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A TreATmenT ImprovemenT proTocol Improving

TIP 59 TreATmenT ImprovemenT proTocol Improving Cultural Competence

TIP 59

U.S. DEPARTMENT OF HEALTH AND SERVICES Substance and Services Administration Center for Treatment

1 Choke Cherry Road Rockville, MD 20857 Improving Cultural Competence

Acknowledgments This publication was produced by The CDM Group, Inc., under the Knowledge Application Program (KAP) numbers 270-99-7072, 270-04-7049, and 270-09-0307 with the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). Andrea Kopstein, Ph.D., M.P.H., Karl D. White, .D., and Christina Currier served as the Contracting Officer’s Representatives. Disclaimer The views, opinions, and content expressed herein are those of the consensus panel and do not necessarily reflect the views, opinions, or policies of SAMHSA or HHS. No official support of or endorsement by SAMHSA or HHS for these opinions or for particular instruments, software, or resources is intended or should be inferred. Public Domain Notice All materials appearing in this volume except those taken directly from copyrighted sources are in the public domain and may be reproduced or copied without permission from SAMHSA or the authors. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of , SAMHSA, HHS. Electronic Access and Copies of Publication This publication may be ordered or downloaded from SAMHSA’s Publications Ordering Web page http://store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-726- 4727) (English and Español). Recommended Citation Substance Abuse and Mental Health Services Administration. Improving Cultural Competence. Treatment Improvement Protocol (TIP) Series No. 59. HHS Publication No. (SMA) 14-4849. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. Originating Office Quality Improvement and Workforce Development Branch, Division of Services Improvement, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857.

HHS Publication No. (SMA) 14-4849 First Printed 2014

ii Please share your thoughts about this publication by completing a brief online survey at:

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The survey takes about 7 minutes to complete and is anonymous. Your feedback will SAMHSA develop future products. Contents

Consensus Panel ...... vii KAP Expert Panel and Federal Government Participants ...... ix What Is a TIP? ...... xi Foreword ...... xiii Executive Summary ...... xv Chapter 1—Introduction to Cultural Competence ...... 1 Purpose and Objectives of the TIP...... 2 Core Assumptions...... 4 What Is Cultural Competence? ...... 5 Why Is Cultural Competence Important? ...... 7 How Is Cultural Competence Achieved? ...... 9 What Is ? ...... 11 What Is Race? ...... 13 What Is Ethnicity? ...... 15 What Is ? ...... 16 What Are the Cross-Cutting Factors in Race, Ethnicity, and Culture? ...... 16 As You Proceed ...... 33 Chapter 2—Core Competencies for Counselors and Other Clinical Staff ...... 35 Core Counselor Competencies ...... 36 Self-Assessment for Individual Cultural Competence ...... 55 Chapter 3—Culturally Responsive Evaluation and Treatment Planning ...... 57 Step 1: Engage Clients...... 59 Step 2: Familiarize Clients and Their With Treatment and Evaluation Processes . 59 Step 3: Endorse Collaboration in Interviews, Assessments, and Treatment Planning ...... 60 Step 4: Integrate Culturally Relevant and Themes ...... 61 Step 5: Gather Culturally Relevant Collateral Information ...... 64 Step 6: Select Culturally Appropriate Screening and Assessment Tools...... 65 Step 7: Determine Readiness and Motivation for Change ...... 69 Step 8: Provide Culturally Responsive Case Management ...... 70 Step 9: Integrate Cultural Factors Into Treatment Planning ...... 71

iii Improving Cultural Competence

Chapter 4—Pursuing Organizational Cultural Competence ...... 73 Cultural Competence at the Organizational Level ...... 74 Organizational Values ...... 76 Governance ...... 78 Planning ...... 80 Evaluation and Monitoring ...... 84 Services ...... 88 Workforce and Staff Development ...... 90 Organizational Infrastructure ...... 96 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups ...... 101 Introduction ...... 102 Counseling for African and Black ...... 103 Counseling for , , and Other Pacific Islanders ...... 116 Counseling for and Latinos ...... 128 Counseling for Native Americans...... 138 Counseling for ...... 150 Chapter 6— and the Culture of Recovery ...... 159 What Are Drug Cultures? ...... 161 The Role of Drug Cultures in Substance Abuse Treatment ...... 171 Appendix A: Bibliography ...... 177 Appendix B: Instruments To Measure Identity and ...... 253 Appendix C: Tools for Assessing Cultural Competence ...... 259 Appendix D: Screening and Assessment Instruments ...... 277 Appendix E: Cultural Formulation in Diagnosis and Cultural Concepts of Distress ...... 283 Appendix F: Cultural Resources ...... 287 Appendix G: Glossary ...... 295 Appendix H: Resource Panel ...... 299 Appendix I: Cultural Competence and Network Participants ...... 301 Appendix J: Field Reviewers ...... 303 Appendix K: Acknowledgments ...... 307 List of Exhibits Exhibit 1-1: Multidimensional Model for Developing Cultural Competence ...... 6 Exhibit 1-2: The Continuum of Cultural Competence ...... 10 Exhibit 1-3: Common Characteristics of Culture ...... 12 Exhibit 1-4: and Culture ...... 22 iv Contents

Exhibit 1-5: Cultural Identification and Cultural Change Terminology ...... 24 Exhibit 1-6: Five Levels of Acculturation ...... 25 Exhibit 1-7: Measuring Acculturation ...... 27 Exhibit 2-1: Stages of Racial and Cultural Identity Development ...... 40 Exhibit 2-2: Counselor ...... 43 Exhibit 2-3: ACA Counselor Competencies: Counselor s' Awareness of Their Own Cultural Values and ...... 46 Exhibit 2-4: ACA Counselor Competencies: Awareness of Clients' ...... 47 Exhibit 2-5: Attitudes and Behaviors of Culturally Competent Counselors ...... 49 Exhibit 2-6: ACA Counselor Competencies: Culturally Appropriate Intervention Strategies ...... 56 Exhibit 3-1: Client–Counselor Matching ...... 71 Exhibit 4-1: Requirements for Organizational Cultural Competence ...... 75 Exhibit 4-2: Creating Culturally Responsive Treatment Environments ...... 75 Exhibit 4-3: Hands Across Cultures Mission Statement ...... 78 Exhibit 4-4: Critical Treatment Issues To Consider in Providing Culturally Responsive Services ...... 80 Exhibit 4-5: Qualities of Effective Cultural Competence Training ...... 92 Exhibit 4-6: OMH Staff Education and Training Guidelines ...... 94 Exhibit 4-7: Cultural Competence Initiative Across Time in One Organization ...... 99 Exhibit 5-1: Core Culturally Responsive Principles in Counseling ..... 110 Exhibit 5-2: Lifetime Prevalence of Substance Use Disorders According to Ethnic Subgroup and Status ...... 130 Exhibit 5-3: Native Americans and Community ...... 143 Exhibit 5-4: The Lakota Version of the 12 Steps ...... 147 Exhibit 6-1: How Drug Cultures Differ ...... 162 Exhibit 6-2: The Language of a ...... 164 Exhibit 6-3: The Values and Beliefs of a Culture ...... 166 Exhibit 6-4: and Drug Cultures ...... 166 Exhibit 6-5: The of Drug Cultures ...... 168 Exhibit 6-6: Questions Regarding Knowledge and Skill Demands of Heroin Use ...... 168 Exhibit 6-7: 12-Step Group Values and the Culture of Recovery ...... 174

v Consensus Panel

Note: Information given indicates each participant’s affiliation during the the panel was convened and may no longer reflect the individual’s current affiliation. Chair Workgroup Leaders Felipe González Castro, M.S.W., Ph.D. Virgil A. Gooding, Sr., M.A., M.S.W., LISC Department of Clinical Director University II, Inc. Tempe, AZ Cedar Rapids, IA Co-Chairs Ford H. Kuramoto, D.S.W. President Loretta J. Bradley, M.A., Ph.D. National Families Professor Against Substance Abuse Department of , CA Tech University Lubbock, TX Harry Montoya, M.A. President/Chief Executive Officer Jacqueline P. Butler, M.S.W., CCDC, Hands Across Cultures LISW Española, NM Professor of Clinical Psychiatry Substance Abuse Division Onaje M. Salim, M.A., NCAC-II, CCS College of Medicine Director University of Cincinnati Cork Institute Southeast Cincinnati, OH Technology Transfer Center Morehouse School of Medicine Byford, M.S.W., LCSW , GA City-County Health Department , OK Panelists Ting-Fun May Lai, M.S.W., CSW, Barbara Lee Aragon, M.S.W. CASAC Academic Fellow Director Department of Health Services Center North Highlands, CA Hamilton-Madison House , NY

vii Improving Cultural Competence

Debra A. Claymore, M.Ed.Adm. Rafaela R. Robles, Ed.D. D. Claymore & Associates, Inc. Director Loveland, CO Technology Transfer Center Basin/ Addiction E. Daniel Edwards, D.S.W. Centro de Estudios en Adicción Director Universidad Central Caribe Program Bayamon, PR University of Salt Lake City, UT Gloria M. Rodriguez, D.S.W. Scientist Tonda L. Hughes, M.S.N., Ph.D., FAAN Division of Addiction Services Associate Professor Department of Health and Senior College of Nursing Services University of at Trenton, NJ Chicago, IL Ann S. Yabusaki, M.Ed., M.A., Ph.D. David Mathews, M.A., Ph.D. Director Director of Adult Services Coalition for a Drug-Free River Community Care, Inc. Honolulu, HI Jackson, KY Anthony (Tony) Taiwai Ng, M.D. Consultant , DC Barry Pilson, Ph.D. Adjunct Professor School of Social Work Tulane University Metairie, LA

viii

KAP Expert Panel and Federal Government Participants

Note: Information given indicates each participant’s affiliation during the time the panel was convened and may no longer reflect the individual’s current affiliation.

Barry S. Brown, Ph.D. Jerry P. Flanzer, D.S.W., LCSW, CAC Adjunct Professor Chief of Services University of at Wilmington Division of Clinical and Services Research Carolina Beach, NC National Institute on Drug Abuse National Institutes of Health Jacqueline Butler, M.S.W., LISW, LPCC, Bethesda, MD CCDC III, CJS Professor of Clinical Psychiatry Galer, D.B.A. College of Medicine Independent Consultant University of Cincinnati Westminster, MA Cincinnati, OH Renata J. Henry, M.Ed. Deion Cash Director Executive Director Division of Alcoholism, Drug Abuse and Community Treatment and Correction Mental Health Center, Inc. Department of Health and Social Canton, OH Services New Castle, DE Debra A. Claymore, M.Ed.Adm. D. Claymore & Associates, Inc. Joel Hochberg, M.A. Loveland, CO President Asher & Partners Carlo C. DiClemente, Ph.D. Los Angeles, CA Chair Department of Psychology Jack Hollis, Ph.D. University of County Associate Director Baltimore, MD Center for Health Research Kaiser Permanente Catherine E. Dube, Ed.D. Portland, OR Independent Consultant Brown University Providence, RI

ix Improving Cultural Competence

Mary Beth Johnson, M.S.W. Everett Rogers, Ph.D. Director Center for Communications Programs Addiction Technology Transfer Center Johns Hopkins University University of — City Baltimore, MD Kansas City, MO Jean R. Slutsky, P.A., M.S.P.H. Eduardo Lopez, B.S. Director Executive Producer Center for Outcomes and EVS Communications Agency for Healthcare Research and Quality Washington, DC Rockville, MD Holly A. Massett, Ph.D. Nedra Klein Weinreich, M.S. Academy for Educational Development President Washington, DC Weinreich Communications Canoga Park, CA Diane Miller, Ph.D. Chief Clarissa Wittenberg Scientific Communications Branch Director National Institute on Abuse Office of Communications and and Alcoholism Public Liaison National Institutes of Health National Institute of Mental Health Bethesda, MD National Institutes of Health Bethesda, MD Harry B. Montoya, M.A. President/Chief Executive Officer Consulting Members of the KAP Hands Across Cultures Expert Panel Española, NM Paul Purnell, M.A Richard K. Ries, M.D. Social Solutions, L.L.C. Director/Professor Potomac, MD Outpatient Mental Health Services Dual Disorder Programs Scott Ratzan, M.D., M.P.A., M.A. , WA Academy for Educational Development Washington, DC Gloria M. Rodriguez, D.S.W. Research Scientist Thomas W. Valente, Ph.D. Division of Addiction Services Director, Master of Public Health Program New Jersey Department of Health and Senior Department of Preventive Medicine Services School of Medicine Trenton, NJ University of Southern Alhambra, CA Patricia A. Wright, Ed.D. Independent Consultant Baltimore, MD

x What Is a TIP?

Treatment Improvement Protocols (TIPs) are developed by the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services (HHS). TIPs are best practice guidelines for the treatment of substance use disorders. TIPs draw on the experience and knowledge of clinical, research, and administrative experts to evaluate the quality and appropriateness of various forms of treatment. TIPs are distributed to facilities and individuals across the country. Published TIPs can be accessed via the at http://store.samhsa.gov. Although each TIP strives to include an evidence base for the practices it recommends, SAMHSA recognizes that the field of substance abuse treatment is continually evolving, and research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey front-line information quickly but responsibly. If research supports a particular approach, citations are provided.

xi

Foreword

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the . SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities. The Treatment Improvement Protocol (TIP) series fulfills SAMHSA’s mission to reduce the impact of substance abuse and mental illness on America’s communities by providing evidence- based and best practice guidance to clinicians, program administrators, and payers. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-federal clinical researchers, clinicians, program administrators, and patient advocates debates and discusses their particular area of expertise until they reach a consensus on best practices. This panel’s work is then reviewed and critiqued by field reviewers. The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have helped bridge the gap between the promise of research and the needs of practicing clinicians and administrators to serve, in the most scientifically sound and effective ways, in need of behavioral health services. We are grateful to all who have joined with to contribute to advances in the behavioral health field.

Pamela S. Hyde, J.D. Administrator Substance Abuse and Mental Health Services Administration

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration

xiii

Executive Summary

The development of culturally responsive assist readers in understanding the role of clinical skills is vital to the effectiveness of culture in the delivery of behavioral health behavioral health services. According to the services (both generally and with reference to U.S. Department of Health and Human specific cultural groups). This TIP is organized Services (HHS), cultural competence “refers to into six chapters and begins with an introduc- the ability to and respect the beliefs, tion to cultural competence. The following , interpersonal styles, and behaviors of subheadings provide a summary of each chap- individuals and families receiving services, as ter and an overview of this publication. well as staff members who are providing such services. Cultural competence is a dynamic, Introduction to Cultural ongoing developmental process that requires a Competence long-term commitment and is achieved over time” (HHS 2003a, p. 12). It has also been Why is the development of cultural compe- called “a of behaviors, attitudes, and policies tence and culturally responsive services that . . . enable a system, agency, or group of important in the behavioral health field? professionals to work effectively in cross- Culturally responsive skills can improve client cultural situations” (Cross et al. 1989, p. 13). in services, therapeutic - This Treatment Improvement Protocol (TIP) ships between clients and providers, and uses Sue’s (2001) multidimensional model for treatment retention and outcomes. Cultural developing cultural competence. Adapted to competence is an essential ingredient in de- address cultural competence across behavioral creasing disparities in behavioral health. health settings, this model serves as a frame- The development of cultural competence can work for targeting three organizational levels have far-reaching effects not only for clients, of treatment: individual counselor and staff, but also for providers and communities. Cul- clinical and programmatic, and organizational tural competence improves an organization’s and administrative. The chapters target specif- sustainability by reinforcing the of diver- ic racial, ethnic, and cultural considerations sity, flexibility, and responsiveness in address- along with the core elements of cultural com- ing the current and changing needs of clients, petence highlighted in the model. These core communities, and the healthcare environment. elements include cultural awareness, general Culturally responsive organizational strategies cultural knowledge, cultural knowledge of and clinical services can help mitigate organi- behavioral health, and cultural skill develop- zational and provide cost-effective treat- ment. The primary objective of this TIP is to ment, in part by matching services to client

xv Improving Cultural Competence

needs appropriately from the outset. So organize their world. Culture is not a definable too, culturally responsive organizational poli- entity to which people belong or do not be- cies and procedures support staff engagement long. Within a nation, race, or community, in culturally responsive care by establishing people belong to multiple cultural groups and access to training, supervision, and congruent negotiate multiple cultural expectations on a policies and procedures that enable staff to daily basis. These expectations, or cultural respond in a culturally appropriate manner to norms, are the spoken or unspoken rules or clients’ psychological, linguistic, and physical standards for a given group that indicate needs. whether a certain social event or behavior is appropriate or inappropriate. The word “cul- What is the process of becoming culturally ture” is sometimes applied to groups formed competent as a counselor or culturally on the basis of age, socioeconomic status, responsive as an organization? Cultural , , recovery status, competence is not acquired in a limited common interest, or proximity. Counselors timeframe or by learning a set of facts about and administrators should understand that specific ; cultures are diverse and each client embraces his or her culture(s) in a continuously evolving. Developing cultural unique way and that there is considerable competence is an ongoing process that begins diversity within and across races, ethnicities, with cultural awareness and a commitment to and culture heritages. Other cultures and understanding the role that culture plays in often exist within larger cultures. behavioral health services. For counselors, the first step is to understand their own cultures as What are race and ethnicity? Race is often a basis for understanding others. Next, they referred to as a biological category based on must cultivate the willingness and ability to genetic traits like skin color (HHS 2001), but acquire knowledge of their clients’ cultures. there are no reliable means of identifying race This involves learning about and respecting through biological criteria. Despite its limita- client worldviews, beliefs, values, and attitudes tions, the concept of race is important to toward mental health, help-seeking behavior, discussions of cultural competence. Race— substance use, and behavioral health services. when defined as a social construct to describe Behavioral health counselors should incorpo- people with shared physical characteristics— rate culturally appropriate knowledge, under- can have tremendous social significance. The standing, and attitudes into their actions (e.g., term ethnicity is often used interchangeably , verbal messages, treat- with race, although by definition, ethnicity— ment policies, services offered), thereby con- unlike race—implies a certain sense of belong- veying their cultural competence and their ing. It is generally based on shared values, organizations’ cultural responsiveness during beliefs, and origins rather than shared physical assessment, treatment planning, and the characteristics. With the exception of its final treatment process. chapter, which examines drug cultures, this TIP focuses on the major racial and ethnic What is culture? Culture is the conceptual groups identified by the U. S. Census Bureau system developed by a community or within the : African and Black to structure the way people view . It Americans, Asian Americans (including Na- involves a particular set of beliefs, norms, and tive Hawaiians and other Pacific Islanders), values that influence ideas about relationships, Hispanics and Latinos, Native Americans, and how people live their lives, and the way people White Americans. xvi Executive Summary

What constitutes cultural identity? Cultural including adequate allocation of resources, identity, in the simplest terms, involves an reinforces the importance of sustaining affiliation or identification with a particular cultural competence in counselors and group or groups. An individual’s cultural other clinical staff. identity reflects the values, norms, and • Advocating culturally responsive practices worldview of the larger culture, but it is de- increases within the community, fined by more than these factors. Cultural agency, and staff. identity includes individual traits and - • Achieving cultural competence requires utes shaped by race, ethnicity, language, life the participation of racially and ethnically experiences, historical events, acculturation, diverse groups and underserved popula- geographic and other environmental influ- tions in the development and implementa- ences, and other forces. Thus, no two individ- tion of treatment approaches and training uals will possess exactly the same cultural activities. identity even if they identify with the same • Consideration of culture is important at all cultural group(s). Cultural identities are not levels of operation and in all stages of static; they develop, evolve, and change across treatment and recovery. the life cycle. Core Competencies for This TIP explores cultural identity and its influence on assessment, treatment planning, Counselors and Other and therapeutic and healing practices. The Clinical Staff introduction it provides to the cross-cutting factors of race, ethnicity, and culture will help Cultural competence has come to mean more counselors gain knowledge about the many than a discrete skill set or knowledge base; forces that shape cultures, communities, and cultural competence also requires self- the lives of clients, including, but not limited evaluation on the part of the practitioner. to, families and , roles, socioec- Culturally competent counselors are aware of onomic status, , education, immigra- their own culture and values, and they tion, and migration. acknowledge their own assumptions and What core assumptions serve as the foun- biases about other cultures. Moreover, cultur- dation of this TIP? The consensus panel ally competent counselors strive to understand developed several core assumptions upon how these assumptions affect their ability to which to structure the content of this TIP: provide culturally responsive services to clients • An understanding of race, ethnicity, and from similar or diverse cultures. culture (including one’s own) is necessary Counselors should begin the process of be- to appreciate the diversity of human dy- coming culturally competent by identifying namics and to treat clients effectively. • and exploring their and Incorporating cultural competence into worldview along with their clinical worldview, treatment improves therapeutic deci- uncovering how these views shape their per- sionmaking and offers alternative ways to ceptions of and during the counseling process. define and plan a treatment program firm- In addition to understanding themselves and ly directed toward and recovery. • how their culture and values can affect the Organizational commitment to supporting therapeutic process, culturally competent culturally responsive treatment services, counselors possess a general understanding of

xvii Improving Cultural Competence

the cultures of the specific clients with whom organization as a whole. Chapter 3 presents they work. Counselors should also understand culturally responsive evaluation and treatment how individual cultural differences affect planning as a series of nine steps. substance abuse, health beliefs, help-seeking Step 1: Engage clients. Because the intake behavior, and of behavioral health meeting is often the first encounter clients services. Culturally competent counselors: have with the behavioral health system, it is • Frame issues in culturally relevant ways. vital that they leave the meeting feeling un- • Allow for complexity of issues based on derstood and hopeful. Counselors should cultural context. to establish rapport with clients before launch- • Make allowances for variations in the use ing into a series of questions. of personal space. • Are respectful of culturally specific mean- Step 2: Familiarize clients and ings of touch (e.g., hugging). members with the evaluation and treatment • Explore culturally based experiences of process. Often, clients and family members power and powerlessness. are not familiar with treatment jargon, the • Adjust communication styles to the cli- treatment program, the facility, or the expecta- ent’s culture. tions of treatment; furthermore, not all clients • Interpret emotional expressions in light of will have had an opportunity to express their the client’s culture. own expectations or apprehension. Clinical • Expand roles and practices as needed. and other treatment staff must not assume that clients already understand the treatment Chapter 2 addresses counselors’ core cultural process. Instead, they need to take sufficient competencies and presents clinical activities, time to talk with clients (and their families, as including clinical supervision tools. The key appropriate) about how treatment works and areas explored include cultural awareness and what to expect from treatment providers. cultural identity development, the cultural lens of counseling, key components of cultural Step 3: Endorse a collaborative approach in knowledge for behavioral health counselors, facilitating interviews, conducting assess- and specific counseling skills that support ments, and planning treatment. Counselors culturally responsive services. should educate clients about their role in interview, assessment, and treatment planning Culturally Responsive processes. From first , they should Evaluation and Treatment encourage clients and their families to partici- pate actively by asking questions, voicing Planning specific treatment needs, and being involved in treatment planning. Counselors should allow The role of culture should be considered clients and family members to give feedback during initial intakes and interviews, in on the cultural of the treatment plan. screening and assessment processes, and in the development of treatment planning. Culturally Step 4: Obtain and integrate culturally responsive treatment can only occur when the relevant information and themes. By explor- making of clinical and programmatic decisions ing culturally relevant themes, counselors will includes culturally relevant information and better understand each client and will be practices and is endorsed and supported by better equipped to develop a culturally in- clinical staff, clinical supervisors, and the formed evaluation and treatment plan. Areas

xviii Executive Summary

to explore include immigration and migration Like counselors, case managers should possess , cultural identity, acculturation status, cultural self-knowledge and a basic knowledge health beliefs, healing practices, and other of other cultures. They should possess traits information culturally relevant to the client. conducive to working well with diverse groups and the ability to apply cultural competence in Step 5: Gather culturally relevant collateral practical ways. Case management includes the information. Such information is a powerful use, as necessary, of interpreters who can tool in assessing clients’ presenting problems, communicate well in the specific dialects understanding the influence of cultural factors spoken by each client and who are familiar on clients, and gathering resources to support with behavioral health vocabulary relevant to treatment endeavors. By involving others in the the specific behavioral health setting in which early phases of treatment, providers will likely service provision will occur. Case managers obtain more external support for each client’s should acquire cultural and community engagement in treatment services. Counselors knowledge to assist with the coordination of can obtain supplemental information (with social, health, and other essential services and client permission) from family members, medi- to secure culturally relevant services in and cal and court records, probation and parole outside the treatment facility. Case managers officers, community members, and so on. should also keep a list of culturally appropriate Step 6: Select culturally appropriate screen- referral resources to help meet client needs. ing and assessment tools. In selecting eval- Step 9: Integrate cultural factors into uation tools, counselors should note the treatment planning. Counselors should be availability of normative data for the popula- flexible in designing a treatment plan to meet tions to which their clients belong, the inci- the cultural needs of clients and should inte- dence of test item , the role of grate traditional healing practices into treat- acculturation in understanding test items, and ment plans when appropriate, using resources the adaptation of testing materials to each available in the clients’ cultural communities. client’s culture and language. Treatment goals and objectives need to be Step 7: Determine readiness and motiva- culturally relevant, and the treatment envi- tion for change. Although few studies focus ronment must be conducive to client partici- on the use of motivational interviewing with pation in treatment planning and to the specific cultural groups, its theories and strate- gathering of client feedback on the cultural gies may be more culturally appropriate for relevance of the treatment being provided. most clients than other approaches. Through reflective listening, motivational interviewing Pursuing Organizational focuses on helping clients explore ambivalence Cultural Competence toward change, decisions, and subsequent treatment. It is a nonconfrontational, client- Organizational cultural competence is a dy- centered approach that reinforces clients as the namic, ongoing process that begins with experts on what will work and supports the awareness and commitment and evolves into key idea that change is a process. culturally responsive organizational policies Step 8: Provide culturally responsive case and procedures. A commitment to improving management. Many core competencies for cultural competence must include resources to counselors are also relevant to case managers. help support ongoing fidelity to these policies and procedures along with an ongoing process

xix Improving Cultural Competence

of reassessment and adaptation as client and policies and procedures, will enable counselors community needs evolve. Chapter 4 presents to respond more consistently to clients in a 20 organizational tasks that support counse- culturally competent manner. lors’ development of cultural competence and improve organizational development of cultur- Behavioral Health ally responsive treatment services. Treatment for Major Racial Beginning with the organization’s vision and and Ethnic Groups mission statement, administrators and govern- ing boards need to develop, implement, and Knowledge of a culture’s attitudes toward support a strategic planning process that mental illness, substance use, healing, and demonstrates commitment to cultural compe- help-seeking patterns, practices, and beliefs is tence. Key staff members assigned to oversee essential in understanding clients’ presenting the development of culturally responsive problems, developing culturally competent services act as liaisons and facilitators in estab- counseling skills, and formulating culturally lishing a cultural competence committee and relevant agency policies and procedures. conducting an organizational self-assessment Treatment providers need to learn and under- of cultural competence. With the involvement stand how identification with one or more of community members, staff, clients and their cultural groups influences each client’s families, board members, and other invested worldview, beliefs, and surrounding individuals, the cultural competence commit- of use, healing, and treatment. supports and oversees organizational self- assessment, using it to identify strengths and Chapter 5 provides a review of the literature as specific areas for improvement in cultural it pertains to specific racial and ethnic groups responsiveness. Based on the results of the identified by the U.S. Census Bureau. a self-assessment, the committee develops and brief introduction, the chapter explores each implements a cultural competence plan. major racial and ’s specific pat- terns of substance use and substance use dis- An organizational self-assessment helps the orders, help-seeking patterns, beliefs about committee prioritize the steps needed to and traditions involving substance use, beliefs improve culturally responsive services. The and attitudes about treatment, assessment and plan should address strategies for recruiting, treatment considerations (including co- hiring, retaining, and promoting qualified, occurring disorders and culturally specific diverse staff members; the use of interpreters disorders), and theoretical approaches and or bilingual staff members; staff training, treatment interventions (including evidence- professional development, and education; based and best practices as well as traditional fostering community involvement; facilities healing practices). design and operation; development of cultur- ally appropriate program materials; how to Chapter 5 also offers assistance in providing incorporate culturally relevant treatment treatment to African and Black Americans, approaches; and development and implemen- Asian Americans (including Native Hawaiian tation of supporting policies and procedures, and other Pacific Islanders), Latinos, Native including reassessment processes. An organi- Americans, and White Americans. Counse- zation’s commitment to and support of cultur- lors, clinical supervisors, and administrators ally responsive services, including congruent are encouraged to use the information in this chapter as a starting point for learning about xx Executive Summary the major cultural groups of their clients. learn to experience “getting high” as a pleasur- Nonetheless, many forces shape how an indi- able activity; they also learn the skills needed vidual identifies with, is influenced by, or to procure and use effectively and to portrays his/her culture, and numerous subcul- avoid the pitfalls of the drug-using tures can exist within any culture; thus, gener- (e.g., getting arrested, running out of money to alizations about various groups buy drugs). Perhaps most importantly, the should be avoided. who uses gains acceptance from a group of peers even as mainstream society Drug Cultures and the increasingly discriminates against him or her Culture of Recovery because of his or her substance use or mental illness. Prejudice from mainstream society may This TIP emphasizes the concept that many make ties with the drug culture even stronger; subcultures exist within and across diverse he or she may feel as if there is no other place ethnic and racial populations and cultures. to turn for social and cultural support. Drug cultures are a formidable example—they Within a treatment program, an understand- can influence the presentation of mental, ing of drug cultures will help providers engage substance use, and co-occurring disorders new clients and recognize the social and cul- while also affecting prevention and treatment tural that might lead back to strategies and outcomes. Drug cultures differ substance use or other high-risk behaviors that from the types of cultures discussed in the rest are contraindicated for individuals who are of this TIP, but they do share some common being treated for psychological symptoms features. For instance, there is not a single and/or mental illness. However, unlike other drug culture in the United States today, but types of cultural affiliations, the treatment rather, a number of distinct (although some- provider’s relationship to the drug culture does times related) drug cultures that differ accord- not just involve understanding; the provider ing to substances used, geographic location, must actively work to weaken that connection socioeconomic status, and other factors. Drug and it with other experiences that meet cultures focusing on illicit substances may be the client’s social and cultural needs. In many of greater importance in the lives of people cases, this involves helping the client connect who use substances, but people who use legal with a “culture of recovery” to meet those substances, such as alcohol, can also partici- needs over the long course of recovery. pate in a drug culture. For example, people who drink heavily at a or fraterni- In sum, this TIP was written to help counse- ty/sorority house can develop their own drug lors and organizations provide culturally re- culture that works to encourage new people to sponsive services. Practices and procedures use, supports high levels of continued use or that improve one’s cultural competence will binge use, and reinforces denial. likely result in better outcomes for clients in treatment for mental and substance use disor- Understanding the role that drug cultures play ders. Culturally competent counseling can in clients’ lives is particularly important be- improve counselor credibility, client satisfac- cause these cultures, more than any other tion, and client self-disclosure while increasing cultural connections, influence clients’ sub- clients’ willingness to continue in treatment. stance use or abuse and the behaviors in which they engage to manage mental disorders. Through drug cultures, people new to using

xxi

Introduction to Cultural 1 Competence

IN THIS CHAPTER Hoshi was born and grew up in . He has been living in the United States for nearly 20 years, going to graduate school and • Purpose and Objectives working as a systems analyst, while his family has remained in of the TIP Japan. Hoshi entered a residential treatment center for alcohol • Core Assumptions dependence where the treatment program expected every client to • What Is Cultural notify his or her family members about being in treatment. This Competence? had proven to be a positive step for many other clients and their • Why Is Cultural families in this treatment program, where the was that con- Competence Important? tact with family helped clients become honest about their sub- • How Is Cultural stance abuse, reconnect with possibly estranged relatives, and take Competence Achieved? responsibility for the decision to seek treatment. • What Is Culture? He was reluctant, but staff members persuaded Hoshi to comply • What Is Race? with program expectations. He wrote to his family, describing his What Is Ethnicity? • current life and explaining his need for treatment. It was not until • What Is Cultural Identity? weeks later, after he had been discharged from residential treat- • What Are the Cross- ment and was participating in the program’s continuing care pro- Cutting Factors in Race, gram, that he received a reply. Staff members were shocked to learn Ethnicity, and Culture? that Hoshi’s had disowned him because he had “shamed” • As You Proceed the family by disclosing the details of his life to the program staff, publicly admitting that he had a drinking problem. As Hoshi’s story demonstrates, a well-meaning but culturally inap- propriate intervention can be counterproductive to recovery. The program applied a “one size fits all” model without being sensitive to the possibility that such an approach might harm the client. Fortunately, Hoshi eventually reconciled with his family, and the program administration and staff began to develop initiatives to improve their cultural awareness and competence. Counselors and other behavioral health service providers who are equipped with a general understanding of how culture affects their

1 Improving Cultural Competence

own worldviews as well as those of their cli- support allows counselors, case managers, and ents will be able to work more effectively with administrators to begin to integrate culturally clients who have substance use and mental congruent and responsive services more con- disorders. Even when culture is not a con- sistently across the continuum of care— scious consideration in providing interventions including outreach and early intervention, and services, it is a dynamic force that often assessment, treatment planning and interven- influences client responses to treatment and tion, and recovery services. subsequent outcomes. Although outcome The key objectives of this TIP are helping research is limited, culturally responsive be- readers understand: havioral health counseling results in greater • Why it is important for behavioral health counselor credibility, better client satisfaction, organizations and counselors who provide more client self-disclosure, and greater will- prevention and treatment services to con- ingness among clients to continue with coun- sider culture. seling (Goode et al. 2006; Lie et al. 2011; • Ponterotto et al. 2000). This Treatment The role culture plays in the treatment Improvement Protocol (TIP) examines the process, both generally and with reference significance of culture in substance abuse to specific cultural groups. patterns, mental health, treatment-seeking Intended Audience behaviors, assessment and counseling process- es, program development, and organizational The primary audiences for this TIP are pre- practices in behavioral health services. vention professionals, substance abuse counse- lors, mental health clinicians, and other Purpose and Objectives of behavioral health service providers and admin- istrators. Those who work with culturally the TIP diverse populations will it particularly useful, though all behavioral health workers— This TIP is intended to help counselors and regardless of their client populations—can behavioral health organizations make progress benefit from an awareness of the importance toward cultural competence. Gaining cultural of culture in shaping their own perceptions as competence, like any important counseling well as those of their clients. Secondary audi- skill, is an ongoing process that is never com- ences include educators, researchers, policy- pleted; such skills cannot be taught in any makers for treatment and related services, single or training session. Nevertheless, consumers, and other healthcare and social this TIP provides a framework to help practi- service professionals who work with clients tioners and administrators integrate cultural who have behavioral health disorders. factors into their evaluation and treatment of clients with behavioral health disorders. It also Structure of the TIP seeks to motivate professionals and organiza- This TIP focuses on the essential ingredients tions to examine and broaden their cultural for developing cultural competence as a coun- awareness, embrace diversity, and develop a selor and for providing culturally responsive heightened respect for people of all cultural services in clinical settings as an organization. groups. This TIP places significant im- Chapter 1 defines cultural competence, pre- portance on the role of program management sents a rationale for pursuing it, and describes and organizational commitment in the devel- the process of becoming culturally competent opment of cultural competence. Organizational and responsive to client needs. The chapter

2 Chapter 1—Introduction to Cultural Competence

highlights the consensus panel’s core assump- Terminology tions. It introduces a framework, adapting Throughout the TIP, the term substance abuse Sue’s (2001) multidimensional model of cul- is used to refer to both substance abuse and tural competence as the guiding model across . This term was chosen chapters. The initial chapter ends with a broad partly because substance abuse treatment overview of the concepts integral to an under- professionals commonly use the term sub- standing of race, ethnicity, and culture. stance abuse to describe any excessive use of Chapter 2 addresses the development of cul- addictive substances. In this TIP, the term tural awareness and describes core competen- refers to use of alcohol as well as other sub- cies for counselors and other clinical staff, stances of abuse. Readers should attend to the beginning with self-knowledge and ending context in which the term occurs to determine with skill development. It covers behaviors and what possible range of meanings it covers; in skills for cultivating cultural competence as most cases, however, the term will refer to all well as attitudes conducive to working effec- varieties of substance use disorders described tively with diverse client populations. by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; Chapter 3 provides guidelines for culturally American Psychiatric Association, 2013). responsive clinical services, including inter- viewing skills, assessment practices, and treat- Throughout the TIP, the term behavioral ment planning. health refers to a state of mental/emotional being and/or choices and actions that affect Chapter 4 provides organizational strategies to wellness. Behavioral health problems include promote the development and implementation substance abuse or misuse, alcohol and drug of culturally responsive practices from the top addiction, psychological distress, suicide, and down, beginning with organizational self- mental and substance use disorders. This assessment of current services and continuing includes a range of problems, from unhealthy through implementation and oversight of an to diagnosable and treatable diseases like organizational plan targeting initiatives to serious mental illness and substance use disor- improve culturally responsive services. ders, which are often chronic in nature but Chapter 5 provides a general introduction for from which people can and do . The each major racial and ethnic group, providing term is also used in this TIP to describe the specific cultural knowledge related to sub- service systems encompassing the promotion stance use patterns, beliefs and attitudes to- of emotional health, the prevention of mental ward help-seeking behavior and treatment, and substance use disorders, substance use and and an overview of research- and practice- related problems, treatments and services for based treatment approaches and interventions. mental and substance use disorders, and re- covery support. Behavioral health conditions, Chapter 6 closes the TIP with an exploration taken together, are the leading causes of disa- of the concept of “drug culture”—the relation- bility burden in ; efforts to ship between the drug culture and mainstream improve their prevention and treatment will culture, the values and rituals of drug cultures, benefit society as a whole. Efforts to reduce how people “benefit” from participation in the impact of mental and substance use disor- drug cultures, and the role of the drug culture ders on communities in the United States, in substance abuse treatment. such as those described in this TIP, will help achieve nationwide improvements in health.

