Introduction

Many African American adolescents who are in need of mental health treatment services fail to receive these services (Department of Health and Human Services [DHHS], 1999). When services are initiated, many African American adolescents drop out between the first and third appointment or fail to complete a course of treatment (McKay, Harrison, Gonzales, Kim, & Quintana, 2002). The gap between need for and utilization of services is especially serious for African American adolescents, who are already at increased risk for poor health outcomes as a result of poverty, unemployment, poor education, and the consequences of living in troubled communities (Canino & Spurlock, 1994). Given the long-term risk of failing to provide mental health services to this population, it is crucial to examine barriers to access and utilization in order to eliminate them. A lack of attention to the current disparities will have far-reaching negative effects for African American adolescents, their families, and our society resulting in increased stress and disability, homelessness, incarceration, substance abuse, community violence, child abuse and neglect, increased foster care placement, and juvenile delinquency, etc. (Brach & Fraserirector, 2000; DHHS, 1999; Fiscella, Franks, Gold, & Clancy, 2000).

An overwhelming body of literature regarding access to and utilization of mental health services documents the structural barriers to care, such as transportation, cost, and location (Anderson, 1995; DHHS, 1999, 2001); and additional literature documents the personal knowledge barriers to care (Caldwell, 1996; Cauce et al., 2002; Taylor, Jackson, & Chatters, 1997). However, little literature exists regarding the barriers in access and utilization outcomes as perceived by racial and ethnic minority consumers (Buston, 2002; Littell, Alexander, & Reynolds, 2001; Snowden, 2003). The historical and socio-cultural contextual factors relating to racial/ethnic bias in health outcomes can be investigated as having a possible role in the reduction and elimination of disparities in mental health services (Bachrach & Newcomer, 2002; DHHS, 2001; Snowden, 2003). This paper focuses on increasing providers’ knowledge of the socio-cultural factors that influence mental health service utilization for African American Adolescents. The purpose of this paper is to present: (1) the socio-cultural factors which influence the need for and utilization of mental health treatment services; (2) knowledge to aid in the development of effective engagement strategies; (3) treatment interventions for facilitating biased-free practice and (4) implications for social work research. It is intended to increase practitioners’ awareness of, and knowledge about, quality mental health services to African American adolescents. Practitioners can improve their competence with regards the socio-cultural influence on the way in which individuals think about, explain, and cope with health and illness (Stroman, 2000). The overall purpose is to enhance providers’ practice skills for working with African American adolescents and decrease bias in therapeutic engagement and intervention with African Americans.

The need to improve access and utilization, develop more equitable health service systems, and increase knowledge for developing therapeutic interventions that are sensitive and applicable to the cultural diversity of our citizenry is clear. Improvements in the design and delivery of mental health services should reflect the cultural variations in individual perceptions of and response to health and illness. One strategy for improving health outcomes for African Americans involve enhancing cultural competence for both non-African American and African American providers and creating culturally sensitive health care environments (Brach & Fraserirector, 2000; Fellin, 1996). Understanding and accepting the cultural differences with regards to the way in which individuals think about, explain, and deal with health and illness can facilitate the development of culturally competent health care services and systems.

Background and Significance

African Americans are substantially disadvantaged according to indicators that measure and define health status outcomes for individuals, communities, and populations (Fong & Mokuau, 1999; Institute of Medicine [IOM], 2003; Lee & Estes, 2003; Longest, 2002; US Public Health Services, 2000). Racial and ethnic disparities in the use of mental health services by African American adolescents are well documented (Allen-Meares, 1995; Cauce et al., 2002; Cuffe, Waller, Cuccaro, Pumariega, & Garrison, 1995; DHHS, 1999, 2001). The existing discrepancy between the number of African American adolescents in need of mental health services and the number who actually receive services suggests changes are needed to increase access, facilitate utilization, and improve treatment outcomes (Barkley, 2000; Cuffe et al., 1995; McCabe et al., 1999; McKay et al., 2002; Moorse, Johnson, & Heyliger, 2000; National Research Council and Institute of Medicine [NRC & IOM], 2000; Simms, Freundlich, Battistelli, & Kaufmann, 1999). Without understanding the way in which the perceived lack of culturally relevant knowledge, by provider systems, impacts service utilization (Cauce et al., 2002; Spencer, Kohn, & Woods, 2002), services will remain unchanged, under-utilized, and the unmet mental health needs of African American adolescents who are at higher risk for emotional and/or behavioral disturbance will continue.

