Cultural Diversity in Mental Health Practice: Ethical and Competency Issuesby William W. Deardorff, Ph.D, ABPP.
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Introduction Overview of the course Learning Objectives The changing American population Definitions and Concepts Culture Race Ethnicity Multiculturalism and Diversity Culture-centered Acculturation Racial/Minority Identity Development Cultural Competence Culturally Competent Mental Health Practitioner Multiculturalism and Ethics American Psychological Association The National Association of Social Workers (NASW) American Counseling Association (ACA) Cultural Bias in Mental Health Treatment Cultural Encapsulation Cultural Competencies Increasing Cultural Awareness Cultural Empathy Multicultural Sensitivity A Model for Developing Cultural Competencies The Culturally Competent Mental Health Professional References
The term “melting pot” was first coined by the playwright Israel Zangwill as the title of his 1908 Broadway play. He used the term to describe how immigrants from many different backgrounds came together in the United States. In his Broadway production, feuding Russian Jewish and Cossack families immigrated to America where they learned that hatred and tolerance have no place. The “melting pot” metaphor purported that over time the distinct customs, habits, and traditions associated with particular groups would disappear as individuals assimilated into the larger culture. In a new context, a uniquely American culture would emerge that would accommodate some elements of diverse immigrant cultures, such as holiday traditions, language phrases, etc.
Beginning in the 1960’s, scholars and political activists began to recognize that the “melting pot” concept failed to acknowledge that immigrant groups do not, and should not, entirely abandon their distinct identities. Rather, multiculturalism and diversity should be embraced. The composition of racial and ethnic groups change through marriage and interactions with other groups in society while they also, at the same time, maintain many of their basic traits and cultural attributes. The concept of the “melting pot” metaphor as an organizing framework, which had been relied upon for decades, began to be abandoned for the alternative notion of the “American mosaic.” Multiculturalism within the context of the “American mosaic, emphasizes the unique cultural heritage of racial and ethnic groups, some of whom seek to preserve their native languages and lifestyles. Within this framework and conceptualization, individuals can be Americans while at the same time claiming other identities including those based on racial and ethnic heritage, gender, and sexual preference.
Given that the United States population is becoming more racially and ethnically diverse, and given the fact that we have become more of an “American mosaic” rather than a “melting pot,” being able to provide mental health services within the context of “multiculturalism” is of the utmost importance. Even so, many mental health practitioners may not have a deep appreciation of multicultural issues and know how to incorporate their appreciation of racial and ethnic diversity into actual treatment approaches.
Overview of the course
This course will begin with a review of American diversity based on the results of the 2010 census. An examination of the diversity trends relating to the composition of the American population will provide a context for a discussion of issues related to providing mental health services to a diverse group. The course will then discuss concepts and definitions related to cultural diversity and cross-cultural mental health treatment. The course will then review multicultural competency concepts with the goal of achieving culture-centered mental health services. Finally, the course will provide suggestions for how to directly incorporate a culture-centered approach into one’s mental health practice.
The changing American population
The 2010 census revealed that the country’s population is growing rapidly and its racial and ethnic composition are ever-changing. Minority groups of the past and present continue to expand and have grown considerably. The following is a brief summary of some of the 2010 census data taken directly from the government website. Data from the census underscores the importance of multiculturalism in mental health services (See the following Figure): The examination of racial and ethnic group distributions nationally shows that while the non-Hispanic white only population is still numerically and proportionally the largest major race and ethnic group in the United States, it is also growing at the slowest rate. Conversely, the Hispanic and Asian populations have grown considerably, in part because of relatively higher levels of immigration. The overwhelming majority (97 percent) of the total U.S. population reported only one race in 2010. This group totaled 299.7 million. Of these, the largest group reported white alone (223.6 million), accounting for 72 percent of all people living in the United States. The black or African-American population totaled 38.9 million and represented 13 percent of the total population. Approximately 14.7 million people (about 5 percent of all respondents) identified their race as Asian alone. There were 2.9 million respondents who indicated American Indian and Alaska Native alone (0.9 percent). The smallest major race group was Native Hawaiian and Other Pacific Islander alone (0.5 million), which represented 0.2 percent of the total population. The remainder of respondents who reported only one race, 19.1 million people (6 percent of all respondents), were classified as "some other race" alone.