3 Improving Cultural Competence

Core Assumptions importance of cultural competence in the delivery of effective behavioral health services. The consensus panel developed assumptions Assumption 3: Incorporating cultural compe- that serve as the fundamental platform of this tence into treatment improves therapeutic TIP. Assumptions were derived from clinical decision-making and offers alternate ways to and administrative experiences, available define and plan a treatment program that is empirical evidence, conceptual writings, and firmly directed toward progress and recov- program and treatment service models. ery—as defined by both the counselor and Assumption 1: The focus of cultural compe- client. Using culturally responsive practices is tence, in practice, has historically been on essential and provides many benefits for or- individual providers. However, counselors will ganizations, staff, communities, and clients. not be able to sustain culturally responsive Assumption 4: Consideration of culture is treatment without the organization’s commit- important at all levels of operation— ment to support and allocate resources to individual, programmatic, and organization- promote these practices. Organizations that al—across behavioral health treatment set- value diversity and reflect cultural competence tings. It is also important in all activities and through congruent policies and procedures are at every treatment phase: outreach, initial more likely to be successful in the ever- contact, screening, assessment, placement, changing landscape of communities, treatment treatment, continuing care and recovery ser- services, and individual client needs. vices, research, and education. Because organi- Assumption 2: An understanding of race, zations and systems have their own internal ethnicity, and culture (including one’s own) is cultures, it is vital that treatment facilities, necessary to appreciate the diversity of human training and educational programs on dynamics and to treat all clients effectively. substance-related and mental disorders and Before counselors begin to probe the cultures, treatment processes, and licensing agencies races, and ethnicities of their clients and use and accrediting bodies incorporate culturally this information to improve client treatment, responsive practices into their curricula, stand- the consensus panel recommends first that ards, criteria, and requirements. counselors examine and understand their own Assumption 5: Achieving cultural compe- cultural , racial and ethnic heritages, tence in an organization requires the partici- and cultural values and beliefs. This applies to pation of racially and ethnically diverse groups all practitioners regardless of race, ethnicity, or and underserved populations in the develop- cultural identity. Beyond that, clinicians ment and implementation of culturally re- should clearly identify the influences of their sponsive practices, program structure and own cultural experiences on the counseling design, treatment strategies and approaches, relationship. In other words, each counselor and staff professional development. Culturally must understand, embrace, and, if warranted, congruent interventions cannot be successfully reexamine and adjust his or her own world- applied when generated outside a community view to practice in a culturally competent or without community participation. Clients, manner. So too, all support staff, clinicians, potential clients, their families, and their com- administrators, and policymakers—including munities should be invited to participate in the those not from the mainstream culture— development of a cultural competence plan (an must become educated and convinced of the

4 Chapter 1—Introduction to Cultural Competence

organization’s plan to improve cultural compe- among professionals that enables effective tence and to provide culturally responsive work in cross-cultural situations. ‘Culture’ re- services) and, subsequently, the design of fers to integrated patterns of human behavior that include the language, thoughts, communi- culturally relevant treatment services and cations, actions, customs, beliefs, values, and organizational policies and procedures. of racial, ethnic, religious, or social groups. ‘Competence’ implies having the ca- Assumption 6: Public advocacy of culturally pacity to function effectively as an individual responsive practices can increase trust among and an organization within the context of the the community, agency, and staff. The com- cultural beliefs, behaviors, and needs presented munity is thus empowered with a voice in by consumers and their communities. (p. 28) organizational operations. Advocacy can Numerous evolving definitions and models of further function as a secondary form of public cultural competence reflect an increasingly education and awareness as well as outreach. complex and multidimensional view of how High participation allows treatment race, ethnicity, and culture shape individu- to be viewed as of and for the community. als—their beliefs, values, behaviors, and ways of being (see Bhui et al. 2007 for a systemic What Is Cultural review of cultural competence models in Competence? mental health). In this TIP, Sue’s (2001) multidimensional model of cultural compe- In 1989, Cross et al. provided one of the more tence guides its overall organization and the universally accepted definitions of cultural specific content of each chapter. The model competence in clinical practice: “A set of was adapted to fit the unique topic areas congruent behaviors, attitudes, and policies addressed by this TIP (Exhibit 1-1) and to that come together in a system, agency, or target essential elements of cultural compe- among professionals and enable the system, tence in providing behavioral health services agency, or professionals to work effectively in across three main dimensions, as shown in the cross-cultural situations” (p. 13). cube. (Note: Each subsequent chapter displays a version of this cube shaded to emphasize the Since then, others have interpreted this defini- focus of that chapter.) tion in terms of a particular field or attempted to refine, expand, or elaborate on earlier con- Dimension 1: Racially and ceptions of cultural competence. At the root Culturally Specific Attributes of this concept is the idea that cultural compe- Exhibit 1-1 and this TIP focus on main popu- tence is demonstrated through practical lation groups as identified by the U.S. Census means—that is, the ability to provide effective Bureau (Humes et al. 2011), but this dimen- services. Bazron and Scallet (1998) defined sion is inclusive of other multiracial and cul- culturally responsive services as those that are turally diverse groups and can also include “responsive to the unique cultural needs of sexual orientation, gender orientation, socioec- bicultural/bilingual and culturally distinct onomic status, and geographic location. There populations” (p. 2). The Office of Minority are often many cultural groups within a given Health (OMH 2000) merged several existing population or ethnic heritage. For simplicity, definitions to conclude that: these groups are not represented on the actual Cultural and linguistic competence is a set of model, and it is assumed that the reader congruent behaviors, attitudes, and policies acknowledges the vast inter- and intragroup that come together in a system, agency, or variations that exist in all population, ethnic,

5 Improving Cultural Competence

Exhibit 1-1: Multidimensional Model for Developing Cultural Competence

and cultural groups. Refer to Chapters 5 and 6 skills that ensure delivery of culturally appro- to gain further clinical knowledge about spe- priate treatment interventions. Several chap- cific racial, ethnic, and cultural groups. ters capture the ingredients of this dimension. Chapter 1 provides an overview of cultural Dimension 2: Core Elements of competence and concepts, Chapter 2 provides Cultural Competence an indepth look at the role and effects of the This dimension includes cultural awareness, counselor’s cultural awareness and identity cultural knowledge, and cultural skill devel- within the counseling process, Chapter 3 opment. To provide culturally responsive provides an overview of cultural considerations treatment services, counselors, other clinical and essential clinical skills in the assessment staff, and organizations need to become aware and treatment planning process, and Chapter of their own attitudes, beliefs, biases, and 5 specifically addresses the role of culture assumptions about others. Providers need to across specific treatment interventions. invest in gaining cultural knowledge of the Dimension 3: Foci of Culturally populations that they serve and obtaining Responsive Services specific cultural knowledge as it relates to help-seeking, treatment, and recovery. This This dimension targets key levels of treatment dimension also involves competence in clinical services: the individual staff member level, the

6 Chapter 1—Introduction to Cultural Competence

clinical and programmatic level, and the or- ing translation and interpreter services. For ganizational and administrative level. Inter- clients, culturally responsive services honor the ventions need to occur at each of these levels beliefs that culture is embedded in the clients’ to endorse and provide culturally responsive language and their implicit and explicit com- treatment services, and such interventions are munication styles and that language- addressed in the following chapters. Chapter 2 accommodating services can have a positive focuses on core counselor competencies; effect on clients’ responses to treatment and Chapter 3 centers on clinical/program attrib- subsequent engagement in recovery services. utes in interviewing, assessment, and treat- The Affordable Care Act, along with growing ment planning that promote culturally recognition of racial and ethnic health dispari- responsive interventions; and Chapter 4 ad- ties and implementation of national initiatives dresses the elements necessary to improve to reduce them (HHS 2011b), necessitates culturally responsive services within treatment enhanced culturally responsive services and programs and behavioral health organizations. cultural competence among providers. Most Why Is Cultural behavioral health studies have found dispari- ties in access, utilization, and quality in behav- Competence Important? ioral health services among diverse ethnic and racial groups in the United States (Alegria et Foremost, cultural competence provides clients al. 2008b; Alegria et al. 2011; HHS 2011b; Le with more opportunities to access services that Cook and Alegria 2011; Satre et al. 2010). reflect a cultural perspective on and alternative, The lack of cultural knowledge among provid- culturally congruent approaches to their pre- ers, culturally responsive environments, and senting problems. Culturally responsive ser- diversity in the workforce contribute to dis- vices will likely provide a greater sense of parities in healthcare. Even limited cultural safety from the client’s perspective, supporting competence is a significant barrier that can the belief that culture is essential to healing. translate to ineffective provider–consumer Even though not all clients identify with or communication, delays in appropriate treat- desire to connect with their cultures, culturally ment and level of care, misdiagnosis, lower responsive services offer clients a chance to rates of consumer compliance with treatment, explore the impact of culture (including his- and poorer outcome (Barr 2008; Carpenter- torical and generational events), acculturation, Song et al. 2011; Dixon et al. 2011). Increas- discrimination, and bias, and such services also ing the cultural competence of the healthcare allow them to examine how these impacts workforce and across healthcare settings is relate to or affect their mental and physical crucial to increasing behavioral health equity. health. Culturally responsive practice recog- nizes the fundamental importance of language Additionally, adopting and integrating cultur- and the right to language accessibility, includ- ally responsive policies and practices into What Are Health Disparities? A health disparity is a particular of health closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systemat- ically experienced greater obstacles to health based on their racial or ethnic group; religion; socioec- onomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual or gender orientation; geographic location; or other characteristics historically tied to discrimination or exclusion.

Source: U.S. Department of Health and Human Services (HHS) 2011a.

7 Improving Cultural Competence

behavioral health services provides many establish community involvement in the ongo- benefits not only for the client, but also for the ing implementation of culturally responsive organization and its staff. Foremost, it increas- services, the community will be more aware of es the likelihood of sustainability. Cultural available treatment services and thus will competence supports the viability of services become more likely to use them as its in- by bringing to the forefront the value of diver- volvement with and trust for the organization sity, flexibility, and responsiveness in organiza- grows. Likewise, clients and staff are more apt tions and among practitioners. Beyond the to be empowered and invested if they are necessity of adopting culturally responsive involved in the ongoing development and practices to meet funding, state licensing, delivery of culturally responsive services. Cli- and/or national accreditation requirements, ent and staff satisfaction can increase if organ- cultural competence essential in organizational izations provide culturally congruent risk management (the process of making and treatment services and clinical supervision. implementing decisions that will optimize An organization also benefits from culturally therapeutic outcomes and minimize adverse responsive practices through planning for, effects upon clients and, ultimately, the organ- attracting, and retaining a diverse workforce ization). For instance, implementing culturally that reflects the multiracial and multiethnic responsive services is likely to increase access heritages and cultural groups of its client base to care and improve assessment, treatment and community. Developing culturally respon- planning, and placement. So too, it is likely to sive organizational policies includes hiring and enhance effective communication between promotional practices that support staff diver- clients and treatment providers, thus decreas- sity at all levels of the organization, including ing associated with misunderstanding the board appointments. Increasing diversity does clients’ presenting problems or the needs of not guarantee culturally responsive practices, clients with regard to appropriate referrals for but it is more likely that doing so will lead to evaluation or treatment. broader, varied treatment services to meet Organizational investment in improving client and community needs. Organizations cultural competence and increasing culturally are less able to ignore the roles of race, ethnici- responsive services will likely increase use and ty, and culture in the delivery of behavioral cost effectiveness because services are more health services if staff composition at each appropriately matched to clients from the level of the organization reflects this diversity. beginning. A key principle in culturally re- Culturally responsive practice reinforces the sponsive practices is engagement of the com- counselor’s need for self-exploration of cultur- munity, clients, and staff. As organizations al identity and awareness and the importance The Enhanced National Standards for of acquiring knowledge and skills to meet Culturally and Linguistically Appropriate clients’ specific cultural needs. Cultural com- Services in Health and (OMH petence requires an understanding of the 2013) are meant to reduce and eliminate client’s worldview and the interactions be- disparities, improve quality of care, and tween that worldview and the cultural identi- promote health equality by establishing a ties of the counselor and the client in the blueprint for health and the organization therapeutic process. Culturally responsive of health care (see Appendix C or visit practice reminds counselors that a client’s http://www.thinkculturalhealth.hhs.gov). worldview shapes his or her perspectives,

8 Chapter 1—Introduction to Cultural Competence

beliefs, and behaviors surrounding substance changing an organization’s mission statement, use and dependence, illness and health, seek- or attending a training on cultural compe- ing help, treatment engagement, counseling tence. Becoming culturally competent is a expectations, communication, and so on. developmental process that begins with Cultural competence includes addressing the awareness and commitment and evolves into client individually rather than applying gen- skill building and culturally responsive behav- eral treatment approaches based on assump- ior within organizations and among providers. tions and biases. It also can counteract a Cultural competence is the ability to recognize potentially omnipotent stance on the part of the importance of race, ethnicity, and culture counselors that they know what clients need in the provision of behavioral health services. more than the clients themselves do. Cultural Specifically, it is awareness and acknowledg- competence highlights the need for counselors ment that people from other cultural groups to take time to build a relationship with each do not necessarily share the same beliefs and of their clients, to understand their clients, and practices or perceive, interpret, or encounter to assess for and access services that will meet similar experiences in the same way. Thus, each client’s individual needs. cultural competence is more than speaking The importance and benefit of cultural com- another language or being able to recognize petence does not end with changes in organi- the basic features of a cultural group. Cultural zational policies and procedures, increases in competence means recognizing that each of program accessibility and tailored treatment us, by virtue of our culture, has at least some services, or enhancement of staff training. In ethnocentric views that are provided by that programs that prioritize and endorse cultural culture and shaped by our individual interpre- competence at all levels of service, clients, too, tation of it. Cultural competence is rooted in will have more exposure to psychoeducational respect, validation, and openness toward and clinical experiences that explore the roles someone whose social and cultural back- of race, ethnicity, culture, and diversity in the ground is different from one’s own (Center for treatment process. Treatment will help clients Substance Abuse Treatment [CSAT] 1999b). address their own biases, which can affect Nonetheless, cultural competence literature their perspectives and subsequent relationships highlights how difficult it is to appreciate with other clients, staff members, and individ- cultural differences and to address these dif- uals outside of the program, including other ferences effectively, because many people tend people in recovery. Culturally responsive to see things solely from their own culture- services prepare clients not only to embrace bound perspectives. For counselors, specific their own cultural groups and life experiences, cognitions, attitudes, and behaviors character- but to acknowledge and respect the experienc- ize the path to culturally competent counsel- es, perspectives, and diversity of others. ing and culturally responsive services. Exhibit How Is Cultural 1-2 depicts the continuum of thoughts and behaviors that lead to cultural competence in Competence Achieved? the provision of treatment. The “stages” are not necessarily linear, and not all people begin Cultural groups are diverse and continuously with a negative impression of other cultural evolving, defying precise definitions. Cultural groups—they may simply fail to recognize competence is not acquired merely by learning differences and diverse ways of being. For a given set of facts about specific populations,

9 Improving Cultural Competence

Exhibit 1-2: The Continuum of Cultural Competence

Stage 1: Cultural Destructiveness

Organizational Level: At best, the behavioral health organization negates the relevance of culture in the delivery of behavioral health services. Agencies expect individuals from diverse ethnic and cultural backgrounds to fit into the existing treatment program rather than adapting the program to each client to provide culturally congruent services. Driving this expectation is the attitude that mainstream culture and current services are superior and that other approaches (e.g., Native American traditional healing practices) need not be considered. Organizations can also take a more adversarial role at this level—failing to provide basic services, creating an uncomfortable environment to covertly discourage the use of services, or expecting the individual to leave culture at the door.

Individual Level: Counselors can also operate from this stance, holding a myopic view of “effective” treatment. However, it would likely be difficult to operate at this level as a counselor without organiza- tional endorsement. Counselors can project superiority by stating with authority and conviction in sessions that their approach is the best and expressing directly to clients that they should be grateful to receive these services. At the same time, these counselors filter interactions through a biased lens without engaging in self-reflection or examination of the impact of their prejudice. Stage 2: Cultural Incapacity Organizational Level: Due to lack of organizational responsiveness, services and may be biased, and clients may view them as oppressive. An agency functioning at cultural incapacity expects clients from diverse backgrounds to conform to services rather than the agency being flexible and adapting services to meet client needs. Treatment of diverse individuals is often paternalistic, limiting their active participation in treatment planning or minimizing the need for culturally congruent treatment services. Individual Level: Counselors ignore the relevance of culture while using the dominant client popula- tion and/or culture as the norm for assessment, treatment planning, and determination of services. At this level, counselors can be aware of the need to approach treatment differently but likely believe that they are powerless over circumstances or the organizational system. Stage 3: Cultural Blindness Organizational Level: The core belief that perpetuates cultural blindness is the assumption that all cultural groups are alike and have similar experiences. Taking the position that individuals across cultural groups are more alike than different, organizations can rationalize that “good” treatment services will suffice for all clients regardless of ethnicity, race, religion, sexual orientation, national origin, or class. Consequently, organizations that operate at this level will continue developing and implementing policies and procedures that propagate discrimination. Individual Level: At this stage, counselors uphold the belief that there are no essential differences among individuals across cultural groups—that everyone experiences discrimination and is to the biases of others. Counselors rationalize that approaching all clients as individuals negates the need to focus specifically on cultural competence. For example, some counselors may believe that there is (Continued on the next page.)

10 Chapter 1—Introduction to Cultural Competence

Exhibit 1-2: The Continuum of Cultural Competence (continued)

too much focus on cultural competence and that training in this area has become the “pop culture” in the counseling field, or they may feel that too much time is spent on cultural issues when a good assessment addressing individual issues and needs would suffice. Stage 4: Cultural Precompetence Organizational Level: Organizations at this stage begin to develop a basic understanding of and appreciation for the importance of sociocultural factors in the delivery of care. Similar to the prepara- tion stage identified in the stages of change model (Prochaska et al. 1992; Miller and Rollnick 2013), this level involves recognition of the need for more culturally responsive services, further exploration of steps toward creating more appropriate services for culturally diverse populations, and a general commitment characterized by small organizational changes. Despite having incomplete knowledge, agencies at this stage can evolve toward organizational cultural competence with support, planning, and commitment from the governing and advisory boards, community, and administrators. Individual Level: Counselors acknowledge a need for more training specific to the populations they serve at this level of development. They acknowledge the need to attend more to ethnicity, race, and culture in the provision of services, but they probably lack the information and skills necessary to translate their recognition into behavioral change. Even so, they are open to training, recognize the importance of developing cultural competence, and have taken small steps to improve their clinical knowledge. Stage 5: Cultural Competence and Proficiency Organizational Level: Organizations are aware of the importance of integrating services that are congruent with diverse populations. Organizations understand that a commitment to cultural compe- tence begins with strategic planning to conduct an organizational self-assessment and adopt a cultural competence plan. There is a willingness to be more transparent in evaluating current services and practices and in developing policies and practices that meet the diverse needs of the treatment popu- lation and the community at large. Proficiency on an organizational level is characterized by an ongo- ing commitment to workforce development, training, and evaluation; development of culturally specific and congruent services; and continual performance evaluation and improvement. Individual Level: Recognition of the vital need to adopt culturally responsive practices is present. Counselors acknowledge significant differences across and within races, ethnicities, and cultural groups, and they know that these differences need to be integrated into assessment, treatment plan- ning, and services. At this stage, counselors are committed to an ongoing process of becoming cultur- ally competent. Sources: Comas-Diaz 2012; Cross et al. 1989; Sue and Constantine 2005. most people, the process of becoming cultural- and values concerning the nature of relation- ly competent is complex, with movement back ships, the way people live their lives, and the and forth along the continuum and with way people organize their environments. feelings and thoughts from more than one Culture is a complex and rich concept. Under- stage sometimes existing concurrently. standing it requires a willingness to examine and grasp its many elements and to compre- What Is Culture? hend how they come together. Castro (1998) identified the elements generally agreed to Culture is defined by a community or society. constitute a culture as: It structures the way people view the world. It • A common heritage and history that is involves the particular set of beliefs, norms, passed from one to the next.

11 Improving Cultural Competence

• Shared values, beliefs, customs, behaviors, more or less equally well to cultural groups traditions, institutions, arts, , and based on , ethnicity, region (e.g., lifestyle. Southern, Midwestern), profession, and social • Similar relationship and interests (Exhibit 1-3 reviews common char- patterns. acteristics of culture). • A common pattern or style of communica- However, culture is not a definable entity to tion or language. which people belong or do not belong. Within • Geographic location of residence (e.g., a nation, race, or community, people belong to country; community; urban, suburban, or multiple cultural groups, each with its own set rural location). of cultural norms (i.e., spoken or unspoken • Patterns of dress and diet. rules or standards that indicate whether a Although these criteria cannot be strictly certain behavior, attitude, or belief is appropri- applied to every cultural group, they do suffi- ate or inappropriate). ciently define cultures so that groups are distinguishable to their members and to others The word “culture” can be applied to describe (Castro 1998). Note that these criteria apply the ways of life of groups formed on the bases

Exhibit 1-3: Common Characteristics of Culture

The following list provides examples of common elements that distinguish one culture from another. Not every cultural group will define or endorse every item on this list, but most cultural groups will uphold the most common characteristics, which include: • Identity development (multiple identities and self-concept). • Rites of passage (rituals and rites that mark specific developmental milestones). • Broad role of sex and sexuality. • Images, symbols, and . • Religion and . • View, use, and sources of power and authority. • Role and use of language (direct or implied). • Ceremonies, celebrations, and traditions. • Learning modalities, acquisition of knowledge and skills. • Patterns of interpersonal interaction (culturally idiosyncratic behaviors). • Assumptions, prejudices, , and expectations of others. • Reward or status systems (meaning of success, role models, or heroes). • Migration patterns and geographic location. • Concepts of sanction and punishment. • Social groupings (support networks, external relationships, and organizational structures). • Perspectives on the role and status of children and families. • Patterns and perspectives on gender roles and relationships. • Means of establishing trust, credibility, and (appropriate protocols). • Coping behaviors and strategies for mediating conflict or solving problems. • Sources for acquiring and validating information, attitudes, and beliefs. • View of the past and future, and the group’s or individual’s sense of place in society and the world. • History and other past circumstances that have contributed to a group’s current economic, social, and political status within the broader culture as well as the experiences associated with developing certain beliefs, norms, and values.

Sources: American Psychological Association (APA) 1990; Center for Substance Abuse Prevention 1994; Charon 2004; Dogra and Karim 2010.

12 Chapter 1—Introduction to Cultural Competence

of age, profession, socioeconomic status, disa- American Indian/ Native, and Native bility, sexual orientation, geographic location, Hawaiian/Pacific Islander—are limiting in membership in self-help support groups, and that they are categories developed to describe so forth. In this TIP, with the exception of the identifiable populations that exist currently drug culture, the focus is on cultural groups within the United States. The U.S. Census that are shaped by a dynamic interplay among defines Hispanics/Latinos as an ethnic group specific factors that shape a person’s identity, rather than a racial group (see the “What Is including race, ethnicity, religion, socioeco- Ethnicity?” section later in this chapter). nomic status, and others. Racial labels do not always have meaning What Is Race? in other parts of the world; how one’s race is defined can change according to one’s current Race is often thought to be based on genetic environment or society. A person viewed as traits (e.g., skin color), but there is no reliable Black in the United States can possibly be means of identifying race based on genetic viewed as White in Africa. Racial categories information (HHS 2001). Indeed, 85 percent also do not easily account for the complexity of human genetic diversity is found within any of multiracial identities. An estimated 3 per- “racial” group (Barbujani et al. 1997). Thus, cent of United States residents (9 million what we perceive as diverse races (based largely individuals) indicated in the 2010 Census that on selective physical characteristics, such as they are of more than one race (Humes et al. skin color) are much more genetically similar 2011). The percentage of the total United than they are different. Moreover, physical States population who identify as being of characteristics ascribed to a particular racial mixed race is expected to grow significantly in group can also appear in people who are not in coming years, and some estimate that it will that group. Asians, for example, often have an rise as high as one in five individuals by 2050 epicanthic eye fold, but this characteristic is (Lee and Bean 2004). also shared by the Kung San bushmen, an White Americans constitute the largest racial African nomadic (HHS 2001). group in the United States. In the 2010 Although it lacks a genetic basis, the concept Census, 72 percent of the United States popu- of race is important in discussing cultural lation consisted of non-Hispanic Whites, a competence. Race is a social construct that classification that has been used by the Census describes people with shared physical charac- Bureau and others to refer to non-Hispanic teristics. It can have tremendous social signifi- people of European, North African, or Middle cance in terms of behavioral health services, Eastern descent (Humes et al. 2011). The U.S. social opportunities, status, , and so on. Census Bureau predicts, however, that White The that people who share physical Americans will be outnumbered by of characteristics also share beliefs, values, atti- color sometime between the years 2030 and tudes, and ways of being can have a profound 2050. The primary reasons for the decreasing impact on people’s lives regardless of whether proportion of White Americans are immigra- they identify with the race to which they are tion patterns and lower birth rates among ascribed by themselves or others. The major Whites relative to Americans of other racial racial groupings designated by the U.S. Census backgrounds (Sue and Sue 2003b). Bureau—African American or Black, White Whites are often referred to collectively as American or Caucasian, Asian American, Caucasians, although technically, the term

13 Improving Cultural Competence

refers to a subgroup of from the The racial category of Asian is defined by the region of Eastern and West U.S. Census Bureau (2001a) as people “having . To complicate matters, some Caucasian origins in any of the original of the people—notably some Asian Indians—are Far , , or the Indian sub- typically counted as Asian (U.S. Census continent including, for example, Cambodia, Bureau 2001a). Many subgroups of White , , Japan, Korea, , , Americans (of European, Middle Eastern, or the Philippine Islands, , and Vietnam” North African descent) have had very differ- (p. A-3). In the 2010 census, Asian Americans ent experiences when immigrating to the accounted for 4.8 percent of the total United United States. States population, or 5.6 percent when biracial or multiracial Asians were included (Hoeffel African Americans, or Blacks, are the second et al. 2012). For those who identified with largest racial group in the United States, mak- only one Asian group, 23 percent of Asian ing up about 13 percent of the United States Americans were Chinese; 19 percent, Asian population in 2010 (Humes et al. 2011). Indian; 17 percent, Filipino; 11 percent, Although most African Americans trace their Vietnamese; 10 percent, Korean; and 5 per- roots to Africans brought to the as cent, Japanese. Asian Americans comprised slaves centuries ago, an increasing number are about 43 ethnic subgroups, speaking more new immigrants from Africa and the Caribbe- than 100 languages and dialects (HHS 2001). an. The terms African American and Black The tremendous cultural differences among are used synonymously at times in literature these groups make generalizations difficult. and research, but some recent immigrants do not consider themselves to be African Until recently, Asian Americans were often Americans, assuming that the designation grouped with Pacific Islanders (collectively only applies to people of African descent born called Asians and Pacific Islanders, or APIs) in the United States. The racial designation for data and analysis. Beginning Black, however, encompasses a multitude of with the 2000 Census, however, the Federal cultural and ethnic variations and identities Government recognized Pacific Islanders as a (e.g., African Caribbean, African Bermudian, distinct racial group. As a result, this TIP does West African, etc.). The history and experi- not combine Asians with Pacific Islanders. ence of African Americans has varied consid- Nonetheless, remnants of the old classification erably in different parts of the United States, system are evident in research based on the and the experience of in this API grouping. Where possible, the TIP uses country varies even more when the culture and data solely for Asians; however, in some cases, history of more recent immigrants is consid- the only research available is for the combined ered. Today, African American culture embod- API grouping. ies elements of Caribbean, Latin American, Native American is a term that describes both European, and African cultural groups. Not- American Indians and . Racially, ing this diversity, Brisbane (1998) observed Native Americans are related to Asian peoples that “these cultures are so unique that practices (notably, those from Siberia in ), but of some African Americans may not be un- they are considered a distinct racial category derstood by other African Americans…there by the U.S. Census Bureau, which further is no one culture to which all African stipulates that people categorized in this Americans…belong” (p. 2). fashion have to have a “Tribal affiliation

14 Chapter 1—Introduction to Cultural Competence

or community attachment” (U.S. Census Bu- Ethnicity differs from race in that groups of reau 2001a, p. A-3). There are 566 federally people can share a common racial ancestry recognized American Indian or Alaska Native yet have very different ethnic identities. Tribal entities (U.S. Department of the Interior, Thus, by definition, ethnicity—unlike race— Indian 2013a), but there are numerous is an explicitly cultural phenomenon. It is other recognized only by States and based on a shared cultural or family herit- others that go unrecognized by any govern- age as well as shared values and beliefs ment agency. These Tribes, despite sharing a rather than shared physical characteristics. racial background, represent a widely diverse group of cultures with diverse languages, foreign-born population (Larsen 2004; , histories, beliefs, and practices. Ramirez and de la Cruz 2003). Foreign-born Latinos include legal immigrants, some of What Is Ethnicity? whom have succeeded in becoming natural- ized American citizens, as well as undocu- The term ethnicity is sometimes used inter- mented or illegal immigrants to the United changeably with “race,” although it is im- States. Approximately three-quarters (74 portant to draw distinctions between the two. percent) of the Nation’s unauthorized immi- According to Yang (2000), ethnicity refers to grant population are Hispanics, mostly from the social identity and mutual sense of belong- (Passel and Cohn 2008). ing that defines a group of people through common historical or family origins, beliefs, The terms “Hispanic” and “Latino” refer to and standards of behavior (i.e., culture). In people whose cultural origins are in or some cases, ethnicity also refers to identifica- Portugal or the countries of the tion with a or group whose identity can Hemisphere whose culture is significantly be based on race as well as culture. Some influenced by Spanish or Portuguese coloniza- Latinos, for example, self-identify in terms of tion. Regional and political differences exist both their ethnicity (e.g., their Cuban herit- among various groups as to whether they age) and their race (e.g., whether they are dark prefer one term over the other. The literature or light skinned). currently uses both terms interchangeably, as both terms are widely used and refer generally Because Latinos can belong to a number of to the same Latin-heritage population of the races, the Census Bureau defines them as an United States. That said, a distinction can ethnic group rather than a race. In 2010, technically be drawn between Hispanic (liter- Latinos comprised 16 percent of the United ally meaning people from Spain or its former States population (Ennis et al. 2011). They are colonies) and Latino (which refers to persons the fastest growing ethnic group in the United whose origins lie in countries ranging from States; between 2000 and 2010, the number of Mexico to Central and South America and Latinos in the country increased 43 percent, a the Caribbean, which were colonized by rate nearly four times higher than that for the Spain, and including Portugal and its former total population (Ennis et al. 2011). By 2050, colonies as well). For that reason, this TIP uses Latinos are expected to make up 29 percent of the more inclusive term Latino, except when the total population (Passel and Cohn 2008). research specifically indicates the other. The Nearly 60 percent of Latino Americans were term Latinas is used to refer specifically to born in the United States, but Latinos also women who are a part of this cultural group. account for more than half of the nation’s

