their lives. These included:
o Programming related to the economics of the community and owning one’s own
business
o Job training
o Preparing resumes and interviewing
o Recovery education
o Programming/services to help with rebuilding one’s life after jail or treatment

7) Enhance Agency Environment /Physical Space. Several recommendations for improving

the physical appearance of an agency so as to make it more welcoming were offered:
20
 o Make the center more visually appealing with more colors and artwork
o Make the agency more appealing visually to Asians
o Include artwork representing different cultures

Discussion and Implications

The findings discussed in this report highlight the complex and dynamic role of race, ethnicity,
and culture in the helping relationship and in the development of services and systems that are
responsive to the worldviews and values of diverse groups. Eight overarching themes are
discussed which summarize a range of positive, as well as negative, care experiences. Further,
it is important to note that many of the negative experiences discussed exist within the context
of similar themes in the broader cultural competence and multicultural health literature
nationwide. Thus, themes that suggest racism, bias, and discrimination are not unique to
Connecticut; rather they mirror social patterns that have challenged health care and U.S. culture
in general for generations. Nevertheless, the negative experiences discussed in this report
represent an important call to action. Needed are unique and creative interventions designed to
enhance attention to culture and service equity.

Echoing themes in the recovery literature findings suggest that, when asked, service users know
what works for them. This was well illustrated by the range of recommendations for improving
care offered by respondents. While all may not be feasible to implement now, some likely
represent low-hanging fruit that can be implemented with limited system effort or costs. To
further evolve and prioritize recommendations offered by respondents, it is recommended that a
Eliminating Disparities Subcommittee of the Multicultural Advisory Council be formed. In addition
to MCAC members, individuals invited to join this subcommittee should include service users,
direct care providers and relevant individuals from the DMHAS executive leadership. Goals of
this group should be to discuss the feasibility of implementing these and other recommendations
for improving care, in addition to identifying individuals or departments responsible for
advancing goals, identifying timeframes and strategies for measuring success, etc. Such
concrete planning will assist in the translation of ideas for change to action and guard against
recommendations remaining unaddressed. Further, inclusion of service users in the process of
planning for cultural competence and disparities system change can create greater alignment
between service needs and service offerings, ultimately reducing recidivism rates, behavioral
health care costs, and the disability burden borne by culturally diverse communities and society
as a whole.

While it is beyond the scope of this document to present a comprehensive discussion of the
range of recommendations offered by service users, some findings and recommendations are
discussed to provide an illustration of the ways in which recommendations and findings can
inform the development of specific interventions. Such translation of recommendations for
enhancing cultural competence and eliminating disparities, as noted above, should be an
ongoing task of the Eliminating Disparities Subcommittee, or some other OMA/Executive
Leadership action planning group charged with cultural competence and continuous quality
improvement in the area of health care disparities.

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Provider and System Strengths

Cultural Competence Training and Technical Assistance

Several provider and system strengths were reported, many of which are discussed in the
broader multicultural literature as key competencies for working with diverse groups. Such
strengths include respondent reports of feeling linked in; feeling that providers understand their
cultural background; feeling respected, cared for, and listened to; time flexibility; being able to
speak in one’s primary language; providers having “been there” and being willing to open doors
and help individuals get their needs met; to name a few. While many respondents seen by
ethnically similar providers reported these and other positive care experiences, there were
instances in which respondents not seen by ethnically similar providers also reported positive
experiences. Taken together, these results highlight a well documented finding that ethnic
match alone does not translate to positive outcomes, but rather, provider behaviors such as
communicating cultural understanding, respect, listening, time flexibility, meeting outside of
traditional treatment settings, etc, are more predictive of positive care experiences and
outcomes.

From a system perspective, these findings suggests that while ethnic match and ethnically
similar programs are useful, also important are providers and programs being able to implement
multicultural care practices such as those discussed above and others outlined in the
multicultural literature. Given this, to ensure that all providers are appropriately skilled to work
effectively with diverse groups of service users, it is recommended that innovative and ongoing
cultural competence training and follow-up technical assistance be provided. Further, it is
recommended that the follow-up technical assistance occur on site with direct care teams
focusing on specific questions and cultural challenges experienced by providers in their direct
service work. Inclusion of intensive follow-up TA will assist providers in the translation of cultural
competence principles to practice. Typically, standard cultural competence training does not
include follow-up TA, or evaluation, contributing to questions regarding the general effectiveness
of cultural competence training. As a result, to optimize the quality of the training and TA
offered, ongoing evaluation is recommended.

An additional and important system strength is that service users expressed interest in being
involved in system interventions to improve care. For instance, frequently cited
recommendations were for the development of peer-to-peer programs and youth and consumer
councils, and for peers to be involved more in training providers. Building on these system
strengths, and as a strategy for creating innovative training and education approaches, it is
recommended that service users be involved in developing and implementing ongoing training
and TA efforts. Such trainings could include the use of recovery and culture narratives such as
those reported here as a means of teaching key cultural competence principles. In addition,
working with service users in developing and conducting training can help to ensure that
important nuances of culture and a recovery orientation care are included in training materials
and facilitated discussions.

