Identify barriers and bias in treating individuals from different cultures.
Utilize culturally sensitive and appropriate interventions based on the race, ethnicity and language spoken.
Identify resources that are available to eliminate the language barriers and communication barriers.
Assess the culturally diverse needs of the client.
Culture has been defined as "the shared values, traditions, norms, customs, arts, history, folklore, and institutions of a group of people." Why should we even be concerned about culture?
First, understanding culture helps us to understand how others interpret their environment. We know that culture shapes how people see their world and how they function within that world. Culture shapes personal and group values and attitudes, including perceptions about what works and what doesn’t work, what is helpful and what is not, what makes sense and what does not.
Secondly, understanding culture helps service providers avoid stereotypes and biases that can undermine their efforts. It promotes a focus on the positive characteristics of a particular group, and reflects an appreciation of cultural differences. Finally, culture plays a complex role in the development of health and human service delivery programs.
Factors that Influence Culture
While we know that cultural influences shape how individuals and groups create identifiable values, norms, symbols, and ways of living that are transferred from one generation to another, it is important for us to distinguish the differences created by such factors as age, gender, geographic location, and lifestyle. Race and ethnicity are commonly thought to be dominant elements of culture, but a true definition of culture is actually much broader than this.
For example, ethnic and racial groups are usually categorized very broadly as African American, Hispanic, American Indian and Native Alaskan, or Asian American and Pacific Islander. These broad categories are sometimes misleading, because they can often mask substantial differences within groups. The larger group may share nothing more than common physical traits, language, or religious backgrounds. We often fail to consider the distinct factors which influence culture within larger populations that determine how people think and behave.
Values and Attitudes
Culture shapes how people experience their world. It is a vital component of how services are both delivered and received. Cultural competence begins with an awareness of your own cultural beliefs and practices, and recognition that people from other cultures may not share them. This means more than speaking another language or recognizing the cultural icons of a people. It means changing prejudgments or biases you may have of a people’s cultural beliefs and customs.
It is important to promote mutual respect. Cultural competence is rooted in respect, validation and openness towards someone with different social and cultural perceptions and expectations than your own. People tend to have an “ethnocentric” view in which they see their own culture as the best. Some individuals may be threatened by, or defensive about, cultural differences. Moving toward culturally appropriate service delivery means being:
knowledgeable about cultural differences and their impact on attitudes and behaviors;
sensitive, understanding, non-judgmental, and respectful in dealings with people whose culture is different from your own; and flexible and skillful in responding and adapting to different cultural contexts and circumstances.
Also, it means recognizing that acculturation occurs differently for everyone. This means more than different rates among different families from the same cultural background; it means different rates among members of the same family as well.
For example, the beliefs, customs, and traditions of people from other cultures are often at odds with Western medicine and its heavy emphasis on science. Consistent with the Anglo-American emphasis on scientific reasoning, Western medicine tends to emphasize biological explanations for illness (such as bacteria, viruses or environmental causes); whereas in other cultures the natural, supernatural or religious/spiritual reasons explain the cause of the problem (the yin and yang are out of balance; you have broken a taboo; or you have been thinking or doing evil.
Cultural competence is defined as “a set of cultural behaviors and attitudes integrated into the practice methods of a system, agency, or its professionals, that enables them to work effectively in cross cultural situations.” Cultural competency is achieved by translating and integrating knowledge about individuals and groups of people into specific practices and policies applied in appropriate cultural settings. When professionals are culturally competent, they establish positive helping relationships, engage the client, and improve the quality of services they provide.
Culture plays a complex role in the development of health and human service delivery programs the need for the provision of culturally appropriate services is driven by the demographic realities of our nation. Understanding culture and its relationship to service delivery will increase access to services as well as improve the quality of the service outcomes. Research has begun to provide the underpinnings for the development of standards for the delivery of services to diverse populations. The following Principles are drawn from research material on the role culture plays in providing services to older adults.
There is an ethic to culturally competent practice. When professionals practice in a culturally competent way, programs that appropriately serve people of diverse cultures can be developed. Each person must first posses the core fundamental capacities of warmth, empathy and genuineness. To achieve cultural competence, professionals must first have a sense of compassion and respect for people who are culturally different. Then, practitioners can learn behaviors that are congruent with cultural competence. Just learning the behavior is not enough. Underlying the behavior must be an attitudinal set of behavior skills and moral responsibility. It is not about the things one does. It is about fundamental attitudes. When a person has an inherent caring, appreciation and respect for others they can display warmth, empathy and genuineness. This then enables them to have culturally congruent behaviors and attitudes. When these three essentials intersect, practitioners can exemplify cultural competence in a manner that recognizes, values and affirms cultural differences among their clients.
Communication provides an opportunity for persons of different cultures to learn from each other. It is important to build skills that enhance communication. Be open, honest, respectful, nonjudgmental, and - most of all - willing to listen and learn. Listening and observational skills are essential. Letting people know that you are interested in what they have to say is vital to building trust. Communication strategies have to capture the attention of your audience. This means not only using the language and dialect of the people you are serving, it means using communication vehicles that are proven to have significant value and use by your target audience.
Culturally competent service providers must take into account the full range of factors that influence how any one individual service recipient behaves and communicates. The two levels of influencing factors are: overall cultural differences between racial and ethnic groups, as well as individual-level differences (based on age, education, literacy, income, gender and geographic location).
Acculturation is a process that occurs when two distinct cultural groups have continuous first-hand contact, resulting in subsequent changes in the original cultural patterns of either or both groups. The degree to which acculturation takes place is influenced directly by both the cultural and individual-level differences.
The DSM-IV TR Outline for Cultural Formulation When Assessing and Diagnosing Patients:
Rendering psychological and psychiatric assistance to a diverse population carries with it some special issues as well as those more generally noted in other curricula. Consequently, faculty and clinicians in the mental health and behavioral health fields have been working to include diagnostic and clinical criteria that would assist practitioners in becoming more culturally and linguistically competent. One concise clinical tool to aid the clinician in this process is the Outline for Cultural Formulation (OCF) found in Appendix I of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (known as DSM-IV-TR) from American Psychiatric Association in Arlington, VA.
Although intended for use with the DSM-IV TR in assessing mental disorders, the OCF is applicable to other clinical health care encounters. It provides a systematic review of the individual’s cultural background, the role of the cultural context in the expression and evaluation of symptoms and dysfunction, and the effect that cultural differences may have on the relationship between the individual and the clinician. As a result of using the OCF, the clinician provides a narrative summary for each of the following categories:
1. Cultural identity of the individual
2. Cultural explanations of the individual’s illness
3. Cultural factors related to the psychosocial environment and levels of functioning
4. Cultural elements of the relationship between the individual and the clinician
5. Overall cultural assessment for diagnosis and care
1. Cultural identity of the individual. Note the individual’s ethnic or cultural reference groups. For immigrants and ethnic minorities, note separately the degree of involvement with both the culture of origin and the host culture, where applicable. Also note language abilities, use, and preference, including multilingualism.
2. Cultural explanations of the individual’s illness. The following may be identified: the predominant idioms of distress through which symptoms or the need for social support are communicated (such as “nerves,” possessing spirits, somatic complaints, and inexplicable misfortune), the meaning and perceived severity of the individual’s symptoms in relation to norms of the cultural reference group, any local illness category that the individual’s family and community use to identify the condition (such as those explained in the DSM-IV TR’s “Glossary of Culture-Bound Syndromes”), the perceived causes or explanatory models that the individual and the reference group use to explain the illness, and current preferences for and past experiences with professional and popular sources of care.
3. Cultural factors related to the psychosocial environment and levels of functioning. Note culturally relevant interpretations of social stressors, available social supports, and levels of functioning and disability. These stressors would include those in the local social environment and the role of religion and kin networks in providing emotional, instrumental, and informational support.
4. Cultural elements of the relationship between the individual and the clinician. Indicate differences in culture and social status between the individual and the clinician and problems that these differences may cause in diagnosis and treatment, such as difficulty in communicating in the individual’s first language, in eliciting symptoms or understanding their cultural significance, in negotiating an appropriate relationship or level of intimacy, and in determining whether a behavior is normative or pathological.
5. Overall cultural assessment for diagnosis and care. The formulation concludes with a discussion of how cultural considerations specifically influence comprehensive diagnosis and care.
The clinician assesses the first four interrelated sections, which provide information that will have an effect (in the fifth section) on the differential diagnosis and the treatment plan. Clinicians must cultivate an attitude of “cultural humility” in knowing their limits of knowledge and skills in applying the OCF with accuracy rather than reinforcing potentially damaging stereotypes and over-generalizations.
Cultural identity involves a range of variables not only including ethnicity, acculturation and biculturality, and language, but also age, gender, socioeconomic status, sexual orientation, religious and spiritual beliefs, disabilities, political orientation, and health literacy, among other factors. In addition, assessment of cultural identity must move from merely the clinician’s perspective to include the patient’s self-construal of identity over time.
The second section asks the clinician to inquire about the patient’s idioms of distress, explanatory models, and treatment pathways (including complementary and alternative medicine and indigenous approaches) and to assess these pathways against the norms of the cultural reference group. The third section highlights the importance of the assessment of family and kin systems and religion and spirituality. The fourth section focuses on the complex nature of the interaction between the clinician and the individual including transference and counter-transference, which may either aid or interfere with the treatment relationship. In the final section, the clinician summarizes his or her understanding of the previous sections and can apply this understanding to a differential diagnosis and treatment plan.
AAPI Mental Health
The National Asian American Pacific Islander Mental Health Association (NAAPIMHA) has found the DSM IV TR Outline for Cultural Formulation provides a rich theoretical framework in making culturally appropriate assessments, diagnosis, and treatment plans. Using the DSM IV TR, NAAPIMHA developed a curriculum and pre-service training program in 2002 that is designed to help reduce disparities in mental health care for diverse populations by building a workforce capacity. The aim of the curriculum was to address the mental health needs of Asian Americans and Pacific Islanders and was developed under a grant from the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.
The curriculum, called Growing Our Own, is for the disciplines of psychiatry, psychology, social work, and counseling. It draws upon years of experience, assessing what does and does not work in providing culturally competent mental health services to the AAPI communities.
The five modules of the Growing Our Own curriculum build on each other and are intended to help the intern or resident develop an approach that avoids simplistic cookbook conclusions. The five modules are as follows:
Module 1 – Self Assessment helps interns or residents to recognize the biases that influence what we see and how these biases affect decision-making.
Module 2 – Connecting With Your Client is designed to help trainees become familiar with AAPI in general and provide them with the requisite knowledge, skills, and attitudes to communicate effectively with consumers and work with interpreters.
Module 3 – Culturally Responsive Assessment and Diagnosis is designed to identify factors that lead to the development of a culturally competent assessment and diagnosis.
Module 4 – Culturally Responsive Intervention focuses on concepts and strategies the intern or resident should consider in formulating and implementing a culturally responsive intervention plan, regardless of the particular intervention model employed.
Module 5 – Culturally Responsive Systems identifies barriers that consumers and service providers face under the current mental health system, highlights the important role of mental health professionals as agents of institutional change, and offers recommendations to help guide culturally competent systems change.
Clinicians should follow four steps when caring for all patients, but in particular those patients who are from a social or cultural background different from that of the care provider. Clinicians should think of these four steps as a “review of systems” focused on issues that, if not addressed, may lead to poor health outcomes. The four steps are:
1. Identify the core cross-cultural issues
2. Explore the meaning of the illness
3. Determine the social context
Step 1—Identify the Core Cross-Cultural Issues. When a clinician sees a patient from a different or unfamiliar socio-cultural background, he or she should consider a broad set of core cross-cultural issues that may be important for that individual. The clinician should try to place the individual patient on a continuum as it relates to issues that are important to all cultures by considering the following:
Styles of communication: How does the patient communicate? Communication includes issues relating to: eye contact, physical contact, and personal space; and issues about how the patient may prefer to hear “bad news.” For example, is the patient deferential or confrontational? Does the patient display stoicism or express symptoms willingly?
Mistrust and prejudice: Does the patient mistrust the health care system? If so, clinicians should recognize prejudice and its effects and attempt to build trust by reassuring the patient of one’s intentions. Keep in perspective “what’s at stake” for the patient, and show respect for the patient’s concerns.
Autonomy, authority, and family dynamics: How does the patient make decisions? What is the role of the family versus the individual in decision making? What support does the patient have from his or her family of origin, partner, and friends? What is the role of the authority figure within the family or social group? What role does community or spiritual leaders play in important decisions?
The role of the practitioner and biomedicine: What does the patient expect of clinicians and what is the clinician’s role? What are the patients’ expectations for the practitioner and biomedicine? What perspectives does the patient have about the practitioner? Does the patient consider the clinician to be a service provider or gatekeeper, for example? What are the patient’s views on alternative medicine versus biomedicine?
Traditions, customs and spirituality: How do these factors influence the patient? These attitudes include issues regarding medical procedures, such as drawing blood, and rituals pertinent to the medical encounter. What culturally specific “alternative” therapies does the patient consider, including culturally specific diet and preferences?
Sexual and gender issues: How central are these issues to the patient’s life? Is there gender concordance or discordance? What attitudes does the patient have toward the physical exam and the gender of the practitioner? Clinicians should use the preferred pronoun for patients who are transgender or transsexual and consider the issue of shame or embarrassment when discussing sexual issues. Consider also the differences in sexual behavior, orientation, and identity.
Step 2—Explore the Meaning of the Illness. Each patient will have a different understanding about disease and treatment. These perspectives will shape the patient’s behavior. It may be particularly helpful to assess the patient’s concept of illness, or “explanatory model,” when the practitioner does not feel he or she understands the patient’s behavior, when there is non-adherence to a treatment plan, or when there is some sort of conflict.
Clinicians can make such determinations by asking the patient the following questions:
What do you think has caused your problem? How?
Why do you think it started when it did?
How does it affect you?
What worries you most: the severity of the condition, or duration of the illness, or both?
What kind of treatment do you think you should receive? What expectations do you have?
Step 3—Determine the Social Context. The “social context” is of equal importance as an area of exploration, given how social and cultural factors are intertwined. Certain key areas should be considered when identifying the patient’s social context:
Tension (social stress and support systems): Does the patient have social support, or is he or she isolated?
Environment change (degree and reason for change, expectations, and acculturation): What was the patient’s previous health care experience, and how does that experience shape his or her interaction with the health care system now?
Life control (including social status, poverty, and education): What resources does the patient have? Can he or she afford medications?
Literacy and language: Does the patient have limited English proficiency or literacy, and how does such a limit affect his or her health care?
Step 4—Negotiate. Once the above information is obtained, the clinician should engage in negotiation with the patient to try to achieve the best possible outcome. Sometimes what is acceptable is better than what is optimal, if the risk of trying to secure the optimal would involve losing the patient’s trust. Such negotiation requires exploring the meaning of the illness for the patient and formulating a mutually acceptable plan.
Counselors bring with them their own degree of effectiveness with these generic characteristics. They also bring with them their cultural manifestations as well as their unique personal, social and psychological background. These factors interact with the cultural and personal factors brought by the client. The interaction of these two sets of factors must be explored along with other counseling-related considerations for each client who comes for counseling. The effective counselor is one who can adapt the counseling models, theories, or techniques to the unique individual needs of each client. This skill requires that the counselor be able to see the client as both an individual and as a member of a particular cultural group. Multicultural counseling requires the recognition of: (1) the importance of racial/ethnic group membership on the socialization of the client; (2) the importance of and the uniqueness of the individual; (3) the presence of and place of values in the counseling process; and (4) the uniqueness of learning styles, vocational goals, and life purposes of clients, within the context of principles of democratic social justice (Locke, 1986).