15 Improving Cultural Competence

Within a racial group (e.g., Asian, White, can be more important than ethnic culture in Black, Native American), there are many defining their sense of identity. The section diverse ethnicities, and these diverse ethnici- that follows provides more detailed infor- ties often reflect vast differences in cultural mation on the most important cross-cutting histories. The White -Saxon Protestant factors involved in the creation of a person’s peoples of England and Northern Europe cultural identity. have, for example, many differing cultural attributes and a very different history in the What Are the Cross- United States than the Mediterranean peoples Cutting Factors in Race, of Southern Europe (e.g., Italians, ). Ethnicity, and Culture? What Is Cultural Identity? Language and Communication Cultural identity describes an individual’s Language is a key element of culture, but affiliation or identification with a particular speaking the same language does not neces- group or groups. Cultural identity arises sarily mean that people share the same cultural through the interaction of individuals and beliefs. For example, English is spoken in culture(s) over the life cycle. Cultural identities , , , India, Belize, and are not static; they develop and change across , among other countries. Even within stages of the life cycle. People reevaluate their the United States, people from different re- cultural identities and sometimes resist, rebel, gions can have diverse cultural identities even or reformulate them over time. All people, though they speak the same language. Con- regardless of race or ethnicity, develop a cul- versely, those who share an ethnicity do not tural identity (Helms 1995). Cultural identity automatically share a language. Families who is not consistent even among people who immigrated to this country several identify with the same culture. Two Korean earlier may identify with their culture of origin immigrants could both identify strongly with but no longer be able to speak its language. Korean culture but embrace or reject different English is the most common language in the elements of that culture based on their par- United States, but 18 percent of the total ticular life experiences (e.g., being raised in an population report speaking a language other urban or rural community, belonging to a than English at (Shin and Bruno 2003). lower- or upper-class family). Cultural groups may also place different levels of importance Styles of communication and nonverbal meth- on various aspects of cultural identities. In ods of communication are also important addition, individuals can hold two or more aspects of cultural groups. Issues such as the cultural identities simultaneously. use of direct versus indirect communication, appropriate personal space, social parameters Some of the factors that are likely to vary for and displays of physical contact, use of among members of the same culture include silence, preferred ways of moving, meaning of socioeconomic status, geographic location, gestures, degree to which arguments and gender, education level, occupational status, verbal confrontations are acceptable, degree of sexuality, and political and religious affiliation. formality expected in communication, and For individuals whose families are highly amount of eye contact expected are all cultur- acculturated, some of these characteristics ally defined and reflect very basic ethnic and (e.g., geographic location, occupation, religion) cultural differences (Comas-Diaz 2012;

16 Chapter 1—Introduction to Cultural Competence

Franks 2000; Sue 2001). More specifically, the Americans (Franks 2000). Thus, African relative importance of nonverbal messages Americans typically rely to a greater degree varies greatly from culture to culture; high- than White Americans on nonverbal cues in context cultural groups place greater im- communicating. Conversely, White American portance on nonverbal cues and the context of culture is low context (as are some European verbal messages than do low-context cultural cultural groups, such as German and British); groups (Hall 1976). For example, most Asian communication is expected to be explicit, and Americans come from high-context cultural formal information is conveyed primarily groups in which sensitive messages are encod- through the literal content of spoken or writ- ed carefully to avoid giving offense. ten messages. A behavioral health service provider who lis- Geographic Location tens only to the literal meaning of words can Cultural groups form within communities and clients’ actual messages. What is left un- among people who interact meaningfully with said, or the way in which something is said, each other. Although one can speak of a na- can be more important than the words used to tional culture, the fact is that any culture is convey the message. African Americans have subject to local adaptations. Local norms or a relatively high-context culture compared community rules can significantly affect a with White Americans but a somewhat culture. Thus, it is important for providers to lower-context culture compared with Asian be familiar with the local cultural groups they

Advice to Counselors: Cultural Differences in Communication

The following examples provide broad descriptions that do not necessarily fit all cultural groups from a specific racial or ethnic group. Counselors should avoid assuming that a client has a particular expectation or expression of nonverbal and verbal communication based solely on race, ethnicity, or cultural heritage. For example, a counselor could make an assumption during an interview that a Native American client prefers a nondirective counseling style coupled with long periods of silence, whereas the client expects a more direct, active, goal-oriented approach. Counselors should be knowledgeable and remain open to differences in communication patterns that can be present when counseling others from diverse backgrounds. The following are some examples of general differ- ences among cultural groups: • Individuals from many White/European cultural groups can be uncomfortable with extended silences and can believe them to indicate that nothing is being accomplished (Franks et al. 2000), whereas Native Americans, who often place great emphasis on the value of listening, can find extended silences appropriate for gathering thoughts or showing that they are open to another’s words (Coyhis 2000). • Latinos often value personalismo (i.e., warm, genuine communication) in interpersonal relations and value personal rapport in business dealings; they prefer personal relationships to formal ones (Barón 2000; Castro et al. 1999a). Many Latinos also initially engage in plática (small talk) to evaluate the relationship and often use plática prior to disclosing more personal information or addressing serious issues (Comas-Diaz 2012). On the other hand, Asian Americans can be put off by a communication style that is too personal or emotional, and some may lack confidence in a professional whose communication style is too personal (Lee and Mock 2005a). • Some cultural groups are more comfortable with a high degree of verbal confrontation and argument; others stress balance and harmony in relationships and shun confrontation. For some, forceful, direct communication can seem rude or disrespectful. In many Native American and Latino cultural groups, cooperation and (simpatía) is valued. Members often avoid disagreement, contradiction, and disharmony within the group (Sue and Sue 2013a).

17 Improving Cultural Competence

encounter—to not think, for example, in terms (Schoeneberger et al. 2006). Even among of a homogeneous Mexican culture so much as members of the same culture, less substance the Mexican , CA, or use is observed in those who live in more rural the Mexican culture of El Paso, TX. regions. For example, O’Connell and associ- ates (2005) found that alcohol consumption Geographical factors can also have a signifi- was lower for American Indians living on cant effect on a client’s culture. For example, reservations than for those who were geo- clients coming from a rural area—even if they graphically dispersed (and typically living in come from different ethnicities—can have a urban areas). Likewise, individuals born or great deal in common, whereas individuals living in urban areas may be at greater risk for from the same ethnicity who were raised in serious mental illness. In one systematic study, different geographic locales can have very higher distribution rates of were different experiences and, consequently, atti- found in urban areas, particularly among tudes. For example, although the vast majority people who were born in metropolitan areas of Asian Americans live in urban areas (95 (McGrath et al. 2004). percent in 2002; Reeves and Bennett 2003), a particular Asian American client may have Worldview, Values, and Traditions been born in a rural community or come from There are many ways of conceptualizing how a culture (e.g., the Hmong) that developed in culture influences an individual. Culture can remote areas; the client may retain cultural be seen as a frame through which one looks at values and interests that reflect those origins. the world, as a repertoire of beliefs and prac- Other clients who currently live in cities may tices that can be used as needed, as a narrative still consider a rural locale as their home and or story explaining who people are and why regularly return to it. Many Native Americans they do what they do, as a set of institutions who live in urban areas or in communities defining different aspects of values and tradi- adjacent to reservations, for example, travel tions, as a series of boundaries that use values regularly back to their home reservations and traditions to delineate one group of people (Cornell and Kalt 2010; Lobo 2003). from another, and so on. According to Lamont In addition to its potential influence upon and Small (2008), such schemata recognize culture, geography can strongly affect sub- that culture shapes what people believe (i.e., stance use and abuse, mental health and well- their values and worldviews) and what they do being, and access to and use of health services to demonstrate their beliefs (i.e., their tradi- (Baicker et al. 2005). In the Substance Abuse tions and practices). Cultural groups define and Mental Health Services Administration’s the values, worldviews, and traditions of their (SAMHSA’s) 2012 National Survey on Drug members—from food preferences to appropri- Use and Health (NSDUH), past-month illicit ate leisure activities—including use of alcohol drug use rates among individuals ages 12 and and/or drugs (Bhugra and Becker 2005). Thus, older were 9.9 percent in large metropolitan it is impossible to review and summarize the areas, 8.3 percent in nonmetropolitan urban- variety of cultural values, traditions, and ized areas, 5.9 percent in less urbanized non- worldviews found in the United States in this metropolitan areas, and 4.8 percent in rural publication. Providers are encouraged to areas (SAMHSA 2013d). In very rural or speak with their clients to learn about their remote areas, illicit drug use is likely to be worldviews, values, and traditions and to seek even less common than in rural areas training and consultation to gain specific

18 Chapter 1—Introduction to Cultural Competence

knowledge about clients’ cultural beliefs and therapy appear in TIP 39, Substance Abuse practices. Treatment and (CSAT 2004b). Family and Gender Roles Although families are important in all cultural Gender roles are largely cultural constructs; groups, concepts of and attitudes toward diverse cultural groups have different under- family are culturally defined and can vary in a standings of the proper roles, attitudes, and number of ways, including the relative im- behaviors for men and women. Even within portance of particular family ties, the family’s modern American society, there are variations inclusiveness, how hierarchical the family is, in how cultural groups respond to gender and how family roles and behaviors are de- norms. For example, after controlling for fined (McGoldrick et al. 2005). In some cul- income and education, African American tural groups (e.g., White Americans of Western women are less accepting than White European descent, such as German, English), American women of traditional American family is limited to the , where- gender stereotypes regarding public behavior as in other groups (e.g., African Americans; but more accepting of traditional domestic Asian Americans; Native Americans; White gender roles (Dugger 1991; Haynes 2000). Americans of Southern European descent, such Culturally defined gender roles also appear to as Italian, Greek), the idea of family typically have a strong effect on substance use and includes many other blood or marital relations abuse. This can perhaps be seen most clearly (Almeida 2005; Hines and Boyd-Franklin in international research indicating that, in 2005; Marinangeli 2001; McGill and Pearce with more egalitarian relationships 2005; McGoldrick et al. 2005). Some cultural between men and women, women typically groups clearly define roles for different family consume more alcohol and have drinking members and carefully prescribe methods of patterns more closely resembling those of men behaving toward one another based on specific in the society (Bloomfield et al. 2006). A relationships. For example, in Korean culture, similar effect can be seen in research conduct- are expected to defer to their in- ed in the United States with Latino men and about many decisions (Kim and Ryu 2005). women with varying levels of acculturation to Even in cultural groups with carefully defined mainstream American society (Markides et al. roles and rules for family members, family 2012; Zemore 2005). dynamics may change as the result of internal The terms for and definitions of gender roles or external forces. The process of accultura- can also vary. For example, in Latino cultural tion, for instance, can significantly affect groups, importance is placed on machismo (the family roles and dynamics among immigrant belief that men must be strong and protect families, causing the dissolution of longstand- their families), caballerismo (men’s emotional ing cultural hierarchies and traditions within connectedness), and marianismo (the idea that the family and resulting in conflict between women should be self-sacrificing, endure or different generations of the family suffering for the sake of their families, and (Hernandez 2005; Juang et al. 2012; Lee and defer to their ) (Arciniega et al. 2008; Mock 2005a). Information on family therapy Torres et al. 2002). These strong gender roles with major ethnic/racial groups is provided in have benefits in Latino culture, such as simpli- Chapter 5 of this TIP. Details of the role of fying and clarifying roles and responsibilities, family in treatment and the provision of family

19 Improving Cultural Competence

but they are also sources of potential problems, Treatment: Addressing the Specific Needs of such as limiting help-seeking behavior or the Women (CSAT 2009c), and TIP 56, Addressing identification of difficulties. For example, the Specific Behavioral Health Needs of Men because of the need to appear in control, a (SAMHSA 2013a). TIP 42, Substance Abuse Latino man can have difficulty admitting that Treatment for Persons With Co-Occurring his substance use is out of control or that he is Disorders, addresses the relationships among experiencing psychological distress (Castro et gender, mental illness, and substance use al. 1999a). For Latinas, the difficulties of disorders (CSAT 2005d). negotiating traditional gender roles while encountering new values through accultura- Socioeconomic Status and tion can lead to increased substance use/abuse Education and mental distress (Gil and Vazquez 1996; Sociologists often discuss social class as an Gloria and Peregoy 1996; Mora 2002). important aspect in defining an individual’s Negotiating gender roles in a treatment set- cultural background. In this TIP, socioeco- ting is often difficult; providers should not nomic status (SES) is used as a category simi- assume that a client’s traditional culture-based lar to class—the difference being that gender roles are best for him or her or that socioeconomic status is a more flexible and mainstream American ideas about gender are less hierarchically defined concept. SES in the most appropriate. The client’s degree of accul- United States is related to many factors, in- turation and adherence to traditional values cluding occupational prestige and education, must be taken into consideration and respect- yet it is primarily associated with income level. ed. Two TIPs explore the relationship of Thus, SES affects culture in several ways, gender to substance abuse and substance namely through a person’s ability to accumu- abuse treatment: TIP 51, Substance Abuse late material wealth, access opportunities, and

What Causes Health Disparities? The National Institutes of Health (NIH; 2012, Overview, p. 1) define health disparities as “differences in the incidence, prevalence, morbidity, and burden of diseases and other adverse health conditions that exist among specific population groups.” Numerous studies have found longstanding health disparities among racial/ethnic groups in the United States (Smedly et al. 2003), and the Agency for Healthcare Research and Quality (AHRQ) issues yearly reports that provide updates on this topic (AHRQ 2012). An Institute of Medicine report on disparities (Smedly et al. 2003) found multiple causes for these disparities, including historical inequalities that have influenced the healthcare system, persistent racial and ethnic discrimination, and distrust of the healthcare system among certain ethnic and racial groups. However, the most persistent and prominent cause appears to be disparities in SES, which affect insurance coverage and access to quality care (Russell 2011). These economic disparities account for significantly higher death rates, particularly among African Americans compared with non-Hispanic Whites (Arias 2010), as well as greater lack of insurance coverage or worse coverage for people of color (Smedly et al. 2003).

Evidence-based interventions to reduce health disparities are limited (Beach et al. 2006; Carpenter- Song et al. 2011). Current strategies generally focus on reducing risk factors that affect groups who experience a greater burden from poor health (Murray et al. 2006). The Federal Government has recognized the need to address health disparities and has made this issue a priority for agencies that deal with health care (HHS 2011b). As part of this effort, it has created the National Institute on Minority Health and Health Disparities (see http://ncmhd.nih.gov/). More specific information on mental health and substance abuse treatment disparities is provided in Chapter 5 of this TIP.

20 Chapter 1—Introduction to Cultural Competence

Social Determinants of Health Per Healthy People 2020 (http://www.healthypeople.gov), a federal prevention agenda involving a multiagency effort to identify preventable threats to health and set goals for reducing them, “social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” Social determinants include access to educational, economic, and vocational training; job oppor- tunities; transportation; healthcare services; emerging healthcare technologies; availability of communi- ty-based resources, basic resources to meet daily living needs, language services, and social support; exposure to ; social disorder; community and concentrated ; and residential segregation.

Source: Office of Disease Prevention and Health Promotion, HHS 2013. use resources. Discrimination and historical 2006; Room et al. 2003). However, other racism have led to lasting inequalities in SES factors, such as the availability of social sup- (Weller et al. 2012; Williams and Williams- port systems and education, as well as the Morris 2000). SES affects mental health and individual’s acculturation level, can also play a substance use. From 2005 to 2010, adults 45 role. Karriker-Jaffe and Zemore (2009) found through 64 years of age were five times more that, in immigrants, a greater level of accul- likely to have if they were poor turation was associated with increased heavy (National Center for Health Statistics 2012). drinking for those with above-average SES Serious mental illness among adults living in but not for those with lower SES. Besides poverty has a prevalence rate of 9.1 percent lower socioeconomic status, neighborhood (SAMHSA 2010). Some research demon- poverty (defined as having a high [≥20 per- strates higher risk for schizophrenia from cent] proportion of residents living in poverty) lower socioeconomic levels, but other studies was associated with and higher draw no definite conclusion (Murali and rates of substance-related problems, particu- Oyebode 2010). Most literature suggests that larly for men (McKinney et al. 2012). poverty and its consequences, including lim- Education is also an important factor related ited access to resources, increase stress and to SES (Exhibit 1-4). Higher levels of educa- vulnerability among individuals who may tion are associated with increased income, already be predisposed to mental illness. Of- although the degree to which education in- ten, theoretical discussions explaining a signif- creases income varies among diverse ra- icant relationship between mental illness and cial/ethnic groups (Crissey 2009). Research in SES suggest a bidirectional relationship in the United States has found that problems which stress from poverty leads to mental with alcohol are often associated with lower illness vulnerability and/or mental illness leads SES and lower levels of education (Crum to difficulty in maintaining employment and 2003; Mulia et al. 2008). However, other sufficient income. studies have shown that greater frequency of Studies have had conflicting results as to drinking and number of drinks consumed are whether people with high or low SES are generally associated with higher levels of more likely to abuse substances (Jones-Webb education and higher SES (Casswell et al. et al. 1995). In international studies, increases 2003; van Oers et al. 1999). For example, the in wealth on a societal level have been associ- 2012 NSDUH showed that adult rates of ated with increases in alcohol consumption past-month alcohol use increased with in- (Bergmark and Kuendig 2008; Kuntsche et al. creasing levels of education; among those with

21 Improving Cultural Competence

Exhibit 1-4: Education and Culture Culture has an effect on an individual’s attitudes toward education; for instance, a lack of cultural understanding on the part of educational institutions affects student goals and achievements (Sue 2001). A number of factors besides culture also appear to affect educational attainment, including immigration status and longstanding systemic biases. For example, 88 percent of the native-born United States population ages 25 and older had at least a high school degree in 2007, but only 68 percent who were foreign-born were high school graduates (Crissey 2009). Research also highlights large within-group differences in educational attainment. For example, among Asian Americans, who overall have high levels of education, some groups had very low rates—only 16 percent of and 5 percent of other Southeast Asian Americans had a college degree in 2000 (Reeves and Bennett 2003).

Immigration status does not always affect education status in the same way. For non-Latino Whites and Blacks, being born outside the United States is associated with a greater likelihood of obtaining at least a bachelor’s degree. African immigrants have the highest level of education of any immigrant group, higher than White or Asian immigrants (African Immigrant 2000).

less than a high school education, 36.6 percent when they come from diverse ethnic/racial were current drinkers, whereas 68.6 percent of backgrounds, typically share certain experienc- college graduates were current drinkers. es and expectations in common. Often, they (SAMHSA 2013d). Education can also affect encounter a difficult process of acculturation substance use independently of SES. For (as discussed throughout this chapter). They example, lower education levels seem to relate can also share concerns surrounding the re- to heavy drinking independently of socioeco- newal of visas, obtainment of citizenship, or nomic status (Kuntsche et al. 2006). fears of possible deportation depending on their legal status. Immigration itself is stressful The desperation associated with poverty and a for immigrants, though the reasons for mi- lack of opportunity—as well as the increased grating and the legal status of the immigrant exposure to illicit drugs that comes from living affect the degree of stress. For documented in a more impoverished environment—can residents, the process of adaptation tends to be also increase drug use (Bourgois 2003). Lower smoother than for those who are undocu- SES and the concurrent lack of either money mented. Undocumented persons may be wary or insurance to pay for treatment are associat- of deportation, are less likely to seek social ed with less access to substance abuse treat- services, and frequently encounter hostility ment and mental health services (Chow et al. (Padilla and Salgado de Snyder 1992). 2003). For example, compared with Medicare coverage, private insurance coverage increases Nonetheless, there are numerous variables that the odds twofold that someone who has a contribute to or influence well-being, quality will enter treatment of life, cultural adaptation, and the develop- (Schmidt and Weisner 2005). Thus, lower ment of resilience (e.g., the to mobi- SES can have a dramatic effect on recovery. lize social supports and bicultural integration; Castro and Murray 2010). Research suggests Immigration and Migration that immigrants may not experience higher With the exception of American Indians, rates of mental illness than nonimmigrants Alaska Natives, Native Hawaiians, and other (Alegria et al. 2006), yet immigration nearly Pacific Islanders, the United States is a coun- always includes separation from one’s family try of immigrants. Recent immigrants, even and culture and can involve a grieving process

22 Chapter 1—Introduction to Cultural Competence

The Cultural Orientation Resource higher rates than their parents or older mem- Center bers of the . Parental frustra- tion may occur if traditional standards of The Cultural Orientation Resource Center, funded by the U.S. Department of State’s behavior conflict with mainstream norms Bureau of Population, , and Migration, acquired by their children. The differences in is a useful resource for clinicians to gain infor- parents’ values and expectations and adoles- mation about topics including culture, reset- cents’ behavior can lead to distress in close- tlement experiences, and historical and knit immigrant families. This disruption, background information. This site is also quite useful for refugees. It provides refugee orienta- known as the acculturation gap, can result in tion materials and guidance in establishing increased – conflicts (APA 2012; housing, language, transportation, education, Falicov 2012; Telzer 2010). For some youth, it and community services, among other pressing may contribute to experimentation with alco- refugee concerns. hol and/or illicit drugs—increased accultura- tion is typically associated with increased as a result of these losses as well as other substance use and substance use disorders. changes, including changes in socioeconomic status, physical environment, social support, Overall, “old country” or traditional behavioral and cultural practices. norms and expectations for appropriate behav- ior become increasingly devalued in American Immigrants who are refugees from war, fam- majority culture for members of various immi- ine, oppression, and other dangerous environ- grant groups (Padilla and Salgado de Snyder ments are more vulnerable to psychological 1992; Sandhu and Malik 2001). Research distress (APA 2010). They are likely to have shows that family cohesion and adaptability left behind painful and often life-threatening decrease with time spent in the United States, situations in their countries of origin and can regardless of the amount of involvement in still bear the scars of these experiences. Some mainstream culture. This suggests that other refugees come to the United States with high factors may confound the relationship between expectations for improved living conditions, family conflict and increased exposure to only to find significant barriers to their full American culture (Smokowski et al. 2008). participation in American society (e.g., lan- guage barriers, discrimination, poverty). Expe- Advice to Counselors and Clinical riencing such traumatic conditions can also Supervisors: Initial Interview and increase substance use/abuse among some Assessment Questions groups of immigrants (see TIP 57, Trauma- When working with clients who are recent Informed Care in Behavioral Health Services immigrants or have immigrated to United States [SAMHSA 2014]). Behavioral health services during their lifetime, the APA (1990) recom- mends exploring: must assess the needs of refugee populations, • Number of generations in the United States. as the clinical issues for these populations may • Number of years in the United States. be considerably different than for immigrant • Fluency in English (or literacy). groups (Kaczorowski et al. 2011). • Extent (or lack) of family support. • Community resources. For immigrant families, disruption of roles • Level of education. and norms often occurs upon in the • Change in social status due to immigration. United States (for review, see Falicov 2012). • Extent of personal relationships with people from diverse cultural backgrounds. Generally, youth adopt American customs, Stress due to migration and acculturation. values, and behaviors much more easily and at

23 Improving Cultural Competence

Clients who are migrants (e.g., seasonal work- As a result, people may feel conflicted about ers) pose a particular set of challenges for their identities—wanting to fit in with the treatment providers because of the difficulties mainstream culture while also wanting to involved in connecting clients to treatment retain the values of their culture of origin. For programs and recovery communities. In the clients, sorting through these conflicting United States, migrant workers are considered cultural expectations and forging a comforta- one of most marginalized and underserved ble identity can be an important part of the populations (Bail et al. 2012). Migrants face recovery process. Some of the more commonly many logistical obstacles to treatment-seeking, used terms related to cultural identity are such as lack of childcare, insurance, access to defined in Exhibit 1-5. regular health care, and transportation (Hovey All immigrants undergo some acculturation 2001; Rosenbaum and Shin 2005). Current over time, but the rate of change varies from data are limited but suggest high rates of group to group, among individuals, and across alcohol use, alcohol use disor- ders, and binge drinking, often Exhibit 1-5: Cultural Identification and Cultural occurring as a response to Change Terminology stress or boredom associated Acculturation is the process whereby an individual from one with the migrant lifestyle cultural group learns and adopts elements of another cultural (Hovey 2001; Worby and group, integrating them into his or her original culture. Although Organista 2007). In addition, it can refer to any process of cultural integration, it is typically limited data on migrant men- used to describe the ways in which an immigrant or nonmajority tal health reflect mixed find- individual or group adopts cultural elements from the majority or mainstream culture, as the incentive is typically greater for accul- ings regarding increased risk turation to occur in this direction (see Lopez-Class et al. 2011 for for mental illness or psycho- a historical review of acculturation concepts). logical distress (Alderete et al. Assimilation is one outcome of acculturation. It involves the 2000). One factor associated complete of the ways of life of the new cultural group, with mental health status is resulting in the assimilated group losing nearly all of its original or the set of circumstances lead- native culture. ing up to the migrant worker’s Segmented assimilation describes a more complicated process decision to migrate for em- of assimilation whereby an immigrant group does not assimilate ployment (Grzywacz et al. entirely with mainstream culture but adopts aspects of other 2006). diverse cultural groups that are themselves outside mainstream culture (e.g., involvement in the drug culture; see Chapter 6 of Acculturation and this TIP and Portes et al. 2005). Cultural Identification Biculturalism occurs when an individual acquires the knowledge, skills, and identity of both his or her culture of origin and the Many factors contribute to an mainstream/majority culture and is equally (or nearly equally) individual’s cultural identity, capable of social and cultural interaction in both societies. and that identity is not a static attribute. There are many can denote a process whereby an individual adopts the culture that surrounds him or her (similar to acculturation), forces at work that pressure a but the term has more recently been used to describe the pro- person to alter his or her cess by which individuals come to value their native cultures and cultural identity to conform to begin to learn about and adopt their native cultural lifeways. the mainstream culture’s Sources: LaFromboise et al. 1993; Paniagua 1998; Portes et al. concept of a “proper” identity. 2005; Smokowski et al. 2008; Stone et al. 2006.

24 Chapter 1—Introduction to Cultural Competence

different periods of history. Earlier theories and with higher rates of substance use disor- suggested that immigrants generally assimilat- ders among White, Asian, and Latino immi- ed within three generations from the time of grants (Alegria et al. 2006; Grant et al. 2004a; immigration and that assimilation was associ- Grant et al. 2004b; Vega et al. 2004). Place of ated with socioeconomic gains. More recent birth is most strongly associated with higher scholarship suggests that this is changing rates of substance use and disorders thereof. among some cultural groups who may lack the For example, research suggests a rate of sub- financial or human capital necessary to suc- stance use disorders about three times higher ceed in mainstream society or who may find for born in the United that continued involvement in their native or States than for those born in Mexico (Alegria traditional culture has benefits that outweigh et al. 2008a; Escobar and Vega 2000). Asian those associated with acculturation (Portes et adolescents born in the United States present al. 2005; Portes and Rumbaut 2005). a higher rate of past-month alcohol use than Asian adolescents not born in the United Acculturation typically occurs at varying speeds States (8.7 versus 4.7 percent); however, the for different generations, even within the same rate of nonmedical use of prescription drugs is family. Acculturation can thus be a source of higher among Asian adolescents not born in conflict within families, especially when parents the United States than among those born in and children have different levels of accultura- the United States (2.7 versus 1.4 percent; tion (Exhibit 1-6) (Castro and Murray 2010; SAMHSA, Center for Behavioral Health Farver et al. 2002; Hernandez 2005). Others Statistics and Quality 2012). have suggested that acculturation can negative- ly affect mental health because it erodes tradi- Acculturation can increase substance tional family networks and/or because it results use/abuse, in part because the process of accul- in the loss of traditional culture, which other- turation is itself stressful (Berry 1998; Vega et wise would have a protective function (Escobar al. 2004). Mora (2002) asserts that the stress and Vega 2000; Sandhu and Malik 2001). associated with acculturation has a significant effect on increasing substance use and abuse Many studies have found that increased accul- among Latinas; this can be observed most turation or factors related to acculturation are clearly in the increases in substance use associ- associated with increased alcohol and drug use ated with being a second- or third-generation Exhibit 1-6: Five Levels of Acculturation Numerous models have been developed to explain the process of acculturation. Choney et al. (1995) proposed a model, applicable to a number of different contexts, that features five levels: 1. A traditional orientation: The individual is entirely oriented toward his or her native culture. 2. A transitional orientation: The individual is more oriented toward traditional culture but has some familiarity with mainstream culture. 3. A bicultural orientation: The individual is equally comfortable with and knowledgeable of both traditional and mainstream culture. 4. An assimilated orientation: The individual is mostly oriented toward mainstream culture but has some familiarity with the traditional/native culture. 5. A marginal orientation: The individual is not comfortable with either culture. Note: This is not a stage model in which a person naturally moves from one orientation to the next, nor does this model place greater value on one level versus another. The authors emphasize that each level of acculturation has strengths.

25 Improving Cultural Competence

Latina from an immigrant family. The stress equality in a society, the more similar alcohol associated with acculturation could also con- consumption patterns are for men and women tribute to rates of mental disorders and co- (Bloomfield et al. 2006). Many immigrants to occurring disorders (CODs), which are higher the United States (where gender equality is among more acculturated groups of immi- relatively strong) come from societies with less grants (Cherpitel et al. 2007; Escobar and gender equality and thus with greater prohibi- Vega 2000; Grant et al. 2004a; Organista et al. tions against alcohol use for women. 2003; Vega et al. 2009; Ward 2008). In fact, Karriker-Jaffe and Zemore (2009) found that American-born Latinos who have used sub- higher levels of acculturation are associated stances are three times more likely to have with increased alcohol consumption only CODs than foreign-born Latinos who have when combined with above-average SES (and used substances (Vega et al. 2009). Research not with lower SES), suggesting that income also suggests that acculturation could interact is another factor to consider when evaluating with factors such as culture or stress in in- the effect of acculturation on alcohol use. creasing mental disorders. There are exceptions to the idea that accul- Rates of substance use/abuse in the United turation increases substance use/abuse. Most States are among the highest in the world notably, immigrants coming from countries (United , Office on Drugs and Crime with unusually high levels of drinking do not 2008, 2012), so for many immigrants, adopt- necessarily experience a change in their use, ing mainstream American cultural values and and they may even consume less alcohol and lifestyles can also entail changing attitudes fewer drugs that they did in their native coun- toward substance use. As an example, Marin tries. Even among those born in the United (1998) found that, compared with Whites, States, however, data suggest that greater Mexican Americans expected significantly identification with one’s traditional culture has more negative consequences and fewer posi- a protective function. For example, in the tive ones from drinking, but Marin also found National Latino and Asian American Study, that the more acculturated the Mexican the largest national survey specifically target- American participants were, the more closely ing these population groups to date, greater their expectations resembled those of Whites. ethnic identification was associated with Other factors that can contribute to increased significantly lower rates of alcohol use disor- substance use among more acculturated clients ders among Asian Americans (Chae et al. include changes in traditional gender roles, 2008), and the use of Spanish with one’s exposure to socially and physically challenging family was linked with significantly lower inner-city environments (Amaro and Aguiar rates of alcohol use disorders in Latinos 1995), and employment outside the home (Canino et al. 2008). (often a role-transforming change that can Less research is available on the relationship of contribute to increased risk of alcohol depend- acculturation to substance use and substance ence). Although much of the research has use disorders among nonimmigrants, but some focused on the relationship of acculturation to data suggest that a lower level of identification male substance use/abuse patterns, women can with one’s native culture is linked with heavier, be even more affected by acculturation. Multi- lengthier substance use among American ple studies using international samples have Indians living on reservations (Herman-Stahl found that the greater the amount of gender et al. 2003). For some American Indians, more

26 Chapter 1—Introduction to Cultural Competence

involvement in Tribal culture and traditional the mainstream culture and retain the tradi- spiritual activities is associated with better tions and beliefs of their cultures of origin. For posttreatment outcomes for alcohol use disor- such clients, sorting through these conflicting ders (Stone et al. 2006). American Indians cultural expectations and forging a comforta- who drink heavily but live a traditional life- ble identity can be an important part of the style have better recovery outcomes than those recovery process. Familiarity with cultural who do not live a traditional lifestyle (Kunitz identity formation models and theories of et al. 1994). Likewise, African Americans may acculturation (including acculturation meas- have greater motivation for treatment if they urement methods; see Exhibit 1-7) can help recognize that they have a drug problem and behavioral health workers provide services also have a strong Afrocentric identity with greater flexibility and sensitivity (see (Longshore et al. 1998b). Strong cultural or Appendix B for instruments that measure racial/ethnic identity can have protective aspects of cultural identity and acculturation). features, whereas acculturation can lead to a loss of cultural identity that increases sub- Heritage and History stance abuse and contributes to poorer recov- A culture’s history and heritage explain the ery outcomes for both Native Americans and culture’s development through the actions of African Americans. members of that culture and also through the actions of others toward the specific culture. Overall, acculturation and cultural identifica- Providers should be knowledgeable about the tion have tremendous implications for behav- many positive aspects of each culture’s history ioral health services. Research has shown an and heritage and resourceful in learning how association between low levels of acculturation to integrate these into clinical practice. and low usage rates of mainstream healthcare services. Individuals can feel conflicted about Nearly all immigrant groups have experienced their identities—wanting to both fit in with some degree of trauma in leaving behind

Exhibit 1-7: Measuring Acculturation Acculturation is a construct that includes factors relating to behavior, knowledge, values, self- identification, and language use (Zea et al. 2003). One of the biggest problems in analyzing the effects of acculturation is determining how to define and evaluate it. In research literature, accultura- tion is inconsistently defined and measured. In some large-scale surveys, it is not defined at all, but only implied in other factors, such as length of stay in the United States, English language use, or place of birth. Overall, instruments that assess acculturation do not ask the same questions or ad- dress the same factors, thus making it unclear whether acculturation is truly being evaluated (Zane and Mak 2003). More research is warranted on how to conceptualize and evaluate acculturation and cultural identity.

