Culture in care

Reducing socioeconomic barriers to care.
Integrating cultural nuance and religious understanding.
Advocating for public policy changes to support patients’ mental health.

These are a few of the actions Stanford Medicine therapists who work with marginalized communities say are keys to effectively caring for patients who face societal discrimination.

“Most of our systems of care are tailored to support individuals from the majority population,” said Christina Khan, MD, PhD, a clinical professor of psychiatry and behavioral sciences and co-chief of the psychiatry department’s Diversity and Cultural Mental Health Section.

“This bias perpetuates mental health care disparities among marginalized groups. If we hope to move toward greater equity and justice in mental health care, we must support individuals from marginalized backgrounds in a way that considers their culture.”

To understand the challenges to providing support for these groups, Stanford Medicine asked five therapists from the Department of Psychiatry and Behavioral Sciences with expertise in culturally informed care to envision mental health support tailored to their needs. 

Here’s what we asked:

• What are special factors affecting the mental health of the communities you serve?
• What tops your wish list of changes that would promote equity and justice in mental health care?
• What inspires you about your work?

Rania Awaad, MD

Clinical professor and director of the Muslim Mental Health and Islamic Psychology Lab; co-founder of Maristan, a Muslim mental health nonprofit dedicated to providing culturally sensitive and accessible mental health services and educational resources; director of centerspace, a clinic that provides culturally contextualized mental health care; and co-chief of
the psychiatry department’s Diversity and Cultural Mental Health Section

One of the most difficult issues for the American Muslim community is Islamophobia and other forms of
discrimination that make this community feel marginalized. Suicide attempts among this population of people are twice the national average. Religiously congruent mental health services are few and far between.

I want people to know that this group has a rich heritage and tradition. Anyone who’s going to work within the Muslim community needs to know how integral faith, religion and spirituality are to this community.

When patients are able to bring their faith into the story, they find relief because their coping mechanisms are aligned with their spiritual and faith practices.

I have a dream to revive the concept of the maristans — institutions from the eighth century onward that were dedicated to healing psychological illnesses — that have spiritual symbolism within their architecture.

We can take something that’s from antiquity and bridge it to the modern day with focused and holistic care.

Benjamin Zewdu Belai, MD

Clinical assistant professor and psychiatrist at the centerspace clinic and Stanford Health Care Evaluation clinic, focused on cultural psychiatry, and at Roots Community Health Center, a clinic that serves predominantly low-income, Black and immigrant communities in East Oakland and San Jose

The most significant challenges for improving mental health care are socioeconomic. When I first started working in Oakland, I was surprised to find that stigma toward mental health, though a barrier, was rarely the limiting factor in finding treatment.

Instead, the major barrier was a lack of affordable, culturally responsive providers. This left patients on long waitlists and fed mistrust of the health care system.

The change I would recommend is to improve reimbursement rates for public insurance and expand creative incentive programs such as loan forgiveness for psychiatrists working in underserved communities.

Hopefully, this would relieve the dire shortage of psychiatric providers who take insurance and reduce wait times for patients. 

The most inspiring aspect of my work has been following up with patients whose lives have changed after our clinic’s interventions. It’s incredible that even brief interventions with a mental health specialist can have profound changes on people’s lives.

Christina Khan, MD, PhD

Clinical professor and founder and director of THRIVE, Stanford Medicine’s LGBTQ+ mental health clinic

LGBTQ+ populations suffer from all of the same mental disorders as do other people. However, one factor that greatly increases the mental illness risk for LGBTQ+ people is the stress they experience due to stigma, for example, internal identity-questioning that results from experiencing discrimination.

People who identify as LGBTQ+ are keenly aware of the impact of mental health on well-being but are sometimes afraid to seek help after having previous negative health care experiences such as being misgendered or being asked unnecessary questions about their body.

My No. 1 ask would be that the human rights of all individuals be advanced by legislation such as the proposed Equality Act, which would provide consistent and explicit anti-discrimination protections for LGBTQ+ people. Legislation such as this would expose minorities to fewer stress-inducing situations. 

It’s not easy to break through the barriers of discrimination but small shifts can be life-changing for our patients. I love working with marginalized populations so that I can help move the needle towards justice.

Stacy Lin, PhD

Clinical assistant professor and director of psychotherapy for the Stanford Mental Health for Asians Research and Treatment Clinic

Racism and violence against Asian American and Pacific Islander folks, which has increased in the COVID-19 era, affect Asians’ mental health, as does the model minority myth that perpetuates stereotypes of Asians being unilaterally successful and not needing help.

My patients’ mental health experiences are heterogenous. I wish their health care integrated their cultural values and acknowledged systems-level factors such as racism that are not addressed in most of our interventions, which tend to focus on the individual.

Having a more expansive definition of psychotherapy — that includes individual-level change and advocacy that targets systemic discrimination — promotes healing.  

Being alongside people as they find meaning from even the most painful experiences of their lives is an honor.

Watching patients grow more rooted in themselves and develop agency over shaping their own futures reminds me to show up for them fully every day. 

Axel Valle, PsyD

Clinical assistant professor and co-director of La Clínica Latina, focused on mental health care for people who identify as Latino or Hispanic

Latinos in the U.S. encounter significant barriers to accessing high-quality mental health care. Most commonly, those are language and cultural barriers between them and health care providers. Encouraging providers to appreciate, learn and navigate cultural nuances is crucial for dismantling health care disparities.

To cultivate change by selectively hiring clinicians, it’s essential to consider language to bridge existing gaps in mental health inequities. Having providers who are fluent in the patient’s language not only broadens their access to care but also substantially improves patient outcomes.

As a clinical psychologist, I find inspiration in the resilience and adaptability of Latinos facing mental health challenges.

Witnessing patients progress through therapy with willingness, gratitude and humility is a testament to the potential impact of culturally sensitive care.