By 2025, 48% of the children in the US will identify themselves as a member of a racial or minority group (US Public Health Services, 2000). The racial and ethnic groups we most recognize—Hispanics, African Americans, Asian and Pacific Islanders, and Native Americans—are quite diverse within these larger categories of race, ethnicity, and culture. Adolescents from these groups face social and economic inequality, including greater exposure to racism, discrimination, violence and poverty. This negative exposure negatively influences their mental health.

The need to understand the influence of race/ethnicity/culture on the utilization of mental health services is a response to the: (1) current and projected demographic changes over the next 25 years; (2) need to eliminate the disproportionate burden of disability from unmet health needs for African Americans; (3) need for culturally appropriate treatment interventions and outcomes; and (4) increase in awareness and understanding of provider bias which contributes to mental health disparities (Betancourt, Green, & Carrillo, 2002; Betancourt, Green, Carrillo & Ananeh-Firempong, 2003; DHHS, 2001; IOM, 2003; National Association of Social Workers [NASW], 2001; National Center for Cultural Competence [NCCC], 1999; Stroman, 2000). Ultimately, the practical need is to improve the mental health status of all children and adolescents. Treatment interventions that are designed to respect and understand the influence of culture and race on health are most effective within the individual’s frame of reference (Brach & Fraserirector, 2000; Cross, Brazon, Dennis, & Issacs, 1989; DHHS, 2001; Littell et al., 2001; McPhatter, 1997; Snowden, 2003; Sue & Sue, 1999).

The Impetus for Culturally Appropriate Mental Health Services

It seems appropriate to transfer much of the knowledge acquired in the practice of internal medicine from one ethnic and/or racial group to another. However, in the treatment of behavioral and emotional problems, which are inherently linked to social determinants this transfer, is not always appropriate or successful. In fact, it is no more appropriate to treat adolescents as if they are little adults and have the same psychological need as their parents (Martin, 2003; Stroman, 2000).

The 1999 Mental Health Report of the Surgeon General (DHHS, 1999), documents the striking disparities between the availability of mental health services to whites and those available to African Americans. In the United States African Americans are less likely to receive mental health services and when they do receive care it is likely to be of poor quality. Subsequent discussions move beyond the descriptive analysis to explain culture as an inextricable influence on beliefs about mental health and mental illness. Barriers to seeking care include care cost, stigma, perceptions regarding clinician’s lack of awareness of cultural issues, bias, miscommunication, and client fear and mistrust of treatment services (DHHS, 1999, 2001; Porter, Garcia, Jackson, & Valldez, 1997).

Not everyone agrees, but some researchers suggest ethnic matching of client and therapist and the use of ethnic-specific services increases the number of treatment visits and decreases treatment dropout for some African Americans (Barkley, 2000; Jerrell, 1998; Krauss, Goldsamt, Bula, & Sember, 1997; McKay et al., 2002; Snowden, 1998; Sue, 1997; Sue & Sue, 1999). Early termination of mental health treatment services is in response to geographical location of services to perspective African American consumers, and the lack of therapist-client match on language, ethnicity, and attitude (DHHS, 2001). These variables can influence the perceptions African Americans have of service delivery systems, structural barriers to service access, and the interpersonal receptivity of office environments.

Because ethnic match is not always available in mental health treatment services and recruitment and retention of minority providers may not be economically feasible, culturally competent practitioners providing treatment to African American families are vital for access and utilization (Betancourt et al., 2002; Brach & Fraserirector, 2000; DHHS, 2001; Moorse et al., 2000; Porter et al., 1997). Provider cultural competence can facilitate genuine therapeutic engagement and the application of appropriately designed treatment intervention. With specific regard to AA adolescents, effective interventions are designed to respect the socio-cultural influences on adolescent health (McPhatter, 1997). The values, beliefs, and attitudes used to explain and understand health status are unique to the socio-cultural influences of an individual’s environment. These attributes will vary with regards to one’s perception, cause, and treatment of illness and disease. Health beliefs influence help seeking behavior, health promotion practices, and preferences for traditional and non-traditional health care interventions. As individual perceptions of illness vary in accordance with their cultural values, beliefs, and conceptual understanding, effective practitioners must be aware of and acknowledge these variables when developing an effective therapeutic relationship (Fong & Mokuau, 1999; Littell et al., 2001; Marin et al., 1995; McKenzie & Smeltzer, 1997; Wurzbach, 2002).