Many acculturation tools focus on specific racial or ethnic groups (for example, see Wallace et al. 2010). Acculturation and cultural identity instruments typically ask questions about language use and preference (e.g., whether English is used at home), media preferences (e.g., preference for foreign language programming), social interactions (e.g., with persons from other ethnici- ties/cultural groups), cultural knowledge (e.g., knowledge of beliefs, traditions, and ceremonies specific to a cultural or ethnic group), and cultural values (Zea et al. 2003). Others evaluate accultura- tion simply by asking which culture a person identifies with most. Organista et al. (2003) and Zane and Mak (2003) reviewed measures designed to evaluate acculturation and cultural identity. Appendix B provides a sample of acculturation and cultural identity instruments.

27 Improving Cultural Competence

family members, friends, and/or familiar review in Williams and Williams-Morris places. Their eagerness to assimilate or remain 2000). separate depends greatly on the circumstances According to theories of historical trauma, the of their immigration (Castro and Murray traumas of the past continue to affect later 2010). Additionally, some immigrants are generations of a group of people. This concept refugees from war, famine, natural disasters, was first developed to explain how the trauma and/or persecution. The depths of suffering of the Holocaust continued to affect the de- that some clients have endured can result in scendants of survivors (Duran et al. 1998; multiple or confusing symptoms. For example, Sotero 2006). In the United States, it has a traumatized Congolese woman could speak perhaps been best explored in relation to the of hearing voices, and it could be unclear traumas endured by Native American peoples whether these voices suggest an issue requiring during the colonization and expansion of the spiritual healing within a , United States. One can extend this concept a traumatic stress reaction, or a mental disor- to other groups (e.g., African Americans, der involving the onset of auditory hallucina- Cambodians, Rwandans) who suffered trau- tions. Those who have watched close family matic events like or genocide. members die violently can have “survivor guilt” as well as agonizing memories. Amodeo et al. Among Native Americans in treatment for (1997) report that “somatic complaints, in- substance use and/or mental disorders, histori- cluding trouble sleeping, loss of appetite, cal trauma is an important clinical issue (Brave stomach pains, other bodily pains, headaches, Heart et al. 2011; Duran et al. 1998; Evans- fatigue or lack of , memory problems, Campbell 2008). Some research indicates that mood swings and social withdrawal have been thinking about historical loss or displaying reported to be among the refugees’ most fre- symptoms associated with historical trauma quent presenting problems” (p. 70). For an plays into increases in alcohol use disorders, overview of the impact of trauma, see TIP 57, other substance use, and lower family cohesion Trauma-Informed Care in Behavioral Health (Whitbeck et al. 2004; Wiechelt et al. 2012). Services (SAMHSA 2014). Brave Heart (1999) theorizes that historical traumas perpetuate their effects among Native Abueg and Chun (1998) caution, however, Americans by harming parenting skills and that “traumatic experience is not homogenous” increasing abuse of children, which creates a (p. 292). Experiences before, during, and after cyclical pattern—greater levels of mental and migration and/or encampment vary depending substance use disorders in the next generation on the country of origin as well as the time along with continued poor parenting skills. and motivation for migration. Within the Specifically, Libby et al. (2008) found that United States, cultural groups such as African substance use was involved in the intergenera- Americans and Native Americans have long tional transmission of trauma. Additional histories of traumatic events, which have had research highlights a relationship between lasting effects on the descendants of those elevated chronic trauma exposure and preva- who experienced the original trauma. Conse- lence of both mental and substance use disor- quently, past as well as present discrimination ders among large samples of American Indian and racism are related to a number of negative adults living on reservations (Beals et al. 2005; consequences across diverse populations, in- Manson et al. 2005). cluding lower SES, health disparities, and fewer employment and educational opportunities (see

28 Chapter 1—Introduction to Cultural Competence

Sotero (2006) reviews research on historical 2002). As a result of a lack of acceptance trauma across diverse populations and propos- within both mainstream and diverse eth- es a similar explanation of how deliberately nic/racial communities, various gay cultures perpetrated, large-scale traumatic events con- have developed in the United States. For some tinue affecting communities years after they individuals, gay culture provides an alternative occur. She argues that the generation that to their culture of origin, but unfortunately, directly experiences the trauma suffers material cultural pressures can make the individual feel (e.g., displacement), psychological (e.g., post- like he or she has to select which identity is traumatic stress disorder), economic (e.g., loss most important (Greene 1997). However, a of sources of income/sustenance), and cultural person can be, for example, both gay and (e.g., lost knowledge of traditions and beliefs) Latino without experiencing any conflicts effects. These lasting sequelae of trauma then about claiming both identities at the same affect the next generation, who can suffer in time. For more information on substance many similar ways, resulting in poorer coping abuse treatment for persons who identify as skills or in attempts to self-medicate distress gay, lesbian, or bisexual, refer to the CSAT through substance abuse. (2001) publication, A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Sexuality Bisexual, and Transgender Individuals. Attitudes toward sexuality in general and Heterosexual behaviors are carefully prescribed toward sexual identity or orientation are cul- by a culture. Typically, these prescriptions are turally defined. Each culture determines how determined based on gender; behaviors con- to conceptualize specific sexual behaviors, the sidered acceptable for men can be considered degree to which they accept same-sex relation- unacceptable for women and vice versa. In ships, and the types of sexual behaviors con- addition, cultures define the role of alcohol or sidered acceptable or not (Ahmad and Bhugra other substances in , sexual behaviors, 2010). In any cultural group, diverse views and and relationships (Room 1996). Other factors attitudes about appropriate gender norms and that can vary across cultural groups include the behavior can exist. For example, in some Latino appropriate age for sexual activity, the rituals cultural groups, homosexual behavior, espe- and actions surrounding sexual activity, the use cially among men, is not seen as an identity but of birth control, the level of secrecy or open- as a curable illness or immoral behavior (Kusnir ness related to sexual acts, the role of sex 2005). In some Latino cultural groups, self- workers, attitudes toward , identifying as other than heterosexual may and the level of sexual freedom in choosing provoke a more negative response than engag- partners. ing in some homosexual behaviors (de Korin and Petry 2005; Greene 1997; Kusnir 2005). Perspectives on Health, Illness, For individuals from various ethnic/racial and Healing groups in United States, having a sexual iden- Beliefs, attitudes, and behaviors related to tity different from the norm can result in health, illness, and healing vary across racial, increased substance use/abuse, in part because ethnic, and cultural groups. Many cultural of increased stress. Additionally, alcohol and groups hold views that differ significantly drug use can be more acceptable within some from those of Western medical practice and segments of gay/lesbian/bisexual cultures thus can affect treatment (Sussman 2004). The (Balsam et al. 2004; CSAT 2001; Mays et al. field of medical was developed,

29 Improving Cultural Competence

in part, to analyze these differences, and much describes cultural concepts of distress recog- has been written about the range of cultural nized by the DSM-5. Other specific examples beliefs concerning health and healing. In of cultural differences relating to the use of general, cultural groups differ in how they health care and alternative approaches to define and determine health and illness; who medical diagnosis and treatment are also is able to diagnosis and treat an illness; their presented in Chapter 5. beliefs about the causes of illness; and their remedies (including the use of Western medi- Religion and Spirituality cines), treatments, and healing practices for Religious traditions or spiritual beliefs are illness (Bhugra and Gupta 2010; Comas-Diaz often very important factors for defining an 2012). In addition, there are complex rules individual’s cultural background. In turn, about which members of a community or attention to religion and spirituality during family can make decisions about health care the course of treatment is one facet of cultur- across cultural groups (Sussman 2004). ally competent services (Whitley 2012). , , , and Buddhists In mainstream American society, healthcare (among others) can be members of any racial professionals are typically viewed as the only or ethnic group; in the same vein, people of ones who have real expertise about health and the same ethnicity who belong to different illness. However, other societies have different religions sometimes have less in common than views. For instance, among the Subanun peo- people of the same religion but different ple of the , all members of the ethnicities. In some cases, religious affiliation community learn about healing and diagnosis; is an especially important factor in defining a when an individual is , the diagnosis of his person’s culture. For instance, the American or her problem is an activity that involves the Religious Identification Survey reported that whole community (Frake 1961). Cultural 47 percent of the respondents who identified groups also differ in their understanding of the culturally as Jewish were not practicing Jews causes of illness, and many cultural groups (Kosmin et al. 2001). recognize a spiritual element in physical ill- ness. The Hmong, for example, believe that According to the American Religious Identifi- illness has a spiritual cause and that healing cation Survey (Kosmin and Keysar 2009), only may require shamans who communicate with 15 percent of Americans identified as not spirits to diagnose and treat an illness having a religion; of those, less than 2 percent (Fadiman 1997; Gensheimer 2006). identified as atheist or agnostic. In another survey from the Pew Forum on Religion and With respect to mental health, providers Public Life (2008), 1.6 percent of respondents should be aware that any or stated that they were atheist; 2.4 percent, symptom is only considered a disorder or agnostic; and 6.3 percent, secular and unaffili- problem by comparison with a socially defined ated with a religion. Many religions are prac- norm. For instance, in some societies, someone ticed in the United States today. This TIP who hears voices can be considered to have cannot cover them all in detail in. However, greater access to the spirit world and to be this TIP does briefly describe the four most blessed in some way. Furthermore, there are common (by size of self-identified member- mental disorders that only present in a specific ship) religious traditions. cultural group or locality; these are called cultural concepts of distress. Appendix E

30 Chapter 1—Introduction to Cultural Competence

Advice to Counselors: Spirituality, Religion, Substance Abuse, and Mental Illness For people in treatment and recovery, it can be especially important to distinguish between spirituali- ty and religion. For example, some clients are willing to think of themselves as spiritual but not necessarily religious. Religion is organized, with each religion having its own set of beliefs and prac- tices designed to organize and further its members’ spirituality. Spirituality, on the other hand, is typically conceived of as a personal matter involving an individual’s search for meaning; it does not require an affiliation with any religious group (Cook 2004). People can have spiritual experiences or develop their own spirituality outside of the context of an organized religion.

Spirituality often plays an important role in recovery from mental illness and substance abuse, and higher ratings of spirituality (using a variety of scales) have been associated with increased rates of abstinence (Laudet et al. 2006; Zemore and Kaskutas 2004). If substance abuse represents a lack of personal control, discipline, and order, then spirituality and religion can help counter this by provid- ing a sense of purpose, order, self-discipline, humility, serenity, and acceptance. In addition, spiritual- ity can help a person with mental illness gain a sense of meaning or purpose, develop inner strength, and learn acceptance and tolerance. Chappel (1998) maintains that the development of spirituality requires a concerted and consistent effort through such activities as prayer, meditation, discussion with others, reading, and participation in other spiritual activities. Counselors, he says, have an obli- gation to understand the role that spirituality can play in promoting and supporting recovery. The first step in this process is for counselors to learn about and respect clients’ beliefs; understanding the roles of religion and spirituality is one form of cultural competence (Whitley 2012).

Christianity has dispersed over time and exists in , in its various forms, remains the various geographic regions. The majority of predominant religion in the United States Jews in the United States would be considered today. According to Kosmin and Keysar White, but Ethiopian Jews (the Beta Israel) (2009), 76 percent of the population in 2008 and members of other African-Jewish com- identified as Christian, with the largest denom- munities would likely be seen as African ination being Catholics (25.1 percent), fol- Americans; the Jewish community from India lowed by (15.8 percent). Christianity (Bene Israel), as Asian Americans; and Jews encompasses a variety of denominations with who immigrated to the United States from different beliefs and attitudes toward issues , as Latinos. In 2001, approxi- such as alcohol and/or other substance use. mately 5 percent of people who identified as Most mainstream Christian religions support adherents to (the religion, as opposed behavioral health treatment, and many church- to people who identify as culturally Jewish) es serve as sites for self-help groups or for were Latinos, and approximately 1 percent Christian recovery programs. Some Christian were African Americans (Kosmin et al. 2001). sects, however, are not as amenable to sub- Regarding beliefs about and practices sur- stance abuse and mental health treatment as rounding substance use, there are no prohibi- others. tions against alcohol use (or other substance Judaism use) in Judaism, but rates of alcohol abuse and dependence are significantly lower for Jews Judaism is the second most common religion than for other populations (Bainwol and in the United States (1.2 percent of the popu- Gressard 1985; Straussner 2001). This could lation as of 2008; Kosmin and Keysar 2009). be partially attributable to , yet there is Most Jews believe that they share a common also a definite cultural component (Hasin et al. ancient background. However, the population 2002). Conversely, rates of use and abuse of

31 Improving Cultural Competence

other substances are about the same or slightly appear to have low rates of substance use higher for Jews in the United States compared disorders. Despite there being no current data with other populations (Straussner 2001). regarding levels of alcohol and other substance Because some Jewish people will feel uncom- use among Muslim immigrants in the United fortable in 12-Step groups that meet in States, Cochrane and Bal (1990) found that, in churches and are largely Christian in composi- a comparison of Sikh, Hindu, Muslim, and tion, mutual-help groups designed specifically White (probably Christian) men in a British for Jewish people have been developed. The community, Muslims by far drank the least, yet largest of these is Jewish Alcoholics, Chemi- those Muslims who consumed the most alco- cally Dependent Persons and Significant hol experienced a greater number of alcohol- Others (see http://www.jbfcs.org/programs- related problems on average. High levels of services/jewish-community-services-2/jacs/ alcohol consumption among Muslims who do for more information). Other Jewish people in drink could be related to feelings of guilt and recovery may prefer participating in secular shame about their behavior, thus potentially self-help programs (Straussner 2001). Most leading to further abuse and avoidance of Jewish people support behavioral health seeking substance abuse treatment when treatment. problems arise (Abudabbeh and Hamid 2001). In 2008, roughly 1.3 million people identified In 2008, about 1.2 million Buddhists were as Muslims in the United States, making it the living in the United States (Kosmin and third most common religion (Kosmin and Keysar 2009). In 2001, according to Kosmin et Keysar 2009). Many Americans assume that al (2001), the majority of Buddhists were all Arabs are Muslim, but the majority of Arab Asian Americans (61 percent), but a signifi- Americans are Christian; Muslims can come cant number of White Americans have em- from any ethnic background (Abudabbeh and braced the religion (they make up 32 percent Hamid 2001). Islam is the most ethnically of Buddhists in the United States), as have diverse religion in America, with a member- African Americans (4 percent) and Latinos (2 ship that is 15 percent White, 27 percent percent). In China and Japan, Buddhism is Black, 34 percent Asian, and 10 percent often combined with other religious tradi- Latino (Kosmin et al. 2001). tions, such as or Shintoism, and some immigrants from those countries combine the Attitudes of Muslims toward mental illness beliefs and practices of those religions with and seeking formal mental health services are Buddhism. likely to be affected by cultural and religious beliefs about mental health problems, Buddhists believe that the choices made in knowledge and familiarity with formal ser- each life create karma that influences the next vices, perceived societal prejudice, and the use life and can affect behavior (McLaughlin and of informal indigenous resources (Aloud Braun 1998). The Fifth Precept of Buddhism 2004). Attitudes toward substance use, abuse, is not to use intoxicating substances, and thus, and treatment will likely be shaped by Islam’s the expectation for devout believers is that prohibition of the use of alcohol and other they will not use alcohol or other substances of intoxicants. Many Muslim countries have abuse (Assanangkornchai et al. 2002). In the harsh penalties for the use of alcohol and United States, no specific substance abuse other drugs. For these reasons, Muslims treatment programs specialize in

32 Chapter 1—Introduction to Cultural Competence

Buddhist clients. Buddhist substance abuse within each group as well—there are cultures and mental health treatment programs do within cultures. Clinicians and organizations exist in other countries (e.g., Thailand) and need to develop skills to create an environ- report high outcome rates (70 percent) using ment that is responsive to the unique attrib- culturally specific practices (e.g., herbal sau- utes and experiences of each client, as outlined nas) and religious practices (Barrett 1997). earlier in this chapter in the “What Are the Cross-Cutting Factors in Race, Ethnicity, and As You Proceed Culture?” section. As you read this TIP, re- member that many cross-cutting factors influ- This chapter has established the foundation ence the counselor–client relationship, the and rationale of this TIP; reviewed the core client’s presentation and identification of concepts, models, and terminology of cultural problems, the selection and interpretation of competence; and provided an overview of screening and assessment tools, the client’s factors that are common among diverse racial, responsiveness to specific clinical services, and ethnic, and cultural groups. As you proceed, be the effectiveness of program delivery and aware that diversity occurs not only across organizational structure and planning. racially and ethnically diverse groups, but

33

Core Competencies for 2 Counselors and Other Clinical Staff

IN THIS CHAPTER Gil, a 40-year-old Mexican American man, lives in an upper mid- dle class neighborhood. He has been married for more than 15 • Core Counselor years to his high school sweetheart, a White American woman, and Competencies they have two children. Gil owns a fleet of street-sweeping • Self-Assessment for trucks—a business started by his -in- that Gil has - Individual Cultural panded considerably. Of late, Gil has been spending more time at Competence work. He has also been drinking more than usual and dabbling in

illicit drugs. As his drinking has increased, tensions between Gil and his have escalated. From Gil’s perspective and that of some family members and friends, Gil is just a hard-working guy who deserves to have a as a reward for a hard day’s work. Many people in his Mexican American community do not consid- er Gil’s low-level daily drinking a problem, especially because he drinks primarily at home. Recently, Gil had an accident while working on one of his trucks. The treating identified alcohol abuse as one of several health problems and referred him to a substance abuse treatment center. Gil attended, but argued all the while that he was not a borracho (drunkard) and did not need treatment. He distrusted the counselors, stating that seeking help from professionals for a men- tal disorder was something that only gabachos (Whites) did. Gil was proud of his capacity to “hold his liquor” and felt anger and hostili- ty toward those who encouraged him to reduce his drinking. Gil’s feelings and attitudes were valid; they stemmed from and were in- fluenced by the Mexican American culture and community in which he had been raised from infancy. Gil dropped out of treat- ment. When his wife threatened to him if he did not take immediate action to deal with his drinking problem, he reluctantly

35 Improving Cultural Competence

enrolled in an outpatient treatment program. assist client recovery. Gaining regard, respect, Gil, like all people, is a product of his envi- and trust from clients is crucial for successful ronment—an environment that has provided counseling outcomes (Ackerman and Hilsen- him with a rich cultural and spiritual back- roth 2003; Sue and Sue 2003a). ground, a strong male identity, a deep attach- Effective therapy is an ongoing process of ment to family and community, a strong work building relational bridges that engender trust ethic, and a sense of pride in being able to and confidence. Sensitivity to the client’s support his family. In many Mexican American cultural and personal perspectives, genuine cultural groups, illness disrupts family life, , warmth, humility, respect, and ac- work, and the ability to earn a living. Illness ceptance are the tenets of all sound therapy. has psychological costs as well, including This chapter expands on these concepts and threats to a man’s self-identity and sense of provides a general overview of the core com- manhood (Sobralske 2006). Given this back- petencies needed so that counselors may ground, Gil would understandably be reluctant provide effective treatment to diverse racial to enter treatment, to accept the fact that his and ethnic groups. Using Sue’s (2001) multi- drinking was a problem or an illness, and to dimensional model for developing cultural jeopardize his ability to care for his family and competence, the content focuses on the coun- his company. A culturally competent counselor selor’s need to engage in and develop cultural would recognize, legitimize, and validate Gil’s awareness; cultural knowledge in general; and reluctance to enter and continue in treatment. culturally specific skills and knowledge of In an ideal situation, the treatment counselor wellness, mental illness, substance use, treat- would have experience working with people ments, and skill development. with similar backgrounds and beliefs, and the treatment program would be structured to change Gil’s behavior and attitudes in a man- Core Counselor ner that was in keeping with his culture and Competencies community. His initial treatment might have succeeded if the counselor had been culturally Since Sue et al. introduced the phrase “multi- competent and the treatment program had cultural counseling competencies” in 1992, been culturally responsive. researchers and academics have elaborated on the core skill sets that enable counselors to Like Gil, all clients enter treatment carrying work with diverse populations (American beliefs, attitudes, conflicts, and problems Psychological Association [APA] 2002; shaped by their cultural roots as well as their Council of National Psychological present-day . As with Gil, many clients Associations for the Advancement of Ethnic enter treatment with some reluctance and Minority Interests 2009; Pack-Brown and denial. Research shows that if clients such as Williams 2003; Tseng and Streltzer 2004). Gil are greeted by a culturally competent Cultural competence has evolved into more counselor, they are more likely to respond than a discrete skill set or knowledge base; it positively to treatment (Damashek et al. 2012; also requires ongoing self-evaluation on the Griner and Smith 2006; Kopelowicz et al. part of the practitioner. Culturally competent 2012; Whaley and Davis 2007). The presence counselors are aware of their own cultural of counselors of any race or gender who are groups and of their values, assumptions, and culturally competent in responding to the biases regarding other cultural groups. Moreo- needs and issues of their clients can greatly , culturally competent counselors strive to

36 Chapter 2—Core Competencies for Counselors and Other Clinical Staff

Multidimensional Model for Developing Cultural Competence: Individual Staff Level

understand how these factors affect their Self-Knowledge ability to provide culturally effective services Counselors with a strong belief in evidence- to clients. based treatment methods can find it hard to Given the complex definition of culture and relate to clients who prefer traditional healing the fact that racially and ethnically diverse methods. Conversely, counselors with strong clients represent a growing portion of the trust in traditional healers and culturally ac- client population, the need to update and cepted methods can fail to understand clients expand guidelines for cultural competence is who seek scientific explanations of, and solu- increasing. The consensus panel thus adapted tions to, their substance abuse and mental existing guidelines from the Association of health problems. To become culturally compe- Multicultural Counseling for culturally re- tent, counselors should begin by exploring sponsive behavioral health services; some of their own cultural heritage and identifying their key suggestions for counselors and other how it shapes their perceptions of normality, clinical staff are outlined in this chapter. abnormality, and the counseling process.

37 Improving Cultural Competence

Counselors who understand themselves and Models of Racial Identity their own cultural groups and perceptions are Models of racial identity, often structured in better equipped to respect clients with diverse stages, highlight the process that individuals belief systems. In gaining an awareness of their undertake in becoming aware of their sense of cultures, attitudes, beliefs, and assumptions self in relation to race and ethnicity within the through self-examination, training, and clini- context of their families, communities, socie- ties, and cultural histories. Influenced by the cal supervision, counselors should consider the , earlier racial identity factors described in the following sections. models in the United States focused on White Cultural awareness and Black racial identity development (Cross 1995; Helms 1990; Helms and Carter 1991). Counselors who are aware of their own cultural Since then, models have been created to backgrounds are more likely to acknowledge incorporate other races, ethnicities, and cultures. and explore how culture affects their client– counselor relationships. Without cultural Although this chapter highlights two formative awareness, counselors may provide counseling racial identity models (see next page), addi- that ignores or does not address obvious issues tional resources highlight racial identity models that incorporate other diverse groups, includ- that specifically relate to race, ethnic heritage, ing those individuals who identify as multiracial and culture. Lack of awareness can discount (e.g., see Wijeyesinghe and Jackson 2012). the importance of how counselors’ cultural backgrounds—including beliefs, values, and the constructs of these identities are complex attitudes—influence their initial and diagnos- and difficult to define briefly, what follows is tic impressions of clients. Without cultural an overview. Racial identity “refers to a sense awareness, counselors can unwittingly use of group or collective identity based on one’s their own cultural experiences as a template to perception that he or she shares a common prejudge and assess client experiences and heritage with a particular racial group” (Helms clinical presentations. They may struggle to 1990, p. 3). Ethnic and cultural identity is see the cultural uniqueness of each client, “often the frame in which individuals identify assuming that they understand the client’s life consciously or unconsciously with those with experiences and background better than they whom they feel a common bond because of really do. With cultural awareness, counselors similar traditions, behaviors, values, and be- examine how their own beliefs, experiences, liefs” (Chavez and Guido-DiBrito 1999, p. and biases affect their definitions of normal 41). Culture includes, but is not limited to, and abnormal behavior. By valuing this aware- spirituality and religion, rituals and rites of ness, counselors are more likely to take the passage, language, dietary habits (e.g., attitudes time to understand the client’s cultural groups toward food/food preparation, symbolism of and their role in the therapeutic process, the food, religious of food), and leisure client’s relationships, and his or her substance- activities (Bhugra and Becker 2005). related and other presenting clinical problems. Cultural awareness is the first step toward Aspects of racial, ethnic, and cultural identities becoming a culturally competent counselor. are not always apparent and do not always Racial, ethnic, and cultural identities factor into conscious processes for the counse- lor or client, but these factors still play a role A key step in attaining cultural competence is in the therapeutic relationship. Identity devel- for counselors to become aware of their own opment and formation help people make sense racial, ethnic, and cultural identities. Although of themselves and the world around them. If

38 Chapter 2—Core Competencies for Counselors and Other Clinical Staff

positive racial, ethnic, and cultural messages the same race requests a White American are not available or supported in behavioral counselor for therapy during an initial inter- health services, counselors and clients can lack view), or view a client’s behavior through a veil affirmative views of their own identities and of societal biases or stereotypes. By acknowl- may internalize negative messages or feel edging and endorsing the active process of disconnected from their racial and cultural racial and cultural identity development, coun- heritages. Counselors from mainstream society selors from diverse groups can normalize their are less likely to be actively aware of their own own development processes and increase their ethnic and cultural identities; in particular, awareness of clients’ parallel processes of White Americans are not naturally drawn into identity development. In counseling, racial, examining their cultural identities, as they ethnic, and cultural identities can be pivotal to typically experience no dissonance when the treatment process in the relationships not engaging in cultural activities. only between the counselor and client, but among everyone involved in the delivery of the In working to attain cultural competence, client’s behavioral health and primary care counselors must explore their own racial and services (e.g., referral sources, family members, cultural heritages and identities to gain a medical personnel, administrators). The case deeper understanding of personal develop- study on page 41 uses stages from the two ment. Many models and theories of racial, models in Exhibit 2-1 to show the interactive ethnic, and cultural development are available; process of racial and cultural identity devel- two common processes are presented below. opment in the treatment context. Exhibit 2-1 highlights the racial/cultural identity development (R/CID) model (Sue Cultural and racial identities are not static and Sue 1999b) and the White racial identity factors that simply mediate individual identity; development (WRID) model (Sue 2001). they are dynamic, interactive developmental Although earlier work focused on a linear processes that influence one’s willingness to developmental process using stages, current acknowledge the effects of race, ethnicity, and thought centers on a more flexible process culture and to act against racism and disparity whereby identification status can loop back to across relationships, situations, and environ- an earlier process or to a later phase. ments (for a review of racial and cultural identity development, see Sue and Sue 2013c). Using either model, counselors can explore For counselors and clinical supervisors, it is relational and clinical challenges associated essential to understand the dynamic nature of with a given phase. Without an understanding cultural identity in all exchanges. Starting with of the cultural identity development process, a personal appraisal, clinical staff members can counselors—regardless of race or ethnicity— begin to reflect—without judgment—on how can unwittingly minimize the importance of their own racial and cultural identities influ- racial and ethnic experiences. They may fail to ence their decisions, treatment planning, case identify cultural needs and secure appropriate presentation, supervision, and interactions treatment services, unconsciously operate from with other staff members. Clinicians can map a superior perspective (e.g., judging a specific the interactive influences of cultural identity behavior as ineffectual, a sign of resistance, or a development among clients, the clients’ fami- symptom of pathology), internalize a client’s , staff members, the organization, other reaction (e.g., an African American counselor agencies, and any other entities involved in the feeling betrayed or inadequate when a client of client’s treatment. Using mapping (see the

39 Improving Cultural Competence

Exhibit 2-1: Stages of Racial and Cultural Identity Development

R/CID Model WRID Model : Has a positive attitude toward Naiveté: Had an early childhood developmental and preference for dominant cultural values; phase of curiosity or minimal awareness of race; places considerable value on characteristics may or may not receive overt or covert messages that represent dominant cultural groups; may about other racial/cultural groups; possesses an devalue or hold negative views of own race or ethnocentric view of culture. other racial/ethnic groups. Conformity: Has minimal awareness of self as a Dissonance and Appreciating: Begins to racial person; strongly in the universality question identity; recognizes conflicting mes- of values and norms; perceives White American sages and observations that challenge be- cultural groups as more highly developed; may liefs/stereotypes of own cultural groups and justify disparity of treatment; may be unaware of value of mainstream cultural groups; develops beliefs that reflect this. growing sense of one’s own cultural heritage Dissonance: Experiences an opportunity to and the existence of racism; moves away from examine own prejudices and biases; moves seeing dominant cultural groups as all good. toward the realization that dominant society Resistance and Immersion: Embraces and oppresses racially and culturally diverse groups; holds a positive attitude toward and prefer- may feel shame, anger, and depression about ence for his or her own race and cultural the perpetuation of racism by White American heritage; rejects dominant values of society cultural groups; and may begin to question and culture; focuses on eliminating oppression previously held beliefs or refortify prior views. within own racial/cultural group; likely to Resistance and Immersion: Increases awareness possess considerable feelings—including of one’s own racism and how racism is projected distrust and anger—toward dominant cultural in society (e.g., media and language); likely feels groups and anything that may represent them; angry about messages concerning other racial places considerable value on characteristics and cultural groups and guilty for being part of an that represent one’s own cultural groups oppressive system; may counteract feelings by without question; develops a growing appre- assuming a paternalistic role (knowing what is ciation for others from racially and culturally best for clients without their involvement) or diverse groups. overidentifying with another racial/cultural group. Introspection: Begins to question the psycho- Introspection: Begins to redefine what it means logical cost of projecting strong feelings to be a White American and to be a racial and toward dominant cultural groups; desires to cultural being; recognizes the inability to fully refocus more energy on personal identity understand the experience of others from di- while respecting own cultural groups; realigns verse racial and cultural backgrounds; may feel perspective to note that not all aspects of disconnected from the White American group. dominant cultural groups—one’s own ra- cial/cultural group or other diverse groups— Integrative Awareness: Appreciates racial, are good or bad; may struggle with and expe- ethnic, and ; is aware of and rience conflicts of loyalty as perspective understands self as a racial and cultural being; is broadens. aware of sociopolitical influences of racism; internalizes a nonracist identity. Integrative Awareness: Has developed a secure, confident sense of racial/cultural Commitment to Antiracist Action: Commits to identity; becomes multicultural; maintains social action to eliminate oppression and disparity pride in racial identity and cultural heritage; (e.g., voicing objection to racist jokes, taking commits to supporting and appreciating all steps to eradicate racism in institutions and public oppressed and diverse groups; tends to policies); likely to be pressured to suppress efforts recognize racism as a societal illness by which and conform rather than build alliances with all can be victimized. people of color.

Sources: Sue 2001; Sue and Sue 1999b.

40 Chapter 2—Core Competencies for Counselors and Other Clinical Staff

Case Study for Counselors: Racial and Cultural Identity The client is a 20-year-old Latino man. His father immigrated to the United States from Mexico as a child, and his (of Latino/Middle Eastern descent) grew up near Albuquerque, . Throughout the initial phase of mental health treatment, the client presented feelings, attitudes, and behavior consistent with the resistance and immersion stage of the R/CID model. During group counseling in a partial hospitalization program, the client said that he did not think treatment was going to work. He believed that no one in treatment, except other Latino men, really understood him or his life experiences. He thought that his low mood was due, in part, to his recent job loss.

The client’s current concerns, symptoms, and diagnosis (bipolar I) were presented and discussed during the treatment team meeting. The client’s counselor (a White American man in the dissonance stage of the WRID model) was concerned that the client might leave treatment against medical advice and also stated that this would not be the first time a Latino client had done so. The team recognized that a Latino counselor would likely be useful in this situation (depending on the counse- lor’s cultural competence). However, no Latino counselor was available, so the team decided that the client’s current counselor should try to gain support from the client’s parents to encourage the client to stay in treatment.

Because the client had signed an appropriate release of information, his counselor was able to contact the parents and arrange a family session. During the family session, the counselor brought up the client’s need for a Latino counselor. His parents disagreed, expressing their belief that it was important for their to learn to relate to the counselor. They said that this was just an excuse their son was using to leave treatment, which had happened before. The parents’ reaction exemplified a conformity response, although other information would need to have been gathered to determine their current stage more accurately.

The counselor, client, parents, and organization were operating from different stages of racial and cultural identity development. Considering the lack of a proactive plan to provide appropriate resources—including the hiring of Latino staff or the development of other culturally appropriate resources (e.g., a peer counselor program)—the organization was most likely in the conformity phase of the WRID model. The counselor had some awareness of the client’s racial and cultural needs and of the organization’s failure to meet them, but he alienated the client despite his good intentions and reinforced mistrust by engaging the client’s parents before working directly with the client. Had the counselor taken the time to understand the client’s concerns and needs, he would likely have created an opportunity to challenge his own beliefs, learn more about the client’s racial and cultural experiences and values, advocate for more appropriate resources for the client within the organization, be more flexible with treatment solutions, and enable the client to have an experi- ence that exceeded his expectations of the treatment provider.