The Multicultural Awareness Continuum (Locke, 1986) was designed to illustrate the areas of awareness through which a counselor must go in the process of counseling a culturally different client. The continuum is linear and the process is developmental, best understood as a lifelong process.
Self-awareness. The first level through which counselors must pass is self-awareness. Self-understanding is a necessary condition before one begins the process of understanding others. Both intrapersonal and interpersonal dynamics must be considered as important components in the projection of beliefs, attitudes, opinions, and values. The examination of one's own thoughts and feelings allows the counselor a better understanding of the cultural "baggage" he or she brings to the situation.
Awareness of one's own culture. Counselors bring cultural baggage to the counseling situation; baggage that may cause certain things to be taken for granted or create expectations about behaviors and manners. For example, consider your own name and the meaning associated with it. Ask yourself the cultural significance of your name. Could your name have some historical significance to cultures other than the culture of your origin? There may be some relationship between your name and the order of your birth. There may have been a special ceremony conducted when you were named.
The naming process of a child is but one of the many examples of how cultural influences are evident and varied. Language is specific to one's cultural group whether formal, informal, verbal, or nonverbal. Language determines the cultural networks in which an individual participates and contributes specific values to the culture.
Awareness of racism, sexism, and poverty. Racism, sexism, and poverty are all aspects of a culture that must be understood from the perspective of how one views their effect both upon oneself and upon others. The words themselves are obviously powerful terms and frequently evoke some defensiveness. Even when racism and sexism are denied as a part of one's personal belief system, one must recognize that he/she never-the-less exists as a part of the larger culture. Even when the anguish of poverty is not felt personally, the counselor must come to grips with his or her own beliefs regarding financially less fortunate people.
Exploration of the issues of racism, sexism, and poverty may be facilitated by a "systems" approach. Such an exploration may lead to examination of the differences between individual behaviors and organizational behaviors, or what might be called the difference between personal prejudice and institutional prejudice. The influence of organizational prejudice can be seen in the attitudes and beliefs of the system in which the counselor works. Similarly, the awareness that frequently church memberships exist along racial lines, or that some social organizations restrict their membership to one sex, should help counselors come to grips with the organizational prejudice which they may be supporting solely on the basis of participation in a particular organization.
Awareness of individual differences. One of the greatest pitfalls of the novice counselor is to overgeneralize things learned about a specific culture as therefore applicable to all members of the culture. A single thread of commonality is often presumed to exist as interwoven among the group simply because it is observed in one or a few member(s) of the culture. On the contrary, cultural group membership does not require one to sacrifice individualism or uniqueness. In response to the counselor who feels all clients should be treated as "individuals," I say clients must be treated as both individuals and members of their particular cultural group.
Total belief in individualism fails to take into account the "collective family-community" relationship which exists in many cultural groups. A real danger lies in the possibility that counselors may unwittingly discount cultural influences and subconsciously believe they understand the culturally different when, in fact, they view others from their own culture's point of view. In practice, what is put forth as a belief in individualism can become a disregard for any culturally specific behaviors that influence client behaviors. In sum, counselors must be aware of individual differences and come to believe in the uniqueness of the individual before moving to the level of awareness of other cultures.
Awareness of other cultures. The four previously discussed levels of the continuum provide the background and foundation necessary for counselors to explore the varied dynamics of other cultural groups. Most cross-cultural emphasis is currently placed upon African Americans, Native Americans, Mexican Americans or Hispanics, and Asian Americans. Language is of great significance and uniqueness to each of these cultural groups, rendering standard English less than complete in communication of ideas. It is necessary for counselors to be sensitive to words which are unique to a particular culture as well as body language and other nonverbal behaviors to which cultural significance is attached.
Awareness of diversity. The culture of the United States has often been referred to as a "melting pot." This characterization suggests that people came to the United States from many different countries and blended into one new culture. Thus, old world practices were altered, discarded, or maintained within the context of the new culture. For the most part, many cultural groups did not fully participate in the melting pot process. Thus, many African American, Native American, Mexican American, and Asian American cultural practices were not welcomed as the new culture formed.
Of more recent vintage is the term "salad bowl" which implies that the culture of the United States is capable of retaining aspects from all cultures (the various ingredients). Viewed in this manner, we are seen as capable of living, working, and growing together while maintaining a unique cultural identity. "Rainbow coalition" is another term used in a recent political campaign to represent the same idea. Such concepts reflect what many have come to refer to as a multicultural or pluralistic society, where certain features of each culture are encouraged and appreciated by other cultural groups.
Skills/Techniques. The final level on the continuum is to implement what has been learned about working with culturally different groups and add specific techniques to the repertoire of counseling skills. Before a counselor can effectively work with clients of diverse cultural heritage, he or she must have developed general competence as a counselor. Passage through the awareness continuum constitutes professional growth and will contribute to an increase in overall counseling effectiveness, but goes much further than that. Counselors must be aware of learning theory and how theory relates to the development of psychological-cultural factors. Counselors must understand the relationship between theory and counselors' strategies or practices. Most importantly, counselors must have developed a sense of worth in their own cultures before attaining competence in counseling the culturally different.
People define cultural constructs within the context of their own life histories, growth, and current situations. A working framework for competence in the care of HIV-infected clients must take the following areas of cultural concern into account for each individual:
- Demographics: race, ethnicity, gender, age, generation
- Communication: language(s), literacy (reading, speaking, health)
- Education level: functional as well as actual
- Economic status of the individual and the environment in which s/he functions
- Occupation/means of support: work status, current means of income (legal? illegal? borderline?), labor, profession
- Geography: current residence, community/neighborhood, place of birth, legal status, travel, nationality, etc.
- Environment and situational context: safety of communities in which the individual spends a significant amount of time; risks related to violence, fear of violence, or coercion; communities of risk (i.e., drug/alcohol use, anonymous sex)
- Personal relationships: family, friends, partnerships, sex, drugs, etc.
- Health (physical, emotional, mental): norms, beliefs, practices, preferred providers, taboos; definitions of health, disease/sick role, disability, and care; HIV and other disease diagnoses, treatments, achievements; perceptions (developed over time) of efficacy, value, and disparity/discrimination in relationships with various healthcare systems and providers
- Gender and sex: gender, gender roles, transitions, sexual orientation, sexual intercourse
- Community affiliations: religious, political, service, social, etc.
- Culture-specific definitions: spirituality, art, ethics, value, locus of control, power
- Individual experiences: development over time that has lead the individual to accept, reject, and/or modify cultural components that were imparted to him/her as a child; life experiences that have expanded, challenged, realigned, or reinforced early cultural influences; individual constellation of factors that make up her/his cultural orientation
- Culture comfort: has the individual integrated a personal set of cultural influences into his/her life? how do those beliefs and practices intersect with health practices and self-acceptance? can the individual function within larger social systems (family, community, social structures)? is the individual in a state of cognitive dissonance, discord, or discomfort with/between the values of personal, familial, and/or social cultures?
Providers. Healthcare providers possess knowledge and skills that were developed in a process of professional education. They have their own language, expectations, and professional cultures. They also have responsibilities:
- To develop skills to assess individual client cultures and to work with the client to integrate components of that culture into a care and treatment plan that the client can accept.
- To be open to learning about the ways of others and willing to see past stereotypes when working with individuals and families.
- To suspend judgment, especially in the assessment phases of care.
- To remember that individuals are unique even within groups: some Hispanics do not speak Spanish, some women are not mothers, some Catholics use birth control, and some college-educated people use alternative/traditional healthcare practices.
- To adopt an attitude of service to the client and the community.
- To explore, understand, and honor their own cultural definitions and values.
- To constantly compare personal culture(s) within the context of professional obligations.
- To deal with any dissonance that occurs between cultures by “honoring and setting aside” or by making personally acceptable changes and developing methods of dealing with larger culture clashes and ethical dilemmas that can occur in cross-cultural settings.
- To accept responsibility as the power broker in healthcare situations to address healthcare in a holistic manner that includes culture.
Client. The client also has obligations:
- To share the components of her/his culture that will impact on the ability to seek care, to participate in the process of developing a healthcare plan, and to implement care prescriptions.
- To seek care from providers who understand his/her culture.
- To teach providers who are open to these discussions.
Unfortunately, many clients feel that they are in a “one down” position in ANY healthcare setting, especially if they are poor, do not understand healthcare systems, have cultural constraints against disagreeing with authority figures, or already suffer from discrimination by virtue of race, ethnicity, gender, status, or diagnosis (especially HIV, drug use, mental health problems, and STDs). Because of this, the provider’s responsibility to honor various cultures is imperative.
Overview of Cultural Diversity and Mental Health Services
The U.S. mental health system is not well equipped to meet the needs of racial and ethnic minority populations. Racial and ethnic minority groups are generally considered to be underserved by the mental health services system (Neighbors et al., 1992; Takeuchi & Uehara, 1996; Center for Mental Health Services [CMHS], 1998). A constellation of barriers deters ethnic and racial minority group members from seeking treatment, and if individual members of groups succeed in accessing services, their treatment may be inappropriate to meet their needs.
Awareness of the problem dates back to the 1960s and 1970s, with the rise of the civil rights and community mental health movements (Rogler et al., 1987) and with successive waves of immigration from Central America, the Caribbean, and Asia (Takeuchi & Uehara, 1996). These historical forces spurred greater recognition of the problems that minority groups confront in relation to mental health services.
Research documents that many members of minority groups fear, or feel ill at ease with, the mental health system (Lin et al., 1982; Sussman et al., 1987; Scheffler & Miller, 1991). These groups experience it as the product of white, European culture, shaped by research primarily on white, European populations. They may find only clinicians who represent a white middle-class orientation, with its cultural values and beliefs, as well as its biases, misconceptions, and stereotypes of other cultures.
Research and clinical practice have propelled advocates and mental health professionals to press for “linguistically and culturally competent services” to improve utilization and effectiveness of treatment for different cultures. Culturally competent services incorporate respect for and understanding of, ethnic and racial groups, as well as their histories, traditions, beliefs, and value systems (CMHS, 1998). Without culturally competent services, the failure to serve racial and ethnic minority groups adequately is expected to worsen, given the huge demographic growth in these populations predicted over the next decades (Takeuchi & Uehara, 1996; CMHS, 1998; Snowden, 1999).
This section of the chapter amplifies these major conclusions. It explains the confluence of clinical, cultural, organizational, and financial reasons for minority groups being underserved by the mental health system. The first task, however, is to explain which ethnic and racial groups constitute underserved populations, to describe their changing demographics, and to define the term “culture” and its consequences for the mental health system.
Introduction to Cultural Diversity and Demographics
The Federal government officially designates four major racial or ethnic minority groups in the United States: African American (black), Asian/Pacific Islander, Hispanic American (Latino), and Native American/American Indian/Alaska Native/Native Hawaiian (referred to subsequently as “American Indians”) (CMHS, 1998). There are many other racial or ethnic minorities and considerable diversity within each of the four groupings listed above. The representation of the four officially designated groups in the U.S. population in 1999 is as follows: African Americans constitute the largest group, at 12.8 percent of the U.S. population; followed by Hispanics (11.4 percent), Asian/Pacific Islanders (4.0 percent), and American Indians (0.9 percent) (U.S. Census Bureau, 1999). Hispanic Americans are among the fastest-growing groups. Because their population growth outpaces that of African Americans, they are projected to be the predominant minority group (24.5 percent of the U.S. population) by the year 2050 (CMHS, 1998).
Racial and ethnic populations differ from one another and from the larger society with respect to culture. The term “culture” is used loosely to denote a common heritage and set of beliefs, norms, and values. The cultures with which members of minority racial and ethnic groups identify often are markedly different from industrial societies of the West. The phrase “cultural identity” specifies a reference group—an identifiable social entity with whom a person identifies and to whom he or she looks for standards of behavior (Cooper & Denner, 1998). Of course, within any given group, an individual’s cultural identity may also involve language, country of origin, acculturation, gender, age, class, religious/spiritual beliefs, sexual orientation, and physical disabilities (Lu et al., 1995). Many people have multiple ethnic or cultural identities.
The historical experiences of ethnic and minority groups in the United States are reflected in differences in economic, social, and political status. The most measurable difference relates to income. Many racial and ethnic minority groups have limited financial resources. In 1994, families from these groups were at least three times as likely as white families to have incomes placing them below the Federally established poverty line. The disparity is even greater when considering extreme poverty—family incomes at a level less than half of the poverty threshold—and is also large when considering children and older persons (O’Hare, 1996). Although some Asian Americans are somewhat better off financially than other minority groups, they still are more than one and a half times more likely than whites to live in poverty. Poverty disproportionately affects minority women and their children (Miranda & Green, 1999). The effects of poverty are compounded by differences in total value of accumulated assets, or total wealth (O’Hare et al., 1991).
Lower socioeconomic status—in terms of income, education, and occupation—has been strongly linked to mental illness. It has been known for decades that people in the lowest socioeconomic strata are about two and a half times more likely than those in the highest strata to have a mental disorder (Holzer et al., 1986; Regier et al., 1993b). The reasons for the association between lower socioeconomic status and mental illness are not well understood. It may be that a combination of greater stress in the lives of the poor and greater vulnerability to a variety of stressors leads to some mental disorders, such as depression. Poor women, for example, experience more frequent, threatening, and uncontrollable life events than do members of the population at large (Belle, 1990). It also may be that the impairments associated with mental disorders lead to lower socioeconomic status (McLeod & Kessler, 1990; Dohrenwend, 1992; Regier et al., 1993b).
Cultural identity imparts distinct patterns of beliefs and practices that have implications for the willingness to seek, and the ability to respond to, mental health services. These include coping styles and ties to family and community, discussed below.
Cultural differences can be reflected in differences in preferred styles of coping with day-to-day problems. Consistent with a cultural emphasis on restraint, certain Asian American groups, for example, encourage a tendency not to dwell on morbid or upsetting thoughts, believing that avoidance of troubling internal events is warranted more than recognition and outward expression (Leong & Lau, 1998). They have little willingness to behave in a fashion that might disrupt social harmony (Uba, 1994). Their emphasis on willpower is similar to the tendency documented among African Americans to minimize the significance of stress and, relatedly, to try to prevail in the face of adversity through increased striving (Broman, 1996).
Culturally rooted traditions of religious beliefs and practices carry important consequences for willingness to seek mental health services. In many traditional societies, mental health problems can be viewed as spiritual concerns and as occasions to renew one’s commitment to a religious or spiritual system of belief and to engage in prescribed religious or spiritual forms of practice. African Americans (Broman, 1996) and a number of ethnic groups (Lu et al., 1995), when faced with personal difficulties, have been shown to seek guidance from religious figures.
Many people of all racial and ethnic backgrounds believe that religion and spirituality favorably impact upon their lives and that well-being, good health, and religious commitment or faith are integrally intertwined (Taylor, 1986; Priest, 1991; Bacote, 1994; Pargament, 1997). Religion and spirituality are deemed important because they can provide comfort, joy, pleasure, and meaning to life as well as be means to deal with death, suffering, pain, injustice, tragedy, and stressful experiences in the life of an individual or family (Pargament, 1997). In the family/community-centered perception of mental illness held by Asians and Hispanics, religious organizations are viewed as an enhancement or substitute when the family is unable to cope or assist with the problem (Acosta et al., 1982; Comas-Diaz, 1989; Cook & Timberlake, 1989; Meadows, 1997).
