LAUSR

World Psychiatry 19:1 February 2020 tailored to the clients’ immediate concerns. Using a client’s language in framing the problem aids both clinician and client in experiencing the problem through the client’s eyes. For example, when a client states that he feels disgust for himself when using drugs, the clinician reminds him that he has previously stated that drugs help him feel confident and stable, and reframes his use of drugs as a potentially unhealthy coping tool when dealing with difficult circumstances. In pediatric mental health practices, one mistake that can impede focus on the client’s concerns is concentrating on generational hierarchies, or only asking the parents about what they see as the problem, bypassing the child’s perspective. Clinicians should address children directly and ask about their concerns. This approach seeks to share a common view of the problem, directed by the client’s experience. Our third lesson for clinicians is to be willing to explain to clients who they are, share with clients some of their social identity, and ask clients to do the same. During a clinical encounter, for example, the clinician can share something he/she enjoys doing or dreamed about when moving to the US. In turn, the clinician may ask the client questions to magnify the importance of the client’s social identity (“Do you want talk about your tattoos and what they represent, as you previously commented?”). These exchanges can facilitate learning about the clients’ cultural, interpersonal or social worldview and attempted coping mechanisms that can shed light on how they comprehend their problems and what might be acceptable solutions. These strategies may also help clinicians avoid attribution errors and build trust based on a joint understanding of what words, behaviors or actions might mean. We acknowledge that barriers to engagement in mental health care for minority populations, as well as for the clinician who treats them, may be attitudinal or structural in nature. These are barriers that require substantial cognitive efforts by clinicians to overcome and that require longer visits in resource poor environments where most of these populations are served. Some attitudinal barriers that interfere with engagement are stigma, bias, prejudice, and racial/ethnic discrimination. Some structural barriers that might also influence engagement include linguistic obstacles in communicating, limited availability of times for care, and poor quality of services. Furthermore, individual factors (e.g., socioeconomic status, self-efficacy, health literacy), organizational factors (e.g., policies and practices), and societal factors (e.g., social and community norms) interact to influence engagement in services. Efforts to improve engagement in mental health care need to address both attitudinal and structural barriers. Clinicians can adopt these engagement recommendations in their individual practices, but systemic changes are needed to solidify these strategies in mental health care settings. Systemic changes include incorporating engagement activities into clinician training and treatment protocols, offering flexible service delivery modes (e.g., by phone or within non-clinical settings), and integrating mental health care management to address social determinants of health. Engaging ethnic minority clients requires clinicians to construct the clinical encounter with egalitarian collaboration that addresses the clients’ needs, empowers their decision making, and amplifies their voice in treatment.