“How To Map Racial and Cultural Identity about, experiences, and interprets the world Development” box on the next page) as prepa- (Koltko-Rivera 2004). Starting in early child- ration for counseling, treatment planning, or hood, worldview development is facilitated by clinical supervision, clinicians can gain aware- significant relationships (particularly with ness of the many forces that influence cultur- parents and family members) and is shaped by ally responsive treatment. the individual’s environment and life experi- Worldview: The cultural lens of ences, influencing values, attitudes, beliefs, and behaviors. In more simplistic terms, each counseling person’s worldview is like a pair of glasses with The term “worldview” refers to a set of colored lenses—the person takes in all of life’s assumptions that guide how one sees, thinks experiences through his or her own uniquely

41 Improving Cultural Competence

How To Map Racial and Cultural Identity Development Completing this diagram can give a clearer perspective on past and anticipated dialog among key stakeholders. The diagram can be used as a training tool to teach racial and cultural identity devel- opment, to help clinicians and organizations recognize their own development, to explore clinical issues and dialogs that occur when diverse parties are at similar or different developmental stages, and to develop tools and resources to address issues that arise from this developmental process. Using case studies, this diagram can serve as an interactive educational exercise to help counselors, clinical supervisors, and agencies gain awareness of the effects of race, ethnicity, and cultural groups. Materials needed: Paper and pencils; handouts on the R/CID and WRID models. Instructions: • Identify all relevant parties, including client, counselor, family, supervisor, referral source, other staff members, and staff from other agencies (e.g., probation/parole, medical center/office, child and youth services). Include yourself. Place the names at each intersection of the hexagon. • List the common statements and behaviors (including lack of verbal responses) that you regarding the cultural needs of the client and/or the general statements made by each party re- garding race, ethnicity, and culture. Write these as one-line abbreviated phrases that represent each person/agency’s stance under the appropriate entry on the diagram. • Using current information, choose the cultural identity development stage that best fits the statements or behaviors (knowing that you may be inaccurate); write it under each name.

tinted view. Not unlike clients, counselors time; definition of family; organization of enter the treatment process with their own priorities and responsibilities; orientation to cultural worldviews that shape their concept of self, family, and/or community; religious or

42 Chapter 2—Core Competencies for Counselors and Other Clinical Staff spiritual beliefs; ideas about success; and so on approaches. In sum, culturally responsive (Exhibit 2-2). practice involves an understanding of multiple perspectives and how these worldviews inter- However, counselors also contend with anoth- act throughout the treatment process— er worldview that is often invisible but still including the views of the counselor, client, powerful—the clinical worldview (Bhugra and family, other clients and staff members, treat- Gupta 2010; Tilburt and Geller 2007; Tseng ment program, organization, and other agen- and Streltzer 2004). Influenced by education, cies, as well as the community. clinical training, and work experiences, coun- selors are introduced into a culture that re- Stereotypes, prejudices, and history flects specific counseling theories, techniques, Cultural competence involves counselors’ treatment modalities, and general office prac- willingness to explore their own histories of tices. This worldview, coupled with their prejudice, cultural stereotyping, and discrimi- personal cultural worldview, significantly nation. Counselors need to be aware of how shapes the counselor’s beliefs pertaining to the their own perceptions of self and others have nature of wellness, illness, and healing; inter- evolved through early childhood influences viewing skills and behavior; diagnostic impres- and other life experiences. For example, how sions; and prognosis. Moreover, it influences were stereotypes of their own races and ethnic the definition of normal versus abnormal or heritages perpetuated in their upbringing? disordered behavior, the determination of What myths and stereotypes were projected treatment priorities, the means of intervention, onto other groups? What historical events and the definitions of successful outcomes and shaped experiences, opportunities, and percep- treatment failures. tions of self and others? Foremost, counselors need to remember that Regardless of their race, cultural group, or worldviews are often unspoken and inconspic- ethnic heritage, counselors need to examine uous; therefore, considerable reflection and how they have directly or indirectly been self-exploration are needed to identify how affected by individual, organizational, and their own cultural worldviews influence their societal stereotypes, prejudice, and discrimina- interactions both inside and outside of coun- tion. How have certain attitudes, beliefs, and seling. Clinical staff members need to question behaviors functioned as deterrents to obtain- how their perspectives are perpetuated in and ing equitable opportunities? In what ways shape client–counselor interactions, treatment have discrimination and societal biases provid- decisions, planning, and selected counseling ed benefits to them as individuals and as counselors? Even though these questions can Exhibit 2-2: Counselor Worldview be uncomfortable, difficult, or painful to ex- plore, awareness is essential regarding how these issues affect one’s role as a counselor, status in the organization, and comfort level in Individual Clinical exploring clients’ life experiences and percep- Cultural Worldview tions during the treatment process. If counse- Worldview lors avoid or minimize the relevance of bias and discrimination in self-exploration, they will likely do the same in the assessment and counseling process.

43 Improving Cultural Competence

Trust and power All counselors should examine their stereotypes, prejudices, and emotional Counselors need to understand the impact of reactions toward others, including their role and status within the client– individuals from their own races or cultural counselor relationship. Client perceptions of backgrounds and individuals from other counselors’ influence, power, and control vary groups. They should examine how these attitudes and biases may be detrimental to in diverse cultural contexts. In some contexts, clients in treatment for substance-related counselors can be seen as all-knowing profes- and mental disorders. sionals, but in others, they can be viewed as representatives of an unjust system. Counse- Clients can have behavioral health issues and lors need to explore how these dynamics affect healthcare concerns associated with discrimi- the counseling process with clients from nation. If counselors are blind to these issues, diverse backgrounds. Do client perceptions they can miss vital information that influences inhibit or facilitate the process? How do they client responses to treatment and willingness affect the level of trust in the client–counselor to follow through with continuing care and relationship? These issues should be identified ancillary services. For example, a counselor and addressed early in the counseling process. may refer a client to a treatment program Clients should have opportunities to talk without noting the client’s history or percep- about and process their perceptions, past tions of the recommended program or type of experiences, and current needs. program. The client may initially agree to Practicing within limits attend the program but not follow through A key element of ethical care is practicing because of past negative experiences and/or within the limits of one’s competence. Coun- the perception within his or her racial/ethnic selors must engage in self-exploration, critical community that the service does not provide thinking, and clinical supervision to under- adequate treatment for clients of color. stand their clinical abilities and limitations

Advice to Counselors and Clinical Supervisors: Using the RESPECT Mnemonic To Reinforce Culturally Responsive Attitudes and Behaviors

• Respect—Understand how respect is shown within given cultural groups. Counselors demon- strate this attitude through verbal and nonverbal communications. • Explanatory model—Devote time in treatment to understanding how clients perceive their pre- senting problems. What are their views about their own substance abuse or mental symptoms? How do they explain the origin of current problems? How similar or different is the counselor’s perspective? • Sociocultural context—Recognize how class, race, ethnicity, gender, education, socioeconomic status, sexual and gender orientation, immigrant status, community, family, gender roles, and so forth affect care. • Power—Acknowledge the power differential between clients and counselors. • Empathy—Express, verbally and nonverbally, the significance of each client’s concerns so that he or she feels understood by the counselor. • Concerns and fears—Elicit clients’ concerns and apprehensions regarding help-seeking behavior and initiation of treatment. • Therapeutic alliance/Trust—Commit to behaviors that enhance the therapeutic relationship; recognize that trust is not inherent but must be earned by counselors. Sources: Bigby and American College of 2003; Campinha-Bacote et al. 2005.

44 Chapter 2—Core Competencies for Counselors and Other Clinical Staff

regarding the services that they are able to Knowledge of Other Cultural provide, the populations that they can serve, Groups and the treatment issues that they have suffi- In addition to an understanding of themselves cient training to address. Cultural competence and how their cultural groups and values can requires an ability to assess accurately one’s affect the therapeutic process, culturally com- clinical and cultural limitations, skills, and petent counselors work to acquire cultural expertise. Counselors risk providing services knowledge and understanding of clients and beyond their expertise if they lack awareness staff with whom they work. From the outset, and knowledge of the influence of cultural counselors need general knowledge and groups on client–counselor relationships, awareness when working with other cultural clinical presentation, and the treatment pro- groups in counseling. For example, they should cess or if they minimize, ignore, or avoid acknowledge that culture influences commu- viewing treatment in a cultural context. nication patterns, values, gender roles and Some counselors may assume that they have socialization, clinical presentations of distress, cultural competence based on having similar counseling expectations, and behavioral norms experiences as clients, being from the same and expectations in and outside the counseling race as clients, identifying as a member of the session (e.g. , touching, greetings, gift-giving, same ethnic heritage or cultural group as accompaniment in sessions, level of formality clients, or attending training on cultural com- between counselor and client). Counselors petence. Other counselors may assume compe- should filter and interpret client presentation tence based on their current or prior from a broad cultural perspective instead of relationships with others from the same race using only their own cultural groups or previ- or cultural background as their clients. These ous client experiences as reference points. experiences can be helpful and filled with Counselors also need to invest the time to many potential learning opportunities, but know clients and their cultures. Culturally they do not make an individual eligible or responsive practice involves a commitment to competent to provide multicultural counseling. obtaining specific cultural knowledge, not Likewise, the assumption that a person from only through ongoing client interactions, but the same cultural group, race, or ethnic herit- also through the use of outside resources, age will intrinsically understand a client from cultural training seminars and programs, a similar background is operating out of two cultural events, professional consultations, common myths: the “ of sameness” (i.e., that people from the same cultural group, race, “Become familiar with the community in or ethnicity are alike) and the myth that “fa- which the client lives and the general miliarity equals competence” (Srivastava cultural norms of the individual client. This 2007). The Association for Multicultural can be accomplished by visiting with Counseling and Development adopted a set people who know the community well, of counselor competencies that was endorsed attending important community by the American Counseling Association celebrations and other events, asking (ACA) for counselors who work with a mul- open-ended questions about community ticultural clientele (Exhibit 2-3). Competen- concerns and quality of life, and identifying community capacities that cies address the attitudes, beliefs, knowledge, affect wellness in the community.” and skills associated with the counselor’s need (Perez and Luquis 2008, p. 177) for self-knowledge.

45 Improving Cultural Competence

Exhibit 2-3: ACA Counselor Competencies: Counselors’ Awareness of Their Own Cultural Values and Biases Attitudes and beliefs: • Culturally skilled counselors have moved from being culturally unaware to being aware and sensitive to their own cultural heritages and to valuing and respecting differences. • Culturally skilled counselors are aware of how their own cultural backgrounds, experiences, attitudes, values, and biases influence psychological processes. • Culturally skilled counselors recognize the limits of their multicultural competence and expertise. • Culturally skilled counselors are comfortable with differences that exist between themselves and their clients in terms of race, ethnicity, culture, and beliefs. Knowledge: • Culturally skilled counselors have specific knowledge about their own racial and cultural heritage and how it personally and professionally affects their definitions of normality, abnormality, and the process of counseling. • Culturally skilled counselors possess knowledge and understanding of how oppression, racism, discrimination, and stereotyping affect them personally and in their work. This allows them to acknowledge their own racist attitudes, beliefs, and feelings. Although this standard applies to all groups, for White American counselors, it can mean that they understand how they may have directly or indirectly benefited from individual, institutional, and . • Culturally skilled counselors possess knowledge about their social impact on others. They are knowledgeable about communication style differences and how their style may clash with or fos- ter the counseling process with minority clients. They anticipate the impact their style may have on others.

Skills: • Culturally skilled counselors seek out educational, consultative, and training experiences to improve their understanding and effectiveness in working with culturally diverse populations. Be- ing able to recognize the limits of their competencies, they seek consultation, seek further train- ing or education, refer out to more qualified individuals or resources, or engage in a combination of these. • Culturally skilled counselors are constantly seeking to understand themselves as racial and cultural beings and are actively seeking a nonracist identity. Source: American Counseling Association Web site (http://www.counseling.org/docs/competencies/ cross-cultural_competencies_and_objectives.pdf). Adapted with permission.

cultural guides, and clinical supervision. throughout the counseling and treatment Counselors need to be mindful that they will relationship. For a review of content areas not know everything about a specific popula- essential in knowing other cultural groups, tion or initially comprehend how an individual refer to the ”What Are the Cross-Cutting client endorses or engages in specific cultural Factors in Race, Ethnicity, and Culture” sec- practices, beliefs, and values. For instance, tion in Chapter 1. These cultural knowledge some clients may not identify with the same content areas include: cultural beliefs, practices, or experiences as • Language and communication. other clients from the same cultural groups. • Geographic location. Nevertheless, counselors need to be as knowl- • Worldview, values, and traditions. edgeable as possible and attend to these cul- • Family and kinship. tural attributes—beginning with the intake • Gender roles. and assessment process and continuing • Socioeconomic status and education.

46 Chapter 2—Core Competencies for Counselors and Other Clinical Staff

• Immigration, migration, and acculturation treatment. For example, a young adult two- stress. spirited (gay) American Indian man may be • Acculturation and cultural identification. more concerned with having access to tradi- • Heritage and history. tional healing practices than to specialized • Sexuality. services for gay men. Counselors and clients • Religion and spirituality. should collaboratively examine presenting • Health, illness, and healing. treatment issues and obstacles to engaging in behavioral health treatment and maintaining Counselors should not make assumptions recovery, and they should discuss how cultural about clients’ race, ethnic heritage, or culture groups and cultural identities can serve as based on appearance, accents, behavior, or guideposts in treatment planning. language. Instead, counselors need to explore with clients their cultural identity, which can Exhibit 2-4 lists ACA-endorsed counselor involve multiple identities (Lynch and Hanson competencies for knowledge of the worldviews 2011). Counselors should discuss what cultural of clients from diverse cultural groups. identity means to clients and how it influences

Exhibit 2-4: ACA Counselor Competencies: Awareness of Clients’ Worldviews Attitudes and beliefs: • Culturally skilled counselors are aware of their negative and positive emotional reactions toward other racial and ethnic groups and recognize that these reactions may prove detrimental to the counseling relationship. They are willing to contrast their own beliefs and attitudes with those of clients from diverse cultures in a nonjudgmental fashion. • Culturally skilled counselors are aware of the stereotypes and preconceived notions they may hold toward other racial and ethnic minority groups.

Knowledge: • Culturally skilled counselors possess specific knowledge and information about the particular group(s) with whom they are working. They are aware of the life experiences, cultural heritages, and historical backgrounds of clients from cultures other than their own. This competence is strongly linked to the minority identity development models available in the literature. • Culturally skilled counselors understand how race, cultural group, ethnicity, and other factors can affect personality formation, vocational choices, manifestation of mental disorders, help-seeking behavior, and the appropriateness or inappropriateness of various counseling approaches. • Culturally skilled counselors understand and have knowledge of sociopolitical influences upon the lives of racial and ethnic minorities. They understand that factors such as immigration issues, poverty, racism, stereotyping, and powerlessness can affect self-esteem and self-concept in the counseling process.

Skills: • Culturally skilled counselors familiarize themselves with relevant research and the latest findings regarding mental health and mental disorders that affect various ethnic and racial groups. They actively seek out educational experiences that enrich their knowledge, understanding, and cross- cultural skills for more effective counseling behavior. • Culturally skilled counselors are actively involved with minority individuals outside of the counsel- ing setting (community events, social and political functions, celebrations, friendships, neighbor- hood groups, etc.); their perspective of minorities is more than an academic/helping exercise.

Source: American Counseling Association Web site (http://www.counseling.org/docs/competencies/ cross-cultural_competencies_and_objectives.pdf). Adapted with permission.

47 Improving Cultural Competence

Cultural Knowledge of Behavioral diverse racial and cultural backgrounds. Health • Beliefs and traditions surrounding sub- stance use, including cultural norms con- Counselors should learn how culture interacts cerning the use of alcohol and drugs. with health beliefs, substance use, and other • Beliefs about treatment, including expecta- behavioral health issues. They can access litera- tions and attitudes toward health care and ture and training that address cultural contexts counseling. and meanings of substance use, behavioral and • Community perceptions of behavioral emotional reactions, help-seeking behavior, and health treatment. treatment. Chapter 5 gives information on • Obstacles encountered by specific popula- culturally responsive behavioral health services tions that make it difficult to access treat- for major ethnic and racial groups. The how- ment, such as geographic distance from to box below lists ways to improve one’s cul- treatment services. tural knowledge of health issues by acquiring • Patterns of co-occurring disorders and knowledge in key areas to work successfully conditions specific to people from diverse with diverse clients: racial and cultural backgrounds (e.g., cul- • Patterns of substance use and treatment- turally specific syndromes, earlier onset of seeking behavior specific to people of

How To Improve Cultural Knowledge of Health, Illness, and Healing To promote culturally responsive services, counselors need to acquire cultural knowledge regarding concepts of health, illness, and healing. The following questions highlight many of the culturally related issues that are prevalent in and pertinent to assessment, treatment planning, and case management. This list of considerations can help facilitate discussions in counseling and clinical supervision contexts: • Does the cultural group in question consider psychological, physical, and spiritual health or well- being as separate entities or as unified aspects of the whole person? • How are illnesses and healing practices defined and conceptualized? • What are acceptable behaviors for managing stress? • How do people who belong to the culture in question typically express and emotional distress? • What behaviors, practices, or customs do members of this culture consider to be preventive? • What words do people from this cultural group use to describe a particular problem? • How do members of the group explain the origins or causes of a particular condition? • Are there culturally specific conditions or cultural concepts of distress? • Are there specific biological and physiological variations among members of this population? • What are the common symptoms that lead to misdiagnosis within this population? • Where do people from this cultural group typically seek help? • What traditional healing practices and treatments are endorsed by members of this group? • Are there biomedical treatments or procedures that would typically be unacceptable? • Are there specific counseling approaches more congruent with the beliefs of most members? • What are common health inequities, including social determinants of health, for this population? • What are acceptable caregiving practices? • Do members of this group attach honor to caring for family members with specific diseases? • Are individuals with specific conditions shunned from the community? • What are the roles of family members in providing health care and in making decisions? • Is discussing consequences of and prognosis for behaviors, conditions, or diseases acceptable? Is it customary for family members to withhold prognosis from the client?

48 Chapter 2—Core Competencies for Counselors and Other Clinical Staff

diabetes, higher prevalence of depression groups; in essence, counselors should commit and substance dependence). to cultural competence and the process of • Assessment and diagnosis, including growth. This commitment is evidenced via culturally appropriate screening and as- investment in ongoing learning and the pur- sessment and awareness of common diag- suit of culturally congruent skills. Counselors nostic biases associated with symptom can demonstrate commitment to cultural presentation. competence through the attitudes and corre- • Individual, family, and group therapy sponding behaviors indicated in Exhibit 2-5. approaches that hold promise in address- Beyond the commitment to and development ing mental and substance-related disorders of these fundamental attitudes and behaviors, specific to the racial and cultural back- counselors need to work toward intervention grounds of diverse clients. strategies that integrate the skills discussed in • Culturally appropriate peer support, the following sections. mutual-help, and other support groups (e.g., the Wellbriety movement, a cultural- Frame issues in culturally relevant ly appropriate 12-Step program for Native ways American people). Counselors should frame clinical issues with • Traditional healing and complementary culturally appropriate references. For example, methods (e.g., use of spiritual leaders, in cultural groups that value the community or herbs, and rituals). family as much as the individual, it is helpful • Continuing care and relapse prevention, to address substance abuse in light of its con- including attention to clients’ cultural en- sequences to family or the community. The vironments, treatment needs, and accessi- counselor might ask, “How are your family bility of care within their communities. and community affected by your use? How do • Treatment engagement/retention patterns. family and community members feel when Skill Development they see you high?” For clients who place more value on their independence, it can be more Becoming culturally competent is an ongoing effective to point out how substance depend- process—one that requires introspection, ence undermines their ability to manage their awareness, knowledge, and skill development. own lives through questions like “How might Counselors need to develop a positive attitude your use affect your ability to reach your goals?” toward learning about multiple cultural

Exhibit 2-5: Attitudes and Behaviors of Culturally Competent Counselors

Attitude Behavior Respect • Exploring, acknowledging, and validating the client’s worldview • Approaching treatment as a collaborative process • Investing time to understand the client’s expectations of treatment • Using consultation, literature, and training to understand culturally specific behaviors that demonstrate respect for the client • Communicating in the client’s preferred language Acceptance • Maintaining a nonjudgmental attitude toward the client • Considering what is important to the client

(Continued on the next page.)

49 Improving Cultural Competence

Exhibit 2-5: Attitudes and Behaviors of Culturally Competent Counselors (continued)

Attitude Behavior Sensitivity • Understanding the client’s experiences of racism, stereotyping, and discrimi- nation • Exploring the client’s cultural identity and what it means to her/him • Actively involving oneself with individuals from diverse backgrounds outside the counseling setting to foster a perspective that is more than academic or work related • Adopting a broader view of family and, when appropriate, including other family or community members in the treatment process • Tailoring treatment to meet the cultural needs of the client (e.g., providing outside resources for traditional healing) Commitment • Proactively addressing racism or bias as it occurs in treatment (e.g., pro- to equality cessing derogatory comments made by another client in a group counseling session) • Identifying the specific barriers to treatment engagement and retention among the populations being served • Recognizing that equality of treatment does not translate to equity—that equity is defined as equality in opportunity, access, and outcome (Srivastava 2007) • Endorsing counseling strategies and treatment approaches that match the unmet needs of diverse populations to ensure treatment engagement, reten- tion, and positive outcomes Openness • Recognizing the value of traditional healing and help-seeking practices • Developing alliances and relationships with traditional practitioners • Seeking consultation with traditional healers and religious and spiritual lead- ers when appropriate • Understanding and accepting that persons from diverse cultural groups can use different cognitive styles (e.g., placing more attention on reflecting and processing than on content; being task oriented) Humility • Recognizing that the client’s trust is earned through consistent and compe- tent behavior rather than the potential status and power that is ascribed to the role of counselor • Acknowledging the limits of one’s competencies and expertise and referring clients to a more appropriate counselor or service when necessary • Seeking consultation, clinical supervision, and training to expand cultural knowledge and cultural competence in counseling skills • Seeking to understand oneself as influenced by ethnicity and cultural groups and actively seeking a nonracist identity • Being sensitive to the power differential between client and counselor Flexibility • Using a variety of verbal and nonverbal responses, approaches, or styles to suit the cultural context of the client • Accommodating different learning styles in treatment approaches (e.g., the use of role-plays or experiential activities to demonstrate coping skills or al- cohol and drug refusal skills) • Using cultural, socioeconomic, environmental, and political contextual factors in conducting evaluations • Integrating cultural practices as treatment strategies (e.g., Alaska Native traditional practices, such as tundra walking and sustenance activities)

50 Chapter 2—Core Competencies for Counselors and Other Clinical Staff

Allow for complexity of issues based Make allowances for variations in on cultural context the use of personal space Counselors must take care with suggesting Cultural groups have different expectations simple solutions to complex problems. It is and norms of propriety concerning how close often better to acknowledge the intricacies of people can be while they communicate and the client’s cultural context and circumstances. how personal communications can be depend- For instance, a Native American single mother ing on the type of relationship (e.g., peers who upholds traditional values could balk at a versus elders). The concept of personal space suggestion to stop spending time with family involves more than the physical distance members who drink heavily. Here, the counse- between people. It also involves cultural expec- lor might encourage the woman to broaden tations regarding posture or stance and the use support within her community by connecting of space within a given environment. These with an elder who supports recovery or by cultural expectations, although they are subtle, engaging in a women’s talking circle. Likewise, can have an impact on treatment. For example, a referral for a psychiatric evaluation for major an Alaska Native may feel more comfortable depression may not be an appropriate initial sitting beside a counselor, whereas a European recommendation for a Chinese client who may prefer to be separated from a counselor by relies on cultural remedies and healing tradi- a desk (Sue and Sue 2013a). The use of space tions. An alternative approach would be to can also be a nonverbal expression of power. explore the client’s beliefs in healing, develop Standing too close to someone can, for exam- steps that respect and incorporate the client’s ple, suggest power over them. Standing too far help-seeking practices, and coordinate services away or sitting behind a desk can indicate to secure a culturally responsive intervention aloofness. Acceptable or expected degrees of (Cardemil et al. 2011; Gallardo et al. 2012; closeness between people are culturally specific; Lynch and Hanson 2011). counselors should be educated on the general

Advice to Counselors and Clinical Supervisors: Behaviors for Counselors To Avoid

• Addressing clients informally; counselors should not assume familiarity until they grasp cultural expectations and client preferences. • Failing to monitor and adjust to the client’s verbal pacing (e.g., not allowing time for clients to respond to questions). • Using counseling jargon and treatment language (e.g., “I am going to send you to our primary stabilization program to obtain a biopsychosocial and then, afterwards, to partial”). • Using statements based on stereotypes or other preconceived ideas generated from experiences with other clients from the same culture. • Using gestures without understanding their meaning and appropriate context within the given culture. • Ignoring the relevance of cultural identity in the client–counselor relationship. • Neglecting the client’s history (i.e., not understanding the client’s individual and cultural back- ground). • Providing an explanation of how current difficulties can be resolved without including the client in the process to obtain his or her own explanations of the problems and how he or she thinks these problems should be addressed. • Downplaying the importance of traditional practices and failing to coordinate these services as needed.

Sources: Fontes 2008; Lynch and Hanson 2011; Pack-Brown and Williams 2003; Srivastava 2007.

51 Improving Cultural Competence

parameters and expectations of the given negative connotations for clients with histories population. However, counselors should not of discrimination and multiple experiences predetermine the clients’ expectations; instead, with racism, for some women, for indigenous they should follow the clients’ lead and inquire peoples with histories of colonization, and for about their preferences. refugees or immigrants who have left oppres- Display sensitivity to culturally sive regimes. In this regard, counselors should use these words carefully. For example, a specific meanings of touch Hmong refugee who experienced trauma in Some treatment and many support groups her country of origin could already feel help- have opening or closing traditions that include less and powerless over the events that oc- holding hands or giving hugs. This form of curred; thus, the concept of powerlessness, touching can be very uncomfortable to new often used in drug and alcohol treatment clients regardless of cultural groups; cultural programs, can be contraindicated in address- prescriptions, including religious beliefs, con- ing her substance-related disorder. However, a cerning appropriate touching can compound White American business executive who has this effect (Comas-Diaz 2012). Many cultural authority over others and a history of financial groups use touch to acknowledge or greet influence may need help acknowledging that someone, to show respect or convey status or he cannot control his substance abuse. power, or to display comfort. As counselors, it Adjust communication styles to the is essential to understand cultural norms about client’s culture touch, which often are guided by gender and age, and the contexts surrounding “appropri- Cultural groups all have different communica- ate” touch for specific cultural groups (Sri- tion styles. Norms for communicating vary in vastava 2007). Counselors need to devote time and between cultural groups based on class, to understanding their clients’ norms for and gender, geographic origins, religion, subcul- interpretations of touch, to assisting clients in tures, and other individual variations. Counse- negotiating and upholding their cultural lors should educate themselves as much as norms, and to helping clients understand the possible regarding the patterns of communi- context and cultural norms that are likely to cating in the client’s cultural, racial, or ethnic prevail in support and treatment groups. population while also being aware of his/her Explore culturally based experiences own communication style. For a comprehen- sive guide in self-assessment and understand- of power and powerlessness ing of communication styles, refer to Culture Ideas about power and powerlessness are Matters: The Peace Corps Cross-Cultural influenced by the client’s culture and social Workbook (Peace Corps Information class. What constitutes power and powerless- Collection and Exchange 2012). ness varies from culture to culture according to the individual’s gender, age, occupation, ances- The following are general guidelines for ascer- taining the client’s communication style: try, religious affiliation, and a host of other • factors. For example, power can be defined in Understand the client’s verbal and nonver- terms of one’s place within the family, with the bal ways of communicating. Be aware of oldest member being the most powerful and the possible need to move away from the youngest being the least powerful. Even comprehending and interpreting client re- the words “power” and “powerlessness” carry sponses in conventional professional ways cultural meaning. These words can carry

52 Chapter 2—Core Competencies for Counselors and Other Clinical Staff

How To Assess Differences in Communication Styles This exercise can be used by counselors and clinical supervisors as a self-assessment tool and a means of exploring differences in communication styles among counselors, clients, and supervisors. It can also serve as a group exercise to help clients discuss and understand cultural differences in communicating with others. This self-administered tool promotes self-understanding and cultural knowledge. It is not an empirically based instrument, nor is it meant to assess client communication styles or skills formally.

Materials needed: Colored pencils/pens and copies of the exercise.

Instructions: • First, place an X along the line for each item that best matches your style or pattern of communi- cation overall. Communication patterns can change across situations and environments depend- ing on expectations, stress level, and familiarity, (e.g., attending a staff meeting versus spending time with friends); try to assign the style that best reflects your patterns across situations. • After reviewing your own patterns, compare differences between you and your client, clinical supervisor, or fellow staff member. For example, select a recent client you treated and place a second X (using a different color pen) on each line to mark your perceived view of this client’s communication style. Then examine the differences between you and your client and generate a list of potential misunderstandings that could occur due to these differences. Use clinical supervi- sion to discuss how your own patterns can hinder and/or promote the counseling process.

NONVERBAL PATTERNS Eye Contact When talking: Direct, sustained Indirect or not sustained When listening: Direct, sustained Indirect or not sustained Vocal Pitch/Tone High/loud Low/soft More expressive Less expressive Speech Rate Fast Slow Pauses or Silence Little use of silence in dialog Pauses; uses silence in dialog Facial Expressions Frequent expression Little expression Use of Other Gestures Frequent expression Little expression

VERBAL PATTERNS Emotional Expression Does express and identify feel- Does not express or identify ings in speech feelings in speech Self-Disclosure Frequently Rarely or little Formality Formal in addressing others Informal and showing respect

(Continued on the next page.)

53 Improving Cultural Competence

How To Assess Differences in Communication Styles (continued) Directness Indirect; subtle; doesn’t Verbally explicit believe in saying everything Context High context: verbal and Low context; relies more on nonverbal cues convey words to convey meaning much of the meaning Orientation Orientation to others, use of Orientation to self; use of “I” plural and third-person statements pronouns (e.g., we, he) Other Things To Consider in Exploring Communication Styles: • Are there known differences in body language and expression within the given cultural group? • What are the common, culturally appropriate parameters of touch across situations? For exam- ple, a handshake could be appropriate as a means of introduction for one cultural group but not for another. • How is personal space used in and outside of the office? Are there known cultural patterns in the use of space and proximity of communication? • What verbal and nonverbal counselor behaviors may affect trust in the counseling process?

Sources: Cormier et al. 2009; Fontes 2008; Srivastava 2007; Sue and Sue 2013a.

(Bland and Kraft 1998). Always be curious not said can possibly be more important about the client’s cultural context and be than what is said. willing to seek clarification and better un- • Listen to storytelling carefully, as it can be derstanding from the client. It is as im- a way of communicating with the thera- portant for counselors to access and pist. As in any good therapy, follow the as- engage in cultural consultation to acquire sociations and listen for possible more specific knowledge and experience. metaphors to better understand relational • Styles of communication and nonverbal meaning, cognition, and within methods of communication are important the context of the conversation. aspects of cultural groups. Issues such as Interpret emotional expressions in the appropriate space to have between light of the client’s culture people; preferred ways of moving, sitting, and standing; the meaning of gestures; and Feelings are expressed differently across and the degree of eye contact expected are all within cultural groups and are influenced by culturally defined and situation specific the nature of a given event and the individuals (Hall 1976). As an example, high-context involved in the situation. A certain level of cultural groups place greater importance emotional expression can be socially appropri- on nonverbal cues and message context, ate within one culture yet inappropriate in whereas low-context cultural groups rely another. In some cultural groups, feelings may largely on verbal message content. Most not be expressed directly, whereas in other Asian Americans come from high-context cultural groups, some emotions are readily cultural groups in which sensitive messages expressed and others suppressed. For example, are encoded carefully to avoid offending expressions of sadness may at first be more others. A provider who listens only to the readily shared by some clients in counseling content could miss the message. What is settings, whereas others may find it more

54 Chapter 2—Core Competencies for Counselors and Other Clinical Staff comfortable to express anger as their initial Providing good care goes beyond counse- response. Counselors must recognize that not lors’ general knowledge, clinical skills, and all cultures place the same value on verbalizing approaches; it involves understanding the feelings. In fact, clients from some cultures multicultural context of clients and of may not perceive that emotional expression is themselves as counselors. Cultural compe- a worthy course of treatment and healing at tence is an ethical issue requiring counse- lors to be invested in developing the tools all. Thus, counselors should not impose a to provide culturally congruent care—care prescribed approach that measures progress that matches the needs and context of the and equates healing with the ability to display client. For a review of and ethical emotions. Likewise, counselors should be dilemmas in a multicultural context, refer careful not to attribute meaning based on their to Pack-Brown and Williams (2003). own cultural backgrounds or to project their own feelings onto clients’ experiences. Instead, Results from the counselor’s understanding of counselors need to assist their clients in iden- and sensitivity to the values, cultures, and tifying and labeling feelings within their own special needs of the individuals and groups cultural contexts. being served (Sue and Sue 2013d). Counselors Expand roles and practices need to adopt an ongoing commitment to developing skills and endorsing practices that Counselors need to acquire a that assist clients in receiving and experiencing the allows for more flexible roles and practices— best possible care. Exhibit 2-6 lists counselor while still maintaining appropriate profession- competencies endorsed by ACA for culturally al boundaries—when working with clients. appropriate intervention strategies. Some clients whose culture places considera- ble emphasis upon and orientation toward Self-Assessment for family could look to counselors for advice with unrelated issues pertaining to other family Individual Cultural members. Other clients may expect a more Competence prescribed and structured approach in which counselors give specific recommendations and Several instruments for evaluating an individ- advice in the session. For example, Asian ual’s cultural competence have been developed American clients appear to expect and benefit and are available online. One assessment tool from a more directive and highly structured that has been widely circulated is Goode’s Self- approach (Fowler et al. 2011; Lee and Mock Assessment Checklist for Personnel Providing 2005a; Sue 2001; Uba 1994). Still others could Services and Supports to Children and Youth expect that counselors be connected to their With Special Health Needs and Their Families. It communities through participation in com- can be adapted for counselors treating adult munity events, in working with traditional clients with behavioral health concerns. This healers, or in building collaborative relation- tool and other additional resources are provid- ships with other community agencies. As ed in Appendix C. For an interactive Web- counselors, it is important to understand the based tool on cultural competence awareness, cultural contexts of clients and how this trans- visit the American Speech-Language-Hearing lates to expectations in the client–counselor Association Web site (http://www.asha.org). relationship. The appropriate role usually

55 Improving Cultural Competence

Exhibit 2-6: ACA Counselor Competencies: Culturally Appropriate Intervention Strategies Attitudes and beliefs: • Culturally skilled counselors respect clients’ religious and/or spiritual beliefs and values, includ- ing attributions and taboos, because they affect worldview, psychosocial functioning, and ex- pressions of distress. • Culturally skilled counselors respect traditional helping practices and intrinsic help-giving - works in minority communities. • Culturally skilled counselors value bilingualism and do not view another language as an impedi- ment to counseling.

