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THE INFLUENCE OF RACE AND ETHNICITY IN CLIENTS’ EXPERIENCES OF MENTAL HEALTH TREATMENT

Oanh l. meyer.

University of CA, San Francisco and University of CA, Davis

University of CA, Davis

Clinicians and researchers have pointed to the need for culturally sensitive mental health interventions. Yet it has not been determined if the inclusion of cultural elements affects the way mental health clients experience services. This study examined 102 clients who had received mental health treatment from outpatient mental health clinics to investigate whether culturally related elements involving race and ethnicity were important to clients and whether they were related to client satisfaction and perceived treatment outcomes. Ethnic minority clients generally felt that issues regarding race and ethnicity were more important than did White clients. When these elements were considered important but were not included in their care, clients were less satisfied with treatment. Consistent with the notion of cultural responsiveness, these findings provide empirical evidence that culturally relevant aspects of the mental health service experience are salient to ethnic minority clients and can affect how they respond to services.

The U.S. Surgeon General’s Report on Mental Health, Culture, Race, and Ethnicity (2001) acknowledged that racial and ethnic minority persons are underserved and ineffectively served by mental health professionals. Similarly, the Institute of Medicine ( IOM, 2002 ) reported that African American and Hispanic patients were more likely to report dissatisfaction with their relationships with providers and to perceive poorer quality of care. Using a clinical sample of Asian American and White mental health outpatients, Zane, Enomoto, and Chun (1994) found that Asian Americans reported lower service satisfaction, less confidence in their provider, and greater levels of symptomatology that were attributed to a lack of culturally responsive therapy. In response to these problems, there has been an impetus to improve the cultural responsiveness of mental health providers through education and training ( Sue & Sue, 1999 ).

Moreover, the American Psychological Association ( APA, Committee on Accreditation, 2002 ) recognized the importance of integrating discussions of race and ethnicity into the field of psychology by highlighting these issues in clinical training programs. In 2003, the APA approved guidelines for multicultural counseling ( APA, 2003 ). These guidelines underscore the importance of attending to racial and ethnic issues, in particular, as they affect the therapy relationship ( Sue, Arredondo, & McDavis, 1992 ).

A variety of terms have been used to refer to the consideration of culture in mental health treatment, including “multicultural competence” “culturally sensitive,” “culturally competent,” or “culturally responsive.” Although the field continues to struggle toward operationalizing multicultural counseling competence and its component parts ( Sue, Zane, Hall, & Berger, 2009 ), researchers have suggested that counselors’ multicultural counseling competence is critical for effectively working with clients of color, accounting for a significant proportion of the variance in clients’ satisfaction beyond ratings of general therapist competence (e.g., Constantine, 2002 ).

Mental health researchers have long recommended the use of a consumer perspective on care provider cultural competency ( Pope-Davis et al., 2002 ). More recently, there has been an emphasis on patient-centered care in health and mental health systems ( Clancy & Collins, 2010 ). Few investigations have examined the client’s subjective experience of race and cultural issues in treatment as well as what occurs during treatment ( Ito & Maramba, 2002 ). Some studies (e.g., Ito & Maramba, 2002 ; Maxie, Arnold, & Stephenson, 2006 ) have investigated therapists’ perspectives regarding their practices, but there has been a lack of empirical research describing how clients actually experience therapy with regards to racial issues ( Chang & Berk, 2009 ). This is troubling given that the client’s evaluation of the therapy relationship (as opposed to the counselor’s view) is most strongly associated with therapy outcome ( Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003 ; Horvath & Bedi, 2002 ; Quintana & Meara, 1990 ; Safran & Segal, 1990). Therefore, the assessment of client satisfaction is a necessary and critical element in the evaluation of mental health services ( DiPalo, 1997 ).

Mental health consumer satisfaction refers to the extent that services gratify the consumer’s wants, wishes, or desires for treatment ( Lebow, 1983 ). This definition also includes the perceived adequacy of treatment and the surrounding milieu (i.e., cost, continuity, availability, accessibility of care, and the reaction to supporting services). Given the continual emphasis on patient-centered care, it is important to understand what mental health clients expect regarding culturally responsive care.

The goal of this study is to examine how race and ethnicity affect the client’s experience of mental health treatment. Definitions of the terms race and ethnicity are varied and distinguishing between these two concepts is often challenging, as indicated by the fact that these terms are sometimes used interchangeably, despite their individual nuances ( Bhugra & Bhui, 2002 ; Bhui, 2002 ; Helms & Cook, 1999 ; Helms & Talleyrand, 1997 ). “Ethnicity” often refers to the historical cultural patterns and collective identities shared by groups from specific geographic regions of the world ( Betancourt & Lopez, 1993 ; Helms & Cook, 1999 ). Although race has been proposed as a social psychological construct and not a biological marker of difference ( Smedley & Smedley, 2005 ), and there is no strong agreement regarding the construct in psychological research ( Cokley, 2007 ; Helms, Jernigan, & Mascher, 2005 ), race is an important topic to study because it is particularly salient for ethnic and racial minorities ( Comas-Dıaz & Jacobsen, 1991 ; Helms, 2007 ; Wright and Littleford, 2002 ). Although we do acknowledge the importance of distinguishing between race and ethnicity, for the purposes of this article and its scope, issues of race and ethnicity are discussed collectively and inclusively, similar to other studies (e.g., Cardemil & Battle, 2003 ).

Racial Match

Racial match, or concordance, has been described as one element of culturally responsive care and a potential factor in reducing mental health disparities for ethnic minorities. Racial/ethnic match occurs when mental health clients and providers share the same race or ethnicity. In a counseling situation, therapist ethnicity may be one of the most important features to which clients first attend. Ward (2005) conducted a qualitative investigation of counseling processes and perceptions of counseling specific to African American clients within a community mental health agency. During the first counseling session, clients reported assessing the race and ethnicity of the counselor above everything else ( Ward, 2005 ). Only after an assessment of racial match did clients assess other counselor variables (e.g., age, gender).

Some studies have shown racial match to be associated with increased utilization, favorable treatment outcomes (i.e., global assessment scores, substance use reduction), lower treatment dropout, and greater satisfaction ( Blank, Tetrick, Brinkley, Smith, & Doheny, 1994 ; Flaskerud & Liu, 1991 ; Flicker, Waldron, Turner, Brody, & Hops, 2008 ; Gamst, Dana, Der-Karabetian, & Kramer, 2001 ; Gamst et al., 2003 ; LaVeist & Nuru-Jeter, 2002 ; O’Sullivan & Lasso, 1992 ; Sue, Fujino, Hu, Takeuchi, & Zane, 1991 ). 1 Maramba and Hall (2002) conducted a meta-analysis of seven studies and found that clients matched with therapists of the same ethnicity were less likely to drop out of therapy and more likely to attend more sessions; however, the effect was small, indicating that ethnic match alone was a weak predictor.

A more recent meta-analysis of 10 studies found no significant difference between racially matched dyads versus unmatched dyads with regard to staying in treatment and overall functioning for African American and White clients ( Shin et al., 2005 ). Despite this, ethnic minority clients may view ethnically similar counselors as more credible sources of help than White counselors because they assume shared commonalities in culture or values, elements that may be important to minority mental health clients ( Meyer, Zane, & Cho, 2011 ; Sue & Zane, 1987 ; Zane et al., 2005 ). It also may be that the counselor’s and client’s racial worldviews (or racial identity stages) have a much stronger impact on the counseling process than race ( Atkinson & Thompson, 1992 ). Ward (2005) found that racial match might be more important for individuals with a stronger Black identity.

