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Center for Substance Abuse Treatment (US). Improving Cultural Competence. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014. (Treatment Improvement Protocol (TIP) Series, No. 59.)
The development of culturally responsive clinical skills is vital to the effectiveness of behavioral health services. According to the U. S. Department of Health and Human Services (HHS), cultural competence “refers to the ability to honor and respect the beliefs, languages, interpersonal styles, and behaviors of individuals and families receiving services, as well as staff members who are providing such services. Cultural competence is a dynamic, ongoing developmental process that requires a long-term commitment and is achieved over time” (HHS 2003a, p. 12). It has also been called “a set of behaviors, attitudes, and policies that … enable a system, agency, or group of professionals to work effectively in cross-cultural situations” (Cross et al. 1989, p. 13).
This Treatment Improvement Protocol (TIP) uses Sue's (2001) multidimensional model for developing cultural competence. Adapted to address cultural competence across behavioral health settings, this model serves as a framework for targeting three organizational levels of treatment: individual counselor and staff, clinical and programmatic, and organizational and administrative. The chapters target specific racial, ethnic, and cultural considerations along with the core elements of cultural competence highlighted in the model. These core elements include cultural awareness, general cultural knowledge, cultural knowledge of behavioral health, and cultural skill development. The primary objective of this TIP is to assist readers in understanding the role of culture in the delivery of behavioral health services (both generally and with reference to specific cultural groups). This TIP is organized into six chapters and begins with an introduction to cultural competence. The following subheadings provide a summary of each chapter and an overview of this publication.
Why is the development of cultural competence and culturally responsive services important in the behavioral health field? Culturally responsive skills can improve client engagement in services, therapeutic relationships between clients and providers, and treatment retention and outcomes. Cultural competence is an essential ingredient in decreasing disparities in behavioral health.
The development of cultural competence can have far-reaching effects not only for clients, but also for providers and communities. Cultural competence improves an organization's sustainability by reinforcing the value of diversity, flexibility, and responsiveness in addressing the current and changing needs of clients, communities, and the healthcare environment. Culturally responsive organizational strategies and clinical services can help mitigate organizational risk and provide cost-effective treatment, in part by matching services to client needs more appropriately from the outset. So too, culturally responsive organizational policies and procedures support staff engagement in culturally responsive care by establishing access to training, supervision, and congruent policies and procedures that enable staff to respond in a culturally appropriate manner to clients' psychological, linguistic, and physical needs.
What is the process of becoming culturally competent as a counselor or culturally responsive as an organization? Cultural competence is not acquired in a limited timeframe or by learning a set of facts about specific populations; cultures are diverse and continuously evolving. Developing cultural competence is an ongoing process that begins with cultural awareness and a commitment to understanding the role that culture plays in behavioral health services. For counselors, the first step is to understand their own cultures as a basis for understanding others. Next, they must cultivate the willingness and ability to acquire knowledge of their clients' cultures. This involves learning about and respecting client worldviews, beliefs, values, and attitudes toward mental health, help-seeking behavior, substance use, and behavioral health services. Behavioral health counselors should incorporate culturally appropriate knowledge, understanding, and attitudes into their actions (e.g., communication style, verbal messages, treatment policies, services offered), thereby conveying their cultural competence and their organizations' cultural responsiveness during assessment, treatment planning, and the treatment process.
What is culture? Culture is the conceptual system developed by a community or society to structure the way people view the world. It involves a particular set of beliefs, norms, and values that influence ideas about relationships, how people live their lives, and the way people organize their world. Culture is not a definable entity to which people belong or do not belong. Within a nation, race, or community, people belong to multiple cultural groups and negotiate multiple cultural expectations on a daily basis. These expectations, or cultural norms, are the spoken or unspoken rules or standards for a given group that indicate whether a certain social event or behavior is appropriate or inappropriate. The word “culture” is sometimes applied to groups formed on the basis of age, socioeconomic status, disability, sexual orientation, recovery status, common interest, or proximity. Counselors and administrators should understand that each client embraces his or her culture(s) in a unique way and that there is considerable diversity within and across races, ethnicities, and culture heritages. Other cultures and subcultures often exist within larger cultures.