Knowledge: • Culturally skilled counselors have a clear and explicit knowledge and understanding of the generic characteristics of counseling and therapy (culture bound, class bound, and monolingual) and how they could clash with the cultural values of various minority groups. • Culturally skilled counselors are aware of institutional barriers that prevent minorities from using behavioral health services. • Culturally skilled counselors know of the potential biases in assessment instruments and use pro- cedures and interpret findings in keeping with the cultural and linguistic characteristics of clients. • Culturally skilled counselors have knowledge of minority family structures, hierarchies, values, and beliefs. They are knowledgeable about family and community characteristics and resources. • Culturally skilled counselors are aware of relevant discriminatory practices at the social and com- munity levels that could be affecting the psychological welfare of the populations being served.

Skills: • Culturally skilled counselors are able to engage in a variety of verbal and nonverbal helping responses. They are able to send and receive both verbal and nonverbal messages accurately and appropriately. They are not tied down to only one method or approach, recognizing that helping styles and approaches can be culture bound. When they sense that their helping style is limited and potentially inappropriate, they can anticipate and ameliorate its negative impact. • Culturally skilled counselors are able to exercise institutional intervention skills on behalf of their clients. They can help clients determine whether a problem stems from racism or bias in others (the concept of health paranoia) so that clients do not inappropriately personalize problems. • Culturally skilled counselors are not averse to seeking consultation with traditional healers, religious and spiritual leaders, and practitioners in the treatment of culturally diverse clients when appropriate. • Culturally skilled counselors take responsibility for interacting in the languages requested by their clients; if not feasible, they make appropriate referrals. A serious problem arises when the linguistic skills of a counselor do not match the language of the client. When language matching is not possible, counselors should seek a translator with cultural knowledge and appropriate pro- fessional background and/or refer to a knowledgeable and competent bilingual counselor. • Culturally skilled counselors have training and expertise in the use of traditional assessment and testing instruments, understand their technical aspects, and are aware of their cultural limita- tions. This allows counselors to use test instruments for the welfare of diverse clients. • Culturally skilled counselors are aware of and work to eliminate biases, prejudices, and discrimi- natory practices. They are aware of sociopolitical contexts in conducting evaluation and provid- ing interventions and are sensitive to issues of oppression, sexism, elitism, and racism. • Culturally skilled counselors educate clients about the processes of psychological intervention, explaining such elements as goals, expectations, legal rights, and the counselor’s theoretical orien- tation.

Source: American Counseling Association Web site (http://www.counseling.org/docs/competencies/ cross-cultural_competencies_and_objectives.pdf). Adapted with permission.

56

Culturally Responsive 3 Evaluation and Treatment Planning

IN THIS CHAPTER Zhang Min, a 25-year-old first-generation Chinese woman, was referred to a counselor by her primary care physician because she • Step 1: Engage Clients reported having episodes of depression. The counselor who con- • Step 2: Familiarize Clients ducted the intake interview had received training in cultural com- and Their Families With petence and was mindful of cultural factors in evaluating Zhang Treatment and Evaluation Min. The referral noted that Zhang Min was born in , Processes so the therapist expected her to be hesitant to discuss her prob- • Step 3: Endorse lems, given the prejudices attached to mental illness and substance Collaboration in Interviews, Assessments, abuse in Chinese culture. During the evaluation, however, the and Treatment Planning therapist was surprised to find that Zhang Min was quite forth- • Step 4: Integrate coming. She mentioned missing important deadlines at work and Culturally Relevant calling in sick at least once a week, and she noted that her cowork- Information and Themes ers had expressed concern after finding a bottle of in her desk. • Step 5: Gather Culturally She admitted that she had been drinking heavily, which she linked Relevant Collateral to work stress and recent discord with her Irish American . Information Further inquiry revealed that Zhang Min’s parents, both Chinese, • Step 6: Select Culturally went to school in England and sent her to a British school in Hong Appropriate Screening Kong. She grew up close to the British expatriate community, and and Assessment Tools her mother was a nurse with the . Zhang Min came to • Step 7: Determine the United States at the age of 8 and grew up in an Irish American Readiness and Motivation for Change neighborhood. She stated that she knew more about Irish culture than about Chinese culture. She felt, with the exception of her • Step 8: Provide Culturally Responsive Case physical features, that she was more Irish than Chinese—a view Management accepted by many of her Irish American friends. Most men she had dated were , and she socialized in groups in which • Step 9: Incorporate Cultural Factors Into alcohol consumption was not only accepted but expected. Treatment Planning Zhang Min first started to drink in high school with her friends. The counselor realized that what she had learned about Asian

57 Improving Cultural Competence

Multidimensional Model for Developing Cultural Competence: Clinical/Program Level

Americans was not necessarily applicable to in planning and evaluation entails being open Zhang Min and that knowledge of Zhang minded, asking the right questions, selecting Min’s entire history was necessary to appreci- appropriate screening and assessment instru- ate the influence of culture in her life. The ments, and choosing effective treatment pro- counselor thus developed treatment strategies viders and modalities for each client. Moreover, more suitable to Zhang Min’s background. it involves identifying culturally relevant con- cerns and issues that should be addressed to Zhang Min’s case demonstrates why thorough improve the client’s recovery process. evaluation, including assessment of the client’s sociocultural background, is essential for treat- This chapter offers clinical staff guidance in ment planning. To provide culturally responsive providing and facilitating culturally responsive evaluation and treatment planning, counselors interviews, assessments, evaluations, and and programs must understand and incorporate treatment planning. Using Sue’s (2001) multi- relevant cultural factors into the process while dimensional model for developing cultural avoiding a stereotypical or “one-size-fits-all” competence, this chapter focuses on clinical approach to treatment. Cultural responsiveness and programmatic decisions and skills that are

58 Chapter 3—Culturally Responsive Evaluation and Treatment Planning

important in evaluation and treatment plan- Improving Cross- ning processes. The chapter is organized Health disparities have multiple causes. One around nine steps to be incorporated by clini- specific influence is cross-cultural communication cians, supported in clinical supervision, and between the counselor and the client. Weiss endorsed by administrators. (2007) recommends these six steps to improve communication with clients: Step 1: Engage Clients 1. Slow down. 2. Use plain, nonpsychiatric language. 3. Show or draw pictures. Once clients are in contact with a treatment 4. Limit the amount of information provided at program, they stand on the far side of a yet-to- one time. be-established therapeutic relationship. It is up 5. Use the “teach-back” method. Ask the client, to counselors and other staff members to bridge in a nonthreatening way, to explain or show what he or she has been told. the gap. Handshakes, facial expressions, greet- 6. Create a shame-free environment that en- ings, and small talk are simple gestures that courages questions and participation. establish a first impression and begin building the therapeutic relationship. Involving one’s whole being in a greeting—thought, body, to understand the problem” (p. 18). It is also attitude, and spirit—is most engaging. important that the client feel engaged with any interpreter used in the intake process. A Fifty percent of racially and ethnically diverse common framework used in many healthcare clients end treatment or counseling after one training programs to highlight culturally visit with a mental health practitioner (Sue and responsive interview behaviors is the LEARN Sue 2013e). At the outset of treatment, clients model (Berlin and Fowkes 1983). The how-to can feel scared, vulnerable, and uncertain about box on the next page presents this model. whether treatment will really help. The initial meeting is often the first encounter clients have Step 2: Familiarize Clients with the treatment system, so it is vital that they leave feeling hopeful and understood. and Their Families With Paniagua (1998) describes how, if a counselor Treatment and Evaluation lacks sensitivity and jumps to premature con- clusions, the first visit can become the last: Processes Pretend that you are a Puerto Rican taxi driv- Behavioral health treatment facilities maintain er in , and at 3:00 p.m. on a their own culture (i.e., the treatment milieu). hot summer day you realize that you have your first appointment with the thera- Counselors, clinical supervisors, and agency pist…later, you learned that the therapist administrators can easily become accustomed made a note that you were probably depressed to this culture and assume that clients are used or psychotic because you dressed carelessly to it as well. However, clients are typically new and had dirty nails and hands…would you to treatment language or jargon, program return for a second appointment? (p. 120) expectations and schedules, and the intake and To engage the client, the counselor should try treatment process. Unfortunately, clients from to establish rapport before launching into a diverse racial and ethnic groups can feel more series of questions. Paniagua (1998) suggests estranged and disconnected from treatment that counselors should draw attention to the services when staff members fail to educate presenting problem “without giving the im- them and their families about treatment ex- pression that too much information is needed pectations or when the clients are not walked

59 Improving Cultural Competence

How To Use the LEARN Mnemonic for Intake Interviews Listen to each client from his or her cultural perspective. Avoid interrupting or posing questions before the client finishes talking; instead, find creative ways to redirect dialog (or explain session limitations if time is short). Take time to learn the client’s perception of his or her problems, concerns about presenting problems and treatment, and preferences for treatment and healing practices.

Explain the overall purpose of the interview and intake process. Walk through the general agenda for the initial session and discuss the reasons for asking about personal information. Remember that the client’s needs come before the set agenda for the interview; don’t cover every intake question at the expense of taking time (usually brief) to address questions and concerns expressed by the client.

Acknowledge client concerns and discuss the probable differences between you and your clients. Take time to understand each client’s explanatory model of illness and health. Recognize, when appropriate, the client’s healing beliefs and practices and explore ways to incorporate these into the treatment plan.

Recommend a course of action through collaboration with the client. The client must know the importance of his or her participation in the treatment planning process. With client assistance, client beliefs and traditions can serve as a framework for healing in treatment. However, not all clients have the same expectations of treatment involvement; some see the counselor as the expert, desire a directive approach, and have little desire to participate in developing the treatment plan themselves.

Negotiate a treatment plan that weaves the client’s cultural norms and lifeways into treatment goals, objectives, and steps. Once the treatment plan and modality are established and implemented, encourage regular dialog to gain feedback and assess treatment satisfaction. Respecting the client’s culture and encouraging communication throughout the process increases client willing to engage in treatment and to adhere to the treatment plan and continuing care recommendations. Sources: Berlin and Fowkes 1983; Dreachslin et al. 2013; Ring 2008.

through the treatment process, starting with intrusive if too much information is requested the goals of the initial intake and interview. By or if the content is a source of family dishonor taking the time to acclimate clients and their or shame. Other clients may resist or distrust families to the treatment process, counselors the process based on a long history of racism and other behavioral health staff members and oppression. Still others feel inhibited from tackle one obstacle that could further impede actively participating because they view the treatment engagement and retention among counselor as the authority or sole expert. racially and ethnically diverse clients. The counselor can help decrease the influence Step 3: Endorse of these issues in the interview process through a collaborative approach that allows Collaboration in time to discuss the expectations of both coun- Interviews, Assessments, selor and client; to explain interview, intake, and treatment planning processes; and to and Treatment Planning establish ways for the client to seek clarifica- tion of his or her assessment results (Mohatt Most clients are unfamiliar with the evalua- et al. 2008a). The counselor can encourage tion and treatment planning process and how collaboration by emphasizing the importance they can participate in it. Some clients may of clients’ input and interpretations. Client view the initial interview and evaluation as feedback is integral in interpreting results and

60 Chapter 3—Culturally Responsive Evaluation and Treatment Planning

can identify cultural issues that may affect Advice to Counselors: Conducting intake and evaluation (Acevedo-Polakovich et Strength-Based Interviews al. 2007). Collaboration should extend to client By nature, initial interviews and evaluations can preferences and desires regarding inclusion of overemphasize presenting problems and con- family and community members in evaluation cerns while underplaying client strengths and and treatment planning. supports. This list, although not exhaustive, reminds clinicians to acknowledge client Step 4: Integrate strengths and supports from the outset. Strengths and supports: Culturally Relevant • Pride and participation in one’s culture Information and Themes • Social skills, traditions, knowledge, and practical skills specific to the client’s culture • Bilingual or multilingual skills By exploring culturally relevant themes, • Traditional, religious, or spiritual practices, counselors can more fully understand their beliefs, and faith clients and identify their cultural strengths • Generational wisdom and challenges. For example, a Korean wom- • Extended families and nonblood kinships an’s family may serve as a source of support • Ability to maintain cultural heritage and practices and provide a sense of identity. At the same • Perseverance in coping with racism and time, however, her family could be ashamed oppression of her co-occurring generalized anxiety and • Culturally specific ways of coping substance use disorders and respond to her • Community involvement and support treatment as a source of further shame be- Source: Hays 2008. cause it encourages her to disclose personal matters to people outside the family. The following section provides a brief overview of important clues about the client’s degree of suggested strength-based topics to incorpo- acculturation in early life and at present, cul- rate into the intake and evaluation process. tural identity, ties to culture of origin, potential cultural conflicts, and resources. Specific ques- Immigration History tions should elicit information about: • Immigration history can shed light on client Length of time in the United States, support systems and identify possible isolation noting when immigration occurred or the or alienation. Some immigrants who live in number of generations who have resided in the United States. ethnic enclaves have many sources of social • support and resources. By contrast, others may Frequency of returns and psychological and personal ties to the country of origin. be isolated, living apart from family, friends, • and the support systems extant in their coun- Primary language and level of English proficiency in speaking and writing. tries of origin. Culturally competent evalua- • tion should always include questions about the Psychological reactions to immigration and adjustments made in the process. client’s country of origin, immigration status, • length of time in the United States, and con- Changes in social status and other areas as a result of coming to this country. nections to his or her country of origin. Ask • American-born clients about their parents’ Major differences in attitudes toward country of origin, the language(s) spoken at alcohol and drug use from the time of home, and affiliation with their parents’ cul- immigration to now. ture(s). Questions like these give the counselor

61 Improving Cultural Competence

Cultural Identity and Advice to Counselors: Asking About Acculturation Culture and Acculturation As shown in Zhang Min’s case at the begin- A thoughtful exploration of cultural and ethnic ning of this chapter, cultural identity is a identity issues will provide clues for determin- unique feature of each client. Counselors ing cultural, racial, and ethnic identity. There are numerous clues that you may derive from should guard against making assumptions your clients’ answers, and they cannot all be about client identity based on general ethnic covered in this TIP; this is only one set of and racial identification by evaluating the sample questions (Fontes 2008). Ask these degree to which an individual identifies with questions tactfully so they do not sound like an his or her culture(s) of origin. As Castro and interrogation. Try to integrate them naturally into a conversation rather than asking one after colleagues (1999b) explain, “for each group, another. Not all questions are relevant in all the level of within-group variability can be settings. Counselors can adapt wording to suit assessed using a core dimension that ranges clients’ cultural contexts and styles of commu- from high cultural involvement and ac- nication, because the questions listed here and ceptance of the traditional culture’s values to throughout this chapter are only examples: • Where were you born? low or no cultural involvement” (p. 515). For • Whom do you consider family? African Americans, for example, this dimen- • What was the first language you learned? sion is called “Afrocentricity.” Scales for Af- • Which other language(s) do you speak? rocentricity have been developed in an attempt • What language or languages are spoken in to provide an indicator of an individual’s level your home? • What is your religion? How observant are of involvement within the traditional or core you in practicing that religion? African-oriented culture (Baldwin and Bell • What activities do you enjoy when you are 1985; Cokley and Williams 2005; Klonoff and not working? Landrine 2000). Many other instruments • How do you identify yourself culturally? based on models of identity evaluate accul- • What aspects of being ______are most important to you? (Use the same term for turation and identity. A detailed discussion of the identified culture as the client.) the theory behind such models is beyond the • How would you describe your home and scope of this Treatment Improvement Proto- neighborhood? col (TIP); however, counselors should have a • Whom do you usually turn to for help when general understanding of what is being meas- facing a problem? • What are your goals for this interview? ured when administering such instruments. The “Asking About Culture and Accultura- American culture, White American culture, or tion” advice box at right addresses exploration both. When a client has two or more ra- of culture and acculturation with clients. For cial/ethnic identities, counselors should assess more information on instruments that measure how the client self-identifies and how he or acculturation and/or identity, see Appendix B. she negotiates the different worlds. Other areas to explore include the cross- cutting factors outlined in Chapter 1, such as Membership in a socioeconomic status (SES), occupation, Clients often identify initially with broader education, gender, and other variables that can racial, ethnic, and cultural groups. However, distinguish an individual from others who each person has a unique history that warrants share his or her cultural identity. For example, an understanding of how culture is practiced a biracial client could identify with African and has evolved for the person and his or her

62 Chapter 3—Culturally Responsive Evaluation and Treatment Planning

family; accordingly, counselors should avoid Advice to Counselors: Eliciting Client generalizations or assumptions. Clients are Views on Presenting Problems often part of a culture within a culture. There Some clients do not see their presenting physi- is not just one Latino, African American, or cal, psychological, and/or behavioral difficulties Native American culture; many variables as problems. Instead, they may view their influence culture and cultural identity (see the presenting difficulties as the result of stress or “What Are the Cross-Cutting Factors in Race, another issue, thus defining or labeling the Ethnicity, and Culture” section in Chapter 1). presenting problem as something other than a physical or mental disorder. In such cases, For example, an African American client from word the following questions using the clients’ East Carroll Parish, LA, might describe his or terminology rather than using the word “prob- her culture quite differently than an African lem.” These questions help explore how clients American from downtown Hartford, CT. view their behavioral health concerns: • I know that clients and counselors some- Beliefs About Health, Healing, times have different ideas about illness and diseases, so can you tell me more about Help-Seeking, and Substance Use your idea of your problem? Just as culture shapes an individual’s sense of • Do you consider your use of alcohol and/or drugs a problem? identity, it also shapes attitudes surrounding • How do you your problem? Do you health practices and substance use. Cultural think it is a serious problem? acceptance of a behavior, for instance, can • What do you think caused your problem? mask a problem or deter a person from seek- • Why do you think it started when it did? ing treatment. Counselors should be aware of • What is going on in your body as a result of this problem? how the client’s culture conceptualizes issues • How has this problem affected your life? related to health, healing and treatment prac- • What frightens or concerns you most about tices, and the use of substances. For example, this problem and its treatment? in cases where alcohol use is discouraged or • How is your problem viewed in your family? frowned upon in the community, the client Is it acceptable? • How is your problem viewed in your com- can experience tremendous shame about munity? Is it acceptable? Is it considered a drinking. Chapter 5 reviews health-related disease? beliefs and practices that can affect help- • Do you know others who have had this seeking behavior across diverse populations. problem? How did they treat the problem? • How does your problem affect your stature Trauma and Loss in the community? • What kinds of treatment do you think will Some immigrant subcultures have experienced help or heal you? violent upheavals and have a higher incidence • How have you treated your drug and/or of trauma than others. The theme of trauma alcohol problem or emotional distress? and loss should therefore be incorporated into • What has been your experience with treat- ment programs? general intake questions. Specific issues under this general theme might include: Sources: Lynch and Hanson 2011; Tang and • Migration, relocation, and emigration Bigby 1996; Taylor 2002. history—which considers separation from homeland, family, and friends—and the • Clients’ personal or familial experiences stressors and loss of social support that can with American Indian boarding schools. accompany these transitions. • Experiences with genocide, persecution, torture, war, and starvation.

63 Improving Cultural Competence

How To Use a Multicultural Intake Checklist Some clients do not see their presenting physical, psychological, and/or behavioral difficulties as problems. Instead, they may view their presenting difficulties as the result of stress or another issue, thus defining or labeling the presenting problem as something other than a physical or mental disorder. In such cases, word questions about the following topics using the client’s terminology, rather than using the word “problem.” Asking questions about the following topics can help you explore how a client may view his or her behavioral health concerns:

 Immigration history  Sexual and gender orientation  Relocations (current migration pat-  Health concerns terns)  Traditional healing practices  Losses associated with immigration  Help-seeking patterns and relocation history  Beliefs about wellness  English language fluency  Beliefs about mental illness and mental health  Bilingual or multilingual fluency treatment  Individualistic/collectivistic orientation  Beliefs about substance use, abuse, and depend-  Racial, ethnic, and cultural identities ence  Tribal affiliation, if appropriate  Beliefs about substance abuse treatment  Geographic location  Family views on substance use and substance  Family and extended family concerns abuse treatment (including nonblood kinships)  Treatment concerns related to cultural differences  Acculturation level (e.g., traditional,  Cultural approaches to healing or treatment of bicultural) substance use and mental disorders  Acculturation stress  Education history and concerns  History of discrimination/racism  Work history and concerns  Trauma history  SES and financial concerns  Historical trauma  Cultural group affiliation  Intergenerational family history and  Current network of support concerns  Community concerns  Gender roles and expectations  Review of confidentiality parameters and concerns  Birth order roles and expectations  Cultural concepts of distress (DSM-5*)  Relationship and concerns  DSM-5 culturally related V-codes *Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American Psychiatric Associa- tion [APA] 2013). Sources: Comas-Diaz 2012; Constantine and Sue 2005; Sussman 2004.

Step 5: Gather Culturally own perspective and may not recall certain events or be aware of how his or her behavior Relevant Collateral affects his or her well-being and that of oth- Information ers. Collateral information—supplemental information obtained with the client’s permis- A client who needs behavioral health treat- sion from sources other than the client—can ment services may be unwilling or unable to be derived from family members, medical and provide a full personal history from his or her court records, probation and parole officers,

64 Chapter 3—Culturally Responsive Evaluation and Treatment Planning

community members, and others. Collateral instruments and their appropriateness for information should include culturally relevant specific cultural groups. Counselors should information obtained from the family, such as continue to explore the availability of mental the organizational memberships, beliefs, and health and substance abuse screening and practices that shape the client’s cultural identi- assessment tools that have been translated into ty and understanding of the world. or adapted for other languages. As families can be a vital source of infor- Culturally Appropriate Screening mation, counselors are likely to attain more Devices support by engaging families earlier in the treatment process. Although counselor inter- The consensus panel does not recommend any actions with family members are often limited specific instruments for screening or assessing to a few formal sessions, the families of racially mental or substance use disorders. Rather, and ethnically diverse clients tend to play a when selecting instruments, practitioners more significant and influential role in clients’ should consider their cultural applicability to participation in treatment. Consequently, the client being served (AACE 2012; Jome special sensitivity to the cultural background and Moody 2002). For example, a screening of family members providing collateral infor- instrument that asks the respondent about his mation is essential. Families, like clients, or her guilt about drinking could be ineffective cannot be easily defined in terms of a generic for members of cultural, ethnic, or religious cultural identity (Congress 2004; Taylor et al. groups that prohibit any consumption of 2012). Even families from the same racial alcohol. Al-Ansari and Negrete’s (1990) re- background or ethnic heritage can be quite search supports this point. They found that dissimilar, thus requiring a multidimensional the Short Alcoholism Screening approach in understanding the role of culture Test was highly sensitive with people who use in the lives of clients and their families. Using alcohol in a traditional Arab Muslim society; the culturagram tool on the next page in however, one question—“Do you ever feel preparation for counseling, treatment plan- guilty about your drinking?”—failed to distin- ning, or clinical supervision, clinicians can guish between people with alcohol dependency learn about the unique attributes and histories disorders in treatment and people who drank that influence clients’ lives in a cultural context. in the community. Questions designed to measure conflict that results from the use of Step 6: Select Culturally alcohol can skew test results for participants from cultures that expect complete abstinence Appropriate Screening from alcohol and/or drugs. Appendix D sum- and Assessment Tools marizes instruments tested on specific popula- tions (e.g., availability of normative data for Discussions of the complexities of psychologi- the population being served). cal testing, the interpretation of assessment Culturally Valid Clinical Scales measures, and the appropriateness of screen- ing procedures are outside the scope of this As the literature consistently demonstrates, TIP. However, counselors and other clinical co-occurring mental disorders are common in service providers should be able to use assess- people who have substance use disorders. ment and screening information in culturally Although an assessment of psychological competent ways. This section discusses several problems helps match clients to appropriate

65 Improving Cultural Competence

How To Use a Culturagram for Mapping the Role of Culture The culturagram is an assessment tool that helps clinicians understand culturally diverse clients and their families (Congress 1994, 2004; Congress and Kung 2005). It examines 10 areas of inquiry, which should include not only questions specific to clients’ life experiences, but also questions specific to their family histories. This diagram can guide an interview, counseling, or clinical supervi- sion session to elicit culturally relevant multigenerational information unique to the client and the client’s family. Give a of the diagram to the client or family for use as an interactive tool in the session. Throughout the interview, the client, family members, and/or the counselor can write brief responses in each box to highlight the unique attributes of the client’s history in the family context. This diagram has been adapted for clients with co-occurring mental and substance use disorders; sample questions follow.

Legal and Time in socioeconomic community status

Reasons for Language relocation or spoken at home migration and in community

Family: List each member Values about and circle the Health beliefs structure, client’s name and beliefs power, myths, about drug and rules and alcohol use

Values about Impact of trauma, education and substance abuse, work Religious and Oppression and other crisis cultural and events institutions, discrimination food, clothing, and holidays

Values about family structure, power, myths, and rules: • Are there specific gender roles and expectations in your family? • Who holds the power within the family? • Are family needs more important than, or equally as important as, individual needs? • Whom do you consider family? Reasons for relocation or migration: • Are you and your family able to return home? • What were your reasons for coming to the United States? • How do you now view the initial reasons for relocation? • What feelings do you have about relocation or migration? • Do you move back and forth from one location to another? • How often do you and your family return to your homeland? • Are you living apart from your family? Legal status and SES: • Has your SES improved or worsened since coming to this country? • Has there been a change in socioeconomic status across generations? (Continued on the next page.)

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Chapter 3—Culturally Responsive Evaluation and Treatment Planning

How To Use a Culturagram for Mapping the Role of Culture (continued)

• What is the family history of documentation? (Note: Clients often need to develop trust before discussing legal status; they may come from a place where confidentiality is unfamiliar.) Time in the community: • How long have you and your family members been in the country? Community? • Are you and your family actively involved in a culturally based community? Languages spoken in and outside the home: • What languages are spoken at home and in the community? • What is your and your family’s level of proficiency in each language? • How dependent are parents and on their children for negotiating activities sur- rounding the use of English? Have children become the family interpreters? Health beliefs and beliefs about help-seeking: • What are the family beliefs about drug and alcohol use? Mental illness? Treatment? • Do you and your family uphold traditional healing practices? • How do help-seeking behaviors differ across generations and in your family? • How do you and your family define illness and wellness? • Are there any objections to the use of Western medicine? Impact of trauma and other crisis events: • How has trauma affected your family across generations? • How have traumas or other crises affected you and/or your family? • Has there been a specific family crisis? • Did the family experience traumatic events prior to migration—war, other forms of violence, displacement including refugee camps, or similar experiences? Oppression and discrimination: • Is there a history of oppression and discrimination in your homeland? • How have you and your family experienced discrimination since immigration? Religious and cultural institutions, food, clothing, and holidays: • Are there specific religious holidays that your family observes? • What holidays do you celebrate? • Are there specific foods that are important to you? • Does clothing play a significant cultural or religious role for you? • Do you belong to a cultural or social club or organization? Values about education and work: • How much importance do you place on work, family, and education? • What are the educational expectations for children within the family? • Has your work status changed (e.g., level of responsibility, prestige, and power) since migration? • Do you or does anyone in your family work several jobs? Sources: Comas-Diaz 2012; Congress 1994, 2004; Singer 2007. treatment, clinicians are cautioned to proceed equally imperfect psychological constructs that carefully. People who are abusing substances or were created to organize and understand experiencing withdrawal from substances can clinical patterns and thus better treat them; exhibit behaviors and thinking patterns con- they do not provide absolute answers. As sistent with mental illness. After a period of research and science evolve, so does our under- abstinence, symptoms that mimic mental standing of mental illness (Benuto 2012). illness can disappear. Moreover, clinical in- Assessment tools are generally developed for struments are imperfect measurements of particular populations and can be inapplicable

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to diverse populations (Blume et al. 2005; Shafer (1996) found that diagnostic criteria Suzuki and Ponterotto 2008). Appendix D seemed to identify alcohol dependency con- summarizes research on the clinical utility of sistently across race and ethnicity, but their instruments for screening and assessing co- sample was limited to African Americans, occurring disorders in various cultural groups. Latinos, and Whites. Other research has shown mixed results. Diagnosis In 1972, the World Health Organization Counselors should consider clients’ cultural (WHO) and the National Institutes of Health backgrounds when evaluating and assessing (NIH) embarked on a study to test the mental and substance use disorders (Bhugra cross-cultural applicability of classification and Gupta 2010). Concerns surrounding systems for various diagnoses, including sub- diagnoses of mental and substance use disor- stance use disorders. WHO and NIH identi- ders (and the cross-cultural applicability of fied factors that appeared to be universal those diagnoses) include the appropriateness aspects of mental and substance use disorders of specific test items or questions, diagnostic and then developed instruments to measure criteria, and psychologically oriented concepts them. These instruments, the Composite (Alarcon 2009; Room 2006). Research into International Diagnostic Interview (CIDI) specific techniques that address cultural differ- and the Schedules for Clinical Assessment in ences in evaluative and diagnostic processes so Neuropsychiatry (SCAN), include some DSM far remains limited and underrepresentative of and International Statistical Classification of diverse populations (Guindon and Sobhany Diseases and Related Health Problems criteria. 2001; Martinez 2009). Studies report that both the CIDI and SCAN Does the DSM-5 accurately diagnose mental were generally accurate, but the investigators and substance use disorders among immi- urge caution in translation and interview pro- grants and other ethnic groups? Caetano and cedures (Room et al. 2003).

Advice to Counselors and Clinical Supervisors: Culturally Responsive Screening and Assessment

• Assess the client’s primary language and language proficiency prior to the administration of any evaluation or use of testing instruments. • Determine whether the assessment materials were translated using specific terms, including idioms that correspond to the client’s literacy level, culture, and language. Do not assume that translation into a stated language exactly matches the specific language of the client. Specifically, the client may not understand the translated language if it does not match his or her ways of thinking or speaking • Educate the client on the purpose of the assessment and its application to the development of the treatment plan. Remember that testing can generate many emotional reactions. • Know how the test was developed. Is normative data available for the population being served? Test results can be inflated, underestimated, or inaccurate due to differences within the client’s population. • Consider the role of acculturation in testing, including the influence of the client’s worldview in responses. Unfamiliarity with mainstream United States culture can affect interpretation of ques- tions, the client–evaluator relationship, and behavior, including participation level during evalua- tion and verbal and behavioral responses.

Sources: Association for Assessment in Counseling and Education (AACE) 2012; Saldaña 2001.