Culture also imprints mental health by influencing whether and how individuals experience the discomfort associated with mental illness. When conveyed by tradition and sanctioned by cultural norms, characteristic modes of expressing suffering are sometimes called “idioms of distress” (Lu et al., 1995). Idioms of distress often reflect values and themes found in the societies in which they originate.
One of the most common idioms of distress is somatization, the expression of mental distress in terms of physical suffering. Somatization occurs widely and is believed to be especially prevalent among persons from a number of ethnic minority backgrounds (Lu et al., 1995). Epidemiological studies have confirmed that there are relatively high rates of somatization among African Americans (Zhang & Snowden, in press). Indeed, somatization resembles an African American folk disorder identified in ethnographic research and is linked to seeking treatment (Snowden, 1998).
A number of idioms of distress are well recognized as culture-bound syndromes and have been included in an appendix to DSM-IV. Among culture-bound syndromes found among some Latino psychiatric patients is ataque de nervios, a syndrome of “uncontrollable shouting, crying, trembling, and aggression typically triggered by a stressful event involving family. . . ” (Lu et al., 1995, p. 489). A Japanese culture-bound syndrome has appeared in that country’s clinical modification of ICD-10 (WHO International Classification of Diseases, 10th edition, 1993). Taijin kyofusho is an intense fear that one’s body or bodily functions give offense to others. Culture-bound syndromes sometimes reflect comprehensive systems of belief, typically emphasizing a need for a balance between opposing forces (e.g., yin/yang, “hot-cold” theory) or the power of supernatural forces (Cheung & Snowden, 1990). Belief in indigenous disorders and adherence to culturally rooted coping practices are more common among older adults and among persons who are less acculturated. It is not well known how applicable DSM-IV diagnostic criteria are to culturally specific symptom expression and culture-bound syndromes.
Family and Community as Resources
Ties to family and community, especially strong in African, Latino, Asian, and Native American communities, are forged by cultural tradition and by the current and historical need to assist arriving immigrants, to provide a sanctuary against discrimination practiced by the larger society, and to provide a sense of belonging and affirming a centrally held cultural or ethnic identity.
Among Mexican-Americans (del Pinal & Singer, 1997) and Asian Americans (Lee, 1998) relatively high rates of marriage and low rates of divorce, along with a greater tendency to live in extended family households, indicate an orientation toward family. Family solidarity has been invoked to explain relatively low rates among minority groups of placing older people in nursing homes (Short et al., 1994).
The relative economic success of Chinese, Japanese, and Korean Americans has been attributed to family and communal bonds of association (Fukuyama, 1995). Community organizations and networks established in the United States include rotating credit associations based on lineage, surname, or region of origin. These organizations and networks facilitate the startup of small businesses.
There is evidence of an African American tradition of voluntary organizations and clubs often having political, economic, and social functions and affiliation with religious organizations (Milburn & Bowman, 1991). African Americans and other racial and ethnic minority groups have drawn upon an extended family tradition in which material and emotional resources are brought to bear from a number of linked households. According to this literature, there is “(a) a high degree of geographical propinquity; (b) a strong sense of family and familial obligation; (c) fluidity of household boundaries, with greater willingness to absorb relatives, both real and fictive, adult and minor, if need arises; (d) frequent interaction with relatives; (e) frequent extended family get-togethers for special occasions and holidays; and (f) a system of mutual aid” (Hatchett & Jackson, 1993, p. 92).
Families play an important role in providing support to individuals with mental health problems. A strong sense of family loyalty means that, despite feelings of stigma and shame, families are an early and important source of assistance in efforts to cope, and that minority families may expect to continue to be involved in the treatment of a mentally ill member (Uba, 1994). Among Mexican American families, researchers have found lower levels of expressed emotion and lower levels of relapse (Karno et al., 1987). Other investigators have demonstrated an association between family warmth and a reduced likelihood of relapse (Lopez et al., in press).
Epidemiology and Utilization of Services
One of the best ways to identify whether a minority group has problems accessing mental health services is to examine their utilization of services in relation to their need for services. As noted previously, a limitation of contemporary mental health knowledge is the lack of standard measures of “need for treatment” and culturally appropriate assessment tools. Minority group members’ needs, as measured indirectly by their prevalence of mental illness in relation to the U.S. population, should be proportional to their utilization, as measured by their representation in the treatment population. These comparisons turn out to be exceedingly complicated by inadequate understanding of the prevalence of mental disorders among minority groups in the United States. Nationwide studies conducted many years ago overlooked institutional populations, which are disproportionately represented by minority groups. Treatment utilization information on minority groups in relation to whites is more plentiful, yet, a clear understanding of health seeking behavior in various cultures is lacking.
The following paragraphs reveal that disparities abound in treatment utilization: some minority groups are underrepresented in the outpatient treatment population while, at the same time, overrepresented in the inpatient population. Possible explanations for the differences in utilization are discussed in a later section.
The prevalence of mental disorders is estimated to be higher among African Americans than among whites (Regier et al., 1993a). This difference does not appear to be due to intrinsic differences between the races; rather, it appears to be due to socioeconomic differences. When socioeconomic factors are taken into account, the prevalence difference disappears. That is, the socioeconomic status-adjusted rates of mental disorder among African Americans turn out to be the same as those of whites. In other words, it is the lower socioeconomic status of African Americans that places them at higher risk for mental disorders (Regier et al., 1993a).
African Americans are underrepresented in some outpatient treatment populations, but overrepresented in public inpatient psychiatric care in relation to whites (Snowden & Cheung, 1990; Snowden, in press-b). Their underrepresentation in outpatient treatment varies according to setting, type of provider, and source of payment. The racial gap between African Americans and whites in utilization is smallest, if not nonexistent, in community-based programs and in treatment financed by public sources, especially Medicaid (Snowden, 1998) and among older people (Padgett et al., 1995). The underrepresentation is largest in privately financed care, especially individual outpatient practice, paid for either by fee-for-service arrangements or managed care. As a result, underrepresentation in the outpatient setting occurs more among working and middle-class African Americans, who are privately insured, than among the poor. This suggests that socioeconomic standing alone cannot explain the problem of underutilization (Snowden, 1998).
African Americans are, as noted above, overrepresented in inpatient psychiatric care (Snowden, in press-b). Their rate of utilization of psychiatric inpatient care is about double that of whites (Snowden & Cheung, 1990). This difference is even higher than would be expected on the basis of prevalence estimates. Overrepresentation is found in hospitals of all types except private psychiatric hospitals. While difficult to explain definitively, the problem of overrepresentation in psychiatric hospitals appears more rooted in poverty, attitudes about seeking help, and a lack of community support than in clinician bias in diagnosis and overt racism, which also have been implicated (Snowden, in press-b). This line of reasoning posits that poverty, disinclination to seek help, and lack of health and mental health services deemed appropriate, and responsive, as well as community support, are major contributors to delays by African Americans in seeking treatment until symptoms become so severe that they warrant inpatient care.
Finally, African Americans are more likely than whites to use the emergency room for mental health problems (Snowden, in press-a). Their overreliance on emergency care for mental health problems is an extension of their overreliance on emergency care for other health problems. The practice of using the emergency room for routine care is generally attributed to a lack of health care providers in the community willing to offer routine treatment to people without insurance (Snowden, in press-a).
Asian Americans/Pacific Islanders
The prevalence of mental illness among Asian Americans is difficult to determine for methodological reasons (i.e., population sampling). Although some studies suggest higher rates of mental illness, there is wide variance across different groups of Asian Americans (Takeuchi & Uehara, 1996). It is not well known how applicable DSM-IV diagnostic criteria are to culturally specific symptom expression and culture-bound syndromes. With respect to treatment-seeking behavior, Asian Americans are distinguished by extremely low levels at which specialty treatment is sought for mental health problems (Leong & Lau, 1998). Asian Americans have proven less likely than whites, African Americans, and Hispanic Americans to seek care. One national sample revealed that Asian Americans were only a quarter as likely as whites, and half as likely as African Americans and Hispanic Americans, to have sought outpatient treatment (Snowden, in press-a). Asian Americans/Pacific Islanders are less likely than whites to be psychiatric inpatients (Snowden & Cheung, 1990). The reasons for the underutilization of services include the stigma and loss of face over mental health problems, limited English proficiency among some Asian immigrants, different cultural explanations for the problems, and the inability to find culturally competent services. These phenomena are more pronounced for recent immigrants (Sue et al., 1994).
Several epidemiological studies revealed few differences between Hispanic Americans and whites in lifetime rates of mental illness (Robins & Regier, 1991; Vega & Kolody, 1998). A recent study of Mexican Americans in Fresno County, California, found that Mexican Americans born in the United States had rates of mental disorders similar to those of other U.S. citizens, whereas immigrants born in Mexico had lower rates (Vega et al., 1998a). A large study conducted in Puerto Rico reported similar rates of mental disorders among residents of that island, compared with those of citizens of the mainland United States (Canino et al., 1987).
Although rates of mental illness may be similar to whites in general, the prevalence of particular mental health problems, the manifestation of symptoms, and help-seeking behaviors within Hispanic subgroups need attention and further research. For instance, the prevalence of depressive symptomatology is higher in Hispanic women (46%) than men (almost 20%); yet, the known risk factors do not totally explain the gender difference (Vega et al., 1998a; Zunzunegui et al., 1998). Several studies indicate that Puerto Rican and Mexican American women with depressive symptomatology are underrepresented in mental health services and overrepresented in general medical services (Hough et al., 1987; Sue et al., 1991, 1994; Duran, 1995; Jimenez et al., 1997).
American Indians/Alaska Natives have, like Asian Americans and Pacific Islanders, been studied in few epidemiological surveys of mental health and mental disorders. The indications are that depression is a significant problem in many American Indian/Alaska Native communities (Nelson et al., 1992). One study of a Northwest Indian village found rates of DSM-III-R affective disorder that were notably higher than rates reported from national epidemiological studies (Kinzie et al., 1992). Alcohol abuse and dependence appear also to be especially problematic, occurring at perhaps twice the rate of occurrence found in any other population group. Relatedly, suicide occurs at alarmingly high levels. (Indian Health Service, 1997). Among Native American veterans, post-traumatic stress disorder has been identified as especially prevalent in relation to whites (Manson, 1998). In terms of patterns of utilization, Native Americans are overrepresented in psychiatric inpatient care in relation to whites, with the exception of private psychiatric hospitals (Snowden & Cheung, 1990; Snowden, in press-b).
Barriers to the Receipt of Treatment
The underrepresentation in outpatient treatment of racial and ethnic minority groups appears to be the result of cultural differences as well as financial, organizational, and diagnostic factors. The service system has not been designed to respond to the cultural and linguistic needs presented by many racial and ethnic minorities. What is unresolved are the relative contribution and significance of each factor for distinct minority groups.
Among adults, the evidence is considerable that persons from minority backgrounds are less likely than are whites to seek outpatient treatment in the specialty mental health sector (Sussman et al., 1987; Gallo et al., 1995; Leong & Lau, 1998; Snowden, 1998; Vega et al., 1998a, 1998b; Zhang et al., 1998). This is not the case for emergency department care, from which African Americans are more likely than whites to seek care for mental health problems, as noted above. Language, like economic and accessibility differences, can play an important role in why people from other cultures do not seek treatment (Hunt, 1984; Comas-Diaz, 1989; Cook & Timberlake, 1989; Taylor, 1989).
The reasons why racial and ethnic minority groups are less apt to seek help appear to be best studied among African Americans. By comparison with whites, African Americans are more likely to give the following reasons for not seeking professional help in the face of depression: lack of time, fear of hospitalization, and fear of treatment (Sussman et al., 1987). Mistrust among African Americans may stem from their experiences of segregation, racism, and discrimination (Primm et al., 1996; Priest, 1991). African Americans have experienced racist slights in their contacts with the mental health system, called “microinsults” by Pierce (1992). Some of these concerns are justified on the basis of research, cited below, revealing clinician bias in overdiagnosis of schizophrenia and underdiagnosis of depression among African Americans.
Lack of trust is likely to operate among other minority groups, according to research about their attitudes toward government-operated institutions rather than toward mental health treatment per se. This is particularly pronounced for immigrant families with relatives who may be undocumented, and hence they are less likely to trust authorities for fear of being reported and having the family member deported. People from El Salvador and Argentina who have experienced imprisonment or watched the government murder family members and engage in other atrocities may have an especially strong mistrust of any governmental authority (Garcia & Rodriguez, 1989). Within the Asian community, previous refugee experiences of groups such as Vietnamese, Indochinese, and Cambodian immigrants parallel those experienced by Salvadoran and Argentine immigrants. They, too, experienced imprisonment, death of family members or friends, physical abuse, and assault, as well as new stresses upon arriving in the United States (Cook & Timberlake, 1989; Mollica, 1989).
American Indians’ past experience in this country also imparted lack of trust of government. Those living on Indian reservations are particularly fearful of sharing any information with white clinicians employed by the government. As with African Americans, the historical relationship of forced control, segregation, racism, and discrimination has affected their ability to trust a white majority population (Herring, 1994; Thompson, 1997).
The stigma of mental illness is another factor preventing African Americans from seeking treatment, but not at a rate significantly different from that of whites. Both African American and white groups report that embarrassment hinders them from seeking treatment (Sussman et al., 1987). In general, African Americans tend to deny the threat of mental illness and strive to overcome mental health problems through self-reliance and determination (Snowden, 1998). Stigma, denial, and self-reliance are likely explanations why other minority groups do not seek treatment, but their contribution has not been evaluated empirically, owing in part to the difficulty of conducting this type of research. One of the few studies of Asian Americans identified the barriers of stigma, suspiciousness, and a lack of awareness about the availability of services (Uba, 1994). Cultural factors tend to encourage the use of family, traditional healers, and informal sources of care rather than treatment-seeking behavior, as noted earlier.
Cost is yet another factor discouraging utilization of mental health services (Chapter 6). Minority persons are less likely than whites to have private health insurance, but this factor alone may have little bearing on access. Public sources of insurance and publicly supported treatment programs fill some of the gap. Even among working class and middle-class African Americans who have private health insurance, there is underrepresentation of African Americans in outpatient treatment (Snowden, 1998). Yet studies focusing only on poor women, most of whom were members of minority groups, have found cost and lack of insurance to be barriers to treatment (Miranda & Green, 1999). The discrepancies in findings suggest that much research remains to be performed on the relative importance of cost, cultural, and organizational barriers, and poverty and income limitations across the spectrum of racial and ethnic and minority groups.
Advocates and experts alike have asserted that bias in clinician judgment is one of the reasons for overutilization of inpatient treatment by African Americans. Bias in clinician judgment is thought to be reflected in overdiagnosis or misdiagnosis of mental disorders. Since diagnosis is heavily reliant on behavioral signs and patients’ reporting of the symptoms, rather than on laboratory tests, clinician judgment plays an enormous role in the diagnosis of mental disorders. The strongest evidence of clinician bias is apparent for African Americans with schizophrenia and depression. Several studies found that African Americans were more likely than were whites to be diagnosed with schizophrenia, yet less likely to be diagnosed with depression (Snowden & Cheung, 1990; Hu et al., 1991; Lawson et al., 1994).