Nine million people reported more than one race in the 2010 Census and made up about 3 percent of the total population. Ninety-two percent of people who reported multiple races provided exactly two races in 2010; white and black was the largest multiple-race combination. An additional 8 percent of the two-or-more-races population reported three races and less than 1 percent reported four or more races.
The Census showed that interracial or interethnic opposite-sex married couple households grew by 28 percent over the decade from 7 percent in 2000 to 10 percent in 2010. A higher percentage of unmarried partners were interracial or interethnic than married couples. Nationally, 10 percent of opposite-sex married couples had partners of a different race or Hispanic origin, compared with 18 percent of opposite-sex unmarried partners and 21 percent of same-sex unmarried partners.
One can also look at the racial composition stratified by generation to see how diversity in the population is increasing. The following Figure displays these results. As can be seen, for those in the GI Generation, the multicultural rate is about 17%. This gradually increases generation by generation to its current level of almost 51%. The Milliennials and Gen-Next are the most racially and ethnically diverse in American history and this trend is likely to continue. Materials for the Course
In addition to the following course materials presented, the reader should also review specific sections of The Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists (American Psychological Association, 2002, 2003), hereafter referred to as the Multicultural Guidelines. This document can be found here or here. Although written for psychologists, it provides a nice summary of the literature in this area and is applicable to all of those who work in mental health. In the document, please review the definitions (many of which are also discussed subsequently) and the following Multicultural Guidelines (1,2, and 5). This course will discuss and expand on these concepts.
Multicultural 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.
Multicultural Guideline #2: Psychologists are encouraged to recognize the importance of multicultural sensitivity/responsiveness, knowledge, and understanding about ethnically and racially different individuals.
Multicultural Guideline #5: Psychologists strive to apply culturally-appropriate skills in clinical and other applied psychological practices.
Definitions and Concepts
There is considerable controversy and overlap in definition and concepts related to race, culture, and ethnicity (APA, 2003; Helms & Talleyrand, 1997; Phinney, 1996). In this section we define important terms and concepts related to diversity. Culture
According to Matsumoto and Jones (2009), culture can be defined as a unique meaning and information system that is shared by a group and transmitted across generations, and that allows the group to meet basic needs of survival, pursue happiness and well-being, and derive meaning from life (p. 327). According to the Multicultural Guidelines, culture can also be defined as the belief systems and value orientations that influence customs, norms, practices, and social institutions, including psychological processes (language, caretaking practices, media, educational systems) and organizations such as media and educational systems (APA, 2003; Fiske, Kitayama, Markus, & Nisbett, 1998). Inherent in this definition is the acknowledgement that all individuals are cultural beings and have a cultural, ethnic, and racial heritage. Culture has been described as the embodiment of a worldview through learned and transmitted beliefs, values, and practices, including religious and spiritual traditions. It also encompasses a way of living informed by the historical, economic, ecological, and political forces on a group. These definitions suggest that culture is fluid and dynamic, and that there are both culturally universal phenomena as well as culturally specific or relative constructs. Race
Definitions of the terms “race” and “ethnicity” are varied and these terms are often used interchangeably whether appropriate or not. Historical definitions of race often refer to physical and biological characteristics. In a more precise definition, the term “race” refers to groups of people who have differences and similarities in biological traits deemed by society to be socially significant, meaning that people treat other people differently because of them. For instance, while differences and similarities in eye color have not been treated as socially significant, differences and similarities in skin color have.
Dictionary definitions of race are as follows: (1) A group of people identified as distinct from other groups because of supposed physical or genetic traits shared by the group. Most biologists and anthropologists do not recognize race as a biologically valid classification, in part because there is more genetic variation within groups than between them. (2) A group of people united or classified together on the basis of common history, nationality, or geographic distribution: the Celtic race. (3) A genealogical line; a lineage. (4) Humans considered as a group.
The biological basis of race has, at times, been the source of fairly heated debates in psychology (See the Multicultural Guidelines for a literature review). Helms and Cook (1999) note that “race” has no consensual definition and that, in fact, biological racial categories and phenotypic characteristics have more within-group variation than between-group variation. The definition of race is often considered to be socially constructed, rather than biologically determined. Within this definition, race is the category to which others assign individuals on the basis of physical characteristics, such as skin color or hair type, and the generalizations and stereotypes made as a result. Thus, “People are treated or studied as though they belong to biologically defined racial groups on the basis of such characteristics” (Helms & Talleyrand, 1997). Ethnicity
Similar to the concepts of race and culture, the term “ethnicity” does not have a commonly agreed upon definition. In general, ethnicity refers to shared cultural practices, perspectives, and distinctions that set apart one group of people from another. That is, ethnicity is a shared cultural heritage (rather than biologically and physically based characteristics). The most common characteristics distinguishing various ethnic groups are ancestry, a sense of history, language, religion, and forms of dress. Ethnic differences are not inherited, they are learned.