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Overall, psychological concepts that are ap- to culturally diverse populations. This model propriate for and easily translated by some divides the change process into several stages: groups are inappropriate for others. In some • Precontemplation. The individual does not Asian cultures, for example, feeling refers more see a need to change. For example, a per- to a physical than an emotive state; questions son at this stage who substances designed to infer emotional states are not does not see any need to alter use, denies easily translated. In most cases, these issues that there is a problem, or blames the can be remedied by using culture-specific problem on other people or circumstances. resources, measurements, and references while • Contemplation. The person becomes aware also adopting a cultural formulation in the of a problem but is ambivalent about the interviewing process (see Appendix E for the course of action. For instance, a person APA’s cultural formulation outline). The struggling with depression recognizes that DSM-5 lists several cultural concepts of dis- the depression has affected his or her life tress (see Appendix E), yet there is little em- and thinks about getting help but remains pirical literature providing data or treatment ambivalent on how he/she may do this. guidance on using the APA’s cultural formula- • Preparation. The individual has deter- tion or addressing cultural concepts of distress mined that the consequences of his or her (Martinez 2009; Mezzich et al. 2009). behavior are too great and that change is necessary. Preparation includes small steps Step 7: Determine toward making specific changes, such as Readiness and Motivation when a person who is overweight begins reading about wellness and weight man- for Change agement. The client still engages in poor health behaviors but may be altering some Clients enter treatment programs at different behaviors or planning to follow a diet. levels of readiness for change. Even clients • Action. The individual has a specific plan who present voluntarily could have been for change and begins to pursue it. In rela- pushed into it by external pressures to accept tion to substance abuse, the client may treatment before reaching the action stage. make an appointment for a drug and alco- These different readiness levels require differ- hol assessment prior to becoming absti- ent approaches. The strategies involved in nent from alcohol and drugs. motivational interviewing can help counselors • Maintenance. The person continues to prepare culturally diverse clients to change engage in behaviors that support his or her their behavior and keep them engaged in decision. For example, an individual with treatment. To understand motivational inter- follows a daily relapse viewing, it is first necessary to examine the prevention plan that helps him or her as- process of change that is involved in recovery. sess warning signs of a manic episode and See TIP 35, Enhancing Motivation for Change reminds him or her of the importance of in Substance Abuse Treatment (Center for engaging in help-seeking behaviors to Substance Abuse Treatment [CSAT] 1999b), minimize the severity of an episode. for more information on this technique. Progress through the stages is nonlinear, with Stages of Change movement back and forth among the stages at Prochaska and DiClemente’s (1984) classic different rates. It is important to recognize transtheoretical model of change is applicable that change is not a one-time process, but

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rather, a series of trials and errors that eventu- interfere with or prevent access to treatment ally translates to successful change. For exam- and ancillary services, compromise appropriate ple, people who are dependent on substances referrals, impede compliance with treatment often attempt to abstain several times before recommendations, and produce poorer treat- they are able to acquire long-term abstinence. ment outcomes. Obstacles may include immi- gration status, lower SES, language barriers, Motivational Interviewing cultural differences, and lack of or poor cov- Motivational interventions assess a person’s erage with health insurance. stage of change and use techniques likely to Case management provides a single profes- move the person forward in the sequence. sional contact through which clients gain Miller and Rollnick (2002) developed a thera- access to a range of services. The goal is to peutic style called motivational interviewing, help assess the need for and coordinate social, which is characterized by the strategic thera- health, and other essential services for each peutic activities of expressing empathy, devel- client. Case management can be an immense oping discrepancy, avoiding argument, rolling help during treatment and recovery for a with resistance, and supporting self-efficacy. person with limited English literacy and The counselor’s major tool is reflective listen- knowledge of the treatment system. Case ing and soliciting change talk (CSAT 1999c). management focuses on the needs of individu- This nonconfrontational, client-centered al clients and their families and anticipates approach to treatment differs significantly how those needs will be affected as treatment from traditional treatments in several ways, proceeds. The case manager advocates for the creating a more welcoming relationship. TIP client (CSAT 1998a; Summers 2012), easing 35 (CSAT 1999c) assesses Project MATCH the way to effective treatment by assisting the and other clinical trials, concluding that the client with critical aspects of life (e.g., food, evidence strongly supports the use of motiva- childcare, employment, housing, legal prob- tional interviewing with a wide variety of lems). Like counselors, case managers should cultural and ethnic groups (Miller and possess self-knowledge and basic knowledge Rollnick 2013; Miller et al. 2008). TIP 35 is a of other cultures, traits conducive to working good motivational interviewing resource. For well with diverse groups, and the ability to specific application of motivational interview- apply cultural competence in practical ways. ing with Native Americans, see Venner and Cultural competence begins with self- colleagues (2006). For improvement of treat- knowledge; counselors and case managers ment compliance among Latinos with depres- should be aware of and responsive to how sion through motivational interviewing, see their culture shapes attitudes and beliefs. Interian and colleagues (2010). This understanding will broaden as they gain knowledge and direct experience with Step 8: Provide Culturally the cultural groups of their client popula- tion, enabling them to better frame client Responsive Case issues and interact with clients in culturally Management specific and appropriate ways. TIP 27, Comprehensive Case Management for Clients from various racial, ethnic, and cultur- Substance Abuse Treatment (CSAT 1998a), offers more information on effec- al populations seeking behavioral health ser- tive case management. vices may face additional obstacles that can

70 Chapter 3—Culturally Responsive Evaluation and Treatment Planning

Exhibit 3-1 discusses the cultural matching of Exhibit 3-1: Client–Counselor Matching counselors with clients. When counselors The literature is inconclusive about the value of cannot provide culturally or linguistically client–counselor matching based on race, competent services, they must know when and ethnicity, or culture (Imel et al. 2011; Larrison et how to bring in an interpreter or to seek other al. 2011; Suarez-Morales et al. 2010). Sue et al. assistance (CSAT 1998a). Case management (1991) found that for people whose primary includes finding an interpreter who communi- language was not English, counselor–client matching for ethnicity and language predicted cates well in the client’s language and dialect longer time in treatment (more sessions) with and who is familiar with the vocabulary re- better outcomes for all ethnic groups studied: quired to communicate effectively about sensi- Asian Americans, African Americans, Mexican tive subject matter. The case manager works Americans, and White Americans. within the system to ensure that the interpret- Ethnic matches may work better for Latinos in er, when needed, can be compensated. Case treatment; gender congruence seems more managers should also have a list of appropriate important than race or ethnicity in client– referrals to meet assorted needs. For example, counselor matching, particularly for female an immigrant who does not speak English clients (Sue and Sue 2013a). For Asian Americans and Pacific Islanders, the many different ethnic may need legal services in his or her language; subgroups make a cultural match more difficult. an undocumented worker may need to know In multicultural communities, racial and ethnic where to go for medical assistance. Culturally matching may help develop a working alliance competent case managers build and maintain between the therapist and the consumer (Chao rich referral resources for their clients. et al. 2012). Other relevant variables of both the client and therapist are age, marital status, The Case Management Society of America’s training, language, and parental status. The extent to which a cultural match is necessary in Standards of Practice for Case Management therapy depends on client preferences, charac- (2010) state that case management is central teristics, presenting problems, and treatment in meeting client needs throughout the course needs. For example, gender matching could be of treatment. The standards stress understand- more important than race/ethnicity matching to ing relevant cultural information and com- female sexual abuse survivors, who may have difficulty discussing their trauma with male municating effectively by respecting and being counselors. responsive to clients and their cultural contexts. For standards that are also applicable to case Most clients want to know that their counselors management, refer to the National Association understands their worldviews, even if they do not share them. Counselors’ understanding of of Social Workers’ Standards on Cultural their clients’ cultures improves treatment out- Competence in Social Work Practice (2001). comes (Suarez-Morales et al. 2010). Fiorentine and Hillhouse (1999) found that empathy, Step 9: Incorporate regardless of race or ethnicity of counselor and client, was the most important predictor of Cultural Factors Into favorable treatment outcomes. Sue et al. (1991) found that clients using outpatient mental Treatment Planning health services more readily attended treatment and stayed longer if services were culturally The cultural adaptation of treatment practices responsive. In the treatment planning process, is a burgeoning area of interest, yet research is matching clients with providers according to limited regarding the process and outcome of cultural (and subcultural, when warranted) backgrounds can help provide treatment that is culturally responsive treatment planning in responsive to the personal, cultural, and clinical behavioral health treatment services for needs of clients (Fontes 2008).

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diverse populations. How do counselors and Group Clinical Supervision organizations respond culturally to the diverse needs of clients in the treatment planning Beverly is a 34-year-old White American who process? How effective are culturally adaptive feels responsible for the tension and dissension treatment goals? (For a review, see Bernal and in her family. Beverly works in the lab of an obstetrics and gynecology practice. Since early Domenech Rodriguez 2012.) Typically, pro- childhood, her younger has had prob- grams that provide culturally responsive ser- lems that have been diagnosed differently by vices approach treatment goals holistically, various medical and mental health profession- including objectives to improve physical als. He takes several medications, including one health and spiritual strength (Howard 2003). for attention deficit disorder. Beverly’s father has been out of work for several months. He is Newer approaches stress implementation of seeing a psychiatrist for depression and is on an strength-based strategies that fortify cultural antidepressant medication. Beverly’s mother heritage, identity, and resiliency. feels burdened by family problems and ineffec- tive in dealing with them. Beverly has always Treatment planning is a dynamic process that helped her parents with their problems, but she evolves along with an understanding of the now feels bad that she cannot improve their clients’ histories and treatment needs. Fore- situation. She believes that if she were to work harder and be more astute, she could lessen her most, counselors should be mindful of each family’s distress. She has had trouble sleeping. client’s linguistic requirements and the availa- In the past, she secretly drank in the evenings to bility of interpreters (for more detail on inter- relieve her tension and anxiety. preters, see Chapter 4). Counselors should be Most counselors agree that Beverly is too sub- flexible in designing treatment plans to meet missive and think assertiveness training will help client needs and, when appropriate, should her put her needs first and move out of the draw upon the institutions and resources of family home. However, a female Asian American clients’ cultural communities. Culturally re- counselor sees Beverly’s priorities differently, sponsive treatment planning is achieved saying that “a morally responsible is duty-bound to care for her parents.” She thinks through active listening and should consider that the family needs Beverly’s help, so it would client values, beliefs, and expectations. Client be selfish to leave them. health beliefs and treatment preferences (e.g., Discuss: purification ceremonies for Native American • How does the counselor’s worldview affect clients) should be incorporated in addressing prioritizing the client’s presenting problems? specific presenting problems. Some people seek • How does the counselor’s individualistic or help for psychological concerns and substance collectivistic culture affect treatment plan- ning? abuse from alternative sources (e.g., clergy, • How might a counselor approach the initial elders, social supports). Others prefer treatment interview and evaluation to minimize the in- programs that use principles and approaches fluence of his or her worldview in the evalu- specific to their cultures. Counselors can sug- ation and treatment planning process? gest appropriate traditional treatment resources Sources: The Office of Nursing Practice and to supplement clinical treatment activities. Professional Services, Centre for Addiction and In sum, clinicians need to incorporate culture- Mental Health & Faculty of Social Work, Univer- sity of 2008; Zhang 1994. based goals and objectives into treatment plans and establish and support open client– counselor dialog to get feedback on the pro- client engagement in treatment services, com- posed plan’s relevance. Doing so can improve pliance with treatment planning and recom- mendations, and treatment outcomes.

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4 Pursuing Organizational Cultural Competence

IN THIS CHAPTER Cavin, a 42-year-old African American man, arrived at a well- known private substance abuse treatment center confused and • Cultural Competence at unable to provide his medical history at intake. Referred to the the Organizational Level center through his employee assistance program, he was accom- • Organizational Values panied by his spouse and 14-year-old son. Cavin’s wife provided • Governance his medical history and recounted her ’s 2-year decline • Planning from a promising career as a journalist, researcher, and social • Evaluation and commentator to a bitter, often paranoid man who abused Monitoring and alcohol. Cavin, she explained, had become increasingly un- • Language Services predictable. Workforce and Staff • Upon , Cavin was initially cooperative and grateful to Development his spouse for her efforts, but as withdrawal continued, he became Organizational • increasingly agitated, insisting that he could detoxify on his own. Infrastructure He resisted any intervention by staff members whom he perceived to be critical or patronizing. On his fourth day in treatment, Cavin began to note the treatment center’s “White” environment. There were almost no African American employees—none at the clinical level. He noted how decor reflected only White American culture. Driven in part by his substance use disorder, he was look- ing for reasons to leave. Later that evening, he checked out. Cavin was unable to relate to his treatment. He found no cultural cues with which to identify or connect. Therefore, he started searching for reasons to leave—behavior typical in persons who abuse substances. People often leave treatment with the conscious hope of managing their substance abuse themselves and the un- conscious drive to relive positive experiences associated with sub- stance use; meanwhile, they all too easily forget the pain imposed by the use of alcohol and other substances. Cavin may have re- mained in treatment if services had been more culturally respon- sive. This is an example of how behavioral health programs benefit

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Multidimensional Model for Developing Cultural Competence: Organizational/ Administrative Level

from commitment to culturally responsive ongoing process; it is not something that is services, staffing, and treatment—if they make achieved once and is then complete. Organiza- no such commitment, their services may be tional structures and components change. The underused, unwelcome, and ineffective. demographics and needs of communities change. Employees and their job descriptions Cultural Competence at change. Consequently, the commitment to the Organizational Level increase cultural competence must also involve a commitment to maintain it through periodic At the organizational level, cultural compe- reassessments and adjustments. Based on the tence or responsiveness refers to a set of con- Cross et al. (1989) definition of the culturally gruent behaviors, attitudes, and policies that competent organization, Goode (2001) identi- enable a system, agency, or group of profes- fies three principal components (Exhibit 4-1) sionals to work effectively in multicultural that coincide with Sue’s (2001) multidimen- environments (Cross et al. 1989). Organiza- sional model for developing cultural compe- tional cultural responsiveness is a dynamic, tence in behavioral health services.

74 Chapter 4—Pursuing Organizational Cultural Competence

Exhibit 4-1: Requirements for Exhibit 4-2: Creating Culturally Organizational Cultural Competence Responsive Treatment Environments

• The organization needs a defined set of Organizational values tasks: values and principles, along with demon- • Commit to cultural competence. strated behaviors, attitudes, policies, and • Review and update vision, mission, and structures that enable effective work across value statements. cultures. • Address cultural competence in strategic • The organization must value diversity, planning processes. conduct self-assessment, manage the dy- Governance tasks: namics of difference, acquire and institu- • Assign a senior manager to oversee the tionalize cultural knowledge, and adapt to organizational development of culturally re- diversity and the cultural contexts of the sponsive practices and services. communities it serves. • Develop culturally competent governing and • The organization must incorporate the advisory boards. above in all aspects of policymaking, ad- • Create a cultural competence committee. ministration, and service delivery and - tematically involve consumers and families. Planning tasks: • Engage clients, staff, and community in the Source: Goode 2001. planning, development, and implementation of culturally responsive services. This chapter provides a broad overview of • Develop a cultural competence plan. • Review and develop policies and procedures how behavioral health organizations can create to ensure culturally responsive organiza- an institutional framework for culturally tional practices. responsive program delivery, staff develop- Evaluation and monitoring tasks: ment, policies and procedures, and administra- • Create demographic profiles of the commu- tive practices. Built on the U.S. Department of nity, clientele, staff, and board. Health and Human Services’ (HHS’s) Office • Conduct an organizational self-assessment of Minority Health (OMH) Enhanced of cultural competence. National Standards for Culturally and Language services tasks: Linguistically Appropriate Services in Health • Plan for language services proactively. and Health Care (OMH 2013; for review, see • Establish practice and training guidelines for the provision of language services. Appendix C), this chapter is organized around the Health Resources and Services Workforce and staff development tasks: • Develop staff recruitment, retention, and Administration’s (HRSA’s) domains of organi- promotion strategies that reflect the popula- zational cultural competence: organizational tion(s) served. values, governance, planning, evaluation and • Create training plans and curricula that monitoring, communication (language ser- address cultural competence. vices), workforce and staff development, and • Give culturally congruent clinical supervision. • Evaluate staff performance on culturally organizational infrastructure (Linkins et al. congruent and complementary attitudes, 2002). (Another domain, services and inter- knowledge, and skills. ventions, is covered in Chapter 3.) Organizational infrastructure: Within each domain, specific organizational • Invest in long-range fiscal planning to pro- tasks are suggested to aid program and ad- mote cultural competence. • Create an environment that reflects the ministrative staff in developing a culturally populations served. responsive clinical, work, and organizational • Develop outreach strategies to improve environment (Exhibit 4-2); these domains and access to care. Source: Linkins et al. 2002.

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tasks are adapted to behavioral health services. Cultural competence demands an ongoing Task overlap across domains may require work commitment to openness and learning, taking time and taking risks, sitting with uncertainty on several tasks at once. HRSA’s organizational and discomfort, and not having quick solu- cultural competence assessment profile is avail- tions or easy answers. It involves building able online (http://www.hrsa.gov/cultural trust, mentoring, and developing and nurtur- competence/healthdlvr.pdf; Linkins et al. ing a frame of reference that considers alli- 2002). ances across culture as enriching rather than threatening shared goals. Organizational Values Task: Commit to Cultural Competence Journey Mental Health Center (JMHC), a large outpatient mental health and substance Counselors are typically a part of a larger abuse treatment clinic in , is an organization or system, but the focus on and organization that is committed to providing responsibility for developing culturally respon- accessible, community-focused, culturally sive services has historically fallen on individ- responsive behavioral health services. JMHC ual practitioners rather than on organizations. offers the following commentary on the im- Most literature on cultural competence ad- portance of clear, culturally responsive organi- dresses the cultural awareness, knowledge, and zational values ( JMHC 2013, paragraphs 1-3): skills of the practitioner, but until recently, it has failed to apply these same concepts to …cultural competence is fundamental to providing quality services that promote indi- agencies. Cultural competence among coun- vidual and family strengths, dignity, and self- selors is only as effective as their agencies’ reliance. Cultural competence broadens and commitment to and support of cultural com- enriches the delivery of mental health and petence and ability to value diversity through alcohol and other drug abuse (AODA) ser- culturally congruent administrative practices, vices by providing a more holistic, relevant view of the world and the helping process. including—but not limited to—policies and Cultural competence does not stand apart procedures, programming, staffing, and com- from, but is intrinsic to good clinical practice. munity involvement. Its threads are woven into the tapestry of ef- fective assessment, treatment planning, inter- Counselors are unlikely to affect organization- vention, advocacy, and support. In addition, al change to the same degree as the agency’s cultural competence is intrinsic to effective overall administration can. Hence, culturally staff relationships and business practices. responsive treatment cannot be sustained Cultural competence promotes relationships without an agency’s commitment and support. based upon understanding and knowledge of In fact, the organization itself can prevent how one’s own cultural beliefs and values in- clients from receiving culturally responsive fluence the organization of information, per- ceptions, feelings, experiences, and coping services or treatment opportunities. Organiza- strategies. It involves being able to identify, tions that are unaware of cultural issues can learn from, and incorporate these into the fail to recognize that diverse groups may have helping process. When cultural competence is difficulty accessing and engaging in treatment. an integral part of personal competence, there Also, counselors who attempt to use culturally is the maximum opportunity to increase the amount and quality of information and the responsive practices—such as the involvement speed with which that information can be of family members (as defined by the client) shared and processed and to form healthy al- and traditional healers—can encounter insur- liances. mountable hurdles if their agencies’ policies

76 Chapter 4—Pursuing Organizational Cultural Competence

Organizations that fail to endorse and evolving, respond to unforeseen barriers, and make a commitment to cultural compe- revise innovations that are not working as tence will more than likely displace the intended. It is important that leadership be responsibility of cultural competence onto genuinely committed to the effort and that counselors or clients. If the responsibility is their support be tangibly apparent in the on the clients, it is likely that the clients will allocation of relevant resources. A strong have to “fit” or change to match the treatment or program rather than treat- commitment to improving organizational ment services being adapted to fit the cultural competence should include the obli- needs of clients. gation to monitor procedures after they have been implemented, maintain and reevaluate and resources do not support these practices. new practices, and provide resources and The system can actually impede efforts made opportunities for ongoing training and cultur- by counselors invested and trained in cultural ally competent supervision. competence. Thus, the development of cultural Task: Review and Update Vision, competence begins at the top level of the Mission, and Value Statements organization, with an initial focus on systemic changes. The organization’s mission, vision, and value statements are vitally important in creating a Cultural competence does not occur by acci- that promotes cultur- dent. To maximize its effectiveness in working ally responsive behavioral health services. with diverse groups, the organization must Agencies should examine how these state- first view diversity as an asset. As importantly, ments are developed. Are stakeholders in- the organization must ensure that its process volved in the development process? In what of developing cultural competence has the ways does the organization ensure that its genuine, full, and lasting support of the organ- values and mission reflect the community and ization’s leadership. The chief executive officer populations that it serves? Does the organiza- (CEO), senior management, and board of tion see this task as a singular event, or has it directors play critical roles. A strong mandate planned for periodic review of its values and from the board or CEO, coupled with a com- mission to ensure continued organizational mitment to provide resources, can be a good responsiveness as needs, populations, or envi- motivator for staff and committees to under- ronments change? take major organizational change. Support of cultural competence must be made clear Initially, the planning committee should de- throughout the organization and community termine how the culture of the organization as in meaningful ways, in words and actions. well as the surrounding community can sup- port achievement of the mission and vision Leadership can make a difference in the im- statements. Culturally responsive organiza- plementation of culturally responsive practices tional statements cannot provide a tangible by creating an organizational climate that framework unless supported by community, encourages and supports such practices. This referral, and client demographics; a needs includes a willingness to discuss the im- assessment; and an implementation plan. portance of cultural competence, try new Mission and vision statements need to be practices or approaches, tolerate the uncertain- operationalized through identified goals as ty that accompanies transitional periods dur- well as measurable indicators to track progress. ing which practices and procedures are The Hands Across Cultures Corporation of

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northern New Mexico, which serves Native organizations can begin to gain insight into peoples within pueblos (American Indians), the demands and challenges of providing the City of Española, Pojoaque Valley, and culturally responsive services. Moreover, stra- surrounding communities (predominantly tegic planning is an opportunity to explore Latino), addresses the importance of the and develop short- and long-term goals that cultural context of its work in its mission and focus on incorporating culturally responsive philosophy statements (Exhibit 4-3). delivery systems while addressing issues of sustainability (i.e., how to provide resources Task: Address Cultural and support the implementation of culturally Competence in Strategic Planning responsive policies and procedures over time). Processes A formal strategic planning meeting should be The strategic planning process provides an held to determine specific goals, objectives, opportunity to reevaluate an agency’s values, and tasks that will ensure quality improvement mission, and vision regarding cultural compe- in culturally responsive services. The develop- tence. A comprehensive process involves eval- ment of timelines and methods to evaluate uating the organization’s internal and external progress, obstacles, and directions for each environments prior to holding planning meet- goal are equally important. For organizations ings; this evaluation involves conducting staff, that do not have a specific cultural competence client, and community assessments. From plan prior to the strategic planning meeting, assessing current needs to evaluating global this process can provide the forum for devel- factors that influence the direction and deliv- oping the steps needed to create a formal plan. ery of services (e.g., funding sources, treat- ment mandates, changes in health insurance), Governance Task: Assign a Senior Manager To Exhibit 4-3: Hands Across Cultures Oversee the Development of Mission Statement Culturally Responsive Practices Mission and Services To improve the health, education and well being of the people of Northern New Mexico From the outset, a senior staff member with through family-centered approaches deeply the authority to implement change should be rooted in the multicultural traditions of their assigned to oversee the developmental process communities. of planning, evaluating, and implementing Philosophy culturally responsive administrative and clini- To believe in culture as the foundation of cal services. Key responsibilities include the human growth; spirituality as the strength of the people; each person’s need to and be ongoing development and facilitation of cul- loved; family preservation; individual responsi- tural competence committees and advisory bility; and the pursuit of human potential. boards, management of evaluative processes, With a firm commitment to these beliefs, facilitation of the development of a cultural Hands Across Cultures’ Board of Directors, competence plan and its implementation, and staff, and collaborators hold that: oversight of policies and procedures to ensure Culture Is the Cure cultural competence within the organization La Cultura Cura and among staff. Cultural competence cannot come to fruition with only one voice being Source: Hands Across Cultures 2014. heard, but assigning a key person to oversee

78 Chapter 4—Pursuing Organizational Cultural Competence

the process will more likely keep top-priority other community agencies. Moreover, this goals and objectives in view. board can help identify community leaders and culturally appropriate resources for the Task: Develop Culturally client population to supplement treatment Competent Governing and activities, such as traditional healing practices Advisory Boards (Castro et al. 1999a). The advice box on the Beyond having the foresight to plan for and next page reviews strategies for engaging develop culturally responsive services, it is vital communities in the development of culturally that executive staff members on governing and responsive services. advisory boards and committees are educated Task: Establish a Cultural about and invested in the organization’s mis- Competence Committee sion and plan. For example, the board’s hu- man resources committee may be more By creating a committee within the organiza- invested in developing and reinforcing cultur- tion to guide the process of becoming cultur- ally responsive recruitment and hiring policies ally competent and responsive, the and practices if they are involved in the strate- organization ensures that a core group will gic planning process and educated about the provide oversight and direction. This commit- organization’s mission, values, and vision. At tee should be inclusive not only in terms of the same time, the organization should seek the racial and ethnic composition of the popu- outside direction. Given that sharing infor- lation served, but also in terms of drawing mation about the agency’s activities with from all levels of the organization (Whaley others outside the organization can create and Longoria 2008). Representatives of the some hesitancy or be a potential barrier, the advisory board should also be included. Pro- executive staff can frame the planning process gram administrators should provide direction as an opportunity for positive development to the cultural competence committee. The and community involvement as a powerful person assigned to take the lead on cultural resource. The organization should establish a competence should chair the committee, and community advisory board that includes the CEO should be noticeably involved. stakeholders, specialists, and/or experts in The cultural competence committee will multicultural behavioral health services along oversee the organization’s self-assessment with key administrators and staff. This adviso- process while also creating the demographic ry board should consist of local community profile of the organization’s community, devel- members from whom the organization can oping a cultural competence plan, and formu- solicit valuable advice, input, and potential lating and monitoring procedures that evaluate support for the development of culturally the implementation and effectiveness of the responsive treatment ( Department organization’s plan in developing culturally of Human Services 2004). responsive services and practices. The commit- Representation should include clients, alumni, tee should ensure that the organization’s plans family members, and community-based are continually updated. To succeed, this team organizations and institutions (e.g., commu- must be empowered to influence, formulate, nity centers, faith communities, social service implement, and enforce initiatives on all levels organizations). Developing an inclusive advi- and throughout every department of the sory board of community members can en- organization (Constantine and Sue 2005; hance and extend use of and referral from Fung et al. 2012), including, for example,

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Advice to Administrators: Strategies To Engage Communities in Developing Culturally Responsive Treatment Services

• Ask board members to help recruit key members of the local community. • Create a community advisory group to complement the governing boards in assessing and recommending culturally responsive policies, procedures, and practices. • Develop local community focus groups to discuss key treatment needs, health beliefs, and atti- tudes and behaviors related to substance use, mental illness, and help-seeking that could be un- known to others outside of the community and in the organization. • Develop a policy that supports the use of culturally congruent communication modalities and technologies for sharing information with communities. • Provide inservice training, continuing education, and other professional development activities (e.g., networking events) that focus on strengthening skills for collaboration with culturally and linguistically diverse communities. • Develop policies and procedures to support community involvement in the treatment setting (e.g., incorporating peer support programs, having a presence at community housing events, developing partnerships with traditional healers). • Develop local outreach and educational programs in multiple languages (e.g., provide family education on substance use patterns and community issues in Spanish at a community center). • Participate in community events to raise awareness of services, to develop trust and build rela- tionships, and to gain further knowledge of local cultural groups and community practices. • Periodically analyze community demographic trends and populations served by the treatment organization; ensure representation of these diverse populations on the advisory board. • Become knowledgeable about and use available local goods and services. Sources: Goode 2001; National Center for Cultural Competence 2013; Washington State De- partment of Social and Health Services 2011.

presenting data and subsequent recommenda- appear less time consuming, complex, and tions to the administration and boards based expensive, but it can also represent paternalism on employee feedback about their experiences whereby organizations or administrators with newly adopted, culturally responsive assume that they inherently know what is best procedures in the organization. Exhibit 4-4 for the program, clients, staff, and community. highlights key issues in behavioral health Instead, organizations and the services that treatment that must be addressed in providing culturally responsive services. Exhibit 4-4: Critical Treatment Issues To Consider in Providing Culturally Planning Responsive Services • Access: Degree to which services for clients Task: Engage Clients, Staff, and are quickly and readily available. • Engagement: Having appropriate skills and the Community in the Planning, an environment that have a positive per- Development, and sonal impact on the quality of clients’ Implementation of Culturally commitment to treatment. • Retention: The result of quality services Responsive Services that help maintain clients in treatment with Organizations can sometimes have the best continued commitment. intentions of creating culturally responsive Source: The Department of Chil- services but miss the mark by operating in a dren and Families, Office of Multicultural Affairs 2002. vacuum. Initially, the vacuum approach can

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they provide need to be congruent with the out some means of compensating for addi- specific populations being served; clients and tional work, perceive themselves as powerless the community should have an opportunity to over the proposed changes, or minimize the provide input on how services are delivered need to make any immediate changes. For and the types of services that are needed. example, staff members may view changes as Otherwise, services may be poorly matched to temporary or a phase and believe that the clients, underused by the community, and organization will focus on other issues or new detrimental to agency financial resources. For directions once the pressure or attention on example, an agency could decide that family this specific issue subsides. therapy is a culturally appropriate service and proceed to create a multifamily program Task: Develop a Cultural (treating several families together in a group Competence Plan ) without considering that, for some To ensure the delivery of culturally responsive cultural groups, family shame associated with services, it is important to develop a cultural seeking help can deter the use of such services. competence plan (see the “Criteria for Devel- Staff members are likely to have specific oping an Organizational Cultural Compe- knowledge of client needs and to be able to tence Plan” advice box on the next page). identify potential obstacles or challenges in Using demographic data and an organizational how an organization attempts to implement self-assessment (including community and culturally responsive policies and procedures. advisory board input), the organization’s cul- A parallel process that can influence the po- tural competence committee can begin writing tential success of staff involvement and com- an organizational plan for improving cultural mitment to the development of cultural competence. The committee will need to competence is the organizational culture. assign staff members to research and write Suppose, for example, that the staff perceives each component of the plan, which should the organization’s new commitment to cultural outline specific objectives, means of achieving competence as another expectation of more these objectives, and recommend timelines work without training, adequate clinical and processes for evaluating progress. The supervision, or ongoing support. Maybe staff plan should contain at least the following components: members have historically experienced fre- • quent announcements, mandates, or excite- A narrative introduction that covers com- ment generated by the administration that munity demographics and history, organi- fade quickly. Perhaps the organization ar- zational self-assessment and other ranges committees and meetings, purporting evaluation tools, the rationale for provid- that they want staff input despite the fact ing culturally responsive services, and the that decisions have already been made. organization’s strengths and needs for im- provement in providing services that are The organizational climate sets the stage for responsive to client cultural groups; a brief staff responsiveness and motivation in devel- overview of current priorities, goals, and oping cultural competence and in implement- tasks to help the organization develop and ing culturally responsive services. Without an improve culturally responsive clinical ser- organizational history and culture of support- vices and administrative practices is also ing change across time, staff members will advisable. likely resent an increase in expectations with-

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Advice to Administrators: Criteria for Developing an Organizational Cultural Competence Plan Using the core elements of access, engagement, and retention as criteria in developing a cultural competence plan, the following recommendations are offered: • Develop a thorough knowledge and understanding of the social, cultural, and historical experi- ences of the community of people your agency is serving. • Identify and clearly articulate an understanding of the ethnic, cultural, linguistic, and social groups in the area your agency serves. • Document, track, and evaluate/assess the reasons why clients are not accepted for services. • Know the demographics of clients within the program and their rates of program completion. • Keep profiles of clients who do not complete services. • Design steps for your agency to take to remove identified barriers that keep clients from using your agency’s services. • Establish steps your agency will implement or sustain to create a consumer-friendly environment that reflects and respects the diversity of the clients that use your services. • Establish internal criteria the agency will use to measure the impact of the services and programs that it offers.

Source: The Connecticut Department of Children and Families, Office of Multicultural Affairs 2002.

• Strategies for recruiting, hiring, retaining, (e.g., training, language services, program and promoting qualified diverse staff. development, organizational infrastructure). • Resources and policies to support language • Guidelines for implementation that de- services and culturally responsive services. scribe roles, responsibilities, timeframes, • Methods to enhance professional devel- and specific activities for each step. opment (e.g., staff education and training, The committee must determine how to over- peer consultation, clinical supervision) in see the plan (e.g., by tracking accomplish- culturally responsive treatment services. ments, obstacles, and remediation strategies). • Mechanisms for community involvement, Who will develop and revise guidelines for beginning with the development of a treatment planning, introduce new guidelines community advisory board and cultural to the staff and provide counselor training, and competence committee and including coordinate revisions with the information community participation in relevant technology specialist or department? treatment activities or in support of treat- ment services (e.g., spiritual direction). Task: Develop and Review Policies • Approaches to amending facility design and Procedures To Ensure and operations to present a culturally con- Culturally Responsive gruent atmosphere. • Identification of and recommendations for Organizational Practices culturally and linguistically appropriate In essence, policies and procedures are the program materials. backbone of an organization’s implementation • Programmatic strategies to incorporate of culturally responsive services. By creating, culturally congruent clinical and ancillary reviewing, and adapting clinical and adminis- treatment services. trative policies and procedures in response to • Fiscal planning for funding and human the ever-changing needs of client populations, resources needed for priority activities the agency is able to provide counselors and

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other workers with support and the means to If an organization fails to develop culturally respond in a consistent, yet flexible, manner. responsive policies or procedures yet claims to Programs are likely to have the foresight to endorse or support culturally responsive ser- develop relevant policies and procedures vices, counselors and staff members will likely through the planning and evaluative processes carry the entire burden of implementing these outlined in this chapter, but it is unlikely that services and will face numerous obstacles that they will anticipate every situation. Thus, could prevent the delivery of responsive ser- ongoing flexibility is paramount. vices. Take, for example, a counselor from a county-funded program who was directed by When putting together an organizational her supervisor to complement her counseling cultural competence plan, providers should be approach with the client’s traditional healing careful to follow the requirements set by state beliefs and practices. The agency did not licensing boards, accreditation agencies, and provide staff support, have policies or proce- professional organizations that oversee certifi- dures consistent with this request, or exhibit a cation and licensing of treatment profession- willingness to adapt current procedures to als. Much of the push for cultural competence meet the client’s needs. The counselor had throughout the healthcare field is in response difficulty following this direction because of to the mandates of accrediting agencies, fun- barriers in finding an appropriate traditional ders, and managed care organizations. These practitioner in the local area, coordinating entities have standards and guidelines that services, establishing and securing confidenti- state minimum expectations for client rights, ality for the client and with the practitioner program structure, and staffing, along with (including educating the practitioner about treatment content and conditions. Behavioral confidentiality), arranging transportation for health organizations, including substance the client, obtaining a stipend for services, and abuse treatment programs, must meet these discerning how and when to incorporate the standards to be accredited by national organi- traditional practice into the treatment milieu. zations and compensated by funders. Counselors who feel that they have been left Although many accrediting bodies require a to go it can view implementation of cultural competence plan that is assessed as part culturally responsive practices as an insur- of the accreditation process, their requirements mountable challenge when the agency pro- can be minimal. Consequently, organizations vides limited support or fails to endorse should go beyond such requirements in their adaptive policies that are congruent with the own thinking and planning to ensure that they needs of the client population. Counselors are responding adequately to the needs of the may have high motivation to incorporate communities they serve. Above all, are the culturally responsive care but find themselves policies, procedures, and systems of care suited without appropriate agency resources, permis- to the served populations? Do policies reflect sion, or infrastructure to implement it. By the organization’s commitment to cultural developing and endorsing culturally responsive competence in administrative practices? For policies and procedures, an organization can example, are strategies for professional devel- provide carefully thought-out strategies and opment, personnel recruitment, and retention processes to help staff members provide real- of culturally competent staff members reflec- time responsive services. Well-defined policies tive of the populations and cultures that they and procedures reinforce commitment to and serve? expectations of cultural competence.