Cultural competence is one of many attributes of quality care (Abe-Kim & Takeuchi, 1996; Cross et al., 1989; Flaskerud, 1986) and included in accountability monitoring for behavioral health and managed care organizations (NCQA, 1995; Stork, Scholle, Greeno, Copeland, & Kelleher, 2001). The literature is replete with studies, which demonstrate the central role of family, peers, school, neighborhood, and community in the psycho-social development of children. Individuals exist within a complex set of social, cultural, and ecological systems and the resulting inter/intra personal development affects the psychological health and well being at the individual level. An individual’s ecological environment consists of many social network systems. Each system of influence may be defined by its proximity to the individual. The most influential system—positive or negative—in the lives of children and youth is their immediate family (Cauce et al., 2002). For African Americans other systems of influence include the church and community more so than non-African Americans.

The Socio-Cultural Context

The socio-cultural context is conceptualized by the inter/intra-relationship between an individual’s social system and their culture. From a cultural competence perspective, understanding the client’s socio-cultural context is the path to appropriate treatment. The interactions of this context influences individual mental health status; how vulnerable individuals are to mental illness; the way in which individuals perceive, interpret, define, and give meaning to health and illness. This context influences the beliefs adolescents have of good health, the treatments they seek, and the health practices they use (Stroman, 2000; Wurzbach, 2002). The way in which individuals think about and deal with health and illness is a function of their social context and culture (Cauce et al., 2002; Guerra & Jagers, 1998; Martin, 2003; McClure & Teyber, 2003). Human behavior can be influenced by the individual’s social environment.

The social context includes the ecological environment, personal relationships, social supports systems, family, friends, neighbors, and their interaction. These networks of social groupings include individuals with whom we identify or feel a sense of belonging, for example, gender, sexual orientation, and immigration status. They may include individuals who practice the same religion, are the same age-range cohort, and/or in the same and/or related occupation. This context includes the major social and economic divisions in our society, and the individual’s degree of fit in relation to these divisions. The social context is further influenced by the political, social, economic, and history of our society (King & Williams, 1995; Wright & Anderson, 1998). For African Americans, this history includes the prolonged experience of racism and discrimination.

The cultural context is comprised of the ideas, beliefs, norms, values, attitudes, and knowledge that characterize a particular group of people. It is the sum of a group’s observable patterns of behavior, customs, and way of life. Culture provides standards for deciding what is, what can be, how one feels about it, what to do about it, and how far to go about doing it. It can be thought of as a web of meaning or, in an adolescent’s case, a variety of models for what they are experiencing and behaviors for demonstrating these experiences. Culture is the implicit and/or explicit knowledge which individuals acquire and use to interpret their experiences and generate behavior for living (Erikson, 1963; Leigh, 1998; Lum, 1999; Lynch & Hanson, 1998).

Socio-Cultural Risk Factors and Assessment

Of the many socio-cultural risk factors associated with the development of mental health problems, poverty is one of the most important risk factors in the younger years (US Public Health Services, 2000). African Americans children have higher rates of poverty than many other children in the United States. They are overrepresented in vulnerable, high-need populations because of their placement in child welfare and juvenile justice systems (Garland et al., 2000; McCabe et al., 1999; McPhatter, 1997; Spencer et al., 2002). The problems associated with race and poverty suggests African American adolescents are more likely to be disproportionately represented among young people diagnosed with emotional disturbance (Kirchheimer, 2003; National Council on Disability [NCD], 2002) than white children. From a longitudinal perspective, the legacy of slavery and prolonged experiences with racism and discrimination, researchers suggest that African Americans would have elevated rates of stress and mental illness, rather than lower or similar rates to whites (DHHS, 2001; Freimuth et al., 2001; Gamble, 1997; Williams, Lavizzo-Mourey, & Warren, 1999).

Poverty is not the only correlate to poor mental health. Socioeconomic status is linked to both access to and utilization of mental health services (US Public Health Services, 2000; Moorse et al., 2000). Poor mental health status is more common among individuals who are poor than non-poor. When compared to the socioeconomic status of other racial and ethnic groups in the US, African Americans are relatively poorer than whites (Proctor & Delaker, 2003). In 1999, 22% of African American families had incomes below the poverty line, compared to 10% for the United States as a whole. Among adult women, African Americans have a higher percentage rate for living below the poverty level (21.4%) than white (9.6%) and Asian /Pacific Islander women (10.1%) (DHHS, 2002).