Another definition is as follows: Ethnicity is the acceptance of the group mores and practices of one’s culture of origin and the concomitant sense of belonging. However, individuals may have multiple ethnic identities that operate with different salience at different times (Sedikides and Brewer, 2001; Hornsey and Hogg, 2000).
Multiculturalism and Diversity
According to the APA Multicultural Guidelines, the terms “multiculturalism” and “diversity” have been used interchangeably to include aspects of identity stemming from gender, sexual orientation, disability, socioeconomic status, or age. All of these are critical aspects of an individual’s ethnic/racial and personal identity. The term “multicultural” can also be defined more narrowly as meaning interactions between racial/ethnic groups in the U.S. and the implications for education, training, research, practice, and organizational change.
The concept of diversity has been widely used in employment settings. The application of the term began with reference to women and Persons of Color, underrepresented in the workplace, particularly in decision-making roles. It has since evolved to be more encompassing in its intent and application by referring to individuals’ social identities including age, sexual orientation, physical disability, socioeconomic status, race/ethnicity, workplace role/position, religious and spiritual orientation, and work/family concerns.
Culture-centered
In the Multicultural Guidelines, the term “culture-centered” is used to encourage the mental health professional to use a “cultural lens” as a central focus of professional behavior. In culture-centered practices, mental health professionals recognize that all individuals including themselves are influenced by different contexts, including the historical, ecological, sociopolitical, and disciplinary. According to Pedersen, “If culture is part of the environment, and all behavior is shaped by culture, then culture-centered counseling is responsive to all culturally learned patterns” (Pedersen, 1997, p. 256). For example, a culture-centered focus suggests to the mental health practitioner to consider that behavior may be shaped by culture, the groups to which one belongs, and cultural stereotypes including those about stigmatized group members. According to Pedersen (2008), “A culture centered approach to counseling recognizes culture as central and not marginal, fundamental and not exotic, for all appropriate counseling interventions” (page 5). Acculturation
Acculturation refers to the gradual physical, biological, cultural, and psychological changes that take place in individuals and groups when contact between two cultural groups takes place (Cardemil & Battle, 2003; Chun, Organista, & Marin, 2003). When an individual or group moves to an area dominated by an existing cultural group, there is pressure on the newcomers to conform and accommodate to the dominant culture’s way of life and to devalue or abandon their own cultural roots. Concepts of acculturation have been applied to racial/ethnic minority groups interacting with the larger American Caucasian culture, as well as the usual conceptualization of immigrant groups adjusting to novel environmental situations.
Racial/Minority Identity Development
There are a number of conceptual models for the process of minority or racial identity development. These models purport that all humans, including Caucasians, go through a process of developing a sense of racial or ethnic identity. Although the models differ in their specific explanations of the identity development process and conceptualization of critical stages, a common theme is that individuals at different stages of identify development assign different degrees of importance to the concept of race/ethnicity. One of the more common models was developed by Sue & Sue (1990) and Atkinson, Morton, & Sue (1998). This model of racial/cultural identity development posits that individuals move through the following stages:
As can be seen, in this model, minority individuals move from an initial more self-deprecating conformity stage, through a dissonance stage, a resistance and emergent stage, an introspection stage, and finally to an integrative awareness stage. As will be discussed, when providing mental health services, it is extremely important to assess not only one’s own racial/ethnic/cultural identity development, but also that of the client. These identity developmental stages have the potential to interact between the client and mental health practitioner. Cultural Competence
Cultural Competence is the set of congruent behaviors, attitudes, and policies that enable a practitioner to work effectively in a cross-cultural or multicultural situation (Cross et al., 1989). Cultural Competence reflects an understanding of how cultural and sociopolitical influences shape an individual’s world views and related health behaviors, recognizing that such factors interact at multiple levels of psychological practice (Betancourt et al., 2003).
