3“Culturally competent practice is a long-term developmental process “Culturally competent practice is a long-term developmental process. Proficiency is not achieved after a brief workshop.”(Tripp-Reimer, 1999)
4Unifying Values or Assumptions in Cultural Proficiency Being Different is PositiveServices Must Be Responsive to Cultural NeedsClients Are Empowered
5Cultural CompetenceThe ability to engage in actions or create conditions that maximize the optimal development of client and client systems. Multicultural counseling competence is defined as the counselor’s acquisition of awareness, knowledge, and skills needed to function effectively in a pluralistic democratic society
6(ability to communicate, interact, negotiate, and intervene on behalf of clients from diverse backgrounds), and, on an organizational level, advocating effectively to develop new theories, practices, policies, and organizational structures that are responsive to all groups (Sue, 2001).
7Moving Toward Cultural Proficiency: Fear and Pain People Don’t Know What to ExpectRace is a Dangerous SubjectPeople Wonder if They Will Be Attacked and Feel GuiltyIs This Just “Political Correctness?”Will Things Get out of Control?
8The Importance of Ground Rules (Confidentiality, Personalize Discussion, Say Whatever You Believe, No Blaming)Cultural Proficiency is a Journey Based on Relational and Process ThinkingSelf-Honesty and Sustained Commitment Are Important to the Process of Becoming Culturally Proficient
10Barriers to Culturally Proficient Care Poor communicationLanguage differencesMistrust of health care providersDifferent views of illnessReligious beliefs
11General Characteristics of Culturally Proficient Counselors Counselor Awareness of Own Cultural Values and BiasesCounselor Awareness of Client’s WorldviewCulturally Appropriate Intervention Strategies
13Categories of Difference AgeRaceEthnicityReligionGenderSexual orientationAbility statusClass
14Characteristics of Oppressed Groups Not necessarily a numerical minorityIdentifiable sub-populationInequality in powerSubject to stereotypingDiscriminatory treatmentMore accurate terminology:Dominant/oppressed groups rather than majority/minority groupsProtected classes – groups protected against discrimination by various federal laws:Race, color, ethnic origin, gender (female), age (over 40), religion, physical or mental disability
15Historical Treatment of Oppressed Groups Extermination – genocide, ethnic cleansingDomination/enslavementExpulsionSegregation/apartheidAssimilation/integration
16Pluralism/multiculturalism In the past the dominant USA ideal was assimilation. The United States was the world’s great melting pot. Mental health workers attempted to integrate oppressed groups into the mainstream culture.Today we emphasize appreciation of cultural diversity and pluralism. The presence of oppressed groups and their differing ways of life enriches United States society.
18Racial Identity Assumptions from Multicultural Competency Development by Fernando Ortiz Racism is a basic and integral part of U.S. life and permeates all aspects of our culture and institutions.Persons of color and whites are socialized into U.S. society and, therefore, are exposed to the biases, stereotypes, and racist attitudes, beliefs, and behaviors of the society.
19The level of racial identity development consciousness affects the process and outcome of interracial interactions.How people of color and whites perceive themselves as racial beings seems to be strongly correlated with how they perceive and respond to racial stimuli. Consequently, race-related reality represent major differences in how they view the world.
20Oppressed Peoples and Pathology Genetically deficient modelCulturally deficient modelCulturally diverse model
22Cultural Competence: Awareness Move from being unaware to being aware and sensitive to his or her own cultural heritage and to valuing and respecting differencesAware of own values and biases and how they may affect clients
23Comfortable with differences that exist between themselves and their clients in terms of race, gender, sexual orientation, and other sociodemographic variables. Differences are not seen as being deviantSensitive to circumstances that may dictate referral of the client to a member of his or her own sociodemegraphic group or to another therapist in general
24Acknowledges and is aware of his or her own racist, sexist, heterosexist, or other detrimental attitudes, beliefs, and feelings
25Cultural Competence: Knowledge Possesses specific knowledge and information about the particular group with which he or she is workingHas a good understanding of the sociopolitical system’s operation in the United States with respect to its treatment of marginalized groups in our society
26Has a clear and explicit knowledge and understanding of the generic characteristics of counseling and therapyIs aware of institutional barriers that prevent some diverse clients from using mental health services
27Cultural Competence: Skills Able to generate a wide variety of verbal and nonverbal responsesAble to send and receive both verbal and nonverbal messages accurately and appropriatelyAble to exercise institutional intervention skills on behalf of clients
28Aware of his or her helping style, recognizes own limitations, and can anticipate the impact on the culturally different clientAble to play helping roles characterized by an active systemic focus, which leads to environmental interventions. Not trapped into the conventional counselor/therapist mode of operation
29Culturally Competent Helping Roles Having a more active helping styleWorking outside the officeFocusing on changing environmental conditions as opposed to only focusing on changing the client
30Viewing the client as encountering problems rather than having or being a problem Being oriented toward prevention rather than remediationShouldering increased responsibility for determining the course and outcome of the helping process
31Strategies to Enhance Culturally Proficient Care InterpretersStaff representative of community servedCultural ethnic worker or liaisonConsultation with local healersUse of complementary therapies
32Six Points of Cultural Competence Continuum The cultural competence continuum is helpful in several ways. It gives a standard by which to measure the agencies in which we work. It gives an indication of strengths and areas for improvement. To consider an assessment of your agency, think of the following components:Cross, Bazron, Dennis & Isaacs, 1989
33Cultural Competence Continuum Cultural DestructivenessCultural IncapacityCultural BlindnessCultural Pre-competenceCultural CompetenceCultural Proficiency
34Cultural Destructiveness: When an agency is at this point, the attitudes of agency personnel, the policies and practice of the agency itself are destructive to cultures and individuals within the culture. Extreme examples are programs, agencies or institutions that actively participate in genocide or in seriously damaging cultures.
