Cultural and Linguistic Competency


Systems of care are about increasing access by children and youth to needed mental health services. To do this effectively we must eliminate disparities that occur when members of our diverse community do not share equitably in opportunities for that access. 

Being culturally and linguistically competent can help us be more responsive to the unique needs of the people we serve. Hence, cultural and linguistic competence is a core value of systems of care. 

System of care value

Cultural and linguistic competency is a value of systems of care because of the huge impact that culture has on beliefs and behavior related to mental health, as well as the recognition that behavioral health outcomes improve when treatment is done in a way that is responsive to those beliefs and behaviors. In addition, treatment cannot be fully effective if it is provided in a language that is not understood.

The Texas System of Care website has podcasts about Cultural and Linguistic Competency.

The American Psychiatric Association has a series of videos on best practices for treatment of African American, Asian, Latinx, LGBTQ, Native American and women clients.

In 2019, The SOURCE put together a health equity brief that summarizes the prior three years of work. It’s a fast, easy-to-read way to understand what The SOURCE has done to improve health equity in Elkhart County – and what’s next!

What is Culture?

The Office of Minority Health defines culture as the integrated patterns of human behavior that include language, thoughts, communications, actions, customs, beliefs, values and institutions of racial, ethnic, religious or social groups.

The good news is that you are reading this webpage because you recognize that something maybe isn’t right.

Cultural iceberg

Only part of an iceberg is visible above water. Most of it exists below the surface and is something that we cannot see. When people think of culture, they often think about what can be seen – behavior, music, food, clothing. But the majority of what defines a culture is invisible. It is the beliefs, attitudes and values of people from that culture.

Culture Affects

  • Language
  • Social and Health Behaviors
  • Self-care and handling of emotions
  • Celebrations
  • Lifestyle Attitudes
  • Values
  • Communication Styles
  • Death
  • Art and Music
  • Social Expectations
  • Clothing
  • Working Style
  • Beliefs

… all facets of life.

What is Health Equity?

Health equity means that everyone has a fair and just opportunity to be as healthy as possible.

We use the CLAS (Culturally and Linguistically Appropriate Services) Standards to help us advance health equity, improve quality and help eliminate disparities. Health organizations use the standards to identify what changes can be made to better serve the people coming to them for help.

“The route to achieving equity will not be accomplished by treating everyone equally. It will be achieved by treating everyone justly according to their circumstances.” – Paula Dressel, Race Matters Institute

Cultural and Linguistic Competence is important because it improves access to mental health treatment for those who experience barriers.

The barriers that different cultural groups experience in the United States give us important information about how to reach out to those communities in order to increase their access to mental health services. It is important to note that some barriers reported by cultural groups in the United States relate to historical trauma. These negative experiences create an implicit bias in which the person may not even consciously be aware of their perceptions and fears related to seeking treatment. The mental health community can better serve all communities by understanding cultural barriers. 



An unconscious belief about a set group of individuals that disagrees with our conscious set of beliefs and values.

Many people have unconscious biases about races and cultures different from their own. Sometimes these biases can create barriers to giving or receiving services. For example, some white medical service providers may unconsciously think black males are dangerous and resistant to treatment causing them not to offer beneficial treatment to their patients. Many variables can contribute to implicit biases, e.g. media, social media, child rearing practices, religious beliefs, etc.

Did you know that implicit biases also happen in minority consumers when  it comes to accessing treatment? For example, some African Americans have unconscious biases about seeking health care treatment from their white counterparts.  For many, this is due to health experimentation on African Americans in the past (like the Tuskegee Experiment). Some of these negative experiences still unconsciously cause the black community to have distrust of the medical field or of participation in scientific studies.  
Look Different is an interesting website created by MTV that includes quizzes to test implicit bias related to race, gender and sexual orientation as well as an invitation to take a bias cleanse.


Disproportionality is an over or under representation of a specific population.

For example, in many counties, the largest population is white but arrest and detainment data show more black and Hispanic individuals are arrested or detained than white individuals. This is a disproportionality.

