Is Multicultural Counseling Competency Training the Best Intervention for Disparities In Mental Health Services?

Purpose: For over 30 years multicultural counseling competency (MCC) training has been the dominant intervention used to reduce racial disparities in mental health services. MCC is predicated on the premise that clinicians must be trained to develop the awareness, knowledge, and skills necessary to engage ethnically and culturally diverse clients in successful therapeutic relationships. Surprisingly, little evidence exists to empirically prove this premise or to support MCC as an evidence-based practice. To examine the assumptions that underpin MCC and its effectiveness as an intervention we model clinician and agency factors thought to affect outcome disparities experienced by black clients receiving services for a serious mental illness.

Methods: Data from 15 community mental health centers (CMHCs), 76 clinicians (20% black), and 906 clients (25% black) were analyzed using three different multi-level models to identify the effects of clinicians and agencies on outcome differences between black and white clients and the magnitude of those effects. Outcomes were measured three times using the Behavioral and Symptom Identification Scale (BASIS-24), an indicator of symptomology and functioning. Multicultural Counseling Inventory was used to measure clinicians' level of MCC proficiency. Numerous additional service and demographic variables were included in the analyses at the client and clinician levels. The analyses were conducted with HLM software (version 6.06) and the models contained three levels. Conceptually, level 1 represented treatment outcomes measured over time for each client. At level 2, each client was described by their baseline score (intercept), treatment outcomes (slope), and demographic and service predictors. Level 3 represented the influence of clinician or agency factors on outcome differences between black and white clients.

Results: Clinicians and agencies moderated the relationship between client race and outcomes. There was significant variability among clinicians and agencies, with approximately 20% of each linked to negative outcome differences for black clients (disparities). The moderating effect of clinicians accounted for 28.7% and agencies 21.7% of the variability in outcome disparities between black and white clients. Of the numerous predictors of outcome differences tested at the clinician level only the clinicians' general experiences and relationships with people from ethnic and cultural groups other than their own was significant. MCC awareness, knowledge, skills and the clinicians' race were not predictors of outcome differences. Agencies with high rates of outcome disparities were characterized by low levels of supervisory support, clarity of agency goals, and involvement with clients, coupled with high levels of control by administrators.

Implications: Treatment outcomes for black and white clients vary depending on the clinician and the agency. The magnitude of the combined effects, which account for approximately 50% of the variability in outcome disparities, indicates that clinicians and agencies are critical components of treatment for clients from racial and ethnic minority groups receiving services at CMHCs. The findings also suggest that the traditional approach to reducing disparities of having clinicians participate in MCC training may be less effective than an organizational intervention that restrains clinicians' biases and strengthens their positive involvement with clients from ethnic and cultural groups other than their own.