The Culturally Competent Mental Health Practitioner
According to literature reviewed in the Multicultural Guidelines, a culturally competent mental health practitioner is specially trained in specific behaviors, attitudes, and polices that recognize, respect, and value the uniqueness of individuals, groups and cultures that are different from those associated with the majority. These practitioners have the clinical skills needed to work effectively and ethically with culturally diverse individuals and communities. Culturally competent mental health practitioners have the capacity to:
Conduct self-reflection and assessment Manage the dynamics of difference Acquire and incorporate cultural knowledge into their interventions and interactions, and to develop multicultural skills Adapt to diversity and to the cultural context of their clients Value diversity
Multiculturalism and Ethics
Virtually all of the ethical codes of mental health professional groups promote cultural awareness and “competence” (either directly or indirectly) and prohibit such things as bias, discrimination, and imposing one’s values on others. The following are examples of ethical principles related to cultural issues from three major Ethical Codes (APA, NASW, and ACA).
American Psychological Association
The APA Code of Ethics can be found here. The Standards of the APA Ethics Code specifically state that psychologists should not discriminate unfairly (Standard 3.01, Unfair Discrimination), nor harass (Standard 3.03, Harassment) based on age, gender, gender identity, sexual orientation, race, culture, national origin, language, religion, disability, or socioeconomic status. In addition, psychologists should ensure that they are competent when working with diverse populations (Standard 2.01b, Competence); ensure that they use tests whose validity and reliability have been established for use with members of the population tested (9.02b, Assessments); interpret tests with consideration of linguistic and cultural differences (Standard 9.06); and ensure that consent is obtained when using interpreters (9.03c). The specific sections are as follows:
2.01 Boundaries of Competence (a) Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.
3.01 Unfair Discrimination. In their work-related activities, psychologists do not engage in unfair discrimination based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, socioeconomic status, or any basis proscribed by law.
9.02 Use of Assessments (b) Psychologists use assessment instruments whose validity and reliability have been established for use with members of the population tested. When such validity or reliability has not been established, psychologists describe the strengths and limitations of test results and interpretation.
9.03 Informed Consent in Assessments (c) Psychologists using the services of an interpreter obtain informed consent from the client/patient to use that interpreter, ensure that confidentiality of test results and test security are maintained, and include in their recommendations, reports, and diagnostic or evaluative statements, including forensic testimony, discussion of any limitations on the data obtained.
9.06 Interpreting Assessment Results. When interpreting assessment results, including automated interpretations, psychologists take into account the purpose of the assessment as well as the various test factors, test-taking abilities, and other characteristics of the person being assessed, such as situational, personal, linguistic, and cultural differences, that might affect psychologists’ judgments or reduce the accuracy of their interpretations. They indicate any significant limitations of their interpretations. (See also Standards 2.01b and c, Boundaries of Competence, and 3.01, Unfair Discrimination.)
Ethics also refers to the General Principles that follow the Preamble in the APA Ethics Code. The General Principles are guides for psychologists on how to excel in their professional roles. They can also inform the ethical decision making process. The General Principles state, among other things, that psychologists are aware of and respect cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origins, religion, sexual orientation, language, and socioeconomic status. (Principle E, Respect for People’s Rights and Dignity).
The emphasis on a diverse or multicultural perspective appears to rest primarily on two overarching ethical principles. First, diversity or multiculturalism is justified on the basis of justice, in that it helps ensure a more equal access to quality psychological services to persons from traditionally marginalized groups who otherwise would not find them available. Also, diversity and multiculturalism are justified on the basis of beneficence and nonmaleficence in that psychologists with a diverse or multicultural perspective will do better at treating patients and will reduce the likelihood that they will harm patients.
Although many authors have argued that a diverse or multicultural perspective will improve outcomes, this relationship was verified by the meta-analysis of Griner and Smith (2006) who found that interventions targeted to specific cultural groups were more effective than generic interventions provided to heterogeneous groups. Overall, culturally adapted interventions resulted in significant client improvement across a variety of conditions and outcome measures (p. 541). In other words, psychologists, and all mental health professionals, should be able to upgrade the quality of their services to multicultural patients by accommodating multicultural perspectives into their treatment. This is consistent with Pedersen’s admonition that, “A culture centered approach to counseling recognizes culture as central and not marginal, fundamental and not exotic, for all appropriate counseling interventions” (2008, p.5).