Thirty-eight percent of African American children live with two parent families compared to 69% of all children in the US. For children who are more likely to live with one parent, African American children are more likely to live with their mother than all other children living in the US, 92% verses 69%, respectively (DHHS, 2001; Latimer, 2003). Children from single parent families who live in poverty are predisposed to a number of social, behavioral, emotional, and cognitive risk factors during their growth and development. Many challenges in single parent homes are sometimes facilitated by a single parent who is trying to fulfill the roles of both parents and experiencing considerable stress as a result (Brooks-Gunn & Duncan, 1997; Cauce et al., 2002; Proctor & Delaker, 2003).

Adolescents with emotional and behavioral problems are at increased risk for dropping out of school, and incapable of becoming fully functioning members of society during adulthood. With many childhood mental health disorders persisting into adulthood the cost in human and fiscal terms can be high (Carlson & Lewis, 2002; US Public Health Services, 2000). While it is difficult to put a fiscal cost on the loss incurred when adolescents with emotional problems are damaged in their formative years by the failure to receive needed mental health care, we do know that adolescents who lack these services are unable to learn adequately in school or benefit from healthy peer and family relationships due to unrecognized or untreated emotional problems (NCD, 2002; Putnam, 2002). The frequency of mental health challenges during early development appears to be highest among poor families with children; and a disproportionately number of African American children in this category (Barkley, 2000; US Public Health Services, 2000; Fellin, 1996; Brooks-Gunn & Duncan, 1997).

Epidemiological studies comparing African American and white children suggest that the need for mental health services varies (Broman, 1997; King & Williams, 1995; Spencer et al., 2002). Some studies suggest higher rates of symptoms or of certain types of mental illness among African American children and youth than whites (DHHS, 2001; Moorse et al., 2000). Other reports suggest that the need is the same (DHHS, 1999, 2001). In a study by Shaffer et al. (1996), children were identified as having an unmet need if they were impaired because of mental illness and had no mental health care in the preceding 6 months. In their findings African American children and youth were more likely to have an unmet need than white children and youth.

African American families have a variety of coping strategies that appear to buffer the effects of poverty, discrimination, and stress. Some studies have found African American’s using the following mechanism to cope: (1) facing up to the problem and doing something about it; (2) minimizing perceptions of threat; and (3) religious orientation and prayer (Broman, 1997; Neighbors & Jackson, 1996; Taylor, Jackson, & Chatters, 1997; Taylor, Hardison, & Chatters, 1996). Mutual commitment and a self-help tradition are recognized as protective factors for problem solving in African American communities, especially among family, friends, neighborhoods, religious, and voluntary organizations (Neighbors & Jackson, 1996).

Children grow up in family systems whose members bear the primary responsibility for their socialization. In addition to this universal socialization process, African American parents have to prepare their children to succeed in a society that has a history of being hostile and racist toward African Americans. Early socialization experiences help children develop culturally appropriate behaviors and find ways to meet their social and emotional needs. Adolescent development is a significant period of transition and reorganization. Therefore, it is critical to assess each individual’s unique mental health needs within the context of family, social, and cultural expectations about age-appropriate thoughts, emotions, and behavior (DHHS, 1999; Thomlison, 2002). Many adolescents are fully capable of describing their expectations, needs, and what is important to them about care (Barkley, 2000). Unless they are diagnosed with a serious emotional disturbance, many adolescents have the cognitive capacity to discuss their perceptions of mental health, mental illness, treatment, and outcomes (Buston, 2002). The unique socio-cultural factors of African American family systems do affect mental health service use. Individual perceptions of how the world operates around one’s universe are uniquely connected to their belief system. Therefore, understanding the socio-cultural context—family, community, school, gender, age, race, class, and peer relationships, etc.—during adolescent development, is necessary to designing effective treatment programs for African American adolescents (Cauce et al., 2002; Lewis, 2002; Martin, 2003; McClure & Teyber, 2003; Wright & Anderson, 1998). African American adolescents, like non-African American adolescents, are more likely to make their own decisions about entering and leaving treatment than younger children as well as how they will respond during the treatment process. Therefore, their perception of the identified problem and the interventions used to facilitated problem resolution is vital to treatment outcome. For example, the engagement period is an important phase for practitioners to feel and demonstrate competence in receiving and processing all that the client brings to the therapeutic environment. In addition to the generic knowledge and skills, practitioners must be competent in formulating one or more hypotheses for intervention using cultural knowledge of the adolescent, their problem, and the environment in which they exist (Caple, Salcido, & di Cecco, 1999; Clemento, 2004; Vernon, 2004). To a great degree, practitioners must be skilled in effectively demonstrating their own cultural awareness and assessing the extent to which their cultural differences and/or similarities have on the therapeutic process.