There is a over representation of green apples and an under representation of red apples.


Disparity is a negative difference in access or outcomes among minority populations compared to the majority population.

Here’s an example. Let’s say a large group of people from several races received cancer treatment for 3 years. A follow up showed that the white population reported better access to care and high-quality cancer treatment which preserved their life, but the Native American population reported poor access to care (e.g. no one to translate when scheduling appointments and no printed forms in their language). They also had the highest death rate and decline in health after treatment. This would be a disparity.

The majority of green apples are in better condition and look healthier than the minority red apple.

Everyone can take action to reduce health disparities. The National Partnership for Action has created a community action toolkit that gives tips on how to have an impact.


The environments in which we live our lives have an impact on our health and are called social determinants of health. All of these factors impact a person’s health outcomes – mortality, life expectancy, health status, functional limitations – including mental health. Here are some examples:

Economic stability

job opportunities, income, expenses, debt, medical bills, support



literacy, language, early childhood education, vocational training, higher education, access to the internet

Community and social context

social integration, support systems, community engagement, discrimination, stress, social norms and attitudes

Neighborhood and physical environment

housing, transportation, safety, parks/playgrounds, walkability, zip code, geography, exposure to crime, violence and social disorder


hunger, access to healthy options


Health care system

health coverage, provider availability, provider linguistic and cultural competency, quality of care

YouTube: National Institutes of Health

The Office of Disease Prevention and Health Promotion (ODPHP) gives a nice summary of the social determinants of health.



While many African Americans are descendants of slaves brought to the United States by force, there were Africans in America as far back as the 16th century when black explorers settled here and others that arrived as indentured servants in the 17th century. In addition, many African Americans immigrated more recently to the country. There are approximately 36 million African Americans living in the United States and more than half live in the South.


Child Trends reports that black high school students are twice as likely (12.8 percent) to be suspended as white (6.1 percent) or Hispanic (6.3 percent) high school students, based on data from a 2018 analysis. It appears the disparity is due to differences in how these groups of students are disciplined, implicit bias and subjectively defined offenses. Source

Community and Social Context

According to the CDC, infant mortality is the death of an infant before his or her first birthday. The infant mortality rate is the number of infant deaths for every 1,000 live births. In the United States, infant mortality rates for African American babies are higher than any other racial or ethnic group (Source). This is a health disparity that greatly impacts African American communities. The African American Faith-based Bereavement Initiative has a free, online curriculum on how to help African American families and their communities with the loss of an infant as well as resources communities can use to impact infant mortality rates.

Neighborhood and Physical Environment

A 2011 report by the U.S. Department of Housing and Urban Development and Office of Healthy Homes and Lead Hazard Control found that 28% of African American households had housing-related lead exposure risks compared to 20% of white families (Source).

The Elkhart County Health Department has environmental health programs to help with lead and other potential hazards.

Community and Social Context

In Indiana, 54% of children have not experienced any Adverse Childhood Experiences (ACEs). 23% have experienced 1 ACE and 11% have experienced 2 ACEs. 12% of children in Indiana have experienced 3 or more ACEs, that’s more than 180,000 children.

In our area of the United States, only 38% of black children have no ACEs compared to 52% of Hispanic children, 60% of white children and 79% of Asian American children.

In the United States, the most common ACEs children experience are economic hardship and the divorce/separation of a parent/guardian. The third most common ACE differs based on race and ethnicity. For white or Hispanic children, it is living with an adult with a substance use problem. For black, non-Hispanic children it is parental incarceration. Source


The Indiana KIDS COUNT 2019 report showed that black students are the most likely to feel unsafe at school compared to their peers. Source

Neighborhood and Community Context

Indiana Kids Count reported that Black Hoosier parents are the least likely to report their child lives in a safe neighborhood. Source

Economic Stability

According to Opportunity Insights, in 99% of neighborhoods in the United States, black boys earn less in adulthood than white boys who grow up in families with comparable income. Source 


According to the Health and Human Services Office of Minority Health, African Americans are 20% more likely to experience serious mental health problems than the general population.
Click on the icon to find out more:
Mental Health America shares information on mental health in the African American community including access and treatment issues.
The National Institute on Minority Health and Health Disparities with Omega Psi Phi Fraternity has a handout with information on the mental health of African American men and links to further resources.
For non-Hispanic, African American children, having an incarcerated parent is the third most common Adverse Childhood Experience (ACE). Sesame Street has created resources to help children understand and cope.