The National Association of Social Workers (NASW)
The Code of Ethics of the NASW can be found here. The Code of Ethics of the NASW was approved in 1996 and revised in 2008. Ethical principle and related to cultural diversity are as follows:
1.05 Cultural Competence and Social Diversity (a) Social workers should understand culture and its function in human behavior and society, recognizing the strengths that exist in all cultures. (b) Social workers should have a knowledge base of their clients' cultures and be able to demonstrate competence in the provision of services that are sensitive to clients' cultures and to differences among people and cultural groups. (c) Social workers should obtain education about and seek to understand the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, age, marital status, political belief, religion, and mental or physical disability.
2.01 Respect (a) Social workers should treat colleagues with respect and should represent accurately and fairly the qualifications, views, and obligations of colleagues.
4.02 Discrimination Social workers should not practice, condone, facilitate, or collaborate with any form of discrimination on the basis of race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, or mental or physical disability.
6.04 Social and Political Action (d) Social workers should act to prevent and eliminate domination of, exploitation of, and discrimination against any person, group, or class on the basis of race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, or mental or physical disability.
American Counseling Association (ACA)
The ACA recently revised and updated their Code of Ethics in 2014. The entire document can be found here. The current ACA Code of Ethics probably has the most detailed guidelines addressing cultural diversity. These are found in the following Principles:
A.2.c. Developmental and Cultural Sensitivity Counselors communicate information in ways that are both developmentally and culturally appropriate. Counselors use clear and understandable language when discussing issues related to informed consent. When clients have difficulty understanding the language that counselors use, counselors provide necessary services (e.g., arranging for a qualified interpreter or translator) to ensure comprehension by clients. In collaboration with clients, counselors consider cultural implications of informed consent procedures and, where possible, counselors adjust their practices accordingly.
A.4.b. Personal Values Counselors are aware of—and avoid imposing—their own values, attitudes, beliefs, and behaviors. Counselors respect the diversity of clients, trainees, and research participants and seek training in areas in which they are at risk of imposing their values onto clients, especially when the counselor’s values are inconsistent with the client’s goals or are discriminatory in nature.
B.1.a. Multicultural/Diversity Considerations Counselors maintain awareness and sensitivity regarding cultural meanings of confidentiality and privacy. Counselors respect differing views toward disclosure of information. Counselors hold ongoing discussions with clients as to how, when, and with whom information is to be shared.
E.8. Multicultural Issues/ Diversity in Assessment Counselors select and use with caution assessment techniques normed on populations other than that of the client. Counselors recognize the effects of age, color, culture, disability, ethnic group, gender, race, language preference, religion, spirituality, sexual orientation, and socioeconomic status on test administration and interpretation, and they place test results in proper perspective with other relevant factors.
F.2.b. Multicultural Issues/ Diversity in Supervision Counseling supervisors are aware of and address the role of multiculturalism/ diversity in the supervisory relationship.
F.7.c. Infusing Multicultural Issues/Diversity Counselor educators infuse material related to multiculturalism/diversity into all courses and workshops for the development of professional counselors.
F.11. Multicultural/Diversity Competence in Counselor Education and Training Programs F.11.a. Faculty Diversity Counselor educators are committed to recruiting and retaining a diverse faculty.
F.11.b. Student Diversity Counselor educators actively attempt to recruit and retain a diverse student body. Counselor educators demonstrate commitment to multicultural/diversity competence by recognizing and valuing the diverse cultures and types of abilities that students bring to the training experience. Counselor educators provide appropriate accommodations that enhance and support diverse student well-being and academic performance.
F.11.c. Multicultural/Diversity Competence Counselor educators actively infuse multicultural/diversity competency in their training and supervision practices. They actively train students to gain awareness, knowledge, and skills in the competencies of multicultural practice.
H.5.d. Multicultural and Disability Considerations Counselors who maintain websites provide accessibility to persons with disabilities. They provide translation capabilities for clients who have a different primary language, when feasible. Counselors acknowledge the imperfect nature of such translations and accessibilities.
As can be seen, all of the major professional Codes of Ethics address the importance of being a culturally competent practitioner. Cultural Bias in Mental Health Treatment
The extant research suggests that there is a cultural bias in mental health services (See Pedersen 2008 for a review). Based on these findings over many years, theorists have developed models to explain why cultural bias occurs within the context of mental health treatment.