Although a host of research studies has centered on the topic of racial differences (e.g., racial match) between client and therapist in treatment, little is known regarding the dialogues that take place between therapists and clients ( Maxie et al., 2006 ). The discussion of race and racial differences early in treatment is an example of a cultural competency skill ( Fuertes, Mueller, Chauhan, Walker, & Ladany, 2002 ). Researchers have suggested that open dialogues about issues of race and ethnicity can promote an environment of trust that will ultimately benefit the treatment process ( Cardemil & Battle, 2003 ).

The counseling literature is replete with examples of the importance of counselors acknowledging and addressing racial and ethnic differences between a counselor and client during treatment (Arredondo, 1999; Harley, Jolivette, McCormick, & Tice, 2002 ). Analogue studies ( Thompson & Jenal, 1994 ; Thompson, Worthington, & Atkinson, 1994 ) have found that making sensitive responses to clients’ concerns about racial issues is preferable to ignoring or avoiding clients’ concerns. Other research has found that counselors who directly addressed racial issues in the first two sessions of a 12-session counseling experience reported creating an environment conductive to building a strong therapeutic relationship with their clients ( Fuertes et al., 2002 ). In a qualitative study of African American views about counseling, some participants felt that discussions of race not initiated by the client were indicative of therapists’ racism and discomfort. Overall, there are varied perspectives regarding individuals’ beliefs about the discussion of race and ethnicity in treatment ( Thompson, Bazile, & Akbar, 2004 ).

Cultural issues like race and clients’ history of discrimination certainly have influential roles in treatment because they are a part of the ethnic minority experience ( Bernal & Saez-Santiago, 2006 ; Cardemil & Battle, 2003 ). Discrimination as a topic may be more salient because ethnic minorities typically report higher rates of perceived discrimination than Whites ( Kessler, Mickelson, & Williams, 1999 ). Therefore, it is important to consider how these types of experiences might affect the therapeutic process. Chang and Berk (2009) found that culture-specific knowledge mentioned by participants as conspicuously absent from their therapists’ knowledge base included issues such as racism and discrimination. Although they found that race was salient to a majority of their participants, they were unable to assess the relative importance of the various factors described by clients as salient (e.g., racism and discrimination) in their evaluation of the therapy experience.

PRESENT STUDY

The present study draws on process and outcome research as well as client satisfaction research that emphasizes the role of client perceptions and contributions to positive outcomes ( Tallman & Bohart, 1999 ). We examined if specific elements associated with purportedly culturally sensitive or culturally competent mental health care were important to ethnic minority and White clients and whether or not their inclusion in treatment was actually related to the way clients experienced their treatment. Specifically, we examined provider-client racial match, provider knowledge of ethnic/racial group’s history of discriminations and prejudices, and provider discussions of race and ethnicity in treatment. Given that cultural issues may be of particular concern for ethnic minority clients ( Owen, Leach, Wampold, & Rodolfa, 2010 ; Zane, Hall, Sue, Young, & Nunez, 2004 ), it was hypothesized that these three cultural elements would be more important for ethnic minority clients than White clients. Similar to other studies examining client satisfaction, we assessed client reports of events rather than ratings, allowing for the identification of specific provider behaviors that could be modified to increase client satisfaction and outcomes ( Napoles, Gregorich, Santoyo-Olsson, O’Brien, & Stewart, 2009 ).

A total of 102 mental health clients were drawn from two outpatient samples: (a) young adults seeking care from the private sector (e.g., health maintenance organizations) recruited from a local university and (b) adult clients from two public community-based mental health clinics. 2 The clinics were all located in Northern California. At the time of data collection, the university served a population of over 28,000 students, about half of whom were ethnic minorities. The majority of the clients (70.6%) were receiving services at the two community-based centers that provided outpatient mental health services to adults with serious mental health issues. Staff at these centers were comprised of clinicians, counselors, mental health workers, psychiatrists, and support staff.

The study was comprised of 75 (73.5%) females. In terms of ethnicity, there were 57 (55.9%) White Americans, nine (8.8%) Asian/Pacific Islanders, nine (8.8%) Latinos, 16 (15.7%) African Americans, eight (7.8%) Native Americans, and three (2.9%) biracial individuals (i.e., Black/White). The sample had slightly more Whites (55.9%) than ethnic minorities. Ages of participants ranged from 18–65 years (mean [ M ] = 37.07, standard deviation [ SD ] = 13.31). The majority of the clients were single (75.5%), not employed (63.7%), born in the United States (90.2%), and were being seen by a psychiatrist or psychologist (59.8%). Demographic differences by type of participant were analyzed. Private clients (70% White) did not differ significantly from community-based (CB) clients (50% White) in ethnicity, p = .06, gender (private = 80% female; CB = 70.8%), p = .34, or nativity status (private = 96.7% U.S. born; CB = 88.7% U.S. born), p = .20. No significant differences emerged for length of time seen by provider, with at about 50% of individuals in both groups having seen the provider for at least two years, p = .77. Significant differences emerged for marital status, education level, and employment. Private clients were more likely to be single or never married (66.7% vs. 37.1%), p < .01, to have some college (76.7% vs. 37.1%), p < .01, to be younger (mean age of 23.23 vs. mean age 43.00), p < .001, and less likely to be unemployed (36.7% vs. 79.4%), p < .001.

Clients from the private sector were either currently receiving or had at some point received mental health services for their problems. These clients received course credit for their participation. Community-based clients who were waiting to see their care provider in the clinic were asked by a research staff member to participate in the study. Eligibility for the study was based on consent and sufficient mental capacity to complete all the measures. An Asian American research staff member thoroughly reviewed the consent form and procedures of the study with each client before he or she could participate. Participants completed the questionnaires individually while either waiting to see their provider or after meeting with their provider. The majority of clients spent approximately 20–30 minutes completing the measures. Respondents could also choose to enter a monetary raffle. This study received institutional review board approval.

Cultural elements

Cultural elements were items taken from the Cultural Acceptability of Treatments Survey (CATS). The CATS assesses how clients perceive and respond to specific service elements that address cultural issues ( Leff et al., 2003 ). We examined clients’ expectations regarding provider-client racial match, provider knowledge of discriminations and prejudices faced by one’s ethnic/racial group, and provider discussions of race and ethnicity in treatment. These elements are reflected in the format of the survey, so that each element contains questions regarding its importance and inclusion in treatment. For example, the importance item asks, “How important is it to you that your provider include knowledge about the discriminations and prejudices faced by your racial/ethnic group?” Response choices ranged from 1 ( not important at all ) to 4 ( very important) . The inclusion item asks, “In your treatment, has your provider included knowledge about the discriminations and prejudices faced by your racial/ethnic group?” Response choices ranged from 1 ( never) to 5 ( always) . Demographic questions also were included in this measure.

Client satisfaction and outcomes

Client satisfaction and outcomes were assessed by the Mental Health Statistics Improvement Program (MHSIP) Consumer Survey. The MHSIP consumer survey was developed with input from a variety of stakeholders with support from the Center for Mental Health Services ( CMHS, 1996 ). It is part of a broader mental health report card that also includes indicators obtained from medical records or administrative databases. The MHSIP consumer survey is a 28-item self-report instrument designed to be completed by the client without assistance. It consists of four scales that measure access (six items), quality/appropriateness of care (11 items), outcomes (eight items), and general satisfaction (three items). The items are rated on a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). Clients can also indicate that an item is not applicable to them. The MHSIP survey is widely used in public mental health systems and states ( Teague, Ganju, Hornik, Johnson, & McKinney, 1997 ).