African American adolescents face the usual trials when maturing into early adulthood; i.e. media sexual images, domestic and community violence, gun violence, trauma, divorce rates, drugs, alcohol, and family dysfunction at rates higher than in the past, but in addition they also face problems associated with poverty, racial and ethnic discrimination, and stereotyping (Allen, 1998; Barkley, 2000; Carlson & Lewis, 2002; Clemento, 2004; Martin, 2003). Identity, pride, kinship, social support, and religion provide protective buffering factors via their socio-cultural environment, which can extend through the life cycle process (Hines, Preto, McGoldrick, Almeida, & Weltman, 1999; Taylor et al., 1997; Williams, Spencer, & Jackson, 1999). These cultural influences are necessary to consider when conducting mental health assessments and planning treatment interventions. The extent to which the above factors are assessed as supportive cultural influences toward therapeutic intervention is important.

African American Adolescent Development and Identity Formation

Erikson’s (1963) psychosocial theory describes the developmental tasks of adolescence as: (1) achieving independence; (2) adopting peer norms of behavior; (3) assigning increased importance to body image and acceptance of one’s body image; and (4) establishing sexual, ego, vocational, and moral identities. These tasks demonstrate the movement toward self-sufficiency. The adolescent’s need for services and the process by which service selection occurs may differ from their parents and other adult figures (Barkley, 2000; Cauce et al., 2002; Erikson, 1963; Vernon, 2004). The development of autonomy and identity are extremely important during adolescence because during this period of cognitive growth adolescents learn to reason, think deductively, have the will to test out new abilities, and try making their own decision. During adolescent development both group and individual identity formation occurs.

Adolescents from racial and ethnic minority groups engage in a maturational process where they examine, learn about, and develop an understanding of the meaning and implications of their own and other’s ethnicity (Grant & Haynes, 1999; Miller, 1999; Phinney, 2000). They learn the difference between being a part of or associated with one group verses another. “This age group has the capacity to integrate the past, present, and future; to determine the consistency and inconsistency of statements; and to anticipate consequences” (Grant & Haynes, 1999, p. 390). The process of discriminating individualized socio-cultural differences is influenced by race, class, culture, gender, and age. These filters allow contemplation of the broader social and cultural environment, demonstration of the reliance on logic, consideration of several attributes simultaneously, engagement in hypothetical thinking, abstract reasoning, and self-reflection (Grant & Haynes, 1999).

By utilizing the socio-cultural factors as the inimitable framework for organizing how individuals think and respond, clinicians can observe that the adolescent’s cognitive abilities, affect, and behavior are influenced by this context. In fact, this influence occurs prior to adolescence particularly with regards to the recognition of racial and cultural differences (Caino & Spurlock, 1994; Taylor, 1998; Taylor, Brown, & Denton 1996). For most adolescents, particularly African Americans, their construction of identity occurs within the reality of their own socio-cultural environment. The intra/inter relationship of race and culture entwined in adolescent identity validates an awareness of the multiple filters through which individuals make sense of their world. Culturally competent practitioners have the ability to design treatment interventions that demonstrate a respect for and understanding of the influences of race, culture, class, and gender on adolescent development. Without cultural competence, practitioners are unable to comprehend the world realty of African American adolescents.

In a culturally diverse society, individuals belong to a multiplicity of overlapping social groups, including but not limited, to those identified by race, gender, age, social class, language, immigrant status, minority status, ethnic identification, and sexual orientation, etc. Determining the individual, group or culture identity that is most relevant to providing mental health treatment services to African American adolescents can be a difficult task. The common practice in mental health assessment is to identify individuals according to class, race, skin color, ethnicity, or minority status or the particular psychosocial developmental stage without understanding and/or accepting that these categories facilitate within group difference. Mental health practitioners may not have the luxury of time to methodically dissect the unique contributions of these variables on the psychological functioning of African American adolescents.