System Challenge and Growth Areas

Stereotype Reduction

While important provider and system strengths were noted, also discussed were a number of
negative experiences in care that represent significant system challenges and areas for needed
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intervention. For instance, prominent themes were that respondents felt stereotyped by
providers and felt that providers did not understand their cultural background. In turn, many
respondents reported that this impeded the development of trust and their willingness to share
cultural experiences that were impacting their lives; e.g., experiences of racism and
discrimination in the healthcare system and broader society, trauma and violence in their
neighborhoods, negative experiences with police officers, family dynamics and abuse, etc. As a
means of improving cultural understanding and fostering the development of trust in the helping
relationship, it is recommended that providers directly ask about important areas of culture that
may influence an individual’s life. As an example, use of cultural assessments with questions
that directly address cultural identity, language preferences, experiences with racism and
discrimination, migration history, trauma, and cultural beliefs about mental health and formal
help seeking, for instance, can help to reduce the impact of stereotyping.

Stereotyping literature suggests that obtaining actual information about a person can help to
minimize the automatic nature of stereotyping and “filling in the gaps,” which often happens
outside of conscious awareness in the absence of actual information about a person. In
addition, asking about culture can help communicate cultural understanding and send the
important message that race is not a taboo topic for therapy, in fact, it is appropriate to discuss
as are other areas of culture influencing a person’s life. Given this, it is recommended that
cultural assessments such as the DMHAS OMA Ethnocultural Addendum Form or the Cultural
Formulation in the current Diagnostic and Statistical Manual of Mental Disorders be
disseminated widely throughout the CT system of care to assist providers in incorporating key
cultural areas in the care process. In addition, it is recommended that these and other cultural
assessments be incorporated into training and education curricula and be included on the
DMHAS OMA website for easy access.

Peer Services and Supports

An additional prominent theme was that many service users reported wanting more quality and
individual time with providers. Some respondents, for instance, noted that they felt that they
were invisible, not noticed, or were pushed away by providers. Others stated that they felt like
they were taking part in a self-help program, despite participating in a residential program and
having a counselor. Further, many respondents reported that they felt as though they could not
rely on providers for their recovery because they were busy with paperwork or “heavy
caseloads.” As a strategy for improving quality time with providers, it is recommended that more
peer services and supports be developed. Such programs can serve as a cost effective strategy
for providing service users with additional supports as needed or requested. This may be
particularly useful for organizations, where because of limited resources, service users are seen
primarily in groups, or are seen bimonthly or monthly.

In addition, working with a peer mentor or participating in a peer support program can help an
individual become acclimated to the process of receiving care. This may be particularly
important for individuals seeking services for the first time, or individuals for whom accessing
behavioral health services is not a traditional form of help-seeking in their culture. For such
individuals and others, participating in peer support programs can help to increase voice and
self advocacy and facilitate navigation of behavioral health organizations and systems. In
addition, working with a peer mentor can help an individual to feel socially connected,
understood, and supported. In turn, such benefits can increase an individual’s engagement in
services, reducing recidivism rates, high system costs, and ultimately improving outcomes.

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Increasing peer services and supports can also help with addressing language barriers and
concerns discussed by service users. In particular, many service users discussed difficulties
communicating with providers and some noted that this made them feel more depressed than
when they entered care. Respondents also reported that because certain emotions did not
directly translate to English, it was often difficult to fully discuss their experiences. One cost-
effective strategy for enhancing language assistance services and supports would be to train
bilingual/bicultural peers in translation services and hire them to provide this service. While
some respondents noted that they did not like using translation services, several noted that they
did not like using translation services through the telephone. Training and deploying peers as
translators could help to increase face to face translation provided for interested individuals
which in turn could increase engagement in services.

Conclusion
DMHAS is to be commended on their willingness to ask difficult questions and engage in self-
reflection regarding the role of culture in the service delivery process. Undertaking this
evaluative work speaks to the state’s longstanding commitment to creating a system of care that
is responsive to the cultural values and needs of all individuals seeking care. This same
commitment will likely fuel next step efforts to build on system strengths and improve the cultural
responsiveness of care. Service users have offered an initial vision for enhancing direct care
and outcomes. Working in full partnership with service users, it is imperative that
recommendations offered are further developed and prioritized such that interventions are
aligned from personnel, policy, fiscal, and administrative perspectives. Implementing new
forums and formats for system planning and decision-making can help to ensure translation of
strategies for change to action. Further, continued self-evaluation and the ongoing use of
feedback loops can help to enhance the cultural responsiveness of care, contributing to
improvements in access, retention, engagement, service quality, and outcomes for all
individuals seeking care.

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