Cultural competence and evidence-based practice in mental health: epistemic communities and the politics of pluralism.

Evidence-based practice (EBP) and cultural competence (CC) aim to improve the effectiveness of mental health care for diverse populations. However, there are basic tensions between these approaches. The evidence that purports to ground EBP is limited, often in ways that are biased by specific disciplinary, economic or political interests and cultural assumptions. In particular, the paucity of evidence regarding cultural minorities results in standard practices based on data from the majority population that have uncertain relevance for specific cultural groups. As well, research evidence about intervention outcomes tends to focus on individual symptoms and behaviors and may not reflect culturally relevant outcomes. To some extent, these limitations can be addressed by refining and extending current methods of evidence production. However, consideration of culture raises two deeper problems for EBP: 1) The diagnostic and conceptual frameworks used to pose questions, devise interventions, and determine outcomes in EBP are themselves culturally determined and therefore potentially biased or inappropriate; and 2) Cultural communities may have "ways of knowing" that do not rely on the kinds of observational and experimental measures and methods that characterize EBP. Attention to the nature of clinical evidence and to the importance of cultural context in illness and healing can help both EBP and CC move beyond their current limitations and contribute to the evolution of mental health services that respond effectively to cultural diversity.