Identity formation is achieved as a result of an extended period of exploration and experimentation, which takes place between 11 and 17 years of age (Erikson, 1963). This process leads to individual decisions and/or commitments to various life style variables such as occupation, religion, and politics for early adulthood. Although Erickson’s theory alludes to the importance of culture in identity formation, his framework does not take ethnicity and/or race into consideration nor has it been widely applied to access, utilization, and help-seeking factors for mental health services by African American adolescents (Boldero & Fallon, 1995; Buston, 2002; Cauce et al. 2002; Guerra & Jagers, 1998). During adolescence individuals explore their own identity on several salient levels, i.e., race, religion, culture, ethnicity, gender, age, sexuality, class, etc. Exploration can involve a process of immersion in one’s own culture through activities such as reading, talking to people, peer associations, music, dance, mass media, technology, hairstyles, dress, ethnic art, politics, and participating in cultural events (Allen, 1998). This immersion includes racial socialization group contact, educational achievement, parental attitudes, social class, self-esteem, gender, and regional social norms (Cauce et al., 2002; Miller, 1999; Thompson, 1999; Vernon, 2004).

For African American adolescents their evolving identity may include rejecting the values of the majority culture and/or establishing some level of acculturation (Klonoff & Landrine, 1997; Snowden & Hines, 1999; Spencer, Dupree, Swanson, & Cunningham, 1996; Taylor et al., 1996). This model of development permits adolescents to gain a deeper awareness, understanding, and appreciation of their own ethnic identity. Coming to terms with identity achievement involves the internalization of a deeper understanding and appreciation of ethnicity (Carter, Desole, Sicalides, Glass, & Tyler, 1997). As a clear and confident sense of one’s own ethnicity is achieved, there are two issues to consider for resolution and/or coming to terms with self for African American adolescents. First, acknowledging the cultural differences between their own group and white Americans and second, the lower or disparaged status of African Americans in American society (Martin, 2003; Spencer et al., 2002).

Identity development can be a difficult task for any individual. For many African American adolescents this process is a complicated task given their socio-cultural context, ecological environment, and racial socialization experiences. These adolescents need to develop a positive racial identity to prevail over the prolonged negative stereotypes associated with their racial heritage group. Racial identity develops through racial awareness, which is facilitated by racial socialization. The interpersonal dynamics that result when race and class are part of this process can be unpredictable. Culturally competent practitioners know that race matters. Therefore, knowledge regarding the dynamics, which facilitate racial identity in African American adolescents is integral to the therapeutic process.

Perceptions, Values, Beliefs, and Attitudes as Barriers to Care

Identity formation and development can assist in shaping individual perceptions, values, beliefs, and attitudes. While existing literature on mental health suggest African Americans have problems accessing services, that services don’t meet their needs, or both (Brown, Ojeda, Wyn, & Levan, 2000; DHHS, 2001; IOM, 2003; Moorse et al., 2000; Williams & Rucker, 2000); adolescents are fully capable of describing their expectations, needs, and what is most critical to them about care (Barkley, 2000; Buston, 2002). Their belief system is an extension of their socio-cultural context as well as an important determinant of access to and utilization of mental health services. Unfortunately, little attention has been paid to this relationship with respect to African Americans (Cauce et al., 2002; Dubow, Lovko, & Kausch, 1990; Guerra & Jagers, 1998; Phinney, 2000; Snowden, 2003) and barriers to care.

Perceptions, values, and beliefs are just as critical as trust in mental health treatment and should be considered as potential barriers to care. The barrier, which is discussed less often in the literature, but has an impact on therapeutic engagement and treatment, is individual attitude. Richardson (2001) uses social cognitive theory to demonstrate the extent to which the expectation of a positive outcome as encouragement to engage in mental health services. Her work suggest that African American parents who disproportionately have negative attitudes about mental health services are also concerned about the disapproval from family members and others, and embarrassed about seeking services. Such parents feel they are at fault or will be made to feel at fault for their child’s behavior. Therefore many parents would not want others from their social network to know their child’s mental health status (Littell et al., 2001). African American parents are more likely than white parents to expect providers to lack knowledge of treatment methods for working with their children, find providers untrustworthy and disrespectful, expect providers to give poor care, and lack appropriate knowledge with regards to what mental health professionals do and how interventions help. These perceptions fit with the dynamic intrusion of race on professional relationships and identify concerns that African Americans have about working with racially dissimilar providers. Client perceptions of treatment support the view that the therapeutic relationships influence treatment intervention (Proctor and Davis, 1996). If the engagement process is perceived as awkward and uncomfortable, African American adolescents are less likely to continue with treatment intervention. Both the client and provider bring a set of assumptions about the others race and its potential outcome on the treatment process.