The Access subscale assesses the extent to which clients perceive that services are quickly and readily available to them (“Staff were willing to see me as often as I felt it was necessary”). Quality/appropriateness of care assesses the best possible match between a client and type of care and chosen treatment, as well as service utilization (“Staff told me what side effects to watch out for”). Satisfaction assesses global satisfaction with the treatment (“I liked the services I received here”). Treatment Outcomes assesses the client’s evaluation of improvements in psychological, social, and occupational functioning as a result of care (“My symptoms are not bothering me as much”). Cronbach alphas for the present sample were as follows: access, α = .87; quality of care, α = .92; satisfaction, α = .86; and perceived treatment outcomes α = .94.

Data Analysis

Data were analyzed using Statistical Package for the Social Sciences (SPSS), Version 20.0 ( SPSS Inc., 2011 ). First, to test for ethnic differences in importance ratings of the three cultural elements, a multivariate analysis of variance (MANOVA) was conducted. If a significant overall ethnicity effect was found, t tests were performed. This multivariate adaptation of Fisher’s protected t test guards against inflated setwise Type I error rates and also keeps both F and t tests relatively powerful ( Cohen & Cohen, 1975 ). Second, bivariate analyses were conducted to assess the linear relationships among the key study variables. Given the somewhat small sample size of this study, we had these first two analyses inform which cultural elements should be entered as predictors in subsequent regression analyses.

Third, importance and inclusion scores were standardized, and then discrepancy scores were calculated reflecting the difference between the importance of an element and the extent to which it was included in service. Larger discrepancy scores indicated that clients tended to value the element, but it was not included in care. For example, if a client considered provider knowledge of history of discriminations/prejudices as very important, but it was perceived as not being included in treatment, this would result in a larger discrepancy score. A series of two-step hierarchical regression analyses were run to determine the relative contribution made by demographic and cultural factors on client satisfaction and perceived outcomes. In the first step, age, gender, and type of participant were entered as predictors. In the second step, cultural elements were added to the model. Regression analyses were run for each of type of client service evaluation: access, quality of care, satisfaction, and perceived treatment outcomes, using discrepancy scores as predictors in each analysis.

Characteristics of the Sample

Table 1 presents the mean or percentage distribution of demographic and outcome variables for all individuals by ethnicity. Crosstabs and t tests were employed for categorical and continuous variables, respectively. The ethnic minority and White sample differed significantly by age, nativity status, and employment status. Ethnic minorities were older ( M = 40.16, SD = 13.11) than Whites ( M = 34.64, SD = 13.07), t = −2.09, p < .05 (95% confidence interval [CI] = −10.75, −.28), and also more likely to be born outside the United States than Whites, χ 2 = 7.86, p < .01. Ethnic minorities were also more likely to be unemployed (71.1%) compared with Whites (54.7%). No significant differences emerged on the four outcome variables.

Demographic Characteristics of the Sample and Outcome Ratings by Ethnicity (N = 102)

Note. SD = standard deviation.

Importance of Cultural Elements

A MANOVA tested for an overall ethnic difference in the importance of cultural elements. A significant effect of ethnicity was found, F (3, 98) = 3.98, p < .05. Univariate analyses were then performed to interpret this finding. Sample means of cultural elements for Whites ranged from 2.03 to 2.11, while means for ethnic minorities ranged from 2.44 to 2.96. These results indicate a generally higher level of importance of cultural elements for ethnic minority clients compared with White clients. There were significant differences between White and ethnic minority clients on two of the three cultural elements. Minorities felt that it was significantly more important for their provider to be racially matched ( M = 2.84, SD = 1.16) than Whites ( M = 2.11, SD = 1.13), F = 10.19, p < .01, partial n 2 = .09.

Minorities also felt that it was significantly more important that their provider be knowledgeable about their ethnic/racial group’s history of prejudice and discriminations ( M = 2.96, SD = 1.07) than Whites ( M = 2.29, SD = 1.19), F = 8.56, p < .01, partial n 2 = .08. There was a marginally significant effect of ethnicity on provider discussions of race and ethnicity. Minorities tended to feel it was more important that their provider discuss issues regarding race and ethnicity during their treatment ( M = 2.44, SD = 1.09) than Whites ( M = 2.03, SD = 1.07), F = 3.58, p < .10, partial n 2 = .04. Thus, this element was not included in subsequent regression analyses.

Table 2 displays the intercorrelations for the cultural elements and outcome variables for the entire sample. First, correlations among the three cultural elements scores were low to moderate so that multicollinearity did not pose a problem. Second, correlations among the four types of service experiences were somewhat substantial. However, these moderately strong correlations typically have been found in other previous research (e.g., Howard, El-Mallakh, Rayens, & Clark, 2003 ). These subscales represent very distinct aspects of the service experience, and therefore, have been examined separately in these studies (e.g., Arneill-Py, 2004 ).

Intercorrelations of Cultural Elements and Dependent Variables

Note. SD = standard deviation; IMP = importance; INCLU = inclusion; “Discriminations” = provider knowledge of history of discrimination and prejudices; “Discussions of R&E” =provider discussions of race and ethnicity in treatment.

Relationship Between Cultural Element Discrepancy Scores and Client Experience

Table 3 summarizes the results from the regression analyses, using the cultural elements discrepancy scores as predictors and each of the four types of service evaluations (i.e., access, quality of care, satisfaction, and treatment outcomes) as the dependent variables.

Summary of Hierarchical Regression Analyses Predicting Client Service Experience

Note. SE is the standard error of B.

In terms of Access, for Whites, neither Model 1 ( F = 1.83, p = .15) nor Model 2 ( F = 1.29, p = .28) was significant. For minorities, the first model with just age, gender, and participant type was not significant, F = 0.69, p = .56. However, there was a significant F change and the full model, with cultural elements was significant, F = 3.01, p < .05. Ethnic match was significantly related to clients perceptions of accessibility of treatment, β = .37, p < .05.

For Quality of Care , for Whites, again, neither Model 1 ( F = 1.08, p = .37) nor Model 2 ( F = 1.08, p = .39) was significant. For minorities, the first model with age, gender, and participant type was not significant, F = .35, p = .79. There was a significant F change and the full model, with cultural elements was significant, F = 4.00, p < .01. Both racial match and provider knowledge of discriminations and prejudices were significantly related to client perceptions of quality of care, β = .38, p < .05 and β = .31, p < .05, respectively.

For Satisfaction , for Whites, Model 1, with age, gender, and participant type was significant, F = 2.94, p < .05, although none of the predictors’ regression coefficients were significant. The change in F to Model 2 was not significant and Model 2 was not significant, F = 1.81, p = .13. For minorities, the first model was not significant, F = 1.60, p = .20. There was a significant F change and the full model, with cultural elements was significant, F = 2.67, p < .05. Racial match was marginally associated with client satisfaction, β = .31, p < .10.

Finally, for Treatment Outcomes , for Whites, Model 1 was not significant, F = 1.26, p = .30. The change in F to Model 2 was marginally significant, but Model 2 itself was not, F = 1.87, p = .12. For minorities, the first model was not significant, F = 0.01, p = .99. There was a significant F change although the full model, with cultural elements was not significant, F = 1.94, p = .11.