In addition to problems of overdiagnosis or misdiagnosis, there may well be a problem of underdiagnosis among minority groups, such as Asian Americans, who are seen as “problem-free” (Takeuchi & Uehara, 1996). The presence and extent of this type of clinician bias are not known and need to be investigated.
Improving Treatment for Minority Groups
The previous paragraphs have documented underutilization of treatment, less help-seeking behavior, inappropriate diagnosis, and other problems that have beset racial and ethnic minority groups with respect to mental health treatment. This kind of evidence has fueled the widespread perception of mental health treatment as being uninviting, inappropriate, or not as effective for minority groups as for whites. The Schizophrenia Patient Outcome Research Team demonstrated that African Americans were less likely than others to have received treatment that conformed to recommended practices (Lehman & Steinwachs, 1998). Inferior treatment outcomes are widely assumed but are difficult to prove, especially because of sampling, questionnaire, and other design issues, as well as problems in studying patients who drop out of treatment after one session or who otherwise terminate prematurely. In a classic study, 50 percent of Asian Americans versus 30 percent of whites dropped out of treatment early (Sue & McKinney, 1975). However, the disparity in dropout rates may have abated more recently (O’Sullivan et al., 1989; Snowden et al., 1989). One of the few studies of clinical outcomes, a pre- versus post-treatment study, found that African Americans fared more poorly than did other minority groups treated as outpatients in the Los Angeles area (Sue et al., 1991). Earlier studies from the 1970s and 1980s had given inconsistent results (Sue et al., 1991).
There is mounting awareness that ethnic and cultural influences can alter an individual’s responses to medications (pharmacotherapies). The relatively new field of ethnopsychopharmacology investigates cultural variations and differences that influence the effectiveness of pharmacotherapies used in the mental health field. These differences are both genetic and psychosocial in nature. They range from genetic variations in drug metabolism to cultural practices that affect diet, medication adherence, placebo effect, and simultaneous use of traditional and alternative healing methods (Lin et al., 1997). Just a few examples are provided to illustrate ethnic and racial differences.
Pharmacotherapies given by mouth usually enter the circulation after absorption from the stomach. From the circulation they are distributed throughout the body (including the brain for psychoactive drugs) and then metabolized, usually in the liver, before they are cleared and eliminated from the body (Brody, 1994). The rate of metabolism affects the amount of the drug in the circulation. A slow rate of metabolism leaves more drug in the circulation. Too much drug in the circulation typically leads to heightened side effects. A fast rate of metabolism, on the other hand, leaves less drug in the circulation. Too little drug in the circulation reduces its effectiveness.
There is wide racial and ethnic variation in drug metabolism. This is due to genetic variations in drug-metabolizing enzymes (which are responsible for breaking down drugs in the liver). These genetic variations alter the activity of several drug-metabolizing enzymes. Each drug-metabolizing enzyme normally breaks down not just one type of pharmacotherapy, but usually several types. Since most of the ethnic variation comes in the form of inactivation or reduction in activity in the enzymes, the result is higher amounts of medication in the blood, triggering untoward side effects.
For example, 33 percent of African Americans and 37 percent of Asians are slow metabolizers of several antipsychotic medications and antidepressants (such as tricyclic antidepressants and selective serotonin reuptake inhibitors) (Lin et al., 1997). This awareness should lead to more cautious prescribing practices, which usually entail starting patients at lower doses in the beginning of treatment. Unfortunately, just the opposite typically had been the case with African American patients and antipsychotic drugs. Clinicians in psychiatric emergency services prescribed more oral doses and more injections of antipsychotic medications to African American patients (Segel et al., 1996). The combination of slow metabolism and overmedication of antipsychotic drugs in African Americans can yield very uncomfortable extrapyramidal side effects (Lin et al., 1997). These are the kinds of experiences that likely contribute to the mistrust of mental health services reported among African Americans (Sussman et al., 1987).
Psychosocial factors also can play an important role in ethnic variation. Compliance with dosing may be hindered by communication difficulties; side effects can be misinterpreted or carry different connotations; some groups may be more responsive to placebo treatment; and reliance on psychoactive traditional and alternative healing methods (such as medicinal plants and herbs) may result in interactions with prescribed pharmacotherapies. The result could be greater side effects and enhanced or reduced effectiveness of the pharmacotherapy, depending on the agents involved and their concentrations (Lin et al., 1997). Greater awareness of ethnopsychopharmacology is expected to improve treatment effectiveness for racial and ethnic minorities. More research is needed on this topic across racial and ethnic groups.
20 The term “Latino(a)” refers to all persons of Mexican, Puerto Rican, Cuban, or other Central and South American or Spanish origin (CMHS, 1998).
21 Acculturation refers to the “social distance” separating members of an ethnic or racial group from the wider society in areas of beliefs and values and primary group relations (work, social clubs, family, friends) (Gordon, 1964). Greater acculturation thus reflects greater adoption of mainstream beliefs and practices and entry into primary group relations.
22 Research is emerging on the importance of tailoring services to the special needs of gay, lesbian, and bisexual mental health service users (Cabaj & Stein, 1996).
23 Of the 15 percent of the U.S. population that use mental health services in a given year, about 2.8 percent receive care only from members of the clergy (Larson et al., 1988).
24 In spring 2000, survey field work begins on an NIMH-funded study of the prevalence of mental disorders, mental health symptoms, and related functional impairments in African Americans, Caribbean blacks, and non-Hispanic whites. The study will examine the effects of psychosocial factors and race-associated stress on mental health, and how coping resources and strategies influence that impact. The study will provide a database on mental health, mental disorders, and ethnicity and race. James Jackson, Ph.D., University of Michigan, is principal investigator.
25 African Americans are overrepresented among persons undergoing involuntary civil commitment (Snowden, in press-b).
26 Dystonia (brief or prolonged contraction of muscles), akathisia (an urge to move about constantly), or parkinsonism (tremor and rigidity) (Perry et al., 1997).
Continuing disparities in the diagnosis and effective treatment of depression persist. Many of these contributing factors can be grouped into three broad categories.
First, larger societal issues such as poverty, racism and discrimination, unemployment and underemployment, and inadequate housing have an impact on health/mental health status of diverse racial and ethnic groups.
Second, differential access to services has been demonstrated to be a factor in disparities. Access involves more than availability and affordability of services. Access also refers to an active connection with the patient. Thus, acceptability of services—how they are offered, where they are offered and by whom—is a significant factor in access.
Third, cultural and linguistic factors have been identified as contributing to disparities including language barriers, diverse belief systems related to health, mental health, healing and well-being, culturally influenced help-seeking behaviors, attitudes toward care providers, and individual preferences and approaches to care.
While continuing medical education (CME) can not address all of these issues, all may be positively impacted in the long run by health and mental health care providers who are aware of disparities and societal issues that contribute to them, and who have the knowledge and skills necessary to diagnose and treat depression effectively in culturally and linguistically diverse patient populations.
One of the five essential elements of cultural and linguistic competence is the capacity for self-assessment at both the organizational and individual levels. This continuing education activity will help you to assess yourself on cultural and linguistic competence in relation to the diagnosis and treatment of depression.
This continuing education activity allows you to assess your awareness, knowledge and/or skills in six domains:
- Values and Belief Systems -- perspectives on health, illness, mental health, well-being, care-seeking behaviors, traditional health practices, and spirituality of your patients and their communities as well as family/community dynamics.
- Cultural Influences on Illness and Related Problems -- health and mental health disparities and risk factors for culturally and linguistically diverse groups and communities.
- Depression and Health -- awareness of the relationship between illness and the risk for depression and the impact of depression on treatment and clinical course of diabetes, cardiovascular disease and HIV/AIDS
- Clinical Management -- screening, assessment/diagnosis, treatment/discharge planning, and use of community-based resources.
- Cross-Cultural Communication -- cross-cultural communication, utilization of different modes of communication, and the provision of interpretation/translation services.
- Promotion of Cultural and Linguistic Competence in Systems of Care and Communities -- the practitioners’ role in providing information that enables individuals to intervene on their own behalf, advocate and build community capacity for improved health, mental health, and well being.
The term "culture" can be reasonably applied to various population categories. There are cultures or subcultures, for example, that reflect differences of age, gender, sexual orientation, religion, and geographic region. Each of these groups employ particular ways of viewing and meeting the challenges, traumas, and triumphs of life. For this discussion, however, culture represents race and ethnicity. It is this diversity that both enriches and obstructs much of our involvement and interaction with others.
Across America, racial and ethnic heritages are being dramatically interwoven. An array of languages, religions, customs, and traditions is infusing our nation with both vibrancy and challenge. Molefi Asante, chair of African American Studies at Temple University has stated:
"Once America was a microcosm of European nationalities,
today America is a microcosm of the world."
Such an occurrence is not necessarily the harbinger of chaos. Inevitably and even enthusiastically, this emergence must be accepted and endorsed.
The criminal justice system is not exempt from the consequences of these demographic changes that are generating a new definition of "American." As the European American population continues to decrease in relative percentage, there is a corresponding and accelerating increase of Latino, Asian, and African Americans. This raises the following concerns or questions for victim service providers:
- How does the criminal justice system adhere to equal justice for this diversity of people?
- How can victim assistance programs fashion priorities and ensure competence in order to serve the widening spectrum, rather than exclusive number, of people?
There are two eternal truths about human beings:
- People differ from one another.
- People are similar to one another.
When the distinctiveness of others is considered, there can be a tendency to over-generalize in order to highlight the commonalties within cultural identities. The variety within cultural groups, however, may be obscured by the emphasis placed in distinguish-ing between them. Any aggregate labeling of people is, in other words, part logic and part insult.
The term "Indian," for example, was a misnomer foisted upon the Arawak tribe of the southeastern United States by an errant Italian navigator who had set sail for India. It is now (mistakenly) used to describe all the native populations of the Western Hemisphere.
- "American Indians," perhaps preferably called "Native Americans," are now acknowledged by the Bureau of the Census to be over 500 separate nations and tribes with 187 different languages.
The term "Hispanic" refers to those who share a common language, i.e. Spanish. But not everyone who is from Mexico speaks Spanish, e.g. the native peoples from the central mountains.
- There are also noticeable class differences between destitute Guatemalan refugees who have fled violent political upheaval in their homeland and relatively prosperous Costa Ricans who enjoyed some measure of social and economic stability.
Just as it is presumptuous to consider a Bostonian Irishman, an Anglo-California yuppie, a Jewish Greenwich Village artist, a Texas rodeo star, and a New Age Santa Fe vegetarian as all the same because they are coincidentally "white," it is just as unwise to render all "Latinos" (or Asians or African Americans) as inherently alike. As Ross, Millen, and Martinez have pointed out, "There are some ways in which any particular Chicano is like all other Chicanos, and there are some ways in which a particular Chicano is like no other Chicano."
Points to Reflect Upon in Providing Services
- No one is just what we label or classify them.
- Who we are is inseparable from our racial and ethnic backgrounds but not strictly determined by them.
- All crime victims deserve to be treated as individuals even as the nuances of race and culture (and the degrees of acculturation) are recognized.
- Victim counselors must be aware of the cultural context of the victims with whom they are working, continually assess the adequacy of their communication styles and counseling methods, and be flexible enough to make adjustments on a case-by-case basis.
What "Culturally-Sensitive Service" is Not
I haven't noticed that you are different. We are all humans. We all have the same feelings. I don't care if you are pink, green or purple.
Presumably with good intentions to treat everyone equally, such overtures are sometimes made by victim counselors. There is, however, no universal response to suffering. The role of racial experience and cultural history cannot be readily dissolved into some melting pot of generic humanity. As Tello states:
"What it (color blindness) does demonstrate is the service provider's inability to understand and articulate these differences. When this occurs, the service provider may attempt to justify his or her own position by mini-mizing the role of culture."
Individual experiences in culture, language and identity serve to filter and shape how a person perceives events and reacts to both small and life-altering events. As Parsons writes:
"Ethnic identification is an irreducible entity, central to how persons organize experience."
Memorizing Cultural Idiosyncrasies
Service to culturally diverse crime victims is not primarily a command of every minute custom or memorization of an encyclopedia of rigid "do's and don'ts." This would be an impossible task.
- A stereotypic approach to any victim is obviously simplistic and harmful.
- An attempt should instead be made to learn the significance behind several major cultural forms, for example, the meaning to the persons practicing those traditions.
This will help one gain a personal feel for the culture, and to know people from the perspective they see themselves rather than focus upon their isolated behaviors and "unusual thinking."
Case Example of Multi-cultural Healing in the Aftermath of Victimization:
In the aftermath of Patrick Purdy's deadly rifle assault on the schoolchildren of Cleveland Elementary School in Stockton, California in 1989, for example, there was an outpouring of concern and support from across the nation. Five children had been killed and 29 children and one teacher wounded. Two of the central events in the healing process for the Cambodian and Vietnamese surviving family members were the Buddhist funeral service and a subsequent ceremonial purification of the school grounds for the purpose of "releasing" the children's spirits.
These rituals were strange for the local district attorney's victim assistance staff, but their involvement in facilitating and participating in these events, their willingness to depend upon the Buddhist monks for leadership, and their efforts to quickly learn (only) the most important Southeast Asian mourning customs were keys to being helpful.
Diversity of Victim Service Providers
Race is not the same as culture. There are, for example, "Black Portuguese" residing in the United States. These persons are racially black African but culturally Portuguese as the result of colonization and slavery on the islands off the coast of Africa. Same ethnicity, moreover, does not itself mean biculturally competent. A particular counselor's favorable cross-cultural experiences predict effectiveness with diverse victims more than simply identical race or ethnicity.
- There is undoubtedly a need for more minority victim service providers who know their own ethnic histories, people, culture, and language.
- Victim programs should demonstrate diversity in their staffs relative to the composition of their client populations.
- If there is justification for the absence of such representation, however, there are other avenues that can be developed to meet the needs of diverse peoples.
- These include the use of minority volunteers and organizations, an appropriate referral list, culturally-sensitive protocols, and on-call translators.
Basic Qualifications of Culturally-Competent Service
Compassion and Sincerity
Most minorities have developed a sharp sense for detecting condescension, manipulation, and insincerity. There is no substitute for compassion as the foundation and sincerity as its expression for carrying out victim services equally and fairly. Although it is not possible to feel the same compassion for all victims, it is the responsibility of providers to provide the same compassionate service for every victim. Compassionate and sincere advocacy knows no borders.
The plight of undocumented residents or illegal aliens, for example, involves complex issues of personal prejudices and international politics. Sentiments among Americans regarding the clandestine migration of those who seek a better life here, mostly from Mexico and Central America, range from compassion for the safety and dignity of those fleeing poverty and war to border vigilante hunts and savage beatings.
- Once in the United States, the undocumented become easy prey for employment exploitation, consumer fraud, housing discrimination, and criminal victimization because assistance from government authorities is attached to the fear of deportation.
- There is an epidemic of sexual assaults, for example, committed upon undocumented Latinas. Their immigration status, however, does not mean that they should receive less protection under America's criminal laws or less right to victim services.
Respect is withholding ethnocentric judgements about the cultural practices of others. A place of remembrance for a deceased person, for example, is often found in an Asian home.
