CULTURALLY COMPETENT CARE FOR PATIENTS WITH MENTAL ILLNESS

A mental health condition is a mild to severe disorder that affects an individual’s thinking, mood, and/or behavior (SAMHSA, 2023a). Close to 1 billion people worldwide have some form of mental illness, including 51.5 million in the United States. Of these, 36 million are estimated to be hospitalized each year. Nearly 1 in 3 people with a long-term physical health condition also has a mental health condition (Monaghan & Cos, 2021; Perry & Dilks, 2022).

These numbers make it easy to see that no matter what the role or setting, healthcare professionals will encounter patients who exhibit signs, symptoms, and behaviors indicating mental illness, and will be involved in the provision of care for both physical and mental illness.

Examples of mental health conditions include:

• Antisocial personality disorder
• Anxiety disorders (such as obsessive-compulsive disorder and social anxiety)
• Attention-deficit hyperactivity disorder (ADHD)
• Bipolar disorder
• Borderline personality disorder (BPD)
• Depression
• Eating disorders (such as anorexia nervosa, binge eating disorder, and bulimia nervosa)
• Posttraumatic stress disorder (PTSD)
• Seasonal affective disorder (SAD)
• Self-harm
• Suicide and suicidal behavior
  (SAMHSA, 2023a)

Healthcare clinicians are expected to provide holistic care involving the whole person, which includes physical, mental, spiritual, and social needs, and is rooted in the understanding that all of these aspects affect overall health. Being unwell in one aspect affects the others. This means that the responsibility for providing mental health care needs to be shared across the multidisciplinary workforce, requiring skilled clinicians to deliver both physical and mental health services in diverse clinical settings.

Physical and mental health education, training, and services, however, have historically functioned independently from each other, and as a result those caring for patients with physical disorders report a lack of training and feeling inadequately prepared to care for their patients’ mental health care needs. In addition, they report a lack of access to appropriate training and support in the workplace (McInnes et al., 2022).

Challenges for Integration of Physical and Mental Health Care

Frustrations reported by staff related to caring for patients experiencing mental illness seem to arise from knowledge gaps or skill deficits, and mostly relate to ineffective therapeutic interaction, leaving the caregivers with feelings of inadequacy and professional dissatisfaction.

Nonpsychiatric healthcare professionals often report having to struggle to provide care for patients with mental illness without having the sort of specialized training that is standard for those who work in psychiatric facilities, such as:

• De-escalation
• Communication skills
• Suicide prevention
• Addressing potential violence and aggression
• Maintaining a safe environment

In addition, negative attitudes toward mental illness by healthcare professionals have been reported. These attitudes can have adverse consequences for people with mental illness from delays in seeking care to decreased quality of care provided.

STIGMA AND MENTAL ILLNESS

One of the most significant challenges for the integration of physical and mental health care is stigma. Stigma refers to negative and biased beliefs that a society has about something or someone else (Merriam Webster, 2024). Stigma is disempowering. Stigma undermines health by preventing access to critical health-promoting resources and acting as a destructive stressor leading to harmful affective, cognitive, behavioral, and physiologic responses among individuals. Historically, people with mental illness have experienced discrimination in healthcare settings. In healthcare settings, provider stigma compromises access to diagnosis, treatment, and successful health outcomes.

Nonpsychiatric professionals identify negative attitudes, fear, and even hostility toward patients with mental illness. These patients are commonly misperceived to be dangerous, unpredictable, uncooperative, and frightening. Self-stigma, the process of internalizing these negative stereotypes and applying them to oneself, can also lead to lower rates of willingness to disclose one’s psychiatric history and may prevent seeking healthcare altogether.

Clinician inexperience in caring for patients with mental illness can contribute to delays and misdiagnoses. Implicit bias may occur when a patient’s physical symptoms are ascribed to mental illness, which can lead to delays in referrals and initiation of treatment (Ollila, 2021; Earnshaw et al., 2022).

Despite all that has been learned and the urgency surrounding the need for evidence-based treatment, mental illness continues to be highly stigmatized (see table below). Mental illness–related stigma, including that which occurs in the healthcare system and among healthcare providers, creates serious barriers to access to healthcare and the quality of care a patient receives. The impact of provider stigma has been identified as the strongest barrier toward help-seeking behavior of individuals with mental illness.