Cultural competency on the part of mental health care providers has been mandated in county and federal systems, but it is unclear if cultural elements regarding race and ethnicity actually affect clients’ experiences in treatment. This study demonstrated that issues surrounding race and ethnicity are important to ethnic minorities in the context of mental health treatment, and, in fact, clients are less satisfied when such elements are not included in their care. To our knowledge, this is one of the few empirical investigations of the effects of race and ethnicity elements on client satisfaction and perceived outcomes.

The three culture-specific elements assessed in this study (i.e., racial match, provider knowledge of prejudices/discrimination, and discussions of race and ethnicity) have been previously identified by cultural competence experts as important elements of care ( Brach & Fraser, 2000 ; Leong & Lau, 2001 ). In the present study, ethnic minorities rated racial match and provider knowledge of discriminations/prejudices as significantly more important in their mental health care than Whites, consistent with research on the influence of culture on service issues and outcomes for ethnic and racial minorities ( Zane et al., 2004 ). Provider discussion of race and ethnicity was marginally more important for minorities than Whites.

More noteworthy, when mental health clients felt like a cultural element was important in their care, but did not perceive it to be present, they were less satisfied with aspects of their treatment. However, this was the case only for ethnic minority clients, not for White clients. Across three of the four outcome variables (access, quality of care, and general satisfaction), racial match and provider history of discrimination/prejudices added significantly to the predictive power of the model, beyond that of demographic variables alone (i.e., age, gender, type of participant). Again, this was true only for ethnic minority clients, confirming the literature that highlights the value of including these elements in treatment for ethnic minority individuals (e.g., Flicker et al., 2008 ; Pope-Davis et al., 2002 ; Sue & Sue, 1999 ).

Additionally, various cultural elements were related to different types of client service evaluations for clients. For example, racial match appeared to be a strong predictor of the service experience across access, quality of care, and marginally for general satisfaction. Although a host of studies has debated the importance of racial match on ethnic minority mental healthcare ( Karlsson, 2005 ), studies continue to demonstrate the significance of racial match for minorities. A recent study examining clients with severe mental illness in community mental health centers found that racial match was associated with a stronger working alliance, even in a sample of highly acculturated individuals ( Chao, Steffen, & Heiby, 2012 ).

In the present study, we did not assess racial identity of clients, but given the literature, racial match effects might have even been stronger for individuals who identify strongly with their race or ethnicity ( Atkinson & Thompson, 1992 ). Minority clients who felt that it was important for their provider to understand their ethnic group’s history of discrimination and prejudice and did not feel like this element was present in their care reported lower quality/appropriateness of care. Research has indicated that experiences with racism and discrimination affect the well-being of ethnic minorities (e.g., Hughes & Thomas, 1998 ; Jones, 2003 ), and other research on African Americans have found perceived discrimination to be associated with psychological distress, lower well-being, self-reported ill health, and number of days confined to bed ( Ren, Skinner, Lee, & Kazis, 1999 ; Williams, Yu, Jackson, & Anderson, 1997 ).

In view of these findings, it is not surprising that those minority clients who were with care providers who did not acknowledge and process the reality of living in a racialized society ( Jones, 2003 ) experienced poorer quality of care. Similarly, Thompson and Jenal (1994) found that African American clients paired with White providers who stressed the commonalities among individuals, while failing to address the ethnic issues related to being African American, perceived these providers as denying the influence that race has on their lives. Chang and Berk (2009) found that clients praised therapists who demonstrated culture-specific knowledge and an awareness of the importance of race and culture in shaping individual experience and identity and criticized those who displayed cultural ignorance or insensitivity.

Although racial match and provider knowledge of prejudices and discriminations was significantly related to aspects of the client service experience, neither was related to perceived treatment outcomes. These results seem to corroborate those of other studies that concluded that cultural elements (e.g., racial match) might aid in treatment engagement and/or retention but play only minor roles in treatment outcomes ( Beutler, Machado, & Neufeldt, 1994 ; Cabral & Smith, 2011 ). It should be noted, however, that number of treatment sessions has been associated with treatment outcomes ( Anderson & Lambert, 2001 ; Flaskerud & Hu, 1994 ; Howard, Kopta, Krause, & Orlinsky, 1986 ; Ritsher, Moos, & Finney, 2002 ), and, in some cases, racial match has itself been associated with treatment outcomes ( Cabral & Smith, 2011 ; Gamst, Dana, Der-Karabetian, & Kramer, 2000; Sue et al., 1991 ).

The findings should be considered within the limitations of the study. First, the study did not obtain clinician perspectives or information. Another limitation of the study is the sampling of outpatients in only one urban community; thus, the results may not be generalizable to other community mental health agencies or consumers. For instance, findings from this study may have been different if the sample had been drawn from an inpatient clinic where clients tend to be more clinically impaired.

A third limitation involved the aggregation of the various ethnic minority groups because the small sample sizes of each prevented separate ethnic group analyses. African Americans constituted the majority of the ethnic sample, and the findings of this study may be more specific to this ethnic minority group. However, inequitable treatment is a problem that most ethnic minority group members encounter ( DHHS, 2001 ); therefore, we wanted to study the ethnic minority experience with treatment in general and not for any one particular group. There were no significant differences in terms of ethnicity or gender between the private and community-based clients and type of participant was controlled for in this study. However, future studies with larger sample sizes should disaggregate ethnic/racial minority group members as well as private and community-based mental health clients.

Another limitation of the study was its correlational design, thus, there was ambiguity with respect to causality or temporal sequence. It may be that clients formed their attitudes about importance of a cultural element based on previous questions. For example, the nature of the questions in the study (about race and ethnicity) may have led some clients to believe these elements should be important to them. Future studies utilizing a longitudinal design would help clarify any causal relationship between attitudes about importance and inclusion of cultural elements and satisfaction. We also did not have information regarding the nature of the problems that clients were seeking help for, and this may have been a factor in how salient issues of race and ethnicity were to clients. It may be that clients with more severe psychological problems were not as concerned about racial match as others with less severe issues.

A final limitation of the study involved the use of self-report measures and the fact that some clients reported on current experiences while others reported on previous experiences. As with all client surveys, the clients sampled were susceptible to biases in recall and this may have affected their satisfaction ratings. However, some patient satisfaction research showed that retrospective assessments were not significantly different from their prospective counterparts in means and variances ( Kreulen, Stommel, Gutek, Burns, & Braden, 2002 ).

Despite these limitations, an implication of the study is that addressing issues related to race and ethnicity may be critical to the quality of care for many ethnic minority mental health clients. The exclusion of race and ethnicity elements was consistently related to lower client evaluations regarding accessibility, quality of care, and satisfaction for ethnic minority clients. Mental health practitioners working with minority clients may want to assess client perspectives and preferences regarding race and ethnicity issues in treatment. Failing to do so could result in lower client satisfaction.

Results of this study align with Constantine’s (2002) finding that perceptions of therapists’ multicultural competence was significantly associated with treatment satisfaction. Chang and Berk (2009) encouraged therapists working with clients high on race salience to actively demonstrate their comfort and willingness to broach topics involving race, ethnicity, and culture (REC). On the other hand, the same approach may alienate clients who view REC issues as irrelevant to their presenting problem. Therapists may consider addressing the significance of REC differences with all clients, but they should be responsive to clients’ feedback rather than assume that such differences necessarily be an issue in treatment ( Cardemil & Battle, 2003 ). Although ethnic/racial match and discussions surrounding race and ethnicity may be salient for some ethnic minority clients, others (e.g., those with internalized racism) may not prefer this type of treatment ( Trivedi, 2002 ). Racial/ethnic dynamics in treatment are complex, and, thus, it is important to note that the presence of ethnic/racial match or discussions of race and ethnicity are not the panacea to problems of race in therapy ( Neville, Spanierman, & Doan, 2006 ).