What are race and ethnicity? Race is often referred to as a biological category based on genetic traits like skin color (HHS 2001), but there are no reliable means of identifying race through biological criteria. Despite its limitations, the concept of race is important to discussions of cultural competence. Race—when defined as a social construct to describe people with shared physical characteristics—can have tremendous social significance. The term ethnicity is often used interchangeably with race, although by definition, ethnicity—unlike race—implies a certain sense of belonging. It is generally based on shared values, beliefs, and origins rather than shared physical characteristics. With the exception of its final chapter, which examines drug cultures, this TIP focuses on the major racial and ethnic groups identified by the U. S. Census Bureau within the United States: African and Black Americans, Asian Americans (including Native Hawaiians and other Pacific Islanders), Hispanics and Latinos, Native Americans, and White Americans.
What constitutes cultural identity? Cultural identity, in the simplest terms, involves an affiliation or identification with a particular group or groups. An individual's cultural identity reflects the values, norms, and worldview of the larger culture, but it is defined by more than these factors. Cultural identity includes individual traits and attributes shaped by race, ethnicity, language, life experiences, historical events, acculturation, geographic and other environmental influences, and other forces. Thus, no two individuals will possess exactly the same cultural identity even if they identify with the same cultural group(s). Cultural identities are not static; they develop, evolve, and change across the life cycle.
This TIP explores cultural identity and its influence on assessment, treatment planning, and therapeutic and healing practices. The introduction it provides to the cross-cutting factors of race, ethnicity, and culture will help counselors gain knowledge about the many forces that shape cultures, communities, and the lives of clients, including, but not limited to, families and kinships, gender roles, socioeconomic status, religion, education, immigration, and migration.
What core assumptions serve as the foundation of this TIP? The consensus panel developed several core assumptions upon which to structure the content of this TIP:
An understanding of race, ethnicity, and culture (including one's own) is necessary to appreciate the diversity of human dynamics and to treat clients effectively.
Incorporating cultural competence into treatment improves therapeutic decisionmaking and offers alternative ways to define and plan a treatment program firmly directed toward progress and recovery.
Organizational commitment to supporting culturally responsive treatment services, including adequate allocation of resources, reinforces the importance of sustaining cultural competence in counselors and other clinical staff.
Advocating culturally responsive practices increases trust within the community, agency, and staff.Achieving cultural competence requires the participation of racially and ethnically diverse groups and underserved populations in the development and implementation of treatment approaches and training activities.
Consideration of culture is important at all levels of operation and in all stages of treatment and recovery.
Cultural competence has come to mean more than a discrete skill set or knowledge base; cultural competence also requires self-evaluation on the part of the practitioner. Culturally competent counselors are aware of their own culture and values, and they acknowledge their own assumptions and biases about other cultures. Moreover, culturally competent counselors strive to understand how these assumptions affect their ability to provide culturally responsive services to clients from similar or diverse cultures.
Counselors should begin the process of becoming culturally competent by identifying and exploring their cultural heritage and worldview along with their clinical world view, uncovering how these views shape their perceptions of and during the counseling process. In addition to understanding themselves and how their culture and values can affect the therapeutic process, culturally competent counselors possess a general understanding of the cultures of the specific clients with whom they work. Counselors should also understand how individual cultural differences affect substance abuse, health beliefs, help-seeking behavior, and perceptions of behavioral health services. Culturally competent counselors:
Frame issues in culturally relevant ways. Allow for complexity of issues based on cultural context. Make allowances for variations in the use of personal space. Are respectful of culturally specific meanings of touch (e.g., hugging). Explore culturally based experiences of power and powerlessness. Adjust communication styles to the client's culture. Interpret emotional expressions in light of the client's culture. Expand roles and practices as needed.Chapter 2 addresses counselors' core cultural competencies and presents clinical activities, including clinical supervision tools. The key areas explored include cultural awareness and cultural identity development, the cultural lens of counseling, key components of cultural knowledge for behavioral health counselors, and specific counseling skills that support culturally responsive services.
The role of culture should be considered during initial intakes and interviews, in screening and assessment processes, and in the development of treatment planning. Culturally responsive treatment can only occur when the making of clinical and programmatic decisions includes culturally relevant information and practices and is endorsed and supported by clinical staff, clinical supervisors, and the organization as a whole. Chapter 3 presents culturally responsive evaluation and treatment planning as a series of nine steps.
Step 1: Engage clients. Because the intake meeting is often the first encounter clients have with the behavioral health system, it is vital that they leave the meeting feeling understood and hopeful. Counselors should try to establish rapport with clients before launching into a series of questions.
