Who’s the Ideal Client? How Implicit Bias Affects Care of Ethnic Minorities

Despite claims of person-centered care, the mental health system continues to prioritize the “ideal client,” leading to worse treatment for ethnic minorities.

Ana Florence, PhD
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A new study out of the Yale Program for Recovery and Community Health investigates whether innovations in the mental health field, such as person-centered care planning, impact how ethnic minorities receive care. The study, published in the American Psychologist, finds that despite such innovations, the mental health system continues to prioritize clients seen as “ideal” – an effect known as Implicit Organization Bias.

Clients are often seen as ideal when they help the system operate more efficiently and providers’ preferences, norms, and expectations create an implicit bias that can act as a barrier for culturally diverse clients.

“Mental health organizations hold norms and expectations regarding what an ideal client should act like and typically prefer clients who help them operate efficiently,” the lead researcher, Miraj U. Desai, explains. “This presents serious barriers for cultural minority clients, whose own norms and preferences often conflict with the preferential biases of mental health treatment culture.”
“Under the gaze of strange women,” by Quinn Dombrowski (Flickr)

A growing awareness of the need for cultural competence in the mental health field has informed innovations that would facilitate better serving a culturally diverse clientele. It is unclear, however, whether these innovations facilitate recovery and respect personal preferences for clients from ethnic minority groups.

Person-centered care planning is one such innovation that shifts the model of care from a deficit centered paradigm focused on eliminating symptoms and diagnosis, to one that includes the person’s preferences, values and goals. Not much is known, however, about the ways in which such a model would be responsive to cultures whose center is not the person, but perhaps the family, spirituality or collectiveness.

Mental health systems of care have increasingly become more culturally competent and aware of the need to respect diverse cultural backgrounds. Additionally, a growing body of research and literature contributed to a better understanding of socioeconomic and structural determinants to access effective mental health care. Despite this, health disparities still exist and affect ethnic minorities in ways we don’t fully understand. For example, research on Latinx and Asian groups is scarce even though these communities are growing in the United States.

This study used a phenomenological approach to better understand how providers interact with clients of Latinx and Asian backgrounds. Qualitative in-depth interviews were conducted with twelve providers who work at Community Mental Health Centers and were receiving training or technical assistance in person-centered care planning.

Findings show that organizational culture played a key role in determining care for ethnic minorities. The mental health culture determined the provider’s views about how a client should behave in the clinical setting, creating a set of expectations regarding how one should speak, open up, comply, and accept a problem. In the researchers’ words:

“Even for providers who express more explicit engagement with cultural difference and ethnicity, there were still imprints of an organizational culture within their descriptions of their work”

Findings also show that providers are often presented with challenges when a client does not behave in accordance with the expected norms. According to the study, providers reacted to clients who did not speak in-depth about their feelings, who questioned treatment, did not accept that they have a problem, and did not comply with treatment recommendations.

Additionally, the system is set up in a way that privileges individualism rather than the inclusion of families or the client’s social network. Findings suggest that providers are often unaware of the larger organizational culture and the norms and expectations that determine how they perceive and interact with clients.

Providers who are themselves from an ethnic minority may be more aware of such implicit biases having experienced first-hand the incongruences of the system. According to the researchers:

“Even in these cases, however, providers still found themselves within a system founded on standard or ideal practices. To bring in these alternative perspectives, creativity or resistance may be required.”

Researchers were cautious not to engage in provider blaming. Their intent was to uncover how structural issues – such as norms and expectations established outside of the clinical setting – played into the therapeutic encounter, often in an implicit way outside of the provider’s awareness.

Researchers conclude that these norms, based on the western clinical tradition, shape the organizational culture, and become an implicit organizational bias. This means that without noticing, providers interact with their clients expecting that they behave in a certain way, and when they don’t, challenges in the therapeutic encounter emerge for which clinicians may not have the tools to successfully address.

“Our main finding of this study of providers’ work with Asian and Latinx or Hispanic populations was that there was this invisible culture of the clinic and that, within it, there were ideal ways and styles that helped the system function normally and efficiently.”

Authors suggest that developing organizational bias assessment tools and increasing community participation in health service decision-making processes may be necessary to address the issue.

Additionally, the study points out the need for a structural level of analysis to better contextualize the demands of a system that is increasingly corporatized, faces major funding difficulties, and imposes several bureaucratic demands. The researchers emphasize that this level of analysis should be incorporated into clinical training and taught alongside clinical theory and technique.

This article is an important addition to the limited research on how structural elements play a key role in determining how care is provided to ethnic minorities. Latinx and Asian communities face an additional barrier in the mental health system when met with expectations that don’t always conform to their cultural values. Despite providers’ efforts to be culturally responsive, the system constraints their ability to respond effectively to different needs and the overall organizational culture determines how the therapeutic encounter will unfold, separating ideal clients from non-ideal clients.

Despite innovations in the mental health field, structural barriers remain in place and are often not addressed in training. Training aimed at increasing awareness of the structural elements and conceptual limitations that directly interfere with clinical practice is one-step towards transforming the system to be more inclusive and welcoming of diversity.

 

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Desai, M. U., Paranamana, N., Restrepo-Toro, M., O’Connell, M., Davidson, L. & Stanhope, V. (2020). Implicit Organizational Bias: Mental Health Treatment Culture and Norms as Barriers to Engaging With Diversity. American Psychologist, Publish Ahead of Print, DOI: 10.1037/amp0000621. (Link)

1 COMMENT

  1. Thank you for the report.
    Not that another study does anything more than keep the basic tenets strong, but we take delight in each study illuminating the biases.
    Yet the studies are no more than a bad domestic triangle, a co-dependency in the works.

    Bottom line is, psychiatry itself is rooted in Bias, and can never improve.

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