Leonard A. Evans

Effective Psychotherapy for Low-Income and Minority Patients

The poor, the working-class, or the minority person who needs psychotherapy is characteristically underserved by mental health establishments, which are primarily geared to the needs of middle- or upper-class and nonminority patients (Acosta, 1977; Sue, 1977; Yamamoto, James, & Palley, 1968). Therapists who make up the mental health establishments often lack the knowledge necessary to work effectively with minority populations and subgroups (President’s Commission on Mental Health, 1978). Given this lack of knowledge and the existence of racism in the United States, it is not surprising that many mental health professionals have prejudicial attitudes to-ward minority groups, which can be manifested either in outright rejection or in the provision of less intensive, less interested, unenthusiastic care (Lorion, 1974). These patients will continue to be underserved until mental health professionals become better trained to deal with the unique problems of these patients more effectively.

Self-reported psychiatric symptoms among black, hispanic, and white outpatients

Examined ethnic differences among black, Hispanic, and white applicants for outpatient psychotherapy, using symptoms self-reported on the Symptom Checklist 90-Revised (SCL 90-R). The relationship between self-reported severity of symptoms and therapist-reported severity of psychiatric diagnoses also was examined in order to assess the utility of SCL 90-R as a predictor of diagnostic severity for these ethnic groups. One hundred sixty-five patients completed the SCL 90-R. The patients were predominantly in the low-income social classes. A significant ethnic effect was found on several symptom dimensions, with black patients less likely to report symptoms than Hispanic or white patients. Hispanic patients were found to report the highest symptom levels on 8 of 11 measures. While, overall, therapist diagnostic severity was related significantly to self-reported symptomatology, the relationship was strongest for white patients, significant but less strong for Hispanic patients, and not significant for black patients.

The Hispanic-American Patient

This chapter will discuss sociocultural characteristics of the Hispanic community and show how these characteristics relate to mental health and mental health services. Specific recommendations for treatment approaches and psychotherapy will also be presented. It is important to focus on Hispanic Americans because they constitute the second largest minority group in the United States and the fastest growing ethnic group in our country (Russell & Satterwhite, 1978). It is of further importance since Hispanic Americans in our country have been severely underserved by mental health facilities (Acosta, 1977; Padilla, Ruiz, & Alvarez, 1975; President’s Commission on Mental Health, 1978).

Patient Requests: Correlates and Therapeutic Implications for Hispanic, Black, and Caucasian Patients.

A patients reason for coming to a psychiatric outpatient clinic (his/her request for service) should be the focal point as a therapist develops an appropriate therapeutic plan for that patient. Data have been collected on 173 Hispanic, Black and Caucasian patients with regard to their reasons for coming to the clinic and selected demographic and process/outcome variables. A factor analysis of the patient request data generated three conceptual factors, which account for 13 reasons for coming to the clinic. The relationship of these factors with selected demographic and therapy outcome variables was tested statistically, and implications for therapy with low income and minority patients are discussed.

The Poor and Working-Class Patient

A significant part of our population in the United States are people who fall into the poor or working-class categories (Hollingshead & Redlich, 1958; U.S. Bureau of Census, 1974). An even higher percentage of patients coming to public psychiatric outpatient clinics or community mental health centers fall into these categories. The National Institute of Mental Health (NIMH) has increasingly recognized in the past several years the need to augment services for these groups of people. Typically, the poor and the working class are not being helped effectively in mental health services, even though such clinics and centers have been created for them (President’s Commission on Mental Health, 1978). In realization of these conditions, NIMH has in the past few years moved toward the idea of educating the general medical practitioner to be the primary provider of mental health services for the low-income person.

Consultation and Referral

There may be times during your work with patients when you will want specialized help in establishing the correct psychological diagnosis or management procedures. Or, because of personality differences, conflicting time schedules or for a variety of other reasons, you may wish to discontinue working with a particular patient. In these instances, consider requesting a consultation or referring your patient to another therapist for treatment.

The Black American Patient

Important sociocultural factors in the psychological evaluation and treatment of black American patients are often overlooked or misinterpreted by psychotherapists. This situation stems from two primary sources: the therapist’s paucity of information regarding similarities and differences between the dominant culture and that of the black American, and myths about black Americans that result from misinformation obtained from scientific inquiries of questionable validity as reported in the literature.

Mental Status Examination

The mental status examination (MSE) is a structured assessment of the clinically relevant areas of a client’s behavioral, emotional, and cognitive functioning. It includes descriptions of the client’s overall appearance, comportment, and behavior; it also describes a client’s thought and perceptual processes and content, emotional state, and cognitive abilities, including level of consciousness, orientation and attention, and insight. By coalescing these important domains, the MSE paints a picture of the client at a given point in time.

An Innovative Instructional Format for a Course in Basic Psychopathology

An innovative course in psychopathology for medical students was developed using principles derived from instructional development models. The instructional format consisted of carefully designed self-instructional workbooks and patient-centered workshops. No lectures were presented during the 32-hour course. Statistically significant learning gains were achieved between the pre- and postcourse examinations, and the students were highly enthusiastic about the innovative educational format.

Organic Mental Disorders

Organic mental disorders (OMD’s) comprise a group of Psychopathologic conditions which result from dysfunction of the brain. For this diagnosis to be applied, brain dysfunction should be documented by laboratory and physical examination (e.g., electroencephalograms, x-rays, etc.) and/or by a history which indicates that an organic factor (i.e., drugs or head trauma) are involved. Many persons erroneously believe that OMD’s are conditions generally restricted to elderly or drug intoxicated patients. But, in actuality, brain dysfunction also occurs in connection with many physical illnesses, and indeed, can be the first sign of a developing medical problem. Because of the high incidence and medical significance of these disorders, it is important that you develop expertise in diagnosing and treating them.