1. Increasing Cultural Competence in Clinical Practice
Lillian Comas-Díaz, PhD
Executive Director, Transcultural Mental Health Institute Clinical Professor of Psychiatry and Behavioral Sciences The George Washington University School of Medicine
Frederick M. Jacobsen, MD, MPH
Medical Director, Transcultural Mental Health Institute
Clinical Professor of Psychiatry and Behavioral Sciences The George Washington University School of Medicine
World Federation of Mental Health
October 30, 2007

3. Clinical realities are negotiated by therapists and clients not merely in terms of cognitive models, but in terms of cultural frames deeply invested with personal, ethnic, racial, gender, spiritual, sexual orientation, and class meanings.

5. Race matters in healing
African American patients rate their visits to African American practitioners as more participatory than those in race discordant dyads.
Cooper-Patrick et. al. JAMA, 1999

6. Cutural Competence can promote resilience through:
Enhanced optimism
Improved regulation of attachment behavior
Positive self concept
Active coping style
Improved ability to convert helplessness into learned helpfulness
Better acceptance of social support/altruism
Improved ability to disclose emotions
Jacobsen and Comas-Díaz, 2007

7. APA Multicultural Guidelines
Commitment to cultural awareness and knowledge of self and other.
Guideline 1: Psychologists are encouraged to recognize that, as cultural beings, they may hold attitudes and beliefs that can detrimentally influence their perceptions of and interactions with individuals who are ethnically and racially different from themselves.
Guideline 2: Psychologists are encouraged to recognize the importance of multicultural sensitivity/responsiveness, knowledge and understanding about ethnically and racially different individuals.

8. Diversity: Relationship between Self and other
Diversity variables bear unconscious dimensions which tend to emerge during the multicultural encounter
Virtually every therapeutic (human) encounter is multicultural in nature.

9. Strategies to increase multicultural awareness and knowledge
Identify and challenge internalized privilege and oppression
Commit to ongoing self reflection
Change automatic in-group and out-group perceptions
Increase contact with people of color of equal social status
Transform “us and them” into “us”
Expand your cultural horizons

10. APA Multicultural Guidelines
Practice
Guideline 5: Psychologists strive to apply culturally appropriate skills in clinical and other applied psychological practices.
There are three core areas in this guideline:
Client in context
Culturally appropriate assessment
Broad range of interventions

11. Explanatory Model of Distress
What do you call your distress (problem)?
What do you think your problem does?
What do you think the natural course of your problem is?
What do you fear?
Why do you think this problem has occurred?
How do you think the distress should be treated?
How do you want me to help you?
Who do you turn to for help?
Who should be involved in decision making?
Adapted from Kleinman, 1993

12. The challenge of multicultural practice
1. Exciting, gratifying, and challenging
2. Complicated strain in the mental health practitioner
3. More opportunities for projections based on race and ethnicity.
4. These projections are embedded in the therapeutic relationship.
5. Potentially missed empathic opportunities

13. Ethnocultural Transference and Countertransference
1. Cultural and racial differences may have a catalytic effect on the development of transference leading to a more rapid revelation of core problems.
- racial differences can represent trust and mistrust issues within the development of a therapeutic alliance.
2. References to the race or culture of the therapist have been identified as the first sign of a developing transferential relationship
Comas-Díaz and Jacobsen, 1991

14. INTER-ETHNIC CULTURAL TRANSFERENCE
Overcompliance and friendliness
Denial of ethnicity and culture
Mistrust and suspiciousness
Hostility
Ambivalence
Comas-Díaz and Jacobsen, 1991

15. INTRA-ETHNIC CULTURAL TRANSFERENCE
The Omniscient/omnipotent Therapist
The Traitor
The Folk Hero/Heroine
The Auto-racist
The Ambivalent
Comas-Díaz and Jacobsen, 1991

16. INTER-ETHNIC CULTURAL COUNTERTRANSFERENCE
Denial of cultural differences: "All patients are the same”
Guilt
Pity
Aggression
Ambivalence
The Clinical Anthropologist's Syndrome
Comas-Díaz and Jacobsen, 1991

17. INTRA-ETHNIC CULTURAL COUNTERTRANSFERENCE
Overidentification
Us against them
Distancing
Cultural myopia
Ambivalence
Anger
Survivor's guilt
Hope alternating with despair
Comas-Díaz and Jacobsen, 1991

18. Culturally Competent Practitioners
Conduct self- reflection and assessment
Manage the dynamics of difference
Incorporate cultural knowledge into interactions with clients to develop multicultural skills
Adapt to clients’ cultural contexts
Value diversity

19. Some strategies to develop multicultural competence skills
Identify Cultural identity developmental stages
Use Explanatory model of distress
Examine Cultural transference/countertransference
Develop Cultural empathy
Acquire Multicultural communication skills

21. Course objectives
Apply the APA multicultural guidelines to improve psychological practice
Identify the effect of culture on practice
Implement strategies to compare worldviews of
clients and psychologists
Discuss the usefulness of developmental models and
theories on psychological practice
Adjust psychological practice to provide culturally competent services
Become familiar with resources available to practitioners on cultural competence
menopause and expectation for pregnancy
May want SSRI or NTP rather than other antidepressant
there are many examples of culture-bound uses of psychoactive medication or whose function/use varies tremendously in different cultural contexts: coca leaves in the tea - by Peruvian indians vs addiction
many foreign born immigrants disdain the use of psychtropics in themselves or their loved ones *S marry not Prozac
in the mainstream culture, most patients want quick-fixes
explanation of long-term nature crucial from the beginning with EC translocated have to work doubly hard to encourage maintenance of the regimin

22. Complex therapist expectations from culturally diverse individuals
Integration of clients’ active and non- directive expectations from therapists.
Patients of color expect their psychological practitioner to have diverse roles such as counselor, teacher, guide, folk healer, advisor, advocate, witness, consultant, coach, therapist, and others.