"After my father died, my mother placed his photograph on the hutch in the dining area of her home. She offers the best of the fruit she buys at the market and the first plate of anything she cooks is placed next to the photograph. It is her way of honoring the over 55 years of married life they shared. This custom may be strange to most Westerners, but it is a Japanese and Buddhist tradition to have an ancestral altar" (Dr. Brian Ogawa, Author).
Respect also means not minimizing the experience of others. In the inner city of Los Angeles, gang and drug-related homicides are common. When one particular slaying occurred, the newspaper headline routinely announced, "Just Another Day in South Central." The familiar scenario of young black males seeking reprisal for a cocaine buy gone awry was present. The alarming difference in this case was that the victims were two mistakenly killed teenage girls. For their parents, loved ones, and friends, this was not just another day.
As one of the girl's mothers stated to me, gang violence and the fear it brought to her neighborhood were never acceptable. There was never a "tolerance of crime" merely because it was an everyday occurrence. The day her daughter died was not and can never be ordinary. It is the deepest tragedy which will repeatedly pierce her heart through many years.
Delivery of Services
Translating Standard Materials
A frequent method of outreach to non-English speaking victims is to provide translated materials with portrayals of racially diverse people. When the translation explains how to seek a restraining order, to locate the courthouse and prosecutor's office, to apply for criminal injuries compensation, or to complete forms, such multi-lingual brochures and handbooks improve accessibility to the criminal justice system. Key words in English should also be included to enhance recognition and familiarity. However, several points are important to consider:
- When counseling on the effects of victimization or self-help suggestions are being provided, these must be evaluated as to whether or not these actually give needed assistance or merely bestow readable materials upon those literate in a language.
- All crisis intervention methods and counseling modalities are based upon specific philosophies of suffering and healing. Approaches that are derived from conventional Western theories are most prevalent in victim services.
- Approaches and methods that incorporate the perceptions, beliefs, values, and experience of diverse cultures must also be made available to crime victims.
Victim counseling materials that are developed from within a culture and then translated into English so that an understanding can be gained for what is relevant for that culture would be helpful. However, few such materials exist today. This remains an area for further work and development.
Agency Organization and Outreach
The manner in which we organize our agencies may unknowingly deny or hinder entry to various groups. The responsibility for delivery of services rests with the providers and not with (potential) recipients.
- It is simplistic to bemoan the scarcity of certain groups utilizing services by attributing this primarily to their lack of education or awareness.
- Minorities, in fact, often view prevailing services as unresponsive to their needs and uninformed of their preferred practices and beliefs.
- The methods for reaching culturally diverse victims must therefore include traditional resources within the various communities as well as the inauguration of victim-specific ones.
- The historical role of African American churches, the reliance upon Mexican curanderas and Native American shamans, and the social constructs of Asian life must be understood and incorporated.
- Establishing some type of presence in ethnic neighborhoods, whether store-front offices, mobile crisis units, outreach to homes, or coordination with community-based organizations, is essential.
The first contact minorities have with the criminal justice system will either confirm or dispel suspicion as to how they will be treated.
- Proper pronunciation of a person's surname is an excellent place to start! Surnames also have histories and meaning that allow conversation beyond introduction.
In working with immigrant, refugee, or native populations, it is also helpful to learn a few words of greeting from that culture.
- Be careful, however, of your intonation and loudness.
The Native Hawaiian word "aloha," for example, has been frequently corrupted. The root "ha" refers to the "breath of life," the giving (exhaling) and receiving (inhaling) of life itself. As a greeting, it means the imparting of life to others and the acknowledgment of accepting life from others. When the "ha" is crudely enunciated, it collapses the spiritual essence of this meaning.
- The willingness to go beyond what is comfortable and usual conveys your intent to communicate.
- Victim service providers who properly leave their shoes at the doorstep of Asian families, for example, are seen by these residents as entering to understand and not impose.
The Asian home is a sanctuary wherein various rules and proprieties are followed. Knowing this, a victim service provider should be observant and alert to cues as to appropriate words and actions, rather than be consumed by anxiety about committing mistakes.
Appraise Your Prejudices
Darnell Hawkins, a sociologist in the Black Studies Department at the University of Illinois-Chicago, states:
"Black victims of crime in general are not treated seriously, particularly if the offender is also black."
Attitudes toward black women especially are rooted in the long period of legalized slavery in America and profligated by current prejudices. Black women were the sexual property of white slave masters. Since they had no rights to resist or protest, there was no definition of rape to protect them and thus no legal recourse.
Today, many black women assume they will be treated unfairly by police and prosecutors when they do report rape. Any rape case where there is little corroborating evidence, such as eyewitnesses or physical injuries to substantiate the charges against a defendant, presents obstacles. When the woman is black, there appears to be greater reluctance by legal authorities to proceed beyond preliminary investigation.
Black women, in other words, may be burdened with stereotypes about being sex objects and solicitors. As Evelyn White recites,
"We are considered evil but self-sacrificing . . . sexually inhibited yet promis-cuous. Covered by what is considered our seductively rich but repulsive brown skin . . . society finds it difficult to believe that we really need physical and emotional support just like everybody else."
When racism invades criminal proceedings, it subverts the very concept of justice being blind. In a California prosecutor's office, for example, an assistant district attorney was heard to have made this comment about a young white woman who had been beaten by her African American husband: "She deserves it because she married a nigger." In the mind of this prosecutor, any white woman who is in an intimate relationship with a black male (and perhaps any minority male) has somehow abrogated her rights to ordinary sympathy and legal protection. His attitude universally degrades women and marks any black male as a dangerous partner.
Responding to Hate Crimes
Resistance to rapid ethnographic changes due to large-scale immigration has amassed with long-standing racial bigotry, to produce a climate of racial tension. Whether or not this constitutes an adjustment period to form a more pluralistic society or the brewing of polarization is unknown. With the incidents of ethnoviolence spreading, the signs are not encouraging.
Key questions to consider in responding to hate or bias crimes include:
- How seriously do we regard bias crimes and respond to hate violence?
- Do we understand how being targeted because of race and ethnicity affects these victims?
The ironic effect of any personal prejudice jeopardizing the quality of services to victims of hate crimes is that these victims have been found to suffer more symptoms of post-traumatic stress than other violent crime victims. According to a National Institute Against Prejudice and Violence survey of such victims:
"The substantive character of these responses is quite serious, ranging from psychophysiological problems indicative of great stress (higher levels of depression and withdrawal, increased sleep difficulties, anxiety and loss of confidence) to an extraordinary percentage reporting serious interpersonal difficulties with friends and significant others." (Forum, 5:1, p.6)
Developing a Cross-Cultural Style
Avoid Misuse and Distortion of Cultural Values
On April 14, 1989 Ramon Salcido, a Mexican vineyard worker in California, murdered his daughters, his wife, his mother-in-law, his sister-in-law, and an employer. Alcohol and jealousy fueled Salcido's "journey of destruction," which resulted in the worst mass homicide in the history of Sonoma County. The media accounts portrayed Salcido as a "hot-blooded Latin who gloried in machismo." This implied that his gruesome acts were somehow culturally-based in the characteristic way Latino men treat their wives.
- Although some Latino abusers claim a "cultural birthright" to (brutally) dominate their spouses, their argument is not legally acceptable nor true to the proper meaning of machismo.
- Insensitive representations by the American media and negative stereotypes of the Mexican culture in general have contributed to a distortion of traditional male/female roles governed by machismo.
- Accordingly, the term "macho" often is assigned to the male who is over-aggressive, controlling, temperamental, and boastful.
- The essence of machismo, notwithstanding, is, in the words of Rodriquez and Casaus, "a man who meets his family responsibilities by providing food, shelter, and protection for his wife, children and, in some cases, other relatives living with the family."
- Mexican family life is based upon mutual respect and interdependence. Husbands are reminded not to disrupt the well-being of the family by selfish and outrageous acts.
Mexican culture, in other words, is not pathological as has been assumed by those who have regarded machismo as promoting wife-battering. Indeed, it is the balance of relationships in Latino families which provides the safeguards preventing domestic strife. Ramon Salcido is an aberration of his cultural heritage, as any criminal is of any culture. His savage act was a failure to fulfill machismo, not a fated demonstration of it.
- The lesson for victim service providers is that misinterpreting and exaggerating elements of a culture may be detrimental to understanding the dynamics of victimization experienced by a person of that culture.
- Condemning or disparaging cultural patterns stemming from false summaries also denies victims the ability and right to draw natural strength from their cultures.
Case Example of Cultural Meanings of Mental Health Terms
The therapist told Kim that she needed to "heal the child within her." Kim, a Southeast Asian refugee, listened in astonishment and became very nervous and agitated. She wondered how this Caucasian woman could know that she was pregnant when Kim herself was unaware of this. More so, she did not want another child by her abusive husband! Noticing the look of anguish in her client's face, the therapist hurriedly explained that the term "child within" was not to be taken literally. It was merely an expression from a popular Western therapy that meant the "spirit" of a child within someone. Hearing this explanation, Kim fled the room.
Upon returning to the shelter where she was staying, Kim tearfully announced to a staff member that the spirit of the child she had lost through miscarriage several months earlier was distressed and trapped inside of her! It was many hours before Kim could be assured that her fears were needless.
Evaluate Mental Health Concepts
- For Southeast Asians, the notion of mental health or psychological well-being is novel.
- Individual insight to benefit the "self" is incomprehensible to cultures that assign identity and worth to harmonious relationships.
A critical need for Kim and other battered Asian immigrant or refugee women is therefore to regain a sense of belonging. Without her traditional family ties through her husband, Kim became an oddity in the Southeast Asian community. Her isolation needed to be ameliorated by a strong base of support provided by other women in the shelter.
- Rather than individual therapy, Kim needed to learn how to maintain and broaden her linkages to others, including gaining sufficient proficiency in English to secure employment and networking with other single parents.
- Western views of normality should also be carefully applied.
Case Example of Native American Self-Treatment
The Sioux, for example, practice a form of self-treatment called wacinko. This is a sort of "time-out" by which the person intentionally sets aside active and non-productive involvement in a stressful situation.
This practice has been frequently misdiagnosed by Western psychiatrists as a reactive depressive illness marked by withdrawal.
Wacinko is in fact a solution to a problem, a trust that a resolution will naturally occur. This is a cultural form of healing in which passivity is not hopelessness but hopefulness.
Listening is fundamental to human relationships and counseling. The principles and manner of listening, however, differ across cultures.
- Asians and Pacific Islanders, for example, deflect direct eye contact in conversation as a sign of patient listening and deference.
- Words are believed lost through the force of personalities when attention is drawn to physical presence and posturing.
- Staring is therefore considered impolite and confrontational.
Many Western cultures, on the other hand, value direct eye contact as a sign of sympathy or respect. Looking elsewhere is seen as disinterest, evasiveness, or rudeness. Misunderstanding can accordingly occur if some allowance is not made for these differences.
Learning From Diversity
Serving diverse crime victims is not just learning about other races and cultures, a collection of information and facts. It is learning from them. Unless we covet the wisdom and experience of other people and allow these to have a personal effect upon our lives, we will fail to appreciate the tremendous contributions they can make to our comprehending suffering and the process of healing.
A key principle in Eastern psychotherapies, for example, is that "life is attention." Life is only that which occupies our attention. Where attention goes, in other words, life energy follows. It is therefore crucial to be practical and purposeful to what and to whom we give our attention.
- This is transculturalism, a sharing of some truth across cultures.
- Victim service providers can serve a diversity of people only as well as we engage in such sharing.
Multi-Cultural Victim Services
1. Acknowledgement of the different and valid cultural definitions of personal well-being and recovery from traumatic events.
2. Support of the sophisticated and varied cultural pathways to "mental health" and incorporate these into appropriate victim services and referrals.
3. Extensive cultural awareness training and competency testing to enable victim assistance staff to have the capacity to understand persons whose thinking, behavior, and expressive modes are culturally different.
4. Multiethnic and multilingual teamwork as a resource to implement and monitor effective victim services.
5. Cross-cultural perspective to benefit from the principles and methods of other cultures.
Multicultural Counseling Versus Cross-cultural Counseling
I believe that it is important to clearly define the constructs under consideration and to differentiate similar but not identical concepts. In our attempts to measure cross-cultural counseling competencies, we need to begin with some definitions and clarifications. First, there has been a tendency in the field to use the terms multicultural counseling and cross-cultural counseling interchangeably. As I have pointed out (Leong, 1994), these are different concepts and the latter term is more appropriate for two different reasons. The first reason has to do with the concept of multicultural which refers to "many cultures". Owing to the multiculturalism movement in the United States, many psychologists and counselors had begun using the term "multicultural counseling" inappropriately to refer to what they do when they work with culturally different clients. They have confused multiculturalism as a social movement with what they do. The more appropriate term is cross-cultural counseling since it accurately describes what they do - a counselor from one particular culture is counseling a client from a different culture.
Multicultural counseling, on the other hand, means counseling with many different cultures and this is rarely what counselors and therapists are doing unless they happened to be conducting group psychotherapy with a culturally heterogeneous group of clients (i.e., counseling with many different cultures). Another exception would be a White European therapist conducting couples therapy with a Hispanic American man married to an African American woman and her co-therapist is an Asian American. Such instances are relatively rare. A White European American counselor seeing an African American client on Monday and a Mexican American client on Wednesday is not conducting "multicultural counseling"; rather she is conducting cross-cultural counseling each time she see a client from a cultural background different from hers. Similarly, a therapist who uses a cognitive-behavioral approach with one client on Monday and a humanistic approach with a different client on Wednesday cannot really claim that he is using a multidimensional eclectic approach to therapy with his clients.
A second and more important reason why we should not use the term multicultural counseling in place of cross-cultural counseling is the nature and extent of our knowledge-base. The majority of the studies that have examined the role of culture and its potential influence on counseling and psychotherapy have been bi-cultural, i.e., it has examined and compared only two cultures. Early research in cross-cultural psychology was heavily influenced by anthropology which tended to study one culture at a time in significant depth. Using this monocultural approach, namely the study of one culture at a time, psychologists would, for example, investigate the nature and existence of schizophrenia in different countries around the world. Cross-cultural psychologists now recognize the extreme limitations of such an approach. This approach not only did not provide for direct comparisons between cultures, which is the primary focus of cross-cultural psychology, but it also provided inferences and conclusions based on implicit and biased assumptions of the investigators who tended to be from the West. This problem in turn gave rise to the second approach in cross-cultural psychology, namely bicultural studies. These studies usually involve directly collecting data from 2 countries and comparing the results (e.g., schizophrenia in Britain and the United States). The limitations of this approach is that later studies could not be easily compared to earlier studies since different instruments, sampling procedures, and designs may have been used even though the same topic was studied in many different bicultural studies. The ideal approach in cross-cultural psychology was of course, the multicultural study, where 3 or more cultures were studied using the same design, instruments, and procedures. The more cultures that were included the better. However, these studies tend to be very expensive to undertake and there are only a handful of them in the cross-cultural psychological literature.