Step 2: Familiarize clients and family members with the evaluation and treatment process. Often, clients and family members are not familiar with treatment jargon, the treatment program, the facility, or the expectations of treatment; furthermore, not all clients will have had an opportunity to express their own expectations or apprehension. Clinical and other treatment staff must not assume that clients already understand the treatment process. Instead, they need to take sufficient time to talk with clients (and their families, as appropriate) about how treatment works and what to expect from treatment providers.
Step 3: Endorse a collaborative approach in facilitating interviews, conducting assessments, and planning treatment. Counselors should educate clients about their role in interview, assessment, and treatment planning processes. From first contact, they should encourage clients and their families to participate actively by asking questions, voicing specific treatment needs, and being involved in treatment planning. Counselors should allow clients and family members to give feedback on the cultural relevance of the treatment plan.
Step 4: Obtain and integrate culturally relevant information and themes. By exploring culturally relevant themes, counselors will better understand each client and will be better equipped to develop a culturally informed evaluation and treatment plan. Areas to explore include immigration and migration history, cultural identity, acculturation status, health beliefs, healing practices, and other information culturally relevant to the client.
Step 5: Gather culturally relevant collateral information. Such information is a powerful tool in assessing clients' presenting problems, understanding the influence of cultural factors on clients, and gathering resources to support treatment endeavors. By involving others in the early phases of treatment, providers will likely obtain more external support for each client's engagement in treatment services. Counselors can obtain supplemental information (with client permission) from family members, medical and court records, probation and parole officers, community members, and so on.
Step 6: Select culturally appropriate screening and assessment tools. In selecting evaluation tools, counselors should note the availability of normative data for the populations to which their clients belong, the incidence of test item bias, the role of acculturation in understanding test items, and the adaptation of testing materials to each client's culture and language.
Step 7: Determine readiness and motivation for change. Although few studies focus on the use of motivational interviewing with specific cultural groups, its theories and strategies may be more culturally appropriate for most clients than other approaches. Through reflective listening, motivational interviewing focuses on helping clients explore ambivalence toward change, decisions, and subsequent treatment. It is a nonconfrontational, client-centered approach that reinforces clients as the experts on what will work and supports the key idea that change is a process.
Step 8: Provide culturally responsive case management. Many core competencies for counselors are also relevant to case managers. Like counselors, case managers should possess cultural self-knowledge and a basic knowledge of other cultures. They should possess traits conducive to working well with diverse groups and the ability to apply cultural competence in practical ways. Case management includes the use, as necessary, of interpreters who can communicate well in the specific dialects spoken by each client and who are familiar with behavioral health vocabulary relevant to the specific behavioral health setting in which service provision will occur. Case managers should acquire cultural and community knowledge to assist with the coordination of social, health, and other essential services and to secure culturally relevant services in and outside the treatment facility. Case managers should also keep a list of culturally appropriate referral resources to help meet client needs.
Step 9: Integrate cultural factors into treatment planning. Counselors should be flexible in designing a treatment plan to meet the cultural needs of clients and should integrate traditional healing practices into treatment plans when appropriate, using resources available in the clients' cultural communities. Treatment goals and objectives need to be culturally relevant, and the treatment environment must be conducive to client participation in treatment planning and to the gathering of client feedback on the cultural relevance of the treatment being provided.
Organizational cultural competence is a dynamic, ongoing process that begins with awareness and commitment and evolves into culturally responsive organizational policies and procedures. A commitment to improving cultural competence must include resources to help support ongoing fidelity to these policies and procedures along with an ongoing process of reassessment and adaptation as client and community needs evolve. Chapter 4 presents 20 organizational tasks that support counselors' development of cultural competence and improve organizational development of culturally responsive treatment services.
Beginning with the organization's vision and mission statement, administrators and governing boards need to develop, implement, and support a strategic planning process that demonstrates commitment to cultural competence. Key staff members assigned to oversee the development of culturally responsive services act as liaisons and facilitators in establishing a cultural competence committee and conducting an organizational self-assessment of cultural competence. With the involvement of community members, staff, clients and their families, board members, and other invested individuals, the cultural competence committee supports and oversees organizational self-assessment, using it to identify strengths and specific areas for improvement in cultural responsiveness. Based on the results of the self-assessment, the committee develops and implements a cultural competence plan.