35Examples of Cultural Destructiveness The exclusion laws of that prohibited Asians from bringing spouses into the country; the policy of the U.S. government to remove Native American children from reservations and place them in boarding schools; the enslavement of people of African descent
36Cultural Incapacity: Agencies and systems do not seek to be culturally destructive but lack capacity to help minority clients or communities. Agencies remain extremely biased and the predominant belief is in racial superiority of the dominant group.
37Agency staff and personnel policies and practices are paternalistic toward the “lesser” group and resources are usually channeled away from the “lesser” group in favor of the dominant group. ex. Laws regarding segregation and the philosophy of “separate but equal.”
38Cultural Blindness: Agencies believe that they are unbiased because they treat everyone the same. Agencies maintain that traditional approaches that work with dominant group culture are universally applicable. Agency staff policies and practices ignore cultural strengths and encourage assimilation.
39Outcomes are measured by how closely clients match the dominant pattern. Special projects geared toward minority populations are funded only if money is available and with very little input from the targeted community.
40Cultural Pre-competence: Agencies exhibit a heightened awareness and movement in a positive direction. They realize their weakness in serving underrepresented groups and make attempts to improve. Agencies might experiment by hiring minority staff or explore how to reach people from underrepresented groups in their service area.
41Agency staff, policies and practices begin to seek ways that reaching underrepresented groups can be improved. The danger or caution here is that it is easy to believe that accomplishing one small step or activity fulfills the obligation to the underrepresented group, e.g. Tokenism.
42Cultural Competence: Agencies are characterized by acceptance and respect for difference. At this point, agencies will engage in a continuing self-assessment regarding culture and will seek advice and consultation from minority communities.
43Policies and practices of the agency are adapted to better meet the needs of underrepresented groups. Agencies clearly view minority groups as distinctly different from one another and acknowledge the differences within groups.
44Cultural Proficiency: Differences are held in high esteem Cultural Proficiency: Differences are held in high esteem. An agency seeks to add to the knowledge base by conducting research, developing new approaches, publishing and disseminating results of research projects. Also, the agency staff and personnel, policies and practices will promote empowerment of underrepresented groups and actively advocate on their behalf. Specialists in culturally competent practice are hired on staff.
45Exercise-Agency Assessment: Pairs Think about your agency and reflect on the following questions:
46At what level do you assess your agency? What are some positive attempts made by your agency to become multiculturally proficient?What are the supports and obstacles to developing multicultural proficiency?
47What have you learned about your agency? How do you feel about it? How trusting is the agency for change?What kind of support can you expect?What kind of resistance can you expect?What can you personally commit to do to help your agency become more culturally-competent?
48Why is it important to make culturally relevant mental health services available and accessible to diverse communities?
49The World Health Organization has reported that four of the 10 leading causes of disability in the US and other developed countries are mental disorders. By 2020, Major Depressive illness will be the leading cause of disability in the world for women and children.
50Without treatment the consequences of mental illness for the individual and society are staggering: unnecessary disability, unemployment, substance abuse, homelessness, inappropriate incarceration, suicide, and wasted lives. The economic cost of untreated mental illness is more than 100 billion dollars each year in the United States.
51With appropriate effective medication and a wide range of services tailored to their needs, most people who live with serious mental illnesses can significantly reduce the impact of their illness and find a satisfying measure of achievement and independence.