One of the first models or concepts addressing the issue of cultural bias in mental health treatment was developed by Wrenn (1962). Wrenn introduced the concept of “cultural encapsulation.” This perspective assumes five basic identifying features:
Some authors purport that mental health treatment continues to show evidence of cultural bias, and that the profession of psychotherapy is even more encapsulated now than in the early 1960’s (See Pedersen 2008 for a review). As discussed by Pedersen (2008), evidence of cultural encapsulation in psychotherapy can be found whenever the following assumptions are presumed to be true (See Table):
As can be seen, given these ten assumptions, some level of cultural encapsulation can be seen throughout the mental health literature.
Cultural Competencies
The concept of developing a cultural or multicultural competency as a mental health professional has been addressed in the research literature since at least the early 1980’s (D. W. Sue et al., 1982). More recently, the American Psychological Association published the APA Multicultural Guidelines to Psychological Practice (2002; 2003). As presented previously, this course focuses on Multicultural Guidelines #1, #2, and #5. These three guidelines are actually based on the multicultural awareness competencies research.
Mental health professionals, like all individuals, approach human interactions within the confines of their world view. The term “world view” refers to a set of attitudes and beliefs that shapes one’s perceptions, interpretations, and behaviors. Pedersen’s framework (2008) is contained within Multicultural Guideline #1 (APA, 2002) which encourages mental health professionals to increase their cultural awareness by learning how the basic values of diverse cultures shape their world view. Differences in world view between clients and mental health practitioners can lead to a variety of problems including cultural bias in treatment. The US Surgeon General’s report on culture and mental health suggested that cultural misunderstandings and communication problems between practitioners and their clients may prevent ethnic minorities from using mental health services and receiving appropriate treatment (U.S. Department of Health and Human Services, 2001). Culturally aware providers recognize and respect the importance of values, beliefs, traditions, customs, cognitive orientations, and relational styles of the clients they serve. It should be noted that “cultural awareness” does not imply that a mental health practitioner is required to alter his or her world view to be consistent with that of their clients. Instead, mental health practitioners are encouraged to understand how the differing world views of the practitioner and the client impact all aspects of the treatment relationship (e.g. diagnosis, psychological testing, treatment, treatment goals, etc.). Culturally competent practitioners are aware of their world view, both as a person and as a professional. Increasing Cultural Awareness
Cultural Empathy
Research has demonstrated that mental health practitioners can decrease their ethnocentric and stereotypic attitudes if they are able to adopt the perspective of the other person (Galinsky& Moskowitz, 2000) and develop empathy for the “other” (Finlay & Stephan, 2000). However, effective multicultural treatment requires more than cognitive and affective empathy, it needs to be anchored in “cultural empathy.” Cultural empathy goes beyond recognizing the difference between “self” and “others.” Cultural empathy involves a process of understanding the other individual’s perspective within a cultural framework and using it to develop a understanding of the client from the outside. Cultural empathy is developed through a process of self-reflection, challenging ethnocentrism, exploration of one’s personal world view, openness and respect for cultural differences, along with understanding and negotiation of power dynamics (Comas-Diaz, 2001). Multicultural Sensitivity
An important component of developing cultural competence is the development of multicultural sensitivity. Part of the process of becoming culturally competent includes developing an understanding of the stigmatizing effects of being a member of a devalued, oppressed, “other” group. It is important for the mental health practitioner to understand how the past history of a minority group with the dominant society can influence one’s world view. Examples include such things as African American’s history of slavery, the concentration camps for Japanese Americans, the colonization of major Latino groups, as well as the treatment of the American Indian. Multicultural sensitivity also encourages the mental health practitioner to understand the ongoing stigmatizing effects of being a member of the devalued “other group.”
Developing multicultural sensitivity has been conceptualized as being divided into two stages: Ethnocentric and Ethnorelative (Bennett, 2004). The following are the sensitivity characteristics for these stages:
A MODEL FOR DEVELOPING CULTURAL COMPETENCIES
Much of the research literature on multicultural competencies has focused on the importance of awareness, knowledge, and skill. This three stage developmental model of multicultural competency first begins with “awareness” of culturally learned assumptions, second on “knowledge” about culturally relevant facts, and third on “skill” for culturally appropriate interventions. Developing multicultural awareness competencies requires paying attention to all three of these stages.