An organizational self-assessment helps the committee prioritize the steps needed to improve culturally responsive services. The plan should address strategies for recruiting, hiring, retaining, and promoting qualified, diverse staff members; the use of interpreters or bilingual staff members; staff training, professional development, and education; fostering community involvement; facilities design and operation; development of culturally appropriate program materials; how to incorporate culturally relevant treatment approaches; and development and implementation of supporting policies and procedures, including reassessment processes. An organization's commitment to and support of culturally responsive services, including congruent policies and procedures, will enable counselors to respond more consistently to clients in a culturally competent manner.
Knowledge of a culture's attitudes toward mental illness, substance use, healing, and help-seeking patterns, practices, and beliefs is essential in understanding clients' presenting problems, developing culturally competent counseling skills, and formulating culturally relevant agency policies and procedures. Treatment providers need to learn and understand how identification with one or more cultural groups influences each client's worldview, beliefs, and traditions surrounding initiation of use, healing, and treatment.
Chapter 5 provides a review of the literature as it pertains to specific racial and ethnic groups identified by the U.S. Census Bureau. After a brief introduction, the chapter explores each major racial and ethnic group's specific patterns of substance use and substance use disorders, help-seeking patterns, beliefs about and traditions involving substance use, beliefs and attitudes about treatment, assessment and treatment considerations (including co-occurring disorders and culturally specific disorders), and theoretical approaches and treatment interventions (including evidence-based and best practices as well as traditional healing practices).
Chapter 5 also offers assistance in providing treatment to African and Black Americans, Asian Americans (including Native Hawaiian and other Pacific Islanders), Latinos, Native Americans, and White Americans. Counselors, clinical supervisors, and administrators are encouraged to use the information in this chapter as a starting point for learning about the major cultural groups of their clients. Nonetheless, many forces shape how an individual identifies with, is influenced by, or portrays his/her culture, and numerous subcultures can exist within any culture; thus, generalizations about various population groups should be avoided.
This TIP emphasizes the concept that many subcultures exist within and across diverse ethnic and racial populations and cultures. Drug cultures are a formidable example—they can influence the presentation of mental, substance use, and co-occurring disorders while also affecting prevention and treatment strategies and outcomes. Drug cultures differ from the types of cultures discussed in the rest of this TIP, but they do share some common features. For instance, there is not a single drug culture in the United States today, but rather, a number of distinct (although sometimes related) drug cultures that differ according to substances used, geographic location, socioeconomic status, and other factors. Drug cultures focusing on illicit substances may be of greater importance in the lives of people who use substances, but people who use legal substances, such as alcohol, can also participate in a drug culture. For example, people who drink heavily at a bar or fraternity/sorority house can develop their own drug culture that works to encourage new people to use, supports high levels of continued use or binge use, and reinforces denial.
Understanding the role that drug cultures play in clients' lives is particularly important because these cultures, more than any other cultural connections, influence clients' substance use or abuse and the behaviors in which they engage to manage mental disorders. Through drug cultures, people new to using learn to experience “getting high” as a pleasurable activity; they also learn the skills needed to procure and use drugs effectively and to avoid the pitfalls of the drug-using lifestyle (e.g., getting arrested, running out of money to buy drugs). Perhaps most importantly, the person who uses gains acceptance from a group of peers even as mainstream society increasingly discriminates against him or her because of his or her substance use or mental illness. Prejudice from mainstream society may make ties with the drug culture even stronger; he or she may feel as if there is no other place to turn for social and cultural support.
Within a treatment program, an understanding of drug cultures will help providers engage new clients and recognize the social and cultural bonds that might lead them back to substance use or other high-risk behaviors that are contraindicated for individuals who are being treated for psychological symptoms and/or mental illness. However, unlike other types of cultural affiliations, the treatment provider's relationship to the drug culture does not just involve understanding; the provider must actively work to weaken that connection and replace it with other experiences that meet the client's social and cultural needs. In many cases, this involves helping the client connect with a “culture of recovery” to meet those needs over the long course of recovery.
In sum, this TIP was written to help counselors and organizations provide culturally responsive services. Practices and procedures that improve one's cultural competence will likely result in better outcomes for clients in treatment for mental and substance use disorders. Culturally competent counseling can improve counselor credibility, client satisfaction, and client self-disclosure while increasing clients' willingness to continue in treatment.