52Barriers to Care Physical Organizational Geographic – bus routes, parkingArchitecturalOrganizationalStaff attitudesStaff competenciesAmbience
53Financial Health insurance Managed care Bus/train fare Parking fees Child carePoverty
54Emotional Other Embarrassment Stigma Misperceptions Immigration status Language fluencyLevel of acculturation
55Why is Mental Illness Stigmatized? Its name implies it is different from physical illnessSounds as if it’s “all in one’s head”Some people believe it results from poor choices
56Belief that people with mental illnesses are dangerous and unpredictable, less competent, unable to work, should be institutionalized, can never get better
57Some Health and Social Consequences of Stigma Mental illness and addiction are common, but only 1/3 of those needing treatment seek it due to fear of discriminationPeople deny painful symptoms and are reluctant to seek help at an early, more treatable stage of illness
58The drop-out rate for psychiatric treatment is high because people do not want to be seen attending psychiatric clinics.People with mental illness often hold the same beliefs as society at large and blame themselves for their illness
59The major way people cope with stigma is to withhold information from those who could help them Consumers expect to be rejected by the community and, therefore, are reluctant to engage with others
60The effects of stigma and its resultant social withdrawal may have a greater impact on an individual than the illnessFamily members are also harmed by stigma and may be blamed for causing or contributing to the illness
61Community attitudes can negatively affect recovery rate Mental health professionals are also often stigmatized, holding a diminished status in the eyes of other health care professionals and making recruitment challenging
62Many mental health professionals share negative attitudes towards people with mental illness The diminished attitude towards consumers is applied to self-help and peer-support programs, negatively affecting the number of referrals
63People with mental illness are less likely to be appropriately diagnosed and treated for co-morbid medical conditionsInstitutions, governments, and policy makers contribute to stigma by systematically under-funding mental health services
64Discrimination towards people with mental illness leads to diminished employment opportunities, lack of career advancement, and hostility in the workplaceStigma contributes to the persistent under-funding of research and treatment services
6516% reported stigma in the workplace 74% of people with a mental illness reported they had experienced stigma in the last year16% reported stigma in the workplace13% from staff in a health service(SANE, Australia, 2006)
66The elderly experience the double stigma of being old and mentally ill and are less likely to seek help; their illnesses may not be detected because of the belief that anxiety and depression are a normal part of aging
67Other groups also experience a double or triple stigma – LGBT, people of color, women (“The gay community stigmatizes us for being mentally ill, and the mental health community stigmatizes us forbeing gay”)
68Discrimination is experienced through a loss of human rights, including forced treatment, finding or keeping housing, the right to parent, access to loans, immigration, denial of insurance coverage, and over-representation in the criminal justice systemAdapted from Mood Disorders Society of Canada’s Stigma and Discrimination Research Workshop, Ottowa, ON – 10/2-4/06.
70Mental Illness Across Cultures The expression of mental illness in many cultures is in bodily terms – headache, trouble sleeping, fatigue, stomachache, etc.Hallucinations and delusions will be culturally relevant
71Need to assess level of acculturation Mental illness compounded by immigration experience, conditions leading to immigration, poverty, lack of health insurance, language difficulties, loss of support system, lack of access to traditional healers
72In many parts of the world, spirit possession is common In many parts of the world, spirit possession is common. This may be a way for disadvantaged people to gain status; lose status if symptoms are due to a chemical imbalanceCould be misdiagnosed as schizophrenia
73The cultures that patients come from shape their mental health and affect the kinds of mental health services they use. Likewise the cultures of the clinicians and the service system affect diagnosis, treatment, and the organization and financing of services
75Having a belief system in common with a patient can be an asset or a liability depending on what that belief system means to each and how they handle it in the therapeutic setting.(John Peteet, M.D., is chair of APA's Corresponding Committee onReligion, Spirituality, and Psychiatry)
76AssessmentFew existing tools are valid since they were developed primarily utilizing white, middle-class, native-English-speaking, able-bodied heterosexual men.Simply translating assessment tools does not work
81Purnell Model for Cultural Competence Overview, inhabited localities, topographyCommunicationFamily roles and organizationWorkforce issuesBiocultural ecologyHigh-risk behaviors
82NutritionPregnancy and childbearing practicesDeath ritualsSpiritualityHealth-care practicesHealth-care practitioners
83Locus of Control and Responsibility Internal locus of control – self-relianceExternal locus of control – chance, luck, God, social conditionsInternal locus of responsibility – rugged individualism; blame the individualExternal locus of responsibility – situation-centered; blame the system
84Communication Style Differences American IndiansAsian Americans and HispanicsWhitesBlacks
85Guidelines for Clinical Practice African AmericansAmerican Indians and Alaskan NativesAsian AmericansHispanic/Latino AmericansClients of Multiracial DescentSexual MinoritiesIndividuals With Disabilities