Culturally Proficient Assessment & Treatment

Patricia Sherman, Ph.D., LCSW

It’s Raining Cats and Dogs

“Culturally competent practice is a long-term developmental process. Proficiency is not achieved after a brief workshop.”

(Tripp-Reimer, 1999)

Unifying Values or Assumptions in Cultural

Proficiency

• Being Different is Positive

• Services Must Be Responsive to Cultural Needs

• Clients Are Empowered

Cultural Competence

The ability to engage in actions or create conditions that maximize the optimal development of client and client systems. Multicultural counseling competence is defined as the counselor’s acquisition of awareness, knowledge, and skills needed to function effectively in a pluralistic democratic society

(ability to communicate, interact, negotiate, and intervene on behalf of clients from diverse backgrounds), and, on an organizational level, advocating effectively to develop new theories, practices, policies, and organizational structures that are responsive to all groups (Sue, 2001).

Moving Toward Cultural Proficiency: Fear and Pain

• People Don’t Know What to Expect

• Race is a Dangerous Subject

• People Wonder if They Will Be Attacked and Feel Guilty

• Is This Just “Political Correctness?”

• Will Things Get out of Control?

• The Importance of Ground Rules (Confidentiality, Personalize Discussion, Say Whatever You Believe, No Blaming)

• Cultural Proficiency is a Journey Based on Relational and Process Thinking

• Self-Honesty and Sustained Commitment Are Important to the Process of Becoming Culturally Proficient

Social Distance Exercise

Barriers to Culturally Proficient Care

• Poor communication

• Language differences

• Mistrust of health care providers

• Different views of illness

• Religious beliefs

General Characteristics of Culturally Proficient Counselors

• Counselor Awareness of Own Cultural Values and Biases

• Counselor Awareness of Client’s Worldview

• Culturally Appropriate Intervention Strategies

Assumptions Exercise

Categories of Difference

• Age

• Race

• Ethnicity

• Religion

• Gender

• Sexual orientation

• Ability status

• Class

Characteristics of Oppressed Groups

• Not necessarily a numerical minority• Identifiable sub-population• Inequality in power• Subject to stereotyping• Discriminatory treatment

More accurate terminology:– Dominant/oppressed groups rather than

majority/minority groups

Protected classes – groups protected against discrimination by various federal laws:– Race, color, ethnic origin, gender (female), age (over 40),

religion, physical or mental disability

Historical Treatment of Oppressed Groups

• Extermination – genocide, ethnic cleansing

• Domination/enslavement

• Expulsion

• Segregation/apartheid

• Assimilation/integration

• Pluralism/multiculturalism

In the past the dominant USA ideal was assimilation. The United States was the world’s great melting pot. Mental health workers attempted to integrate oppressed groups into the mainstream culture.

Today we emphasize appreciation of cultural diversity and pluralism. The presence of oppressed groups and their differing ways of life enriches United States society.

The Dual PerspectiveNorton (1978)

Each person is a member of two social environments:• The nurturing environment – the individual’s immediate emotional,

physical, and social environment. Includes family, and sometimes neighborhood and neighborhood institutions such as church and school.

• The sustaining environment – the dominant social system in which the individual must interact to obtain the necessities of life; employment, shopping, etc.

• A strong nurturing environment, supporting the individual’s personal identity and providing a strong, positive self-image protects the individual from the damaging impact of stereotyping, prejudice, and discrimination encountered in contact with the dominant culture.

Copyright © Allyn & Bacon 2003

Racial IdentityAssumptions

from Multicultural Competency Development by Fernando Ortiz

• Racism is a basic and integral part of U.S. life and permeates all aspects of our culture and institutions.

• Persons of color and whites are socialized into U.S. society and, therefore, are exposed to the biases, stereotypes, and racist attitudes, beliefs, and behaviors of the society.

• The level of racial identity development consciousness affects the process and outcome of interracial interactions.

