Implicit Organizational Bias: Mental Health Treatment Culture and Norms as Barriers to Engaging with Diversity

Introduction

BIPOC communities face many structural barriers to accessing mental health care. To reduce this health disparity and better serve multicultural populations, many providers are turning to person-centered care. Person-centered care is intended to improve quality of care by centering the patient’s values, preferences, and goals in collaboratively designed care plans. Although this approach has the potential to improve upon disease-centered models and expert-driven care,  its emphasis on the individual may still create barriers for patients from community-centered cultures. Recognizing the limits of “cultural competence” in improving care, mental health scholars have suggested scrutinizing health provider culture and its relationship to broader structural and sociopolitical issues. 

This study aims to better understand the sources of these barriers to care for Latinx and Asian patient populations by examining shared themes across providers’ descriptions of their encounters. The authors choose to focus on Latinx and Asian patient populations for three key reasons: they represent the two fastest-growing subgroups in the US; they face unique challenges of xenophobia, harassment, and invisibility; and their cultures tend to be more community-centered.

Dr. Miraj U. Desai, PhD is an Instructor at the Program for Recovery and Community Health of the Yale University School of Medicine, Department of Psychiatry. His research interests include cultural, community, anti-racist, and social justice perspectives on mental health. Nadika Paranamana is a Doctoral Candidate in Clinical Psychology at the University of Hartford and a clinical trainee at the Yale University School of Medicine, Street Psychiatry Program. Maria Restrepo-Toro, BNS, MS, is an Educator at the Yale University, Department of Psychiatry, Program for Recovery and Community Health. She is a nationally recognized expert in the field of Latinx psychiatry and the Project Director of the New England Mental Health Technology Transfer Center. Dr. Maria O’Connell, PhD is an Associate Professor of Psychiatry and Director of Research and Evaluation at the Yale Program for Recovery and Community Health. Dr. Larry Davidson, PhD is a Professor of Psychiatry at Yale University, Senior Policy Advisor in the Department of Mental Health and Addiction Services, and Director of the Yale Program for Recovery and Community Health. Dr. Victoria Stanhope, PhD, MSW, MA is an Associate Professor and Director of the PhD Program at New York University Silver School of Social Work. Her professional interests are in mental health services research and policy, with specialization in recovery, person-centered care, and primary and behavioral healthcare integration.

Methods and Findings

Researchers conducted 12 qualitative interviews with providers about their experiences of implementing person-centered care, shared decision-making, and cultural engagement during patient visits. Interview techniques were explicitly designed to elicit participants’ concrete descriptions of their experience, devoid of judgment or opinion about the events. The provider was asked to describe recent work with both a Hispanic or Latinx and an Asian patient, if possible. After collecting and transcribing the interviews, two research team members transformed each interview into a one-page summary of essential moments of the interaction focusing on culture, person-centered care, and social supports. Then, the summaries were reviewed to discover key shared themes and general structures of provider-client engagement. The entire research team reviewed these findings for verification, elaboration, and refinement.

This study found that provider embeddedness in their organizational culture was the primary determinant of care across practice models. Providers implicitly preferred patients who were most aligned with their organization’s clinical norms, thereby making the visit and system run efficiently (e.g., patients who are verbal, admit there is a problem or illness, accept services, are proactive, and are individually oriented). As identified in providers’ own narrations of “noteworthy, challenging, or incongruent” features of care visits with Latinx or Asian patients, this preference became a highly conspicuous determinant of care from the provider perspective. 

Providers revealed an acultural understanding of their purpose as interpreting patient needs and goals to connect patients to a “menu” of mental health services so that patients can learn the skills needed to become “independent” and “empowered.” This prevalent perspective translates into an understanding of cultural competence as a tool for translating their preferred format and mode of care — which they genuinely believe to be best practice — into terms the patient can understand, rather than designing a truly appropriate model of care for culturally diverse BIPOC patients. Some providers are able to recognize and subvert the norms of their field, primarily by drawing on personal experiences of incongruence. However, they may still face friction with their organization’s structures when incorporating alternative practices. 

Conclusions

Provider narratives of interactions with Latinx and Asian patients in a community mental health clinic illustrate that the mental health field’s organizational culture and hidden norms are a major determinant of quality of care and a potential source of institutional bias. Providers’ lack of awareness of their field’s hidden norms — which are often rooted in Euro-American cultural ideals and archetypes — limits their ability to offer “alternative” practices that may better serve their patients, even when those providers believe they are applying a patient-centered approach. In the vast, diverse context of the US, it is critical that mental health professionals unearth their own implicit biases while also taking action to diversify the mental health field’s broader assumptions, structures, and practices.