Pedersen (2008) describes a framework for individuals or groups to increase their multicultural competence through a four step training program (Presumably this could be done as either self-training, through supervision or by group peer review. In most cases, it would be useful to have collegial consultation to assist in the process). This framework is consistent with what is described in the APA Multicultural Guidelines to Psychological Practice (APA, 2002, 2003).
The first step in developing multicultural competence is a “needs” assessment of awareness, knowledge and skill. Assessing awareness requires the ability to accurately judge a situation from one’s own and the other’s cultural viewpoint. A good example of awareness is becoming aware of the assumptions being made about another culture. Becoming aware can help you as the mental health practitioner “ask the right questions.” Once you are able to accurately “ask the right questions,” then “knowledge” helps to obtain the right answer to those questions. A needs assessment of knowledge and information will help clarify what you are going to need to obtain. Assessing your level of skill is the third stage of the needs assessment. This involves measuring what you can already do (either through self-examination, supervision or peer review). An accurate assessment of skill level necessitates a valid awareness and knowledge needs assessment.
Identifying specific objectives at the awareness, knowledge, and skill levels is the second stage of developing multicultural competence. An objective for awareness may include changing your attitudes, opinions, and personal perspectives about a culturally related topic. This might include taking steps to discover your own stereotypical attitudes and opinions. Identifying objectives for increasing knowledge includes focusing on increasing the amount of accurate information available. Increasing the availability of accurate knowledge will also help you improve your cultural awareness. Lastly, identifying objectives for increasing skill includes focusing on your abilities as a mental health practitioner that you can utilize given the previously gathered awareness and knowledge.
The third step in the training program to develop multicultural competencies includes identifying techniques to stimulate awareness, knowledge, and skill. Techniques to stimulate awareness might include experiential exercises that directly challenge your assumptions. Techniques to stimulate increased knowledge often rely on lectures, books, and other educational techniques. Techniques to stimulate increased skill often rely on modeling and demonstrations of a particular activity or behavior. Developing skills is often done through supervision.
The fourth and last step of the process is to evaluate whether you have met the stated objectives regarding awareness, knowledge, and skill competencies.
It is not necessary for the mental health practitioner to develop a completely new repertoire of treatment skills to practice in a culture-centered manner. Rather, it is important for the practitioner to understand that there are situations when adopting culture-centered interventions will be effective. This focus encourages mental health practitioners to develop cultural sensitivity to increase effectiveness with all clients and in all situations. Based on the various ethical guidelines reviewed, as well as discussed in the APA Multicultural Guidelines, there are three main areas that summarize this issue: 1) Focus on the client within his or her own cultural context, 2) Be sure and use culturally appropriate assessment tools, 3) Include a broad range of interventions, taking into account cultural issues.
Mental health practitioners are encouraged to acquire an understanding of how contextual information affects individual’s lives. It is important for the mental health practitioner to understand cultural issues including historical influences. However, it is also important to understand that within-group differences are greater than between-group differences. In other words, the mental health practitioner must recognize that not all members of a particular group (e.g. African Americans) share the same sociopolitical perspectives, etc. It is always important to pay attention to individual differences within a cultural context.
It is beyond the scope of this course to discuss all of the issues related to cultural diversity and psychological assessment. All of the various ethical codes related to mental health practice discuss the importance of being aware of the limitation of assessment practices especially related to cultural issues. This includes such things as validity, reliability, generalization of test results, interpretation of standardized assessments, etc. The mental health practitioner who is culturally competent must utilize all types of psychological assessment tools taking into account these cultural issues.