• How people of color and whites perceive themselves as racial beings seems to be strongly correlated with how they perceive and respond to racial stimuli. Consequently, race-related reality represent major differences in how they view the world.

Oppressed Peoples and Pathology

• Genetically deficient model

• Culturally deficient model

• Culturally diverse model

Nacerima Culture Exercise

Cultural Competence: Awareness

• Move from being unaware to being aware and sensitive to his or her own cultural heritage and to valuing and respecting differences

• Aware of own values and biases and how they may affect clients

• Comfortable with differences that exist between themselves and their clients in terms of race, gender, sexual orientation, and other sociodemographic variables. Differences are not seen as being deviant

• Sensitive to circumstances that may dictate referral of the client to a member of his or her own sociodemegraphic group or to another therapist in general

• Acknowledges and is aware of his or her own racist, sexist, heterosexist, or other detrimental attitudes, beliefs, and feelings

Cultural Competence: Knowledge

• Possesses specific knowledge and information about the particular group with which he or she is working

• Has a good understanding of the sociopolitical system’s operation in the United States with respect to its treatment of marginalized groups in our society

• Has a clear and explicit knowledge and understanding of the generic characteristics of counseling and therapy

• Is aware of institutional barriers that prevent some diverse clients from using mental health services

Cultural Competence: Skills

• Able to generate a wide variety of verbal and nonverbal responses

• Able to send and receive both verbal and nonverbal messages accurately and appropriately

• Able to exercise institutional intervention skills on behalf of clients

• Aware of his or her helping style, recognizes own limitations, and can anticipate the impact on the culturally different client

• Able to play helping roles characterized by an active systemic focus, which leads to environmental interventions. Not trapped into the conventional counselor/therapist mode of operation

Culturally Competent Helping Roles

• Having a more active helping style

• Working outside the office

• Focusing on changing environmental conditions as opposed to only focusing on changing the client

• Viewing the client as encountering problems rather than having or being a problem

• Being oriented toward prevention rather than remediation

• Shouldering increased responsibility for determining the course and outcome of the helping process

Strategies to Enhance Culturally Proficient Care

• Interpreters

• Staff representative of community served

• Cultural ethnic worker or liaison

• Consultation with local healers

• Use of complementary therapies

Six Points of Cultural Competence Continuum

The cultural competence continuum is helpful in several ways. It gives a standard by which to measure the agencies in which we work. It gives an indication of strengths and areas for improvement. To consider an assessment of your agency, think of the following components:

Cross, Bazron, Dennis & Isaacs, 1989

Cultural Competence Continuum

Cultural Destructiveness

Cultural Incapacity

Cultural Blindness

Cultural Pre-competence

Cultural Competence

Cultural Proficiency

• Cultural Destructiveness: When an agency is at this point, the attitudes of agency personnel, the policies and practice of the agency itself are destructive to cultures and individuals within the culture. Extreme examples are programs, agencies or institutions that actively participate in genocide or in seriously damaging cultures.

Examples of Cultural Destructiveness

• The exclusion laws of 1885-1965 that prohibited Asians from bringing spouses into the country; the policy of the U.S. government to remove Native American children from reservations and place them in boarding schools; the enslavement of people of African descent

• Cultural Incapacity: Agencies and systems do not seek to be culturally destructive but lack capacity to help minority clients or communities. Agencies remain extremely biased and the predominant belief is in racial superiority of the dominant group.

• Agency staff and personnel policies and practices are paternalistic toward the “lesser” group and resources are usually channeled away from the “lesser” group in favor of the dominant group. ex. Laws regarding segregation and the philosophy of “separate but equal.”

• Cultural Blindness: Agencies believe that they are unbiased because they treat everyone the same. Agencies maintain that traditional approaches that work with dominant group culture are universally applicable. Agency staff policies and practices ignore cultural strengths and encourage assimilation.

• Outcomes are measured by how closely clients match the dominant pattern. Special projects geared toward minority populations are funded only if money is available and with very little input from the targeted community.