The implications of this methodological dilemma (i.e., multicultural studies are best but too expensive for most investigators to undertake) is that much of the knowledge-base on which cross-cultural psychology in general and cross-cultural counseling in particular is discussed and debated is derived mainly from bicultural and not multicultural studies. This predominance of bicultural studies (only two cultural groups) is also true for racial and ethnic minority psychology. Cultural diversity in the United States is usually represented by five major cultural groups. These groups include White-European Americans, African Americans, Hispanic Americans, Asian Americans, and American Indians. There are actually very few psychological studies of all five groups together using the same design, instruments, and procedures. In fact, most of the studies use the bicultural approach where only 2 groups are compared. Even worse, the typical comparison group is between White-European Americans and African Americans or between White-European Americans and Hispanic Americans. There are actually very few studies comparing African Americans with Hispanic Americans and comparing Hispanic Americans with Asian Americans. In summary, we do not have a knowledge-base to guide multicultural counseling since there are very few multicultural studies.
Cultural Competence Versus Cross-cultural Competence
A second definition problem has to do with the concept of cultural competence versus cross-cultural competence. Most White-European American counselors and psychotherapists have always been a culturally competent psychologists. To be culturally competent is to be able to adapt and function effectively in one's culture. In the same way, African American counselors and psychotherapists are also culturally competent psychologists with reference with their African American cultural heritage. So, the problem is not with cultural competence but with limited cross-cultural competence, i.e., the knowledge and skills to relate and communicate effectively with someone from another culture different from your own.
White-European American psychology has always been a Eurocentric paradigm. his characteristic is not a flaw in and of itself any more that an Afrocentric psychology or an Asian-centered psychology is inherently flawed. No, the first major flaw in White American psychology is not that it is Eurocentric, rather it is that it does not often realize nor acknowledge that it is Eurocentric. The second major flaw is that American psychology operates on the assumption that its theories, scientific data, and formulations are universal when in reality it is quite Eurocentric. In other words, White American psychology not only believes that its culture-specific theories and data are universal, it actively intervenes in the lives and societies of those who are culturally-different with these mistaken or at best untested theories and models.
In essence, White American psychology is a culturally competent psychology on a WITHIN-culture level, namely, its theories and interventions are quite effective and appropriate for White European Americans. However, it is not a culturally competent psychology when it comes to an ACROSS-culture dimension. Hence, as pointed out by Tony Marsella and Paul Pedersen, White-American psychology, as it currently exists, violates it own ethical codes whenever it crosses cultural boundaries without the requisite training and competencies in cross-cultural psychology, and White cultural competence is concerned with how White American psychotherapists can function with White American clients or African American psychotherapists can function with African American clients, cross-cultural competence is concerned with how and whether White American psychotherapists can function effectively with White American clients or vice versa. In other words, what we need to research and measure is NOT cultural competence but cross-cultural competence.
Measurement of Cross-cultural Counseling Competencies
In discussing the measurement of cross-cultural counseling competencies, it would be useful to have a conceptual model to guide those discussions. Fortunately, there is a well articulated model for examining cross-cultural counseling competencies. This model was first specified in the position paper on Cross-Cultural Counseling Competencies commissioned by the Division of Counseling Psychology (Division 17) of the American Psychological Association and published in 1982 in The Counseling Psychologist, the Division 17 journal. This model which is the most comprehensive statement to date on the topic of cross-cultural counseling competencies has also generated the most empirical research. It has also undergone some expansion and elaboration (see Pope-Davis & Coleman, 1997; Sue, Carter, Casas, Fouad, Ivey, Jensen, LaFromboise, Manese, Ponterotto, Vazquez-Nuttall ,1998 ).
The Division 17 position paper identified three dimension of cross-cultural counseling competence, Awareness, Knowledge, and Skills. Awareness refers to the counselor's awareness of his or her own cultural background and how this may bias or skew his perception of the client's experiences and problems due to the client's different cultural background. It requires sensitivity to these cultural differences in the client's attitudes, beliefs and values and the important role these differences may play in the counseling relationship. Knowledge refers to the cross-cultural knowledge that the counselor needs to acquire about client's from different cultural backgrounds so that he or she can work effectively with a range of clients. Skills refer to the special abilities that counselors have acquired in order to work effectively with culturally different clients in providing therapeutic interventions that are culturally relevant and culturally effective. Next, we will provide a quick overview of the different instruments that have been developed to measure these cross-cultural counseling competencies. As indicated below, many of these instruments were developed on the basis of the conceptual model proposed in the Division 17 position paper.
Awareness: Attitudes and Beliefs
All three of the instruments reviewed below for the knowledge and skills dimension also contain measures of the awareness dimension. It is assumed that certain attitudes and beliefs may serve as barriers to counselors developing an awareness of the importance of cross-cultural difference and their impact on both the process and outcome of counseling. A discussion of some of the psychological attitudes and beliefs that may serve as barriers are discussed by Leong and Santiago-Rivera (1998). Items that measure this dimension of awareness try to identify these attitudes and beliefs serving as barriers.
A broader approach to this awareness dimension is provided by John Berry and his colleagues (Berry & Kalin, 1995). As mentioned above, there has been a increasing attention to cultural pluralism or multiculturalism as either a national policy or an educational philosophy. For two decades now, Berry and his colleagues have been measuring the multicultural ideology of Canadian citizens. Similar studies have been conducted in the United States. These attitudes towards creating and supporting a culturally pluralistic society has been measured by Berry and his colleagues by using their scale of multicultural ideology in national surveys.
The Multicultural Ideology Scale (MIS) assesses "support for having a totally diverse society in which ethnocultural groups maintain and share their culture with others". It consists 10 items, with five items in a negative direction five in the positive direction. Of these 5 negative items, 2 advocate assimilation ideology, 1 advocates segregation and 2 claim that diversity weakens unity. An example of an item supporting multiculturalism is as follows: "Recognizing that cultural and racial diversity is a fundamental characteristic of Canadian society". An item representing opposition to multiculturalism is as follows: "The unity of this country is weakened by Canadians of different ethnic and cultural backgrounds sticking to their old ways". Berry has found moderate support for multiculturalism in the Canadian population.
This Multicultural Ideology Scale may be a useful measure of support for cultural pluralism in various mental health agencies and training institutions. Unlike the awareness items from the other measures reviewed below, the MIS measures the attitudinal barriers at the institutional and not individual level. As a short measure, it can be used to assess the positive or negative climate in institutions for the support of the development of cross-cultural counseling competencies among its staff or trainees.
Knowledge and Skills
The Cross-cultural Counseling Inventory (CCCI)
The CCCI was developed by LaFromboise, Coleman and Hernandez (1991) to assess counseling effectiveness with culturally diverse clients. The inventory consist of 20 items and is completed by an observer. Using a 6 point Likert type format which ranges from strongly disagree to strongly agree, respondents rate extent to which the inventory items describe the counselor being observed. The CCCI is based on 11 cross-cultural counseling competencies outlined in the Division 17 position paper mentioned above. These competencies are organized around the three dimensions of awareness, knowledge, and skills.
In terms of reliability, the internal consistency of the inventory is adequate ranging from .88 to .92. Using three experts in cross-cultural counseling, inter-rater reliability was found to be around .78. The inter-rater reliability coefficient rose to .84 when one of the problematic vignettes was removed. Content validity was demonstrated when students were able to classify the items from the CCCI into the appropriate dimension (i.e., awareness, knowledge, and skills) with 80 % agreement. Criterion related validity of the CCCI was demonstrated in several studies. Counselors trained in cross-cultural counseling received higher ratings on the CCCI than counselors who did not receive such training. Factor analytic studies were able to capture three factors that resemble the three dimensions outlined in the Division 17 position paper.
Examples of items from the CCCI include the following: (a) Counselor is aware of how own values might affect the clients (awareness item), (b) Counselor demonstrates knowledge about client's culture (knowledge item), (c) Counselor is willing to suggest referral when cultural differences are extensive (skill item).
Multicultural Counseling Awareness Scale (MCAS)
The MCAS is a 45 item self-report scale developed by Ponterotto and his colleagues in 1991 to measure the three dimensions of the Division 17 position paper. The scale uses a 7 point Likert type format to measure knowledge, skills, and awareness with responses ranging from "not at all true" to "totally true". The scale in the accompanying demographic crushed man requires 1525 minutes to complete the scale is a revised version of the 70 item prototype multicultural counseling awareness scale developed by Pont Toronto in 1991. Like the CCCI, the MCAS is conceptually based on the Division 17 competency report . But unlike the CCCI, it is a self-report measure that counselors complete on themselves.
Using item analysis and sequential factor analysis procedures, an original 70 item version was reduced to the final 45 item version. Unlike the CCCI, the MCAS does include several (3) social desirability items. This is particularly important with a self-report measure of counselor competencies within uses like items for revised scale. The remaining 41 are divided into 12 items related to awareness and 29 items pertaining to knowledge and skills.
The reliability of the MCAS is quite acceptable with coefficient alphas around .93 for the full scale. The alpha for the knowledge and skills factor scale was also .93 while the alpha for the awareness factor scale was lower at .78. Other studies have found similar levels of internal consistency with the knowledge and skills factor around .92 and the awareness factor at .72.
In terms of validity, content validity was established by experts judgment of the items in terms of clarity and conciseness and domain appropriateness. Unlike the CCCI, factor analytic studies of the MCAS found that the two factor solution worked best with one factor measuring knowledge and skills (eigen value of 14.4) while a second factor represented awareness (eigen value of 5.2). In terms of criterion related validity, studies found that Ph.D. double respondents scored significantly higher than Masters and Bachelors level respondents on both subscales (knowledge/skills and awareness). It was also found that a sample of national experts scored significantly higher than did both the practicing school counselors and graduate student samples on both knowledge/skills and awareness factors on the MCAS. Furthermore, respondents who had completed a multicultural workshop or received supervised clinical training with the minority clients scored significantly higher on the knowledge/skills factor than those who did not.
Example of items from the MCAS include the following: (a) I feel all the recent attention directed towards multicultural issues in counseling is overdone and not really warranted (awareness item), (b) I am knowledgeable of acculturation models for various ethnic minority groups (knowledge/skill item), and (c) At this point in my professional development, I feel I could benefit little from clinical supervision of my multicultural client case load (social desirability item).
Multicultural Counseling Inventory (MCI)
The MCI was developed by Sodowski and her colleagues (1994). Like the MCAS, it is also a self-report measure and consists of 43 statements measuring cross-cultural counseling competencies across the three dimensions. Using a 4-point Likert scale format, respondents indicate the extent of accuracy of the statements in relation their own work as counselors, psychologists, or trainees. Responses can range from "very inaccurate" to "very accurate". It can be completed in approximately 15 to 25 minutes. Like the CCCI and MCAS, the MCI is based conceptually on the Division 17 position paper and the delineated three categories of competencies. Unlike the previous measures, the MCI has four subscales: (a) Multicultural counseling skills ( 14 items), (b) Multicultural awareness (10 items), and (c) Multicultural counseling knowledge (11 items) and (d) Multicultural counseling relationship (8 items). The unique feature of the MCI is the focus on the multicultural counseling relationship in the fourth subscale. The subscale measures the counselor's stereotypes of ethnic minorities and their comfort level with these clients.
In terms of reliability, the internal consistency coefficient alphas for the MCI is quite acceptable. In one study, the total scale alpha was .90 while the multicultural counseling skills factor alpha was .83; the multicultural awareness factor was also .83; the multicultural counseling knowledge factor was.79, and the multicultural counseling relationship was .71. Content validity of the MCI was demonstrated by expert judgment of item clarity and content. Inter-rater agreement among these experts were high ranging from 75 to 100 percent. Using counselors who had worked 50 percent or more in the multicultural areas, criterion related validity was demonstrated when these counselors scored significantly higher on the multicultural awareness and multicultural counseling relationship factors than those respondents who had worked consistently with less than 50 percent minority client load service agencies. Further evidence of criterion-related validity was found when 42 graduate students in counseling scored significantly higher at post test on three of the MCI scales after completing a one semester multicultural course than those who had not. In terms of the factor structure of the MCI, the four factor model was the most interpretable.
Examples of items from the MCI include the following: (a) When working with minority clients, I have experience at solving problems in unfamiliar settings (awareness item), (b) When working with minority clients, I form effective working relationships with the clients (skill item), (c) When working with minority clients, I use innovative concepts and treatment methods (knowledge item), and (d) When working with minority clients, I perceive that my race causes the clients to mistrust me (relationship item).
Multicultural Awareness Knowledge and Skills Survey (MAKSS)
The MAKSS was designed by D'Andrea, Daniels and Heck (1991) to assess the effectiveness of training students in cross-cultural counseling. It is also a self-report measure consisting of 60 survey items that cover the three dimensions of awareness, knowledge, and skills. While it has some evidence of reliability (alphas ranging from .75 to .96), it has the least supporting research in terms of validity. Due to this limited research, the MAKSS cannot be recommended at this point and will not be reviewed further.
Conclusion: Some Caveats
It is promising that there are now several instruments available to us to measure the various dimensions of cross-cultural counseling competencies. However, in presenting these measures, I also feel that we need to recognize some of the limitations in these measures. First, there is a difference between interpersonal versus therapeutic cross-cultural competencies. The former refers to a set of interpersonal knowledge and skills that enables a person to related effectively with a person from a different culture. This is the same set of interpersonal cross-cultural competencies that many of the workshops and training programs are providing to the managers and supervisors in order for them to work effectively with co-workers and subordinates from many different cultures. Such interpersonal cross-cultural competencies are also useful to counselors and psychotherapists but primarily in the relationship building aspects of the therapy and early on in the counseling relationship. Therapeutic cross-cultural competencies refer to the set of knowledge and skills that a counselor must have in order to intervene effectively with the client's problem in light of his or her cultural background. This set of competencies involve how culture actually affects diagnosis, etiology and presentation of psychopathology, client's conceptualization of mental illness, and the treatment process itself. Unfortunately, our research and theoretical advances have primarily been focused on the interpersonal cross-cultural competencies and much less so on the therapeutic cross-cultural competencies.
Relatedly, it is not surprising then that many of the instruments reviewed above are more concerned with these relationship building elements in the cross-cultural counseling encounter than the actual treatment process. To-date, there have been very few cross-cultural counseling process studies to help delineate what actually happens in cross-cultural counseling relationships beyond the initial few sessions. Instead, most of these studies have been based on analog designs rather than clinical field studies with real clients being treated by practicing counselors and therapists. Furthermore, there is even more limited linkage between these cross-cultural counseling measures and actual counseling outcomes. There are even fewer studies of counseling outcomes in cross-cultural counseling relationships than studies of the counseling process.
There is also the problem of the distinction between knowledge and skills in cross-cultural counseling competencies as delineated in the conceptual model (Division 17 position paper). This model differentiates between knowledge and skills. Conceptually, this distinction makes sense since it is quite possible that a newly trained counselor or psychologist having been exposed to good training program would possess the knowledge about cross-cultural counseling but not the skills. It is only with extended application of this knowledge with real life clients that such skills develop. Yet, at least one of the instruments find that these two dimensions are combined for their respondents (i.e., knowledge and skills are not qualitatively different). For the other measures, I suspect that the skills dimension is being measured at a global and generic level and does not represent a well sampled domain. One just has to review some of the items representative of the skills domain to see how global and non-specific there are. This problem is probably due to the fact that we have not conducted many empirical studies into the actual counseling process in cross-cultural counseling dyads to identify the relevant elements to be measured. As such, our current measurement of cross-cultural counseling skills are quite crude and of unknown predictive validity in relation to actual counseling outcomes.