At the same time, the findings strongly suggest that training programs in the allied mental health professions need to develop more empirically validated clinical strategies for addressing issues related to race and ethnic minority status when treating ethnic minority clients. Moreover, there should be a particular emphasis on how to manage and cope with life experiences involving prejudice and discrimination.

It is clear that certain elements may be more relevant for minorities, and these differences need to be considered in providing culturally competent mental health care ( Sue & Sue, 1999 ; Zane et al., 2004 ). This study provides empirical evidence that addressing cultural, racial, and ethnic issues in treatment that align with the worldviews and life experiences of ethnic minority clients does enhance the quality of care for this clientele ( Benish, Quintana, & Wampold, 2011 ).

Acknowledgments

We acknowledge the Sacramento County Department of Health and Human Services and the two community-based mental health agencies for granting permission to collect data at their sites. We also thank Dr. Marya Endriga and the California Institute of Mental Health for their support during the initial phases of the study. This research was supported in part by NIMH T32 #MH018261, by the National Center for Advancing Translational Sciences, NIH #UL1 TR 000002, and by the Asian American Center on Disparities Research, NIMH Grant #MH073511.

1 Studies reviewed include both racial and ethnic match studies. For the purposes of this paper however, we are using race to encompass ethnicity (e.g., within the Asian race, Chinese are a specific ethnic group).

2 Combining the samples from the two sites is warranted for several reasons: (a) both samples had received outpatient services for their mental health problems, (b) relatively modest differences were found between the two samples, with no significant differences in any of the outcome variables, and (c) the combined sample provided a broader cross-section of the outpatient mental health consumers in this area.

Contributor Information

Oanh L. Meyer, University of CA, San Francisco and University of CA, Davis.

Nolan Zane, University of CA, Davis.

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Working with Difference and Diversity in Counselling and Psychotherapy

• Rose Cameron - University of Edinburgh, UK
• Description

This book guides you through the complexities of working with difference and diversity in counselling and psychotherapy. It introduces you to contemporary thinking on the construction of difference, social identity and culture, and applies the theory to therapy practice. With reflective exercises and case examples, it will help you to work more confidently and sensitively with difference.

Rose Cameron is a practitioner and a trainer in counselling and psychotherapy. She is currently a Teaching Fellow at the University of Edinburgh.

See what’s new to this edition by selecting the Features tab on this page. Should you need additional information or have questions regarding the HEOA information provided for this title, including what is new to this edition, please email [email protected] . Please include your name, contact information, and the name of the title for which you would like more information. For information on the HEOA, please go to http://ed.gov/policy/highered/leg/hea08/index.html .

For assistance with your order: Please email us at [email protected] or connect with your SAGE representative.

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Each chapter points us towards how difference and diversity in the therapy room can challenge us to be better therapists. The author does not lecture but makes us aware of ourselves in relation to ourselves, social history, the client’s self and the space in the therapy room where differences sit. This short book is not a quick read; nor is it of small impact. It is without doubt one to revisit and be refreshed by when needed. 

A fantastic book. My students love it.

Really useful exploration of working with difference and diversity for trainee and experienced counsellors alike

A very good book which covers a wide range of topics with regards to diversity in therapeutic practice. The case discussions are very relevant and clearly link to the theory presented. The content seems contemporary.

Good challenging text

Need: a practical book on the core topic of working with difference and diversity

Feature: This book explores the key competencies needed to work ethically and in a culturally sensitive manner

Benefit: Students can feel confident and equipped to work with a range of clients and, crucially, with clients who have different identities or backgrounds from their own

N: Students need to identify and be aware of their own socio-cultural position and explore their own prejudices

F: The book is packed with experiential and reflective exercises to help readers reflect on their own 'blind spots, 'invisible norms' and  'unearned privilege' B: Students develop reflexive awareness of their biases and assumptions and to help work with individuals from a range of backgrounds

N: There are a multitude of theoretically dense texts on this topic, and a confusing array of terms (anti-oppressive practice, cross-cultural counselling; multi-cultural counselling, etc.)

F: this book will unpick the key theories and terms through clear and accessible language

B: Students gain a strong foundation of knowledge, getting to grips with the key terms, concepts and theories

N: Many texts take an outmoded approach to the topic, listing areas of difference chapter-by-chapter (gender and sexuality, race and ethnicity, disability, class, age, religion) which doesn't recognise the reality of the clients' lives

F: This book takes an intersectional approach to difference

B: The book helps students understand that individuals can be disadvantaged on the basis of more than one area of difference

Preview this book

Sample materials & chapters.

Sample Chapter - The Social Construction of Difference: Race, Ethnicity, Nationa

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Cultural Diversity in counseling: challenges and opportunities

The U.S. population is becoming more culturally diverse each year, at a faster rate than previously forecasted by census data. Ahead of the nation’s 2020 census, it was estimated that almost four in ten Americans identified with a non-white ethnic group or race. Between 2000 and 2019, the white population decreased by 10%. 1 In the mental health counseling profession, cultural diversity plays a significant role. Whether it’s multicultural representation within the counseling industry or the increased attention on multicultural training to serve an increasingly diverse population more effectively, cultural diversity in counseling is a hot topic.

Multicultural counseling professionals with the right training and expertise are in high demand. Keep reading to learn about cultural diversity in counseling—how different ethnicities are represented in the field, key multicultural considerations in counseling policy and practice, and steps that are being taken to encourage cultural competence in therapy.

Cultural Diversity counseling: representation

Despite increasing diversity in the U.S. and the higher rate at which people of color (POC) experience barriers to care and adverse mental health outcomes, mental health professionals are mostly white. 2 According to the American Psychological Association in 2015, just 15% of psychologists in the U.S. were POC. 3 By 2019, this number hadn’t improved significantly. The Bureau of Labor Statistics reported that in the U.S., almost 70% of social workers and 76% of mental health counselors were white. 4

Having a diverse staff of counselors doesn’t just pertain to race (although racial identity development can be very important in counseling). It also includes having counselors with backgrounds in different religions, different ages, those who are multilingual and can overcome language barriers in therapy, therapists who can provide LGBTQ+ counseling and pull from experience to help their clients. There are so many demographic and psychographic pieces to every person’s identity that can affect how and whether they seek out help. Having someone who feels familiar and shares your characteristics can be really comforting to clients.

This lack of representation makes the need for multicultural counseling competence even more urgent. Cultural identity affects how people view mental health, illness, and the world. This has far-reaching implications for mental health counselors and the counseling profession in general, whether it’s to understand how people of a certain culture seek treatment, how they view the client/therapist counseling relationship, or how they internalize and deal with discrimination issues. Counselors must be able to engage clients from diverse cultures in an equitable and sustainable manner. 5

Challenges and barriers

A key part of increasing diversity in counseling is to understand some of the factors that historically contributed to its homogenous makeup. In some cases, barriers to seeking out and receiving mental health treatment hinge on cultural differences or systemic issues that overwhelmingly impact minority groups.