• Cultural Pre-competence: Agencies exhibit a heightened awareness and movement in a positive direction. They realize their weakness in serving underrepresented groups and make attempts to improve. Agencies might experiment by hiring minority staff or explore how to reach people from underrepresented groups in their service area.

• Agency staff, policies and practices begin to seek ways that reaching underrepresented groups can be improved. The danger or caution here is that it is easy to believe that accomplishing one small step or activity fulfills the obligation to the underrepresented group, e.g. Tokenism.

• Cultural Competence: Agencies are characterized by acceptance and respect for difference. At this point, agencies will engage in a continuing self-assessment regarding culture and will seek advice and consultation from minority communities.

• Policies and practices of the agency are adapted to better meet the needs of underrepresented groups. Agencies clearly view minority groups as distinctly different from one another and acknowledge the differences within groups.

• Cultural Proficiency: Differences are held in high esteem. An agency seeks to add to the knowledge base by conducting research, developing new approaches, publishing and disseminating results of research projects. Also, the agency staff and personnel, policies and practices will promote empowerment of underrepresented groups and actively advocate on their behalf. Specialists in culturally competent practice are hired on staff.

Exercise-Agency Assessment: Pairs

• Think about your agency and reflect on the following questions:

• At what level do you assess your agency?

• What are some positive attempts made by your agency to become multiculturally proficient?

• What are the supports and obstacles to developing multicultural proficiency?

• What have you learned about your agency? How do you feel about it?

• How trusting is the agency for change?

• What kind of support can you expect?

• What kind of resistance can you expect?

• What can you personally commit to do to help your agency become more culturally-competent?

Why is it important to make culturally relevant mental health services available and accessible to diverse

communities?

• The World Health Organization has reported that four of the 10 leading causes of disability in the US and other developed countries are mental disorders. By 2020, Major Depressive illness will be the leading cause of disability in the world for women and children.  

• Without treatment the consequences of mental illness for the individual and society are staggering: unnecessary disability, unemployment, substance abuse, homelessness, inappropriate incarceration, suicide, and wasted lives. The economic cost of untreated mental illness is more than 100 billion dollars each year in the United States.

• With appropriate effective medication and a wide range of services tailored to their needs, most people who live with serious mental illnesses can significantly reduce the impact of their illness and find a satisfying measure of achievement and independence.

Barriers to Care

• Physical– Geographic – bus routes, parking– Architectural

• Organizational – Staff attitudes– Staff competencies– Ambience

• Financial

– Health insurance

– Managed care

– Bus/train fare

– Parking fees

– Child care

– Poverty

• Emotional – Embarrassment– Stigma– Misperceptions

• Other – Immigration status– Language fluency– Level of acculturation

Why is Mental Illness Stigmatized?

• Its name implies it is different from physical illness

• Sounds as if it’s “all in one’s head”

• Some people believe it results from poor choices

• Belief that people with mental illnesses are dangerous and unpredictable, less competent, unable to work, should be institutionalized, can never get better

Some Health and Social Consequences of Stigma

• Mental illness and addiction are common, but only 1/3 of those needing treatment seek it due to fear of discrimination

• People deny painful symptoms and are reluctant to seek help at an early, more treatable stage of illness

• The drop-out rate for psychiatric treatment is high because people do not want to be seen attending psychiatric clinics.

• People with mental illness often hold the same beliefs as society at large and blame themselves for their illness

• The major way people cope with stigma is to withhold information from those who could help them

• Consumers expect to be rejected by the community and, therefore, are reluctant to engage with others

• The effects of stigma and its resultant social withdrawal may have a greater impact on an individual than the illness

• Family members are also harmed by stigma and may be blamed for causing or contributing to the illness

• Community attitudes can negatively affect recovery rate

• Mental health professionals are also often stigmatized, holding a diminished status in the eyes of other health care professionals and making recruitment challenging

• Many mental health professionals share negative attitudes towards people with mental illness