Click on the icon to find out more:
UnidosUS has a report on Mental Health Services for Latino Youth: Bridging the Gap.
Mental Health America has developed unique materials about mental health for the Hispanic/Latino audience.

YouTube: Salud America


Latinx is a gender-neutral way to refer to the Latino/Latina population and the term has been added to the Mirriam Webster Dictionary. The Latinx population is an ethnic group that includes any person of Cuban, Mexican, Puerto Rican, Central American, South American or other Spanish culture of origin, regardless of race. In 2015, there were almost 56 million Latinx in the United States.

Many times in the United States the terms Latino and Hispanic are used interchangeably but they are not the same. Also, there are many disparities that this population faces that disrupt there access to care and mental health treatment. Hispanic usually refers to language and those whose ancestry comes from Spain or Spanish speaking countries. Latino usually refers to geography and
specifically, to Latin America which includes individuals from the Caribbean, South America, and Central America.

Economic Stability

Hispanic workers have the highest rates of fatal work injuries – 3.7 out of every 100,000 full-time Latino workers suffer a fatal illness. Source 

Neighborhood and Physical Environment

 In 2014, 43% of workers in farming, fishing, and forestry were Hispanic or Latino. Those who do agricultural work face a higher risk of illness and death from pesticide. If the pesticide comes home on their clothing, children and family members are also at increased risk. 


Latino children start Kindergarten behind their peers in math. This video explains and gives solutions.

Community and Social Context

Approximately 16.4% of Hispanics in the U.S. held a bachelor’s degree or higher in 2016, compared with 37.3% for non-Hispanic whites and 23.3% for non-Hispanic blacks. Source 

Health Care System

Latinx are more likely to report poor communication with their health care provider and are often under-treated. Source 

Neighborhood and Physical Environment

Indiana KIDS Count reported that Hispanic youth report the least amount of neighborhood support. Source 



American Indians and Alaskan Natives lived and governed themselves in North America long before European and Russian explorers and immigrants arrived. In 2012, there were an estimated 5.2 million American Indian and Alaskan Natives living in the United States. There are 573 federally recognized tribes and another 100 recognized by a state. This American Indian and Alaska Native Culture Card gives an overview of tribal sovereignty, regional differences, customs, identity and more.

Health Care System

According to Mental Health America, “the concept of mental illness and beliefs about why and how it develops have many different meanings and interpretations among Native Americans. Physical complaints and psychological concerns are not distinguished and Native Americans may express emotional distress in ways that are not consistent with standard diagnostic categories.” Source 

Neighborhood and Physical Environment

American Indiana/Alaska Native children are more likely to have been a victim of violence or to have witnessed violence in their neighborhood than other U.S. children. Source 


The educational system provided to American Indian/Alaskan Native children has long been evaluated as inadequate – Meriam Report (1928), Senate report (1969), National Academy of Public Administration report (1999), Bronner Report (2012), Government Accountability Office report (2013). Source 


Fry bread was invented by a group of Native Americans out of necessity after being relocated by the Long Walk and unable to grow their traditional crops. Instead, they had to rely on U.S. military rations of lard, flour, sugar and canned goods. Many believe that fry bread is part of the reason for the current epidemic of obesity and diabetes in Native American populations. There are differing opinions within the community on the meaning and value of fry bread. Source 

Community and Social Context

The Indiana Child Welfare Act (ICWA) was passed in 1978 to protect American Indian/Alaskan Native children and families from biased child welfare practices and disregard for families and culture. The National Indian Child Welfare Association reports that ICWA has succeeded in reducing abusive practices but that “Native families are the most likely to have children removed from their homes as a first resort, and the least likely to be offered family support interventions intended to keep children within the home.” Source 