Cultural barriers

It has been found in high-income countries (HICs), such as the U.S., Canada, and Australia, that individuals belonging to non-dominant cultures seek help later when facing mental distress, even when the situation is more acute. This may be related to a feeling of shame, as was found by research conducted with refugees and migrants in HICs and populations in lower-income countries in Asia. There may be a reluctance to share personal information with strangers or a desire to protect individual dignity and family reputation. For this reason, talk therapy may be less successful for these groups than other counseling modalities. 5

Willingness to seek treatment is also linked to the history of a person’s cultural group. For example, in HICs that have a colonial past, indigenous people are predisposed to mental health issues that can be linked to a history of oppression, dispossession, and intergenerational trauma. Due to histories of persecution and racism, people in Latino and African American communities may also distrust clinicians. 5

A lack of understanding of cultural differences can cause healthcare practitioners to stereotype or misinterpret situations, which may lead to inappropriate or inadequate treatment. 5 Counselors should be committed to expanding their cultural competency and understanding how diverse cultures cope with hardships can help to promote mental health and prevent illness.

Systemic challenges

In addition to cultural differences, there are often overarching systemic issues preventing people from getting the care they need. While most Americans are now insured, many insured patients often have difficulty navigating the American health system and finding providers within their specific insurance network, or could face high out-of-pocket prices and copays on appointments. 6

Even if people are able to access care financially, it may take them a while to get an appointment. One study reports that more than one-third of Americans live in mental health professional shortage areas. These areas are defined by the U.S. government taking into account the ratio of mental health providers to those in need of care, the poverty rate, the proportion of the area that is either young or elderly, the prevalence of alcohol and substance abuse, and travel time to a mental health facility. It’s estimated that more than six thousand mental health providers would be needed to fill the gaps. 7

Another shortage that affects all health care types is that of interpreters. While many health care systems will ensure that interpreters are available for all patients, a lack of interpreters continues to be a problem globally, and can prevent people from getting help or accurately conveying their problems to a health care worker. 5

Why multicultural counseling is important

Imagine trying to explain your feelings after a breakup to someone who's never even gone on a date before. While this example simplifies the disconnect, it hints at the complications that come from seeking emotional support in a difficult situation from someone who perhaps doesn’t have a good understanding of your experience in the first place. A counselor who misgenders LGBTQ clients, or a therapist who doesn’t understand a client’s religious background might even end up causing more harm than good. If a patient feels invalidated by a provider, they could resist seeking help in the future.

Improving cultural diversity in counseling

“Multicultural/diversity competence”—also phrased as “cultural competence in therapy” or “multicultural counseling competence”—refers to a therapist’s awareness of cultural and diversity issues , that person’s understanding and knowledge of themselves and others, and how this is effectively applied in counseling practice. In 2014, The American Counseling Association (ACA) released its ACA Code of Ethics, which directs counselors to recognize and respect clients’ cultural differences when using assessment techniques and in supervisory roles. Counselor educators are advised to include multicultural and diversity training in their workshops and courses and to recruit a diverse student body. 8

Strategies and resources for improving cultural diversity

Within the past decade, professionals in the mental health field have acknowledged the need to incorporate cultural diversity in counseling to provide the best possible care for people with varied racial and ethnic backgrounds. There are many ways for counselors and counseling associations to expand the cultural diversity and competency of their practices. Counselors can:

• Explore and record their own values and beliefs to better see how they naturally relate to others
• Attend diversity-focused conferences to expand their knowledge and network
• Stay up-to-date on research through journals and magazines
• Learn about different cultures–especially if they know they’ll be treating a certain population that’s different from the counselor’s own background

Initiatives and solutions

There are many existing resources available for counselors eager to expand their cultural competency:

• The Substance Abuse and Mental Health Services Administration (SAMHSA) published the Improving Cultural Competence Quick Guide for Clinicians as part of its Treatment Improvement Protocol (TIP) series. This guide defines cultural competence, explains why it’s important and provides guidelines for working with culturally diverse individuals. 9
• A 2019 ACA article on multicultural encounters in mental health counseling highlights the need for counseling professionals to expand their awareness and knowledge of multiculturalism and enhance their skills in order to serve an increasingly diverse population effectively. 10
• The American Psychological Association (APA) created a multicultural training database with videos, curriculum and more to help you learn–and teach–cultural diversity.

Increasing the availability and the quality of multicultural counseling can improve the therapy experience, and hopefully the mental health, of all sorts of people. But this change can’t just come from therapists one-by-one. A push needs to come across the field starting with counselor educators and academic programs that advocate for cultural sensitivity in counseling. Counseling programs like the one at Marquette University are dedicated to exposing students to multicultural counseling from working with immigrant clients to providing racial identity development, teaching cross-cultural communication and underscoring the importance of cultural awareness within a community.

Become a leader in multicultural counseling

With an online Master of Science in Clinical Mental Health Counseling (CMHC) from Marquette University, you can pursue a fulfilling career as a counselor, serving culturally diverse clients. In as few as three years, you’ll be highly qualified to work in a wide range of settings, from hospitals and community health centers to prisons, residential mental health facilities or private practice. The CMHC program combines rigorous coursework taught by seasoned professionals with a practicum and internship in the field.

Take a deep dive into topics such as the foundations of clinical mental health counseling, multicultural training, professional ethics and legal issues, psychopathology and diagnosis, research methods, assessment, family and group counseling, and addictions.

To learn how the Marquette University online MS in Clinical Mental Health Counseling can help you begin or advance your career in counseling, contact an Admissions Advisor today.

• Retrieved on December 28, 2022, from brookings.edu/research/new-census-data-shows-the-nation-is-diversifying-even-faster-than-predicted/
• Retrieved on December 28, 2022, from nami.org/Blogs/NAMI-Blog/March-2022/Addressing-the-Lack-of-Diversity-in-the-Mental-Health-Field
• Retrieved on December 28, 2022, from apa.org/monitor/2018/02/datapoint
• Retrieved on December 28, 2022, from bls.gov/cps/cpsaat11.htm
• Retrieved on December 28, 2022, from frontiersin.org/articles/10.3389/fpubh.2018.00179/full
• Retrieved on October 17, 2023, from aamcresearchinstitute.org/our-work/issue-brief/exploring-barriers-mental-health-care-us
• Retrieved on October 17, 2023, from usafacts.org/articles/over-one-third-of-americans-live-in-areas-lacking-mental-health-professionals/
• Retrieved on December 28, 2022, from counseling.org/resources/aca-code-of-ethics.pdf
• Retrieved on December 28, 2022, from store.samhsa.gov/sites/default/files/d7/priv/sma16-4931.pdf
• Retrieved on December 28, 2022, from ct.counseling.org/2019/11/multicultural-encounters/

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Book Review of Kassan and Moodley's Diversity and Social Justice in Counseling, Psychology, and Psychotherapy: A Case Study Approach

• Naseem Rine-Reesha University of Toronto

An increasing focus on issues of diversity and social justice in counselling, psychology, and psychotherapy has been met with a range of responses and potential paths forward. In Diversity and Social Justice in Counseling, Psychology, and Psychotherapy: A Case Study Approach , editors Anusha Kassan and Roy Moodley assemble an exciting collection of new work from veterans and emerging scholars. This work challenges traditional conceptions of multicultural practice, broadens the range of conversations about diversity, and considers how issues of intersectionality affect the impact of different identities in practice. The incorporation of a case study into each chapter lends coherence to the array of styles and approaches represented in the collection and provides a practical application of theoretical considerations. Novice and experienced practitioners, instructors, and students will find both enjoyment and critical insights in this book.

Author Biography

Naseem rine-reesha, university of toronto.

Naseem Rine-Reesha is a student therapist at the University of Toronto’s Ontario Institute for Studies in Education and a member of the Centre for Diversity in Counselling and Psychotherapy. Their main research interests include issues of social identity in multicultural counselling/psychotherapy and the role of the imagination in preparing diverse populations for success in counselling.