• The diminished attitude towards consumers is applied to self-help and peer-support programs, negatively affecting the number of referrals

• People with mental illness are less likely to be appropriately diagnosed and treated for co-morbid medical conditions

• Institutions, governments, and policy makers contribute to stigma by systematically under-funding mental health services

• Discrimination towards people with mental illness leads to diminished employment opportunities, lack of career advancement, and hostility in the workplace

• Stigma contributes to the persistent under-funding of research and treatment services

• 74% of people with a mental illness reported they had experienced stigma in the last year

• 16% reported stigma in the workplace

• 13% from staff in a health service

(SANE, Australia, 2006)

• The elderly experience the double stigma of being old and mentally ill and are less likely to seek help; their illnesses may not be detected because of the belief that anxiety and depression are a normal part of aging

• Other groups also experience a double or triple stigma – LGBT, people of color, women (“The gay community stigmatizes us for being mentally ill, and the mental health community stigmatizes us for

being gay”)

• Discrimination is experienced through a loss of human rights, including forced treatment, finding or keeping housing, the right to parent, access to loans, immigration, denial of insurance coverage, and over-representation in the criminal justice system

• Adapted from Mood Disorders Society of Canada’s Stigma and Discrimination Research Workshop, Ottowa, ON – 10/2-4/06.

Social Distance Exercise

Mental Illness Across Cultures

• The expression of mental illness in many cultures is in bodily terms – headache, trouble sleeping, fatigue, stomachache, etc.

• Hallucinations and delusions will be culturally relevant

• Need to assess level of acculturation

• Mental illness compounded by immigration experience, conditions leading to immigration, poverty, lack of health insurance, language difficulties, loss of support system, lack of access to traditional healers

• In many parts of the world, spirit possession is common. This may be a way for disadvantaged people to gain status; lose status if symptoms are due to a chemical imbalance

• Could be misdiagnosed as schizophrenia

• The cultures that patients come from shape their mental health and affect the kinds of mental health services they use. Likewise the cultures of the clinicians and the service system affect diagnosis, treatment, and the organization and financing of services

Systems of Care Checklist

• Having a belief system in common with a patient can be an asset or a liability depending on what that belief system means to each and how they handle it in the therapeutic setting.

(John Peteet, M.D., is chair of APA's Corresponding Committee on

Religion, Spirituality, and Psychiatry)

Assessment

• Few existing tools are valid since they were developed primarily utilizing white, middle-class, native-English-speaking, able-bodied heterosexual men.

• Simply translating assessment tools does not work

Holistic Idiographic Framework for Practice

Cultural Assessment – ADDRESSING

• Age and generational influence

• Developmental or acquired

• Disabilities

• Religious and spiritual orientation

• Ethnicity

• Socioeconomic status

• Sexual orientation

• Indigenous heritage

• National origin

• Gender

From Hays, P.A. (2001). Addressing cultural complexities in practice. Washington, DC: APA. Used with permission.

Addressing Exercise

Purnell Model for Cultural Competence

• Overview, inhabited localities, topography

• Communication

• Family roles and organization

• Workforce issues

• Biocultural ecology

• High-risk behaviors

• Nutrition

• Pregnancy and childbearing practices

• Death rituals

• Spirituality

• Health-care practices

• Health-care practitioners

Locus of Control and Responsibility

• Internal locus of control – self-reliance

• External locus of control – chance, luck, God, social conditions

• Internal locus of responsibility – rugged individualism; blame the individual

• External locus of responsibility – situation-centered; blame the system

Communication Style Differences

• American Indians

• Asian Americans and Hispanics

• Whites

• Blacks

Guidelines for Clinical Practice

• African Americans

• American Indians and Alaskan Natives

• Asian Americans

• Hispanic/Latino Americans

• Clients of Multiracial Descent

• Sexual Minorities

• Individuals With Disabilities

Case Study – Ms. Carla Hernandez

Develop action plan to utilize culturally sensitive assessment

and treatment