MENTAL HEALTH MYTHS VS. FACTS

Myth	Fact
(SAMHSA, 2023b)
Children do not experience mental health problems.	Even very young children may show early warning signs of mental health concerns. Half of those with mental health disorders show first signs before the person turns 14 years old.
People with mental health issues are violent, unpredictable, and dangerous.	The vast majority of those with mental health problems are no more likely to be violent than anyone else. Only 3% to 5% of violent acts can be attributed to individuals living with a serious mental illness. In fact, people with severe mental illnesses are over 10 times more likely to be victims of violent crime than the general population.
People with mental health issues, even those who are managing their illness, cannot tolerate the stress of holding down a job.	People with mental health problems are just as productive as other employees. Employers who hire people with mental health problems report good attendance and punctuality as well as motivation, good work, and job tenure on par with or greater than other employees.
Mental health problems are caused by a personality weakness or character flaws, and the individual can snap out of it if they try hard enough.	Mental health problems have nothing to do with being lazy or weak, and many people need help to get better. Many factors contribute to mental health problems, such as genes, physical illness, injury, brain chemistry, life experiences such as trauma or a history of abuse, or family history of mental health problems.
There is no hope for people with mental illness.	Studies show that people with mental health problems get better and many recover completely.
Therapy and self-help are a waste of time.	Treatment for mental health problems varies depending on the individual and could include medication, therapy, or both.

Lack of cultural understanding by healthcare providers may also contribute to underdiagnosis and/or misdiagnosis of mental illness in people from racially/ethnically diverse populations. Factors that contribute to these kinds of misdiagnoses include language differences between patient and provider, stigma of mental illness among minority groups, and cultural presentation of symptoms. While racial/ethnic minority groups overall have similar (or, in some cases, lower) rates of mental disorders than Whites, they often bear a disproportionately high burden of disability resulting from mental disorders. People from racial/ethnic minority groups are also less likely to receive mental health care (APA, 2017).

Best Practices for Culturally Competent Care of a Patient with a Mental Illness

The central element of responding to the patient is the development of a quality therapeutic relationship. A therapeutic relationship requires exceptional communication skills, which include:

• Trust: critical to the relationship and requiring continual effort to maintain it
• Respect: recognizing each individual has inherent dignity, worth, and uniqueness
• Professional intimacy: providing physical care while being privy to the patient’s psychological, spiritual, and social history
• Empathy: understanding, validating, and confirming what the healthcare experience means to the patient
• Power: recognizing the unequal power relationship and not abusing it
  (CNO, 2020)

Effective ways to interact with a patient with a mental illness include:

• Be patient when attempting to communicate; do not rush or pressure the patient to talk.
• Answer questions briefly, quietly, calmly, and honestly.
• Counter distractibility and poor concentration by giving the patient clear, simple, and concrete instructions.
• Attempt to educate patients about any inappropriateness of their behavior without criticizing or blaming them.
• Avoid judging the person, and do not give negative feedback.
• Avoid verbal confrontations with the person.
• Encourage the patient to respect the personal space of others.
• Provide consistent limits on behaviors and verbal abuse; make sure all staff are clear about these limits and that they reinforce them.
• Encourage and support any ideas the person has that are realistic and in keeping with their healthcare regimen. It is far more effective to suggest alternative strategies rather than to forbid an action.
• Encourage the person to organize and slow thoughts and speech patterns by focusing on one topic at a time and asking questions that require brief answers only.
• If a patient’s thoughts and speech become confused, cease the conversation and help to calm the patient by sitting quietly together.
• Offer PRN medications and watch for adverse side effects.
• Encourage participation in relaxation exercises such as deep breathing.
• Acknowledge what patients are experiencing but remind them that they are not in danger, they will be okay, and you are there to help.
• Speak in short, simple sentences and encourage the patient.
• Remind patients to breathe; if they are hyperventilating, have them breathe into their hands cupped over the mouth and nose or a small paper bag.
• Guide the patient through a simple, distracting physical task, such as raising the arms over the head.
  (Townsend, 2018; Martin, 2023; Vera, 2023)