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Working with Difference and Diversity in Counselling and Psychotherapy

• Rose Cameron - University of Edinburgh, UK
• Description

This book guides you through the complexities of working with difference and diversity in counselling and psychotherapy. It introduces you to contemporary thinking on the construction of difference, social identity and culture, and applies the theory to therapy practice. With reflective exercises and case examples, it will help you to work more confidently and sensitively with difference.

Rose Cameron is a practitioner and a trainer in counselling and psychotherapy. She is currently a Teaching Fellow at the University of Edinburgh.

Each chapter points us towards how difference and diversity in the therapy room can challenge us to be better therapists. The author does not lecture but makes us aware of ourselves in relation to ourselves, social history, the client’s self and the space in the therapy room where differences sit. This short book is not a quick read; nor is it of small impact. It is without doubt one to revisit and be refreshed by when needed. 

A fantastic book. My students love it.

Really useful exploration of working with difference and diversity for trainee and experienced counsellors alike

A very good book which covers a wide range of topics with regards to diversity in therapeutic practice. The case discussions are very relevant and clearly link to the theory presented. The content seems contemporary.

Good challenging text

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Sample Chapter - The Social Construction of Difference: Race, Ethnicity, Nationa

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Diversity and Social Justice in Counseling, Psychology, and Psychotherapy: A Case Study Approach

Diversity and Social Justice in Counseling, Psychology, and Psychotherapy: A Case Study Approach offers readers a critical perspective on the ways in which helping professions are practiced in the context of a multifaceted society.

The text is designed to advance readers' understanding that ethnic group and race categories are useful but limited without the inclusion of the intersectionality of the Group of Seven (Big 7) identities (and beyond): race/culture/ethnicity, gender, sexual orientations, class, disability, religion/spirituality, and age. Key concepts, such as multiple and intersecting cultural identities and social locations, power, privilege, stereotyping, discrimination, prejudice, and oppression, are explored through various points of entry. Individual chapters cover the integration of antiracism and critical race theory in practice, Indigeneity and coloniality as analytic tools, feminist therapy, ethical considerations, and more.

The book supports the construction of an intersubjective, intrapsychic, and relational space in practice. Each chapter includes a case vignette that illustrates how cultural, historical, economical, and sociopolitical contexts offer a background to diversity and social justice theory and practice, as well as reflective questions to help readers think critically.

Diversity and Social Justice in Counseling, Psychology, and Psychotherapy is an essential resource for students and practitioners within various helping professions.

• ISBN-10 1516548590
• ISBN-13 978-1516548590
• Publisher Cognella Academic Publishing
• Publication date August 3, 2021
• Language English
• Dimensions 8 x 0.88 x 10 inches
• Print length 434 pages
• See all details

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About the author, product details.

• Publisher ‏ : ‎ Cognella Academic Publishing (August 3, 2021)
• Language ‏ : ‎ English
• Paperback ‏ : ‎ 434 pages
• ISBN-10 ‏ : ‎ 1516548590
• ISBN-13 ‏ : ‎ 978-1516548590
• Item Weight ‏ : ‎ 11.7 ounces
• Dimensions ‏ : ‎ 8 x 0.88 x 10 inches
• #48,647 in Unknown

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Teaching DEI Through Case Studies

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In the summer of 2020, the Black Lives Matter (BLM) movement took center stage across the United States. At the height of a devastating pandemic and in the wake of several high-profile murders of Black Americans by law enforcement and others, a diverse range of citizens took to the streets to protest systemic racism and the inhumane treatment of African Americans.

Through the lens of bystander Darnella Frazier’s smartphone camera, the world watched in horror as George Floyd died at the hands of a white police officer on a street in Minneapolis. On May 25, 2020, officer Derek Chauvin knelt on Floyd’s neck for 9 minutes and 29 seconds as Floyd repeatedly said that he could not breathe. His death, along with those of Breonna Taylor and Ahmaud Arbery a few months earlier, sparked international protests and drew intense scrutiny about how African Americans are treated by the police, the criminal justice system, and their fellow citizens.

The protests of 2020 prompted many companies, organizations, and educational systems to express their public support of the BLM movement and commit to the goal of achieving racial equity and social justice. While for many companies this was likely a fleeting PR move, others announced that they were taking a hard look at their own systemic issues. Business leaders at companies in many industries began the challenging but necessary work of exposing and addressing the deep biases that have been hardwired into their organizations. The Quaker Oats Company, for example, announced its discontinuation of the 130-year-old Aunt Jemima breakfast foods brand, which had been inspired by a minstrel show song and had long perpetuated a Black stereotype.

Many businesses responded by not only committing to increasing diversity within their workforces, but also examining their supply chains and external partners. Target Corporation, headquartered in Minneapolis, pledged to “…work with diverse suppliers that are at least 51 percent owned, controlled, and operated by women; Black, Indigenous, and People of Color; LGBTQ+; veterans or persons with disabilities.” In 2020, U.S. Bank committed to “doubling its Black-owned suppliers within the next 12 months.”

Further, because of the BLM movement, many major companies are recruiting from historically black colleges and universities more than ever before. Morgan State University in Baltimore reports that its online job portal saw a “263 percent increase in employer logins between July 1, 2020, and June 30, 2021, with major companies like Apple, Bank of America, and Estée Lauder reaching out for the first time ever.”

The Growing Diversity of the Student Body

Against this backdrop of the fight for racial equity and social justice, the U.S. is undergoing a significant change in demographics. In a recent article , The Washington Post shared the following conclusions from newly released 2020 census data:

“The country … passed two more milestones on its way to becoming a majority-minority society in the coming decades: For the first time, the portion of White people dipped below 60 percent, slipping from 63.7 percent in 2010 to 57.8 percent in 2020. And the under-18 population is now majority people of color, at 52.7 percent.”

These statistics apply to our students as well as our future leaders and labor force. Businesses and those in the business of educating students for a future of fulfilling work must respond in kind to a changing college campus. Some schools already are, as shown by these recent examples:

• The University of California system announced that for the incoming 2021 class, “underrepresented students will comprise 43 percent of the new admits, with Latinx students making up 37 percent and the number of Black students being admitted increasing by 15.6 percent.”
• In July, the Governing Board of California Community Colleges (CCC) announced its approval of two new requirements, including one adding ethnic studies as a graduation requirement for students seeking associate’s degrees and another mandating that CCC schools incorporate diversity, equity, and inclusion (DEI) and anti-racism into their employment procedures.
• Purdue University has created a new Equity Task Force and has committed more than 75 million USD over five years to support Black students. Purdue states that the “goals of the task force are split into three categories that will measure success in making Purdue a better place for Black students, faculty, and staff: Representation, Experience, and Success.”

DEI in the Curriculum

Universities and college campuses have long been at the forefront of a range of social justice movements, codifying these movements into academic programs such as Black studies, women’s studies, disability studies, queer studies, and more. But there remains much work to be done, including in the integration of DEI content into our curricula. As educators, publishers, and academics who create scholarly content, we are all responsible for taking a close look at how we approach teaching the lessons of diversity. We must build and use curricular tools that reflect the world our students will enter and their experiences within it.

We need more case studies in our classrooms that are written by authors from a range of backgrounds and perspectives—not just by those who represent predominately white, privileged, Western viewpoints.

The traditional case study is one such tool we can use to support DEI and the changing face of business. That said, the case study, long a stalwart in business and management education, is ripe for reinvention where DEI is concerned. It’s true that case studies can expose students to the challenges of a wide variety of organizations, from global publicly traded entities to local startups to social enterprises. But it’s just as essential that cases expose students to a range of perspectives and reflect the myriad backgrounds—cultural and economical—of those who work within the featured organizations.