Finally, it should be pointed out that the two major problems in providing effective mental health services to racial/ethnic and cultural minorities is that of these groups' underutilization of mental health services and their premature termination from such services when they do seek help for their psychological problems. The measures reviewed in this paper only addresses the latter problem (i.e., to minimize ethnic minority clients' premature termination from treatment). This cross-cultural competencies approach, represented by the conceptual model (Division 17 position paper) and the measures reviewed in this paper, is concerned mainly with engaging culturally different clients and minimizing premature termination. There is still the need to address second half of problem, namely underutilization of mental health services by racial and ethnic minorities.
The measurement of cultural competence is a complex but critically important endeavor. Without cultural competence, a service delivery system cannot be expected to effectively engage into services, or effectively treat, consumers of different ethnic and racial backgrounds. In developing an instrument that can be used in evaluating a service system's cultural competence, there are a number of domains that should be assessed. First, and at the most basic level, the instrument must assess "overall competence", for example, the extent to which the service system can deliver interventions consistent with a specified treatment model. Second, the instrument must assess the degree to which a system has knowledge of the range of basic values orientations that consumers from diverse cultures may endorse. Third, the instrument must be capable of assessing the service system's knowledge of the life experiences (immigration and acculturation stress, racial prejudice and discrimination, the socio-political standing of the consumer's ethnic group within the host society) that shape the consumer's everyday lives. Finally, the instrument must be capable of measuring the systems ability to engage and treat the consumer with "ease", showing tolerance of and comfort with diversity.
This paper describes our work on these issues and offers specific recommendations for dimensions that should be included in any measure of cultural competence. Although the Round Table Discussion focuses on Adult Mental Health Services, there is much to be learned from taking a family perspective and focusing on the struggles that an adult must go through with spouses, extended family, and with their children, resulting from acculturation and other immigration-related processes. In the special case of ethnic families, where there is an identifiable clash of the family's cultural values with that of the larger community, research findings appear to offer the clearest guides as to how these cultural value dimensions are related to family functioning. Our own work at the University of Miami's Center for Family Studies has been enriched by our efforts to work with families of troubled youth where the cultures and their respective values have been wonderfully diverse (Hispanic, African-American, Caribbean-Non Hispanic, and Caribbean Non-African American). Even within these bold cultural headings, the heading labels do not clearly identify the diversity within each. It is from the experience of confronting this diversity in our treatment and preventive intervention research, that we needed to find a set of guidelines for understanding how cultural values related to family interactions and the family's functioning that would transcend the specific ethnic label, yet inform the intervention approach. Further, in developing new manualized interventions, we were challenged to specify ways in which therapists could be trained to be culturally competent. In the discussion that follows, we describe the dimensions that we use to guide our family intervention services research, along with specific recommendations as to including these in an instrument on a mental health service's cultural competence.
1. Basic competence: Having a solid foundation
One of the most common mistakes in attempting to achieve cultural competence is failing to start from a foundation of technical competence and assuming that a practitioner can be culturally competent while having weak technical skills in the treatment model used. For this reason, it is important to stress that practitioners must be competent in delivering a specified model of treatment before attempting to be culturally competent in extending this model to ethnic individuals or families. The practitioner must know how and when to use certain interventions and when to deviate from the model and add components of other therapeutic approaches. An example of our work with family therapy is that the practitioner must know the destructive nature of runaway negativity in families and therapy sessions (Alexander, Holtzworth?Munroe & Jameson, 1994) and the importance of promoting good conflict resolution (Szapocznik, Rio, Hervis, Mitrani, Kurtines & Faraci,1991). This knowledge and expertise must be attained before attempting to understand the different ways in which this may emerge in ethnic families and how techniques might need take into account special family characteristics of ethnic families such as lower tolerance for negativity and face to face challenges/disputes (Santisteban, Muir-Malcolm, Mitrani & Szapocznik, in press).
Recommended Cultural Competency Construct Regarding Basic Competence in the Treatment Model
Does the service system have the technical expertise to deliver their core treatment model competently? Do they understand the theoretical assumptions on which their models are based?
2. Value Dimensions Directly Relevant to Family Intervention Services
People of different ethnic cultures can diverge markedly in their values, beliefs, and behaviors, and these differences can have a profound effect on how symptoms develop, are expressed, how symptoms are explained, and how and to whom people communicate their distress. Further, they may have a profound effect on how individuals respond to certain types of treatment because treatments themselves work under certain assumptions that may or may not be compatible with those of the consumer.
For these reasons, a critical step is to better understand the range of core values and beliefs and how these values/beliefs interact with our work as service delivery systems. It is important to note that while the core values of the ethnic consumer are proximal to the work of the practitioner, the ethnic classification of the consumer is quite distal. We use ethnic classification simply as a proxy to help us predict what is of real importance, namely the individual's world-view in important domains that may predict how ethnic individuals/families perceive problems, seek and accept help, and respond to specific family therapy strategies and interventions.
We have found that the best model for organizing the information on values and beliefs is the values orientations work conducted by Kluckhohn and Strodbeck (1961). Their model identifies the diversity of basic assumptions different people may have, assumptions that are based on shared intergenerational teachings and life-experiences, and which are keys to understanding how different people view the world. Kluckhon and Strodbeck postulated five human problems (Human Nature, Person-Nature, Activity Orientation, Time Orientation, and Relational Orientation) common to all cultures. The solutions provided by each culture to these problems are indicative of world view or basic value orientation. In the remainder of this section we present Kluckhon and Strodbeck's five dimensions and show the profound influences that these differing values orientations can have on core constructs in family intervention science.
2a. The Human Nature dimension pertains to a culture's perception of innate human qualities as good or bad - with a range of a) good, b) bad, or c) neutral. Many western theories take a clear stand on this question, teaching that individual's are good and it is learned behaviors that are bad. In our clinical experience with minority families, we have found that the tendency of parents of some cultures to see their misbehaving children or family member as inherently "bad" or "influenced by evil" is qualitatively different from those who see behavior as bad but perceive the family member as inherently good. Furthermore, the value on this dimension can contribute directly to a core construct in family therapy which is described as the rigidity of Identified Patienthood (Szapocznik, et al, 1991). Identified Patienthood is defined as the extent to which all responsibility for a problem is attributed to one person while other contributions to the problem are dismissed. The degree to which one individual is perceived as "the bad seed" or "the black sheep", may directly determine the extent to which family members are willing to accept the need to change family interactions in order to modify a presenting complaint. In this cases, the assumptions of the therapy model were limited when attempting to understand the family's perspective. It must be acknowledged that failure of the consumer to engage into services or to remain in treatment may be due to the incompatible assumptions that consumers and treatment models have about the etiology of the problem.
2b. The Person-Nature Dimension refers to the perceived relationship of people to natural phenomena - with a range of a) subjugation to nature, b) harmony with nature, and c) mastery over nature. The epitome of Eurocentric Western values is the conquest of the new continent by the Europeans and the conquest of the wild west by "Americans". American "can doism" and perseverance in the face of problems derives from a world view that supports mastery. We must therefore begin by acknowledging that most western models of therapy are founded on the value of mastery over nature (i.e., identifying and changing those characteristics that are problematic). However, many cultures see the role of individuals as accepting rather than conquering nature. Rather than striving to defeat cancer, some may strive to gracefully accept this fate. In therapy the latter group may be less likely to want to harp on problems or talk about how they can "battle" the life situation but on what blocks them from accepting it. This has important implication for working with ethnic families because the clashes of assumptions and the apparent "passivity" that families may show, can easily be labeled as lack of motivation, resistance or dependency. Because family therapy is primarily about mastery (persons changing their condition), it may be perceived by the consumer as antithetical to their preferred belief in acceptance. It should also be noted that from the client perspective, the drive toward battling subjugation may be seen as anti-spiritual because the idea of looking to a higher power may appear to be devalued by the model. Because much has been learned, particularly in working with ethnic minority groups, about the strength of looking to the person's spirituality as a powerful resource (Boyd-Franklin, 1989), the competent therapist must have the ability to meet the family where they are, use the resources the family members have successfully relied on over their lives, and be prepared to discuss this set of assumptions in a respectful manner. Further, the competent clinician must be vigilant to situations in which the family does not follow therapeutic prescriptions because of incompatible beliefs along these dimensions.
2c. The Activity Orientation Dimension refers to the nature of behaviors through which a person is judged or judges herself or himself - with a range of a) doing (i.e., achievement oriented), b) being (i.e., who I am) and c) being in becoming (i.e., a search for understanding about one's self). While doing is an important value in western culture, that is we define ourselves through what we do, in Hispanic culture individuals often define themselves by what family or region they come from (being). In our work with Hispanics we found that discussions of "la preciosidad" inherent in Hispanic values was a key component of many joining maneuvers (Perez-Vidal, A., personal communication,1994). "Preciosidad" refers to the inherent quality of being, of who you are, which gives the individual value that is not attached to what they have achieved. Conversely, achievement oriented parents, often only value their children by what they achieve and not for who they are. One of the potential negative consequences of achievement orientation is that children may learn to value their parents, not for their inherent value, but for what they achieve. This can be particularly destructive among the poor, in which children sometimes de-value their parents for their lack of material achievement. Finally, it should be noted that many of our models of therapy have the goal of bettering the person (promoting growth) by achieving a deeper level of understanding about the self, a concept that may seem alien to persons who do not share the values that would give this type of endeavor its worth.
2d. The Time Orientation Dimension refers to the emphasis placed on a particular time period in one's life - with a range of a) present, b) past, and c) future. An understanding of time orientation of our client has considerable value for the planning of interventions. A therapist implementing a prevention intervention (which is by definition future oriented) may be much more effective when working with a client that has a future orientation rather than with families that are present oriented and focused on "today's" issues. It should be noted that socio-economic conditions may have much to do with a present orientation, such as when a family must struggle to survive day to day. With the present-oriented client, the discussion might be more effective when it focuses on how the intervention will impact current circumstances or difficulties such as important immediate precursors to the main problem to be prevented. For example, it may be more effective to frame an intervention as targeting current behavior problems rather than saying it is designed to prevention future drug use by targeting risk factors. Perhaps because of Confucianism, some far east cultures place great value in the past, in the form of ancestry worship and reverence toward parents and other elders. Native Americans also call up their ancestors to help them deal with life. African Americans are formally embracing their African Ancestry as indicated by the growing number of families celebrating the holiday Kwanza. The principles of Kwanza are based on the African tradition and provide guidelines for healthy families and communities. Consequently, when planning interventions, the role of honoring ancestors or the aversion to dishonoring ancestors, may be integrated into the intervention. These principles have been incorporated into prevention projects for African American youth at risk for substance abuse (Cherry et al., 1998).
2e. The Relational Orientation Dimension refers to the nature of a person's relation to other people -- with a range of a) hierarchical (vertical relationships), b) collateral (i.e. horizontal network) and c) individualistic (i.e., autonomy). Having a hierarchical orientation as opposed to an individual orientation is critical in the extent to which clients will be comfortable with family therapy. Those who view themselves primarily through their connection to family will be most in line with the assumptions of a family model. Problems can be discussed in family terms and it is expected that family will be involved. One of our first clear findings was that Hispanic parents were offended when individually oriented interventions meant that therapists would most often see the youth alone therapists informed parents that due to confidentiality, family participation would be minimal.
The extent to which parents have a markedly hierarchical view of family relations has powerful implications for the process of family therapy. When parents view good family functioning as consisting of marked levels of authority, they can perceive open disagreements between parents and adolescents as disrespectful and unacceptable. One of the critical implications of this world view is that therapy interventions that openly encourage the youngsters to "speak their mind" and "tell parents what they really think" may be seen as incompetent or misguided therapy. The "intervention" may be seen as making the problem worse than it was originally, by encouraging what is perceived to be the dysfunctional behavior (disrespectful challenging). From the point of view of understanding the link between process and outcome, the impact can be profound because the types of family interactions that may be hypothesized to be therapeutic (e.g., direct negotiation and problem solving between adolescents and parents) may not be lead to good outcomes for families who are highly hierarchical.
One of the constructs directly related to a preference for hierarchical relations, is familialism, because of the focus on vertical relationships. Familialism has been an often cited core construct among Hispanics and other ethnic cultures and has been shown to consist of three types of values orientation: 1) perceived obligations toward helping family members, 2) reliance on support from family members, and 3) the use of family members as behavioral and attitudinal referents (Sabogal, Marin, Otero-Sabogal, Marin & Perez-Stable, 1987). When there is a high familialism, it is not uncommon to see individuals motivated to behave in more adaptive ways, by the potential benefit to the family and not merely by the benefit to themselves.
A related and commonly identified pattern among Hispanics is Allocentrism (Hofstede, 1980) which refers to the orientation toward collectivism as opposed to individualism. Allocentrism refers to being connected with, interdependent upon, interested in the well-being of, a particular in-group and not just the self interest of the individual (Marin & Triandis, 1985). A powerful driving force is being in harmony with the in-group and may drive relationships to be less confrontational than an individualistic orientation may generate.
It is important to note that issues of hierarchy are not unique to intrafamily relations. Using the theory of Power-Distance, Hofstede (1980) describes how some societies favor marked power differentials in which some (highly intelligent or educated, high social class, high moral status) may be looked up to and should elicit intense respect, conformity and deference. We have found that this orientation can have a very powerful impact in two key areas. First, families characterized by this orientation often favor hierarchical doctor-patient relationship (expert-patient) in which the doctor tells the patient what to do and the patient complies with little or no questioning. This is not uncommon among many of our Hispanic families but is very different from our experience with African Americans who have a history of being wronged by so called experts, are more skeptical, and may prefer to interact in a more egalitarian fashion. Secondly, when programs include multisystemic interventions that attempt to help parents become partners with the school or juvenile justice systems for the sake of their children involved in these systems. Hispanic parents often look upon these institutions with such a high level of respect and awe that it impedes their sense that parents can and should seek to impact these systems. Research on the optimal doctor patient relationships and on programs that involves modification of interactions between ethnic parents and large institutions, would do well to consider the influence of Hofstede's power-distance orientation in their work.
Adding to the complexity of working with ethnic families is the fact that the original values, beliefs, and behaviors of an ethnic culture do not remain static. Perhaps the greatest challenge to understanding an individual or family, is understanding how these core values change over time. As an individual/family spends time in a host culture that shares a different configuration of values, the values and behaviors of the immigrant will, in most instances, be modified. Acculturation has been defined as "the complex process whereby the behaviors and attitudes of a migrant group change toward the dominant group as a result of exposure to a cultural system that is significantly different" (Rogler, Malgady and Rodriguez, 1989). The natural changing of the original ethnic culture is one big reason why an ethnic label or nation of origin does not tell you all you need to know about the values of the individual consumer.
Recommended Cultural Competency Construct Regarding Values Orientation:
Does the service system consider the nature of a person's Values Orientation along each of the dimensions and understand the compatibility or incompatibility between these sets of assumptions and those of the service delivery system and treatment model? Do they understand the specific ways in which these orientations may affect therapy outcome?