Economic Stability

American Indiana/Alaska Native children are more likely than other U.S. children to live in poverty. Source 


Click on the icon to find out more:
Indian Health Services, Behavioral Health Department has programs that work to improve the mental health of Native American and Alaskan Native children and youth.
Suicide rates for American Indian and Alaskan Natives is several times higher than the national average. SAMHSA has a handout on Suicide Prevention in Indian Country. 
YouTube: Indian Health Service



In the 2017 Youth Risk Behavior Surveillance Survey, 63% of high school students who identified as lesbian, gay or bisexual reported feeling sad or hopeless compared to 28% of students who identified as straight. In addition, 23% of lesbian, gay or bisexual students attempted suicide compared to 5% of straight students. For transgender individuals, the suicide rate is even higher
Click on the icon to find out more:
The Trevor Project is a national organization that provides crisis intervention and suicide prevention services to lesbian, gay, bisexual, transgender, queer & questioning young people under 25.
The National QIC has a list of resources for youth, families and professionals on ways to find support, give support and provide culturally responsive services for LGBTQ2S individuals.
The Family Acceptance Project is a research, intervention, education and policy initiative that works to prevent health and mental health risks for lesbian, gay, bisexual and transgender (LGBT) children and youth, including suicide, homelessness and HIV – in the context of their families, cultures and faith communities.
NCTSN created a video that helps providers understand how to create a welcoming and inclusive environment for LGBTQ youth who have experienced trauma.


GLSEN has a Safe Space Toolkit that helps schools support LGBTQ+ youth. 


LGBTQ, LGBTQ2S and SOGIE are different ways to describe all people who identify as having diverse sexual orientation, gender identity, and/or gender expression. Here is a Glossary of Terms from the QIC that explains the language used with this population.

Economic Stability

Nearly one in every ten LGBT employees has left their job because the work environment was unwelcoming. The Human Rights Campaign has resources for LGBTQ employees that address workplace discrimination or coming out at work. Source 

Health Care System

The Centers for Disease Control report differences in the health of adults based on their sexual orientation. In many cases, the health of those who identify as lesbian, gay or bisexual is lower than those that identify as straight (heterosexual). Source 


Most LGBTQ students in Indiana experienced anti-LGBTQ harassment at school, according to a 2017 GLSEN report. Source 

Community and Social Context

LGBTQ youth experience homelessness at higher rates than non-LGBTQ  youth for a range of reasons. According to, a recent study of more than 350 runaway and homeless providers throughout the United States identified four top causes for homelessness among LGBTQ youth: (1) family rejection resulting from sexual orientation or gender identity; (2) physical, emotional, or sexual abuse; (3) aging out of the foster care system; and (4) financial and emotional neglect”. Source 

Health Care System

The Center for American Progress did a survey in 2017 about discrimination in health care. Of LGBQ respondents, 8% said that a doctor or other health care provider refused to see them because of their actual or perceived sexual orientation and 6% said that a doctor or other health care provider refused to give them health care related to their actual or perceived sexual orientation. Of transgender respondents, 29% said a doctor or other health care provider refused to see them because of their actual or perceived gender identity and 12% said a doctor or other health care provider refused to give them health care related to gender transition. Source 


Indiana KIDS COUNT reported in 2019 that students who identify as lesbian, gay or bisexual miss school due to safety concerns at a disproportionate rate. Source 



Although we often talk about poverty as if it is the same for everyone, there are actually different forms of poverty. Generational poverty occurs when two or more generations of a family have lived in poverty. Situational poverty comes about due to a crisis or other event that temporarily places a person in poverty. Relative poverty is experienced by people who are employed but whose income does not meet our society’s average standard of living. Each form of poverty impacts a person differently and tends to create different cultural norms.

Dr. Donna Beegle, who has personal experience with generational poverty, believes that everyone needs to learn about poverty and how it impacts the lives and culture of those who are in it. She calls it Poverty 101.