Like most adolescents, African American adolescents value confidentiality. And, although not specific, perceptions of confidentiality are unique with this group (Barkley, 2000). For many African Americans, seeking professional help is a last resort. From the African American adolescent’s perspective, this professional intervention may require talking with a “White adult about personal and private family concerns”—a social behavior they may have learned over the years is inappropriate. As a cultural value, many African Americans try to handle things on their own. When significant adults in the socio-cultural environment of the African American adolescents have been dissatisfied with past mental health treatment because white providers had little awareness of cultural issues, appeared bias, or there was an inability to speak the client’s language (Cauce et al., 2002; DHHS, 2001; Dubow et al., 1990; Neighbors and Jackson, 1996; US Public Health Services, 2000; Walker, 2001), adolescents may have inherited this perception. These perceptions are passed on through the socialization process with trusted family, friends, and extended relations (Cauce et al., 2002). Client’s fear and mistrust of treatment is especially acute with many African American in comparison to whites (Caldwell, 1996; Mays, Caldwell & Jackson, 1996).

Initiating therapeutic discussions which are pertinent to race, class, prejudice, discrimination, etc. can give a perception that the provider is comfortable discussing such sensitive issues, is willing to engage in a dialogue which may be central to how African American Adolescents see themselves in relation to the world, and the role such variables have in the therapeutic process. Such discussions communicate empathy and cultural sensitivity for the differences between provider and adolescent. Improving communication skills for discussing “forbidden topics” can facilitate trust; demonstrate modeling, and have the potential for changing both clinician and client behavior (Brach & Fraserirector, 2000).

Implication for Practice and Research

Practice

Adolescent mental health practitioners must demonstrate fundamental knowledge and understanding of their target population. Although there are general and consistent patterns regardless of race and class, it is important to acknowledge and understand that adolescence occurs in a larger society, and this requires additional competence when working with African American adolescents. The systemic nature of their socio-cultural environment influences their development. Cultural considerations such as religion, gender, sexual orientation, race, and ethnicity all affect how African American adolescents interact with their environment and how the environment responds to them. By acknowledging the significant influence of the socio-cultural environment, practitioners can identify ways in which the social environment can also facilitate positive mental health status. Practitioners can assess the mental health needs of African Americans and determine the association between the socio-cultural environment and the evidence of mental health problems.

Few African American adolescents self-refer to mental health systems and when the do, they have to move beyond the stranger contact phase during engagement. Just as therapists are interested in getting to know the uniqueness of each client, African American adolescents and their parents want to know their therapist. The engagement phase, when appropriately conducted, can facilitate culturally appropriate communications, and a trustworthy relationship. The intrinsic reward of therapeutic gain for both the adolescent and the provider is observed when the therapeutic encounter encompasses genuine positive regard. African American parents and their children will decide, for themselves, if their clinician is a person of good will. During the engagement phase of the treatment process, a separate and distinct intra personal dialogue is going on with the adolescent, while the clinician is attempting to interpersonally engage the adolescent in the therapeutic process. From this perspective, the provider and the client are in a separate and uniquely different psychological space from the beginning. This example reinforces a traditional principle of social work practice, which is to start where the client is.

Some clinicians may be remiss in explaining the purpose of the contact on neutral terms. When working under the guidelines of managed care, many therapists feel pressed to begin the problem solving process without an appropriate engagement period for building an open, trusting, genuine, and collaborative relationship. African American youth and their parents are especially interested in exploring knowledge about the clinician as a person and as a provider of care to African American populations. This concern may not be exclusive to race, but also class. Therefore, self-disclosure around issues of trust and experience with African American clients may be necessary during the engagement process. For less experienced clinicians, facilitating trust may require more time to educate and explain the therapeutic process than with same race clients. Follow-up telephone calls may be required to indicate a genuine interest when African American clients don’t show up for their initial appointment. For parents who are already over-burdened with family responsibilities, a “reminder phone call” before the adolescent’s scheduled appointment can be a cue to action.

The development of prevention programs as an intervention strategy can be a function of the unique issues African American adolescents identify as having a contribution to both their presenting concerns and coping ability. From a strengths perspective, treatment services for adolescents should be designed to improve self-image, behavioral change, and health and well being. For this group of adolescents, prevention programs can be successful for clarifying perceptions, attitudes, and beliefs about mental illness, treatment services, and outcomes. Finally, prevention programs are cost effective.