3. Understanding Major Life Experiences that are Keys to Working which Ethnic Families. Not all changes in people's ways of seeing the world result from acculturation. Many ethnic families have major life experiences that directly produce powerful attitudes and beliefs and are crucial to consumer responses to treatment. Among African American families or other black families, a major issue is racial prejudice and the many forms that it takes in daily life. Black families will often be skeptical about a therapists ability to address such powerful and painful issues. Among immigrant families, they may be issues of atrocities and trauma that occurred during the actual immigration process or about the stress of deportation that still exist. Among immigrants it may also be about the stress of acculturation and adjusting to the new society or about the weak "minority" status that they have come to know for the first time in a society that looks down upon them. These powerful life experiences are important to know because the clinician gains credibility by being able to inquire about, understand how these stresses affect daily life, and intelligently and sensitively process these with the client. Work by Jackson (1998), for example, has shown that alliance is improved in the treatment of African American adolescents when issues such as anger/rage/alienation and the journey of boyhood to manhood can be directly processed. Not surprisingly, Sue & Zane (1987) identified "credibility" as a key factor in succeeding with ethnic clients, particularly when the clinician does not belong to the client's ethnic/racial group.
Recommended Cultural Competency Construct Regarding The Family's Major Life Experiences.
Does the service system consider the powerful impact of major life experiences linked to ethnicity/race and can they process these experiences, linking them directly to their intervention?
4. Ease in working with culturally diverse individuals. An important but difficult to measure aspect of working with people of diverse cultures is the ease with which a system interacts with the client. At the practitioner level there are varying degrees to which he/she may feel comfortable, at ease, relaxed, and show flexibility when faced with ethnic diversity and diversity of habits, customs, and forms of expression. At the agency level, there are also varying degrees to which the agency can have flexible operating procedures that make ethnic individuals and families feel at home. This can include such things as the decorations and artwork that hang on walls, the reading material offered to clients, and the accommodations for children for cultures who are very nuclear and extended family oriented and may want to bring children or relatives.
Recommended Cultural Competency Construct Regarding The Ease with which the system works with diverse ethnic characteristics.
Does the service system show ease/comfort in working with people of diverse cultures and do their practices demonstrate that they have made adaptations to meet the expectations of the cultures of their clients?
In this paper we have argued the measurement of cultural competence is a complex but critically important endeavor because without cultural competence, a service delivery system cannot be expected to effectively engage into services, or effectively treat, consumers of different ethnic and racial backgrounds. We have also outlined four constructs that should be included in any measure of cultural competence: 1) Overall Competence, 2) Understanding of basic values orientations endorsed by consumers of diverse cultures, 3) Knowledge of the major life experiences (immigration and acculturation stress, racial prejudice and discrimination, the socio-political standing of the consumer's ethnic group within the host society) that shape the consumer's everyday lives, and 4) the "ease" with which practitioners and systems work with people of diverse ethnicity. Throughout we have attempted to explain how it is that these important dimensions interact with efficacy of treatment.
Recommendations of Four Constructs To Be Measured
In an Instrument on a MH Service's Cultural Competency
1. Recommended Cultural Competency Construct Regarding Basic Competence in the Treatment Model: Does the service system have the technical expertise to deliver their core treatment model competently? Do they understand the theoretical assumptions on which their models are based?
2. Recommended Cultural Competency Construct Regarding Values Orientations: Does the service system consider the nature of a person's Values Orientation along each of the dimensions (Human Nature, Person-Nature, Activity Orientation, Time Orientation, and Relational Orientation) and understand the compatibility or incompatibility between these sets of assumptions and those of the service delivery system and treatment model? Do they understand the specific ways in which these orientations may affect therapy outcome?
3. Recommended Cultural Competency Construct Regarding The Family's Major Life Experiences: Does the service system consider the powerful impact of major life experiences linked to ethnicity/race and can they process these experiences, linking them directly to their intervention?
4. Recommended Cultural Competency Construct Regarding The Ease with Which the System Works with Diverse Ethnic Characteristics: Does the service system show ease/comfort in working with people of diverse cultures and do their practices demonstrate that they have made adaptations to meet the expectations of the cultures of their clients?
1 Paper prepared for the Round Table Discussion sponsored by the Multicultural Mental Health Research Center (of the Western Interstate Commission for Higher Education, WICHE) and The Evaluation Center@HSRI, December 16-17, 1998. The paper was adapted from a chapter by Daniel A. Santisteban and colleagues to appear in the book edited by Howard Liddle, Daniel A. Santisteban, Ronald Levant, & James Bray on Family Intervention Science. Joan Muir-Malcolm, Victoria Mitrani, and José Szapocznik also contributed to this paper.
Race, Ethnicity, and Culture
It is necessary to make distinctions between race, ethnicity, and culture, in order both to define cultural competence and to devise methods of bringing it about. Problems abound in the inconsistent ways the terms are used; all three are useful, but they should not be thought interchangeable.
Race is best confined to uses indicative of biological implications of genetic origin. We do not have to take any stance one way or the other about the ultimate scientific legitimacy of the idea of race, but it is useful to mark those occasions when genetic variations are intended. Race does enter into the operations of mental health service systems at times, perhaps not always in the ways intended. For example, pressures for diversity in staffing of organizations are almost always couched in terms of race (more blacks, more Asians) or pseudo-race (more Hispanics).
Ethnicity is a useful term when it refers to sense of identity with or belongingness in relation to some social group. Some black (race) persons may be of Hispanic ethnicity, and some persons with Hispanic surnames (quasi-race) may have only a weak sense of being Hispanic (ethnicity). Ethnicity is often very important for political purposes as it enables the establishing of bonds between persons that are useful for achieving power and political aims. We think that ethnicity as a concept may be extended to cover some identifications beyond those represented by racial, geographic, and linguistic characteristics, the more usual bases for ethnic identification. For example, Page (1993) notes that deaf Hispanics in New Mexico appear to have a much stronger view of themselves as deaf than as Hispanic. It is important to recognize that ethnicity may be assigned as well as adopted. Thus, a person may be regarded by others as a member of some ethnocultural group even though the person may not at all so regard him or herself.
Culture, then, refers to a complex and interrelated set of forces operating on individuals so as to direct their energies and responses along certain lines of thought and action from among the myriad possibilities. Culture is learned and may be thought of generally as the way of life of a group of people with some common and enduring bond among them. Race is not culture, nor is ethnicity. People with highly similar racial background or a common ethnic identification may represent quite different cultures. Some black persons (race) with a strong black identification (ethnicity) may, nonetheless, have much more in common culturally with a white group, say upper middle-class, than with other black groups, e.g., inner-city black culture.
It may be very difficult to specify in particular cases just what is meant by cultural competence, in part because there may be confusion about exactly what is meant by "culture." For example, some investigations have shown that racial-ethnic "matching" of clients and service providers may produce outcomes different from those with unmatched pairs. It seems unlikely that racial (biological) matching could have any effect on characteristics of service encounters. Ethnicity could be important, however, if clients feel more comfortable with someone "of their own kind," and, therefore, respond differently than with persons not having the same identity. It should be clear, however, that even in that case, it would be possible that a client might feel an ethnic affinity that did not exist if the service provider, in fact, had no particular allegiance to the ethnic group of the client. Culture, on the other hand, might be the important determinant of the encounter if the latter depended on a particular understanding of some feature of the client's way of life. If culture were the critical factor in matched interactions, then it should not matter whether the matching reflected racial or ethnic characteristics. Cultural competence cannot substitute for ethnic identity, but the latter may not always be a good cue to culture.
Defining Cultural Competency
It is likely to be difficult to distinguish cultural competency from general sensitivity to individual differences. Any given person or group has multiple "social addresses" (Bronfenbrenner, 1986). Which of those identities will be salient or important at any given time will be dependent on the particular circumstances or context of a situation or interaction. Thus, a person might be culturally sophisticated but not in the way made regnant by a particular interaction. For example, a black, female, small business owner might not be helped at all by being "matched" to a black, male service provider from a working class background. In addition to black ethnicity, it might be that sex, socio-economic status, or business orientation might be important in the example described. In our own work with male veterans, it is veteran identity rather than ethnic identity (Hispancity) that seems to be the more important "ethnic" identification.
Having said that, there is value in being sensitive to the specific needs, values and experiences of ethnically and culturally diverse clients. What may be required is not so much specific cultural knowledge as a developed sensitivity to and tolerance for the fact that people are different in many interesting ways, some of which are moderately predictable from group characteristics (social addresses). If that is so, then training for cultural competence may be better if it is broadly conceived and directed rather than oriented to the acquisition of specific knowledge about cultural habits and traditions. Even if it is believed that specific training in culture is desirable, cultural competence needs to include awareness of the possibility that for any given person at any given time, one or more of many social identities may be more important than what is usually termed culture.
Incorporating cultural values in programs may increase the credibility and perceived relevance of those programs for some participants (Terrell, 1993). Potential increases in "self-esteem and ethnocultural pride" may be particularly important for groups that face discrimination and negative stereotyping. We thought it interesting in our work with Hispanic veterans that they were greatly pleased with printed materials in Spanish even though none of them chose to use the Spanish versions. Again, cultural competence may be manifested more in terms of general sensitivity than specific knowledge or skills.
Cultural competence requires a thorough understanding of the local population being served by an organization and ascertainment of what cultural factors are likely to be at issue. It is not likely that cultural competence can be broadly "manualized." For example, we are acquainted with one American Indian case manager who presents to her co-workers a slide show demonstrating the living conditions of veterans on the reservation and practical considerations limiting access to services. Providing effective mental health services requires developing a unique and complex relationship with each client. Replacing individual evaluations with group-based generalizations can be limiting and promote stereotyping. Lopez and his colleagues (Lopez, Blachar, & Shapiro, in press) have referred to group-based generalizations as the "cultural elements" approach, in which cultural elements are assumed to correlate highly with reports of ethnicity. Yet ethnic groups are by no means homogenous and treating them as such is rarely justified. The empirical evidence for such an approach is weak (Lopez, et al., in press; Phinney, 1996) and may promote fixed, stereotypic views of ethnic groups (Lopez, et al., in press).
Cultural Issues in Overall Quality of Care
A number of factors involving cultural issues may be identified as important to consider in the assessment of the overall quality of care delivery (adapted from WICHE/ AHCPR, 1998; Terrell, 1993).
Language barriers are the most obvious potential impediment to the delivery of good quality mental health services, which depend far more than other health services on accurate understanding of nuances of feelings, values, preferences, and so on. Yet, we are reluctant to designate language competence as a critical feature of cultural competence. One reason is that language facility is to a great extent a fairly straightforward technical skill. Surely the ability to communicate accurately and efficiently should be taken for granted in the delivery of mental health services. Moreover, when language barriers do exist, they are, probably unlike many other cultural barriers, likely to be fairly evident to one or both parties to a transaction so that they can be allowed for. Nonetheless, persons working in mental health service arenas should take care to prepare themselves by acquiring the vocabulary necessary for effective communications, including becoming informed about intricacies of meaning that may be peculiar to particular cultural settings.
Communication expectations have to do with cultural patterns related to the conditions under which communications are undertaken and their preferred forms. For example, it is the current widely accepted practice in the United States to affect a kind and degree of familiarity in interactions, especially by use of informal forms of address such as first names, that is unsuitable, perhaps even offensive in other cultures. On the other hand, professionals are often so accustomed to having legitimacy and authority of their advice taken for granted that they may be disinclined to engage in explanation or justification and may seem presumptuously abrupt.
Health care beliefs and practices are culturally determined, and those of any given subcultural group may or may not be consonant with those of the broader, "science-oriented" society. If a cultural group from which a patient comes is known to believe that mental illness is the result of spirit possession, it is important for clinical personnel working with that patient to know of that belief, but it is also essential that they come to terms with the belief and devise ways of providing effective intervention in light of a belief that they themselves may reject. Mental disorder may be much more stigmatized in some cultures than in others, and understanding both the stigma and how to deal with it in treatment may not be a simple matter. A notable example is the stigma that attaches to mental disorder in the police community. That stigma requires special concern for confidentiality and may even rule out the use of civilian mental health services. When clinical personnel must deal with behaviors that are accepted in another culture but "intolerable" in their own, the limits of cultural competence may be encountered. Cultural competence is often be manifest in the ability of clinicians to engage patients on their own terms and still be effective. Building that sort of competence into organizations is a challenge.
Family organization and relational roles also vary across cultural and subcultural groups and may result in differences in the ways in which mental health services can or ought to be carried out. For example, some cultures may have family systems characterized by patriarchal or matriarchal rule that require elaborate consultations before any decisions are made. Some mental health service providers have been surprised to discover cultural expectations that entire families be present at interviews or treatment sessions. Variations in the ways in which in-law relations are treated are very large.
Sources of stress and coping skills are also important and differ between groups. Both may reflect ethnic as well as cultural differences. For example, discrimination, inadequate employment and educational opportunities, poverty, and a pervasive sense of powerlessness may stem from ethnic identity (Terrell,1993), perhaps even if ethnicity is ascribed to a person rather than being adopted. It is critically important to recognize, however, that two persons of the same apparent racial and ethnic background may differ substantially in, for example, the sense of having suffered from discrimination. Ethnic identification may, of course, also be a source of strengths, e.g., from engendering a sense of social support and belonging.
Coping mechanisms may be fostered by some cultural features or suppressed by others. The approaches taken in mental health services facilities need to be sensitive to the characteristics of the cultures of clients. For example, training in assertiveness should be based on a sense of community and respect for others' experiences to be culturally appropriate for American Indians, who may not share the dominant culture's emphasis on individualism (Terrell, 1993). Enhancing social support resources in clients should also take into account variations in sources of support for different ethnic communities. Some cultures encourage turning to other family members for help rather than seeking treatment from outside the family, let alone from strangers.
Measuring the Facets of Ethnicity and Culture
No characteristic or facet of ethnicity or culture is an invariable consequence of either. In fact, many of the relationships are of modest size, reflecting the fact that nearly all persons are members of numerous subsets or groups and, hence, subject to widely varying influences. It follows, then, that if we are to take account of ethnicity and culture, including assessing competence of service providers to deal with them, we need to undertake the daunting task of identifying the critical variables and locating or developing measures of them. The foregoing list of ethnic and cultural features is a beginning place for initiating a focus on quantifying their effects, but only a beginning place. We wish to emphasize that the measures we list later for potential use in ethnic and cultural studies is only a beginning point.
Theory to guide the understanding of ethnic and cultural factors is underdeveloped. That is especially so if we try to specify the factors that will be central to the development and delivery of effective mental health programs. At present a basis does not exist for anticipating the ethnic and cultural barriers to or facilitators of effective service delivery programs. Consequently, it will be difficult to propose with much confidence any culturally specific mechanisms or programs aimed at preventing or treating the wide array of troubling behavioral and mental disorders.
Mental Health Delivery Systems and Cultural Competence
Attempts at improving the effectiveness of mental health services through increasing cultural competence may address the characteristics of individual providers, settings, or systems. For example, individual providers may be trained to listen for certain cultural themes during early contacts with clients, settings may adjust their ways of operating, such as hours open, to meet the needs of different cultural groups, and systems may adapt their service philosophies so as to become more hospitable, e.g., by coordinating efforts with those of native healers or taking account of family structures.
Many different aspects of service facilities and systems may be the focus of efforts to improve cultural competence. Some of the more important include the following:
Organization of Services
Barriers to access
Efficiency (carved out)
Delivery of Services
Level of service use
Appropriateness of use
Drop out rates
Satisfaction with services
Duration and termination
Perception of counselor effectiveness
Outcomes (noncompliance, self-esteem, inferiority
or personal inadequacy, anxiety, perceived discrimination)
Cost containment (co-payments, high deductible amounts, limits on services covered)
Centralized (versus decentralized)
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