THE Culturally Competent Mental Health Professional
Given all of the previous information presented, one can see how important it is to conduct mental health interventions effectively with racially and ethnically diverse populations. Even if a mental health practitioner has an appreciation of racial and ethnic diversity, this “awareness” must be applied in a tangible manner. Cardemil & Battle (2003) provide an excellent article entitled, “Guess Who’s Coming to Therapy? Getting Comfortable With Conversations About Race and Ethnicity in Psychotherapy” that summarizes these tangible approaches. These authors posit that, “We believe that having open conversations about race and ethnicity is one way for therapists to more fully incorporate diversity issues into their work” (page 278). They acknowledge that mental health professionals may be reluctant to have these conversations with clients primarily for two reasons: (1) The therapist may feel uncomfortable discussing racial and ethnic issues due to the emotionally charged nature of race relations or concerns, or about saying something that could be viewed as offensive and, (2) Mental health professionals may not know that these conversations are relevant or have to initiate the discussion. Cardemil & Battle (2003) believe that therapists would benefit from taking a more active stance by initiating discussions about race and ethnicity with their clients, particularly early in psychotherapy (page 278). In the article, the authors make recommendations for discussing race and ethnicity in psychotherapy. These can be summarized as follows: Suspend Preconceptions About Client’s Race/Ethnicity and Recognize That the Client is an Individual
The authors recommend that the mental health professional remember that the racial and ethnic backgrounds of clients may not be obvious. Making assumptions about a client (e.g. racial, ethnic, past experiences, etc.) may lead to misunderstandings that could negatively impact the treatment process. In order to avoid making erroneous assumptions, the authors recommend that clinicians directly ask their clients how they identify their race/ethnicity. This might also include asking the client about what terminology they use to describe their identity.
Secondly, it is recommended that the practitioner recognize that clients (as individuals) may be different from other members of their racial/ethnic group. Having an open discussion about race and ethnicity helps reduce the possibility of stereotyping and making the incorrect assumption that a client possesses certain group characteristics. As discussed previously, there is significant variability in terms of individual differences within a racial or ethnic group. Understanding the process of racial identity development and acculturation (as reviewed previously) is an important part of this process. Clearly, racial identity development and acculturation can influence the psychotherapy treatment process. This is especially the case when the mental health clinician assumes that the client is in one stage of racial/ethnic identification and, in fact, he or she is in another. Incorrect assumptions about a client’s level of acculturation will also negatively impact the treatment process. Consider How Racial/Ethnic Differences Between Therapist and Client Might Affect Psychotherapy
It is important to gather racial/ethnic background information from one’s client as well as openly recognizing any differences that might exist between the clinician’s racial/ethnic identify and that of the client. Even though clients may never raise these issues explicitly, racial/ethnic differences may still play an important role in the treatment process. As discussed in Cardemil & Battle (2003, page 281), differences between therapists and client can be summarized under three broad headings (See Table). All of these factors can impact the assessment and treatment process.
Differences in Conceptualization of Mental Health and Mental Illness. Differences In Conception of Self In Relation to Family and Community Differences in Communication Style
Acknowledge That Power, Privilege, and Racism Might Affect Interactions With Clients
The clinician should recognize that racism, power, and privilege can affect the psychotherapy treatment process. Although many Caucasian mental health professionals may be aware and sensitive to these issues, it is likely that minority clients will have experienced them more directly on a personal level. In addition, minority clients may have had negative experiences in which the effects of racism, power, and privilege on their lives have been minimized or denied. Failing to acknowledge the societal issues could negatively impact the psychotherapy process.
Clearly, racism, prejudice, and discrimination continue to exist in the United States. Many members of minority groups that seek psychotherapy treatment will have had some personal experience with racism and prejudice in their own lives or in the lives of those around them. People of color may also experience more subtle forms of racism in everyday activities. The mental health clinician must consider how these types of experiences might affect the treatment process.
In addition to the issues of racism and discrimination, it is important for the mental health clinician to consider how power and privilege may influence the minority client. One construct related to this issue is known as “white privilege” or the set of advantages that are automatically afforded to those who share the dominant European-American culture. Example of these “invisible” privileges include seeing one’s own race/ethnicity well represented in the media, educational materials that contain images of people who look similar, etc. Conversations about racism, power, and privilege can be difficult for a mental health clinician, especially when he or she is a member of a group benefitting from the power discrepancies. When in Doubt About the importance of Race, Ethnicity, and Treatment, Err on the Side of Discussion; Be Willing to Take Risks with Clients
Although Cardemil & Battle (2003) do not suggest that extended discussions of race/ethnicity are necessary in every treatment relationship, the authors do believe that these issues warrant more attention than they are currently being given. As such, the authors recommend that, when in doubt about the salience of these issues, the mental health clinician initiate a discussion in order to provide an opportunity for direct examination. Even though conversations about race/ethnicity can be uncomfortable due to a fear of offending or alienating another person, or being judged for “saying the wrong thing,” they are still important. The authors recommend obtaining practice talking openly about ethnicity/race issues by having conversations with interested family members, colleagues, friends, and coworkers. This can help the mental health clinician become more comfortable openly discussing these issues. This comfort can then generalize to the treatment context.
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