Program interventions can provide networking opportunities to obtain community services and supports for at risk youths. Collaborative work with churches, schools, and communities to conduct educational workshops for increasing awareness of mental health issues can decrease some of the stigma regarding illness and treatment. Community-based prevention programs can demonstrate greater potential in sustaining good mental health for youths than traditional institutional methods. Adequate resources for culturally sensitive programs for mental health treatment are needed. These programs should provide opportunities for adolescents to receive self-referred confidential mental health treatment services.

Failure to understand the unique socio-cultural background of African American Adolescents and their families lead to continued misdiagnosis, lack of cooperation, poor use of mental health services, and a general alienation of African American adolescents from the mental health system.

Research

Previous attempts to improve the quality of adolescent mental health services through consumer participation in research investigations have resulted from examining the perceptions and satisfaction levels of European American adolescents and/or their parents. Research investigations which focus on access and utilization of African American adolescents cannot be limited to examining the perceptions of European American parents regarding EA adolescents’ care nor the adolescents themselves. Such studies are biased toward their perspective, the providers who work with them and/or evaluators who conduct the investigation. This has resulted in a lack of understanding of African American adolescent attitudes and behaviors toward treatment engagement in addition to ineffective attempts for intervention.

To develop more culturally effective engagement strategies for African American adolescents, the unique and complex interactions of race, culture, and class during adolescent development must be continually investigated. Research questions that appreciate the challenge of the way in which these variables influence mental health status are needed. Specifically, research regarding the perceptions and attitudes African American adolescents have of mental illness, treatment, and services have not been studied.

While significant attention has been paid to adolescent mental health services, very little is known about how adolescents perceive the services provided. Research on client perception and satisfaction with African American client populations has been limited. Investigations on client perceptions would examine feelings, values, attributes, and skills brought to the therapeutic environment by clients. It is important to consider the client’s perspective of treatment because they are not passive recipients of therapeutic intervention rather the therapeutic relationship reflects a two-way process in which the input of the client is at least as important as that of the therapist (Macran, Ross, Hardy, & Shapiro, 1995).

In order to clarify and understand the developmental differences when assessing the perceptions African American adolescents have of mental health services, it is appropriate to conduct research investigations on the way in which children in treatment and children not in treatment, but at risk for treatment, perceive and conceptualize illness and treatment. Effective treatment interventions for adolescent mental health services must be grounded in a theoretical perspective which demonstrates an appreciation for the process of cognitive development as it influences the capacity to conceptualize illness and treatment (Richardson, 2001). The extent to which treatment interventions are related to the issues that define an individual’s life—such as race, class, and gender—should be explored.

When engaging in research investigations that are dependent on examining specific and relevant phenomena related to race as a variable, i.e., African American, Hispanic, Native American, Asian Americans, there should be a simultaneous focus on socio-cultural variables, historical conditions, biological determinants, and psychological outcomes as important perspectives for understanding life course experiences and outcomes for these populations by investigators. These relationships are dynamic and interactive but rarely discussed from a treatment perspective by white providers. The relationship between an interactive influence of identity and competence processes during adolescent development is under-studied and frequently misunderstood (Cunningham, 1999, Spencer, Swanson, & Cunningham, 1991; Spencer, Dupree, & Swanson, 1996).

Conclusions

Discussions about race can be both a sensitive and a challenging issue. Many therapists may avoid such discussions. This fear can originate from feelings of guilt and/or a fear of not being able to control the discussion once it is initiated. Fortunately, many African American adolescents have knowledge of and experience with race relations as well as the many negative associations made regarding adolescents in general and adolescents of color in particular. Therefore a discussion on the development of practices that will improve outcomes for African Americans in need of mental health services within the therapeutic process is important to discuss.

Given the historical connections to their past, their stage of identity formation, and their level of acculturation, it may be difficult for African American adolescents to perceive and believe that the clinicians care about them. If the therapeutic process is unfamiliar to racially different clients, a seasoned therapist, who is comfortable and confident with their skills in working with resistant clients, may have an advantage over less experienced, more tentative providers.

Without understanding the ways in which socio-cultural contextual factors impact services to this subgroup, treatment modalities will remain unchanged, under-utilization will continue, and the unmet health needs of African American adolescents who are at higher risk for emotional disturbance—due to childhood poverty and its associated social problems will persist.

Can providers, agencies, practitioners, and service systems respond appropriately to the needs of culturally diverse children and their families without further enhancing their competence regarding the socio-cultural influences on health, health status, and health behavior? Perceived cultural misunderstandings and communication issues with majority providers will continue to be a barrier both access and utilization of appropriate care services (Bachrach & Newcomer, 2002).