Moreover, the importance of DEI in case studies extends beyond their subject matter to their authorship. We need more case studies in our classrooms that are written by authors from a range of backgrounds and perspectives—not just by those who represent predominately white, privileged, Western viewpoints.

Fortunately, case studies can be developed far more quickly than textbooks or even mass market book titles. Their short format means that professors can use them not only to keep content fresh and current for students, but also to better capture the shifting nature of businesses and the people who help them thrive. Cases also can show real-time examples of companies undergoing successful evolutions in their DEI initiatives, as well as companies that still have a long way to go.

By looking at business through a DEI lens, students can better see the reality of our economic landscape. They can truly connect to, and see themselves in, today’s business environment.

Building a Modern Case Collection

Our SAGE Business Cases collection is a testament to SAGE’s dedication to prioritizing cases that represent a broad and inclusive range of backgrounds and perspectives from around the world. SAGE is committed to developing cases around emerging and underserved topics that accurately reflect the diversity and shifting priorities of the global business landscape, as well as the experiences of those who work within it.

For example, in 2021 we launched a new case series called Immigrant Entrepreneurs . This groundbreaking series is edited by Bala Mulloth, an assistant professor of public policy at the University of Virginia and himself an immigrant entrepreneur. It features the stories of founders who started businesses outside their countries of origin.

While there has been a spike of interest in case studies that feature protagonists of a variety of backgrounds, we have also seen a rise of nativist politics across countries and cultures. Part of our vision for this series is to combat the damaging and false political narrative that immigrants harm economies. We want to defuse that narrative with positive and inspiring examples of the value immigrants add to communities around the world.

Our SAGE Business Cases platform enables us to quickly publish brief, news-driven cases. Faculty and students can quickly employ the offerings in our Express Case series for classroom or online discussion. Examples include:

• How Will BLM Change Corporate Activism?
• Analyzing Pfizer’s COVID-19 Vaccine PR Strategy

We also offer longer-form cases in our SAGE Originals collection, such as the following:

• Woke-Washing: The Promise and Risk of Linking Branding With Politics
• Policing the Police: Privatization as a Means of Oversight
• Organizational Responses to Athlete Activism Post-Kaepernick: An Exercise in Decision-Making
• Nike and the Balancing Act Between Social Justice and Selling Products

Tools That Reflect the Reality of Business

For its part, AACSB has shown its deep commitment to diversity and inclusion in its 2020 business accreditation standards , in which it embeds ideals related to diversity and inclusion in six out of nine standards, compared to six out of 15 in the 2013 standards. To align with this commitment, our curricular tools must reflect the varied reality of those engaged in the global business environment, no matter their locations, roles, organization types, gender, race, age, religion, sexuality, or disability status.

As educators, publishers, and business school administrators, we have a responsibility to provide all students with not only access and opportunity, but also exposure to a wide range of perspectives. By exposing them to the true, diverse nature of business, we can prepare them for the world today and enable them to change it for the better.

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Call for Case Studies: Strategic Action for Urban Health

The WHO Urban Health team is seeking examples that illustrate a strategic approach to urban health. Collectively, these case studies are intended to show that such an approach can originate and flourish from a wide range of entry points across a diversity of sectors and scales, while leveraging many different combinations of partners. The case studies will inform a major global WHO report on strategic action for urban health, expected in fall 2024. Selected cases will be developed for inclusion in the report; the urban health team will work with submitters of these cases to produce concise summaries. All submitted cases that meet eligibility criteria will be promoted and made available on the WHO website and, as appropriate, in subsequent publications.

Background to this call

The health of urban populations emerges from the interactions of urban environments with the behaviour of individual actors and human institutions. Urban health is both a measure of the levels and patterns of health and wellbeing in cities and the art and science of safeguarding and continually improving them.

Because every aspect of urban life can affect human wellbeing, urban health relies on action across all sectors—not only within health, but across planning, housing, transportation, water, sanitation, energy, and many others. This breadth of influences is widely recognized, yet urban health action has often focused on improving health impacts within a single sector or system, or alternatively, on addressing a narrowly defined set of health outcomes, modifying certain key behaviours, or improving health for a particular population group.

Such efforts have widely succeeded in improving urban health outcomes, and cities are healthier, on average, than rural areas. Yet, much remains to be done. Urban areas feature large—and often growing—health inequities, especially in slums and informal settlements. In virtually all cities, there remain unrealized opportunities to improve health and health equity.

Moreover, the actions needed to improve health in cities often positively impact other goals of sustainable development. There is thus tremendous potential for achieving co-benefits through an approach that accounts for dynamic interactions across sectors.

Achieving the highest levels of urban health—and realizing its wide-ranging potential co-benefits—requires coordinating action across all urban sectors and systems while anticipating future challenges. That is, it depends on a strategy to sustainably mainstream health across urban policy and practice. This ‘strategic’ approach to urban health depends, among other things, on sophisticated arrangements for governance and finance, generating and working with evidence, fostering innovation, and generating and sustaining effective partnerships while promoting broad participation.

WHO’s urban health team has been working to develop guidance on strategic action for urban health, including through a recent series of policy briefs focusing on these issues. This case study call will add to this effort, helping to make visible the relevance, potential, and possibilities of strategic action.

Eligibility criteria and call information

Case studies may represent action at national or subnational (e.g., province, state, municipality, or city) scales and should describe specific interventions, policies, institutions, partnerships, or other pertinent efforts. They need not involve the health sector (though many will) but should be relevant to the health and wellbeing of urban residents. Cases need not represent unqualified successes—indeed, cases that illustrate barriers to success or failed attempts at strategic action will be considered. We are seeking illustrative cases representing all regions, cultures, and levels of development, and a diverse range of urban contexts (including different city sizes, demographic profiles, informal communities, governance structures, and other factors).

This call is for cases that illustrate strategic action, as described in the WHO Strategic Guide to Urban Health Policy briefs. Cases that highlight potential or intended actions that have yet to be formalized or initiated will not be accepted. Likewise, cases that describe narrowly focused interventions or research related to health determinants, risk factors, or outcomes will not be considered unless linked to broader strategic action. We are particularly interested in cases that can demonstrate evidence of health impacts.

Cases should:

• involve a diversity of stakeholders (both government and non-government)
• encompass multiple sectors and health outcomes
• illustrate one or more of the eight principles underlying a strategic approach to urban health referenced in the WHO Strategic Guide to Urban Health Policy briefs.  
• ideally, be relevant to one or more of the cross-cutting recommendations from the WHO Strategic Guide for Urban Health policy briefs.
• represent action currently underway or implemented during the past decade.

Please review the principles and recommendations in the policy briefs to ensure that your case meets the established criteria.

Any stakeholder involved in managing the actions described is invited to submit a case study by completing the survey form here .

In responding, you will be asked to provide basic contact and descriptive information, describe how your case is relevant to the principles and recommendations, answer several questions intended to capture key elements (e.g., context, enablers and barriers, what was done and by who, outcomes) with short textual summaries, and supply additional materials to enrich and substantiate your description (potentially including figures, photos or video, internal or external reports, links to media coverage, or other). Your complete, clear answers will help us ensure that cases are relevant and useful.

The deadline for case submission is July 30, 2024. Please be prepared to work with the WHO team to produce a concise summary if your submission is selected for inclusion in the WHO global report. Any questions can be directed to [email protected] .

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