Economic Stability

According to 2000-2016 data found on, 34.2% of Elkhart children live in poverty, 24% in Goshen and 11.1% in Napannee.

Neighborhood and Physical Environment


Head Start began in 1965 as part of President Johnson’s War on Poverty and has served over 32 million children, giving children from low-income families access to quality preschool.

Attending Head Start increases a child’s likelihood of graduating from high school, attending college and decreases the chance of being unemployed as an adult. Source


In many inner city neighborhoods there are very little to no healthy foods available to access. Many of these high poverty communities only have gas stations, liquor stores and mini marts to access foods to feed there families, leaving families with little to no access to fresh produce. This creates health disparities in minority youth and families.

Community gardens can help – whether built within a neighborhood or even on school grounds

Community and Social Context

Indiana KIDS COUNT reported in 2019 that the most a single parent caring for two children can receive for assistance (welfare) is $288 per month. In 2017, the average TANF cash assistance was $196.74 per month. Although many families may be able to seek other help such as SNAP (food stamps), Section 8 (housing assistance) or child care vouchers, it can be incredibly challenging to move from poverty to financial stability. Source 

Health Care System

Only 33% of low-wage jobs provide paid sick leave compared to 81% of high-wage jobs. This discourages low-income workers from
seeking health care. Source 


In 2016, the food insecurity rate in Elkhart County was 11.3% – that translates to 22,870 people. Source 

Indiana KIDS COUNT reported in 2019 that 29% of Hoosier children that are food insecure are likely ineligible for federal nutrition programs (free or reduced lunch). These are children who live in households that do not have consistent access to adequate food. This can lead to periods of food deprivation and then overeating once food is available again.


The challenges and stressors of living in poverty may increase risk for mental health concerns. 
Click on the icon to find out more:
Indiana residents can find out if they are eligible to receive food assistance, cash assistance and/or health care coverage online. Elkhart County residents can also call or visit the local FSSA office.   
2-1-1 has information on resources in Elkhart County that help with food, clothing, housing,- utilities, education, employment, mental health, addiction and other needs. Call them at 2-1-1 or 1-866-211-9966 or visit their website and do a search by zip code.


Language is also a cultural factor that can influence access to mental health services and health services in general. 

People with Limited English Proficiency (LEP) do not speak English as their primary language and have a limited ability to read, speak, write or understand English. Limited English proficiency can lead to exclusion from programs, delays or denials of service, and inaccurate or incomplete information about services, all of which could be considered discriminatory under Title VI of the Civil Rights Act of 1964. It is important for healthcare organizations to take steps to implement a system that ensures people with LEP have meaningful access to healthcare services.


  • English 82.4% 82.4%
  • Spanish 11.2% 11.2%
  • Other Indo-European 5.5% 5.5%
  • Asian and Pacific Island .7% .7%
  • Other languages .2% .2%
According to the U.S. Census Bureau, 3.6% of households in Elkhart County are considered limited English-speaking. Limited English-speaking means that there are no individuals in the household 14 years or older that speak English “very well”. That percentage equates to over 2,500 households, a majority of which speak Spanish.

Youth and families with LEP may be nervous about coming to see mental health providers. Here is a handy guide to give providers some tips on working with interpreters. Also, check out these 9 tips on working with a medical interpreter. has a free poster to use with clients to identify which language they speak.

Breaking Down the Barriers: Translating Limited English Proficiency Policy into Practice

YouTube: SRB Communications

The National Institute on Minority Health and Health Disparities put together a portal of resources and information. They believe in supporting communication efforts to improve cultural competency and health literacy. The portal is a resource to organizations who work with health disparity populations with Limited English Proficiency (LEP) to help improve language access to health information.

The Source • Youth Mental Health Network


There are a lot of places in your city that can help, too.
Here is a list of some community resources.


For the National Suicide Prevention Lifeline call 1-800-273-8255 or text the word ‘home’ to 741741 for Crisis Text Line.


For the National Suicide Prevention Lifeline call 1-800-273-8255 or text the word ‘home’ to 741741 for Crisis Text Line.