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Evaluation and Monitoring census data and national centers (e.g., Bureau of Labor Statistics) or through local sources, To develop a viable cultural competence plan, including the , city hall, or the county information must be gathered from all levels commissioner’s office (Whealin and Ruzek of the organization, from clients and commu- 2008). Community demographics can provide nity, and from other stakeholders. Beginning a quick benchmark on how well an agency with acquiring initial demographic data from serves the local community and how the the populations that are or could be served by community is represented at all levels of the the agency and extending to soliciting feed- organization. A demographic profile should back from various stakeholders, gathering also summarize information about clinical, information prior to plan development helps medical, and nonclinical staff members as well the organization provide direction and deter- as board members. Other information can also mine priorities. Gathering information also be helpful for specific agencies, as can hiring a allows ongoing monitoring and feedback consultant to gather demographic information regarding the plan’s effectiveness and areas in and conduct the organization’s self-assessment need of improvement. Areas of evaluation and of cultural competence to limit bias; however, monitoring can include a demographic profile lack of funding can prohibit this possibility. of the client, community, staff, and board Task: Conduct Organizational Self- constellations; community needs assessment; client, family, and referral feedback; adminis- Assessment of Cultural trative, clinical, medical, and nonclinical staff Competence assessments; and more (American Evaluation An organization must have an awareness of Association 2011; LaVeist et al. 2008). how it functions within the context of a multi- Task: Create a Demographic cultural environment, evaluating operational Profile of the Community, aspects of the agency as well as staff ability and competence in providing culturally con- Clientele, Staff, and Board gruent services to racially and ethnically di- Intake, admission, and discharge data provide verse populations. Therefore, an agency should a good starting point for determining the assess how well it currently provides culturally demographics of current populations being responsive treatment. An honest and thorough served. Programs would likely benefit from organizational self-assessment can serve as a developing a demographic summary for each blueprint for the cultural competence plan population served, consisting of age, gender, and as a benchmark to evaluate progress race, ethnic and cultural heritage, religion, across time (National Center for Cultural socioeconomic status, spoken and written Competence 2013). To review a sample as- language preferences and capabilities, em- sessment guide, refer to Appendix C. ployment rates, treatment level, and health The importance of organizational self- status (HHS 2003b). With adequate resources, assessment cannot be overstated. Thorough, the organization can generate reports dating reliable, valid evaluations can gauge the effec- back 5 years to determine program trends. tiveness of an agency’s services, structure, and Agencies should also gather demographic practices (e.g., clinical services, governing information on groups in the agency’s local practices, policy development, staff composi- community (Hernandez et al. 2009). This tion, and professional development) with information can be easily obtained through culturally and racially diverse clients, staff, and

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communities. More and more, public and improvement regarding the function of the private funding sources—as well as accrediting organization and the needs of its community. bodies—use an organization’s self-assessment Step 2: Adopt a self-assessment guideline for as a means of measuring compliance, effec- organizational cultural competence (see tiveness, or quality improvement practices. Appendix C). A self-assessment can seem intensive in terms Step 3: Determine the feasibility of using of both labor and capital, but in the long run, consultants and/or external evaluators to it can guide an organization’s quality im- select, analyze, and manage assessment. provement process more efficiently by helping it provide the most relevant services at the For many organizations, hiring outside con- right time. Gathering feedback from many sultants is financially prohibitive. Nonetheless, internal and external sources gives agencies the cultural competence committee could considerable information needed to effectively recommend hiring outside evaluators and evolve as a culturally responsive organization, consultants to help them plan, conduct, and including data on current performance, areas assess the results of the organizational self- needing improvement, and development evaluation. The committee should ensure that needs. In the initial self-assessment, an or- consultants understand the population being ganization should obtain demographic in- served by the treatment facility. This means formation and seek feedback from key understanding the population’s cultural groups stakeholders—including community mem- across dimensions: language and communica- bers, clients, families, and referral sources tion, cultural beliefs and values, history, socio- (e.g., probation and parole offices, family and economic status, education, gender roles, child services, private practitioners)—and substance use patterns, spirituality, and other from all levels of the organization, including distinctive aspects. Candidates should be able administrative, managerial, clinical, medical, to articulate a clear understanding of cultural and support staff. The following steps are competence (American Evaluation Association recommended to help an agency gain the 2011). If consultants will train staff, they information necessary to guide and support should have specific knowledge and profi- the development of its cultural competence ciency in training development and delivery. plan. If financially feasible, it can be useful for the Step 1: With the advisory board and cultural agency to consider using more than one con- competence committee, identify key stake- sultant and to invite each prospective consult- holders who can provide valuable feedback ant to present their qualifications to the board about current strengths and areas in need of of directors and/or to a cultural competence

The Consumer Assessment of Healthcare Providers and Systems Cultural Competence Item Set This assessment tool evaluates provider cultural competence through client surveys. It helps identify strengths and weaknesses of individual behavioral health service providers and organizations, aids in provider comparisons, and assesses the extent to which client responses differ based on race, ethnicity, or primary language. The surveys are available online through the Agency for Healthcare Research and Quality (https://cahps.ahrq.gov/clinician_group/), as is an overview and instructions (https://cahps.ahrq.gov/surveys-guidance/hp/instructions/index.html).

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committee so that the best match can be backgrounds; language preferences; and com- achieved between the agency’s needs and the munity accessibility (e.g., rural versus urban). consultant based on his or her expertise, cost, Appendix C provides standards and lists the and consulting style. If a consultant is hired, items that should be included in evaluating an the organization should establish guidelines agency and its services. Additional resources for working closely with that person, including for provider and organizational assessment of reporting requirements to the cultural compe- cultural competence are available through the tence committee. The organization must National Center for Cultural Competence retain ownership of the process and provide (http://nccc.georgetown.edu/) and the Hogg clear oversight and guidance. Foundation for Mental Health (http://www.hogg.utexas.edu/index.php). Step 4: Select assessment tools suitable for each stakeholder group (e.g., clinical staff, Step 5: Determine distribution, administra- agency referrals, clients). Several self- tion, and data collection procedures (e.g., assessment tools are available, including confidentiality, participant selection methods, checklists and surveys, for use in evaluation or distribution time frames). Whatever methods as development guides. To date, most instru- are used to gather data for the self-assessment ments available have limited empirical support process, it is critical to explain the context of (Delphin-Rittmon et al. 2012b; Shorkey et al. the assessment to all participants. They need 2009). to know why the assessment is being conduct- ed and how the information they give will be More often than not, surveys and feedback used. Confidentiality can be a major concern questionnaires will need to be individually for some respondents, especially staff members developed and tailored to the organization and and clients, and every effort should be made to stakeholder group depending upon setting; address this concern. Ideally, the evaluation available resources; racial, ethnic, and cultural

Advice to Administrators: Gathering Feedback From Clients, Community Members, and Referrals Agencies should incorporate a client satisfaction survey into the assessment process. This survey should include questions to help determine whether clients believe that the organization relates well to persons of their ethnicity or race and gives them an opportunity to pinpoint problem areas. To review a sample assessment tool for clients, refer to the Cultural Understanding Assessment– Client Form (White et al. 2009), available in Appendix C. The tool is also available in Spanish.

If desired, external consultants can conduct interviews with a representative sample of clients, family members, and local community members. The key question should be “What can the treatment provider do to be more responsive to community needs?” The survey process can be as simple as a questionnaire, or it can involve interviews or focus groups with key people in touch with community issues. It can also be helpful to obtain a small but representative sample of community members at large to determine their level of awareness of the services available and their perceptions of the treatment agency based on what they have heard. Information from people not in treatment can be revealing and could suggest areas in which publicity is needed to counter misinformation. Likewise, facilitators can develop, from the information gathered, a map that highlights where people go to receive various services (Center for Substance Abuse Prevention 1995). The agency could also ask their sources of referrals, such as faith-based organizations, community agencies, or primary care physicians, whether they are referring clients to the agency, and if not, why. It is important to know who is not walking through the door.

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instrument(s) should be administered by an changes that will be made based on the find- objective third party, such as a consultant or a ings of and the priorities established through member of the cultural competence commit- this assessment. tee. Staff members should be asked about their Step 7: Establish priorities for the organiza- attitudes toward cultural issues with the un- tion and incorporate these priorities into the derstanding that their attitudes are not neces- cultural competence plan. After obtaining the sarily indicative of the degree to which the results of the self-assessment process, the staff mirrors the cultural groups served. In organization—including boards, cultural soliciting community feedback, the more competence committee, community stake- credibility the organization has in the com- holders, and staff members—needs to estab- munity, the higher the return rate will likely lish realistic priorities based on the current be. The lower the credibility, the more the needs of clients and the community. Signifi- organization needs to reassure respondents cant consideration should be given to the level that it intends to listen to, and act on, what it of influence any given priority could have in hears. If many survey forms are to be distrib- effecting organizational change that will uted, the organization could consider hiring improve culturally responsive services. Some students or community members on a tempo- priorities will require more planning to im- rary basis to make follow-up or reminder calls. plement and can involve more financial and Step 6: Compile and analyze the data. The staff resources, whereas other priorities will be process of reviewing and assessing data should easier to implement from the outset (e.g., be overseen by the cultural competence com- hiring culturally competent counselors who mittee. Basic data analysis procedures should are bilingual versus translating intake and be used to ensure the accuracy of results and program forms). Therefore, long- and short- credibility of reported information. For most range priorities should be established at the well-designed instruments, there are relatively same time to maintain the momentum of simple and appropriate ways to present data. change in the organization. All available data should be assembled in a Step 8: Develop a system to provide ongoing report, along with interpretive comments and monitoring and performance improvement recommended action steps. The report should strategies. Similar to the clinical assessment note areas of strength and needed improve- process with clients, the organizational self- ment and should offer possible explanations assessment is only valuable if it provides guid- for any shortcomings. For example, if the ance, determines direction and priorities, and community is 20 percent African American, facilitates action. Assessment is not a one-time but only 2 percent of the agency’s clientele are activity. It is important to continue monitoring African American, what are some possible to identify barriers that may impede the full explanations for this group’s apparent un- implementation of the cultural competence deruse of services? It is also particularly im- plan, to evaluate progress and performance, portant to share results with those who and to identify new service needs. Establishing participated in the assessment process. Find- a system to monitor an organization’s cultural ings should be made available to staff, clients, responsiveness equips it with the information community members, boards, and managers. necessary to formulate strategies to meet new This increases overall sense of ownership in demands and to continuously improve quality the assessment and cultural competence devel- of services. opment process and in implementing the

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Language Services Planning for language services is crucial, and the need for these services must be assessed by Task: Plan for Language Services staff members who have initial contact with Proactively clients, their family members, and/or other individuals in their support systems (American An organization must anticipate the need for Psychological Association [APA] 1990, 2002). language services and the resources required to If frontline administrative and clinical staff support these services, including funding, staff members are bilingual, the initial screening composition, program materials, and transla- and assessment process can begin uninter- tion services. Assessing the language needs of rupted. If this is not the case, receptionists or the population to be served is essential. Upon frontline clinical staff members should at least determination, the foremost task is letting be familiar with some rudimentary phrases in clients with limited English proficiency know the preferred languages of their client base. that language services are available as a basic The conversation can be scripted so that they right for a client. Treatment providers need to can convey their limited ability to speak the plan for the provision of linguistically appro- client’s language, obtain contact information priate services, beginning with actively recruit- and inquire about language service needs, and ing bicultural and bilingual clinical staff, inform the client that someone who can speak establishing translation services and , the language more fluently will be made avail- and developing treatment materials prior to able to facilitate the initial screening process. client contact. Although it is not realistic to Most importantly, procedures should be in anticipate the language needs of all potential place to provide pretreatment contact and clients, it is important to develop a list of follow-up in the client’s language to bridge the available resources and program procedures gap between initial contact and subsequent that staff members can follow when a client’s arrangement of language services. language needs fall outside the organization’s usual client demographics (The Joint Written and illustrated materials or a video Commission 2009). about the program in the languages spoken by the client population should be available to How To Inform Clients About answer frequently asked questions. All materi- Language Assistance Services als given to clients, family members, and community members should be available in • Use language identification or “I speak…” cards. their primary languages. It is preferable to • Post signs in regularly encountered lan- develop the materials initially in those guages at all points of entry. languages rather than simply translating mate- • Establish uniform procedures for timely, rials from one language to another. Along effective telephone communication be- with language, one should also consider the tween staff members and persons with lim- ited English proficiency. level of literacy of the group in question. Some • Include statements about the services clients may be functionally illiterate even in available and the right to free language as- their native languages. Materials should sistance services in appropriate non-English graphically reflect the population served languages in brochures, booklets, outreach through pictures or photographs, using ethnic materials, and other materials that are rou- tinely distributed to the public. themes and traditional elements familiar to the target audience. Also, materials should be Source: OMH 2000. tested with the populations with whom they

88 Chapter 4—Pursuing Organizational Cultural Competence will be used, perhaps through focus groups, to to identify and disclose dual relationships to ensure that they communicate effectively. supervisors immediately and on supervisors to assess and determine the appropriateness of Task: Establish Practice and using certain translator. Once a selection has Training Guidelines for the been made, a confidentiality agreement should Provision of Language Services be signed. Organizations need to provide Key issues to consider in implementing and information routinely to clients about their overseeing language services within an organi- confidentiality rights in using language ser- zation include staff monitoring of language vices. Implementing a procedure for handling proficiencies, selection of translators and client grievances is also recommended. interpreters, confidentiality issues, and train- In planning for the use of language services, ing needs. First, agencies need to assess lan- organizations should initially provide training guage proficiencies among staff members and for staff on how to incorporate these services encourage them to learn a language relevant to and should familiarize translators and inter- the population served. At a minimum, staff preters with the clinical setting, terminology, members should acquire in the given language behavioral expectations, and content related to some basic terminology and phrases that are behavioral health (see the “Training Content commonly used in the treatment setting. for Language Service Personnel” advice box In recruiting and hiring translators and inter- on the next page). The language of mental preters, administrative staff members should health and substance abuse services requires an consider experience, motivation, skill level, additional degree of specialization. Experi- mastery of English, and fluency in the lan- enced translators and interpreters who are guage in need of interpretation (OMH 2000; unfamiliar with concepts of addiction, illness, American Translators Association 2011). Be and recovery could convey information ade- aware, however, that there can be considerable quately from a linguistic perspective but not variation in dialects and levels of proficiency accurately convey the intent or meaning of within the language, and these must be de- clinically oriented information or dialog. termined in the selection process. To supple- Various training approaches can be used, ment hiring practices, administrative policies including role-plays mirroring intakes, evalua- should provide a means for determining the tions, and counseling sessions; indirect expo- credentials of any language services organiza- sure to client sessions through audio or video tions (Appendix F lists American Translators recordings of sessions or viewing from an Association credentialing information). observation room; direct observation by sitting in on a session, if appropriate; and consulta- Other important hiring issues revolve around tion with other experienced language service potential ethical dilemmas. In particular, care providers and clinical staff. Using other expe- should be taken in using interpreters from the rienced translators and interpreters for train- local community, which can create potential ing and/or for consultations, as well as sharing challenges with confidentiality and dual rela- experiences in a peer support format, can be tionships (e.g., the interpreter may also be very beneficial for new language service client’s or neighbor). Policies should providers. place the burden on language service providers

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Organizations must also create opportunities exactly match the words or meaning of the for translators and interpreters to inquire client’s language or culture by becoming more about and clarify clinical content and mean- descriptive, taking longer to deliver the mes- ing. Language service providers often attempt sage in an effort to match the intent of a to convey terminology or concepts that do not specific word or concept in English. Workforce and Staff Advice to Clinical Supervisors and Administrators: Training Content for Development Language Service Personnel Task: Develop Staff Recruitment, Translators and interpreters need additional training to work in a clinical setting. Initial Retention, and Promotion training should include: Strategies That Reflect the • General mental health and substance abuse information. Populations Served • Introduction to behavioral health services. To determine whether it adequately reflects • Familiarity with interviewing and assessment questions, instruments, and formats. the population it serves, an organization has to • Legal and ethical issues, including confi- assess its personnel, including counselors, dentiality and professional boundaries. administrators, and board of directors. Ac- • Relevant programmatic policies and pro- cording to a 10-year study that collected data cedures. on treatment admissions, racial and ethnic • Review of program materials, forms, ques- tionnaires, and other written clinical mate- composition of treatment populations has not rials that clients receive during the course significantly changed. Racially diverse groups of treatment. (excluding non-Latino Whites) represent • Knowledge of technical vocabulary relevant approximately 40 percent of treatment admis- to the behavioral health field. sions (Substance Abuse and Mental Health • Emphasis on the importance of accurate interpretation and translation without addi- Services Administration [SAMHSA] 2011c), tions or omissions. yet 80 percent of counselors are non-Latino • Behavioral and professional guidelines on Whites (Duffy et al. 2004). In striving to how to manage potential client reactions in improve cultural responsiveness, staff compo- and outside the session (e.g., outward dis- sition should be a major strategic planning plays of anger or hostility; grief reactions; disclosing information to the translator with consideration. As much as possible, the staff a request to keep it a secret from clinical should mirror the client population. staff; discomfort with translator’s biologi- cal, social, and/or demographic character- Nevertheless, providers should avoid hiring istics, such as gender orientation, age, or “ethnic representatives,” which means hiring a socioeconomic status ). single person from an ethnic or cultural group • Importance of in dialog and expecting him or her to serve as the cul- between translator and client, including tural resource on that group for the entire how questions are asked. • General guidelines on how to handle staff. This can be burdensome, if not offensive, personal issues that can be elicited by par- to that person. Belonging to a group does not ticipation in the intake, assessment, and ensure cultural responsiveness toward, treatment processes, including identifica- knowledge of, or skill in working with mem- tion with similar clinical issues (e.g., sub- bers of that group, nor does it guarantee that stance use patterns, family dynamics, traumatic events, emotional distress). the person culturally identifies with that cul- tural group or its heritage. Hiring ethnic

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“Improving the workforce to provide (Anderson et al. 2003; Brach and Fraser 2000; competent services to diverse populations Lie et al. 2011). The organization should be goes far beyond merely increasing the prepared to offer relevant professional devel- number of individuals from each of the respective groups. While this is clearly an opment experiences consistent with counselors’ important strategy, there is a need not personal goals and assigned responsibilities as only to increase the numbers but also to well as the organization’s goals for culturally improve the quality of training for all responsive services. Board members, volun- clinicians, regardless of their racial, ethnic, teers, and interpreters should all receive ap- cultural, or linguistic background. This also propriate training. includes the necessity to recruit, train, and support interpreters.” A professional development training plan (Hoge et al. 2007, p. 192). details the frequency, content, and schedule for staff training and continuing education. Be- cause becoming culturally competent is a representatives undermines the expansion of process, training and support for engaging in diversity at all organizational levels and the culturally responsive services can be more importance of developing opportunities for all appropriate when delivered across a period of staff members to gain awareness and improve time involving follow-up sessions rather than their ability to effectively work with clients. through a single session. Outcome research Some organizations struggle to find multicul- that evaluates the effectiveness of cultural tural staff members that represent the diversity competence training materials, format, and of their communities and clienteles. If re- content in mental health services, including cruitment is perceived as an immediate short- treatment for substance use disorders (Bhui et term goal, ongoing difficulties are likely in al. 2007; Lie et al. 2010), is limited. Nonethe- hiring, promoting, and retaining a diverse staff. less, numerous resources have suggested that Instead, recruitment strategies need to em- effective cultural training does feature certain brace a more comprehensive and long-term qualities (Exhibit 4-5). approach that includes internships, marketing Sometimes, staff members will express re- to those interested in the field at an early age, sistance to participation in training activities mentoring programs for clinical and adminis- aimed at promoting cultural competence— trative roles, support networks, educational they may feel forced to learn about cultural assistance, and training opportunities. competence, or they may feel unable to take Task: Create Training Plans and the time away from their clients to attend the Curricula That Address Cultural “The learning objectives of a professional Competence development program should include awareness- and knowledge-based objec- The primary purpose of training is to increase tives and skills-based objectives that cultural competence in the delivery of services, motivate students to explore personal beginning with outreach and extending to perspectives and multiple worldviews, continuing care services that support behav- understand and embrace culturally com- ioral health. Training should increase staff petent health promotion strategies, and self-awareness and cultural knowledge, review engage in self-directed competency culturally responsive policies and procedures, development.” and improve culturally responsive clinical skills (Perez and Luquis 2008, p. 178).

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Exhibit 4-5: Qualities of Effective Cultural Competence Training The qualifications of the trainer, the selection of training strategies, and the use of reputable training curricula are extremely important in developing culturally competent staff and responsive services. The following concepts should be considered in the development and implementation of cultural training: • Cultural training should begin with educating new staff members about the organization’s vision, values, and mission as related to culturally responsive services. Orientation should address the demographic composition of clientele, policies and procedures for cultural and linguistic ser- vices, counseling and performance expectations for assessment, treatment planning, and deliv- ery of culturally responsive services. • Before developing and initiating a training plan for culturally responsive services, ask staff mem- bers about their training needs specific to the cultural groups that they serve. Receptivity will likely increase if managers and administrators involve clinical staff in the planning process rather than assuming that they know exactly what staff members need regarding cultural training. • Training should occur across time, and a training plan should detail how to provide training for new employees. Too often, trainings occur at one time, ignoring the complexity of cultural groups and suggesting that one training session is sufficient to achieve cultural competence. Cultural competence evolves from ongoing professional development. • Training should incorporate diverse learning strategies, including experiential learning and cultural immersion when appropriate (e.g., participation in community activities, role-plays, case presentations). Training should be experientially based and process oriented, allowing self- reflection as part of the training and assigning self-reflection activities between training sessions (see the how-to box on self-reflection on the next page). • Training should provide information that is practice- or research-based to ensure that partici- pants see it as reputable and clinically sound. • Training should create a welcoming, nonjudgmental, and professional atmosphere in which staff members, regardless of race, ethnicity, or cultural group, have the freedom and safety to ex- plore their own beliefs and to learn about other cultural groups. Training efforts should not scapegoat mainstream cultural groups or make general statements about specific racial or ethnic groups without noting that there are many cultural subgroups within a given racial or ethnic group—often characterized by, but not limited to, geographic location, socioeconomic status, or educational levels. Participation guidelines should be clarified for each training. • Training should be conducted by an interdisciplinary, multicultural training team that is experi- enced in training and well versed in cultural competence. • Trainers should allow time for staff members to ask questions and process the presented materi- als and experiential exercises, and they should use staff questions and exercises to explore and correct misperceptions in a nonjudgmental manner.

Sources: Brach and Fraser 2000; Dixon and Iron 2006; Gilbert 2003; Pack-Brown and Williams 2003; Roysircar 2006; Russell 2009.

trainings. Others might object on the grounds cess, and use this premise to introduce the that they treat everyone equally, thus ignoring need for training centered on culturally re- their own cultural blindness. sponsive care. Some staff members may re- spond to incentives or predetermined The organization’s leadership needs to address objectives and criteria reflected in employee staff reluctance and concerns regarding train- performance evaluations. Others may be more ing through initial education on the rationale motivated by opportunities that arise from the for cultural competence. Assume that staff organization’s commitment to culturally re- members are invested in creating the best sponsive services or by other factors, such as opportunities for their clients to achieve suc- specialized training and supervision, the

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How To Engage in Self-Reflection: A Tool for Counselor Training and Supervision Ask participants to preselect three clients whom they are currently counseling and will likely continue to counsel prior to the next training or supervision session. Selection should be based on clients’ diversity in age, race, gender, ethnicity, socioeconomic status, education, and/or geographic loca- tion. After each participant has selected three clients (remind participants not to disclose actual client identity if this is an external training outside of the agency), ask them to keep a self-reflection journal wherein the number of entries coincide with each client session until the next training. Partic- ipants should write about their internal process, including reactions such as feelings, thoughts, or behaviors during the session that relate to the influence of culture. For example: • Identify racial, ethnic, and cultural similarities and differences between you and your client. • Explain how your cultural and clinical worldviews influence your dialog, treatment planning, and expectations of yourself and your client in the session. • Describe assumptions that you have learned to make about your client’s specific race, ethnicity, or culture(s). • Even if you think these assumptions, beliefs, or biases do not play a role in your current counsel- ing relationship and approach, discuss how they could influence your counseling. Provide a spe- cific example. • Describe the feelings that you have about your client. How do these feelings relate to your client’s racial, ethnic, or cultural identity? • Explain the differences and similarities in worldviews between you and your client. • Discuss how your and your client’s beliefs about health, healing, disease, and addiction differ. • Describe how your client’s experience with discrimination, oppression, and prejudice could influence his/her current level of distress, psychological functioning, and response to treatment. • Explore how you attend to your client’s worldview in each session. • Describe a misunderstanding or erroneous counseling response during a counseling session that appears related to differences in cultural identification, values, or behavior. • Identify cultural knowledge that you must obtain to gain a better understanding of your client. • Discuss the most important lessons that you have learned from your client. desire to be perceived by other staff members curricula on cultural competence on their Web as team players, or their roles as agents of sites. In addition to OMH guidelines on staff change with other staff members. education and training (Exhibit 4-6), guide- lines are available from psychological and Opportunities for cultural competence train- counseling associations (APA 2002). To re- ing abound. National organizations, agencies view sample training modules, see Cultural dedicated to multicultural learning, academic Competence for Health Administration and institutions, government agencies, and infor- Public Health (Rose 2011). mation clearinghouses offer training or have information about training opportunities and Task: Provide Culturally Congruent Clinical Supervision “It takes time and energy to work through significant changes, whether in the work- Little research is available that measures cul- place or in our personal lives. Many times, tural competence among clinical supervisors or resistance to change is a natural reaction evaluates the effects of supervision on cultural of people trying to understand what is competence among counselors (Colistra and expected of them and how the change will Brown-Rice 2011; Constantine and Sue 2005). impact their lives.” Not much is known about the effectiveness of (Addiction Technology Transfer Center 2004, p. 28) clinical supervision in enhancing culturally competent behavior among counselors,

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Exhibit 4-6: OMH Staff Education and Training Guidelines Only general agreement exists as to what constitutes an acceptable cultural competence curriculum. OMH (2000) recommends tailoring curriculum topics to the roles and responsibilities of trainees and the specific needs of populations served over time but suggests that training should at least address: • The effects of cultural differences between counselors and clients/consumers on clinical and other workforce encounters, such as the therapeutic alliance. • The elements of effective communication among staff members and clients/consumers from diverse cultural groups who use different languages, including how to work with interpreters and telephone language services. • Strategies for resolving racial, ethnic, or cultural conflicts between staff members and clients. • The organization’s policies and procedures for written language access, including how to gain access to interpreters and translated written materials. • Parts of the Civil Rights Act of 1964 that address services for clients with limited English profi- ciency. • The organization’s complaint or grievance procedures. • The effects of cultural differences on health promotion and disease prevention, diagnosis and treatment, and supportive care. • The impact of poverty and socioeconomic status, race and racism, ethnicity, and sociocultural factors on access to care, service use, quality of care, and health outcomes. • Differences in the clinical management of diseases and conditions indicated by differences in the race or ethnicity of clients. • The effects of cultural differences among clients/consumers and staff members on health out- comes, client satisfaction, and treatment planning.

Source: OMH 2000. Adapted from material in the public domain.

although some research with a multicultural support culturally responsive services with focus has measured counselor self-efficacy their supervisees). This can significantly im- after receiving supervision and has examined pede organizations attempting to introduce or the dynamics of supervisee–supervisor rela- improve culturally responsive clinical services. tionships. Even though educational institu- It is essential for organizations to provide tions have developed curricula and standards counselors with clinical supervisors who are to reinforce the need for a multicultural per- culturally aware, have engaged in multicultural spective in training, many clinical supervisors training, and model culturally competent lack sufficient training in this area (e.g., avoid behaviors in clinical supervision sessions (e.g., cultural topics in supervision, have difficulty allowing or engaging in discussions centered giving culturally appropriate consultations or on race, ethnicity, and cultural groups in the direction, fail to guide/reinforce timely im- session). Clinical supervision is the glue that plementation of policies or procedures that

Advice to Clinical Supervisors: Culturally Competent Clinical Supervision Supported by a review of research on multicultural clinical supervision, Miville et al. (2005) suggest that clinical supervisors gain awareness of and assess: • Their own racial, ethnic, and cultural identities and attitudes and those of their supervisees. • Their own knowledge base, strengths, and weaknesses and those of their supervisees. • Racial, ethnic, and cultural issues that generate reactions in supervisors and in supervisees. • Current engagement in professional development activities that support culturally responsive practices (see the professional development advice box on the next page).

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How To Discuss Professional Development in Multicultural Counseling This tool facilitates supervisee–supervisor discussions surrounding professional development activi- ties that promote cultural competence. Supervisors can ask supervisees to review the list and check off activities that they have engaged in recently or in the past several months. Supervisors can then use the completed exercise as a starting point for gaining more specific information on activities endorsed by supervisees. Even if supervisees check off no items, reviewing the list reinforces activi- ties that build cultural competence.

Materials needed: A printed copy of the checklist and a pen or pencil. Instructions: Mark off the activities you have engaged in during the past month and/or 6 months. Past Past 6 month months ______I recognized a prejudice I have about certain people. ______I talked to a colleague about a cultural issue. ______I sought guidance about a cultural issue that arose in therapy. ______I attended a multicultural training seminar. ______I attended a cultural event. ______I attended an event in which most other people weren’t of my race. ______I reflected on my racial identity and how it affects my work with clients. ______I read a chapter or an article about multicultural issues. ______I read a novel about a racial group other than my own. ______I sought consultation or supervision about multicultural issues. ______I talked to a friend/associate about how our racial differences affect our relationship. ______I challenged a racist remark—my own or someone else’s. Source: Pack-Brown and Williams 2003, p. 136. Used with permission.

reinforces culturally competent behavior, and that cultural variables influence each aspect of it is often the only avenue of ongoing clinical supervision: the relationship between supervi- training and follow-up after specific workshops sors and supervisees, the supervisors’ and or trainings are offered by the organization. supervisees’ perceptions and assessments of clients’ presenting issues, the interactions Clinical supervisors should adopt a multicul- between supervisees and their clients, and the tural framework to guide the supervision treatment recommendations and directions process (e.g., Sue’s [2001] multidimensional that evolve from supervision. model for developing cultural competence). Endorsement of a model for developing and Task: Evaluate Staff Performance enhancing cultural competence helps both on Culturally Congruent and supervisors and supervisees understand how to Complementary Attitudes, address cultural issues in supervision and Knowledge, and Skills pursue personal and professional development that supports culturally responsive clinical Organizations committed to endorsing and services. (For a specific example, see Field and implementing culturally responsive services colleagues’ [2010] Latina–Latino multicultural need policies and procedures that reflect this developmental supervisory model.) The model commitment in job descriptions and staff guides supervision and reinforces the premise evaluations across all levels of the organiza- tion. By incorporating specific goals,

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Advice to Administrators and Clinical Supervisors: Culturally Responsive Performance Evaluation Criteria Cultural competence is measured by the degree to which counselors, administrators, and other staff members engage in observable actions and attitudes that reflect cultural responsiveness. Following are examples of descriptive evaluation criteria that address a few aspects of culturally responsive behavior: • Engages in ongoing self-analysis to identify and address personal and cultural biases. • Actively seeks to view life through the eyes of others and, through doing so, develops a greater level of sensitivity for the values and life challenges of other groups. • Participates in hands-on training opportunities and seeks practice and feedback that build toward mastery of responsive needs assessment techniques. • Seeks opportunities to engage in cross-cultural activities and interactions.

expectations, and tasks into performance Task: Create an Environment That evaluations, staff members will receive an Reflects the Populations Served important and consistent message from the The self-assessment process should include organization that culturally competent behav- an environmental review of the organization’s ior and responsive services are valued and physical facilities in which barriers to access rewarded. are examined. The plan should address iden- Organizational tified deficits. For example, signage should be written in all primary languages spoken by Infrastructure the clients served; it should be written at an appropriate level of literacy in those lan- Task: Plan Long-Range Fiscal guages. When possible, signs should use Support of Cultural Competence pictures and graphics to replace written in- structions. The design of the facility, includ- An organization’s commitment to providing ing use of space and décor, should be inviting, culturally responsive treatment services will comfortable, and culturally sensitive. The only succeed if resources are consistently plan should establish how to make facilities dedicated to supporting the plan. Realistical- more accessible and culturally appropriate. In ly, treatment program funds may be insuffi- addition, the organization should create an cient to initially meet the goals outlined in environment that reflects the culture(s) of its the organization’s self-assessment. More clients not only within the facility, but often than not, the committee, executive staff, through business practices, such as using local and board will have to prioritize the specific and community vendors. changes that are financially feasible. However, this necessity does not preclude the organiza- Task: Develop Outreach tion from soliciting help from the communi- Strategies To Improve Access to ty, finding creative and inexpensive ways to Care make organizational changes, and using strategic and financial planning to build The best-laid plans for providing culturally resources designated for culturally responsive competent treatment are futile if clients services. cannot access treatment. Providers should develop outreach plans for diverse ethnic and

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Advice to Administrators: Improving Outreach and Access to Care Whenever it is not feasible to provide behavioral health services in the neighborhoods or communi- ties where they are needed, treatment providers should consider the following: • Referring clients to community resources: Ensure that all counselors and referral sources know where to refer individuals for culturally appropriate community services. Individuals should not have to “bounce around” through the system seeking care that is already difficult to access. Have culturally and linguistically appropriate brochures available that describe community ser- vices, eligibility, and the referral process. • Collaborating with other community services: Collaboration with other community-based organizations is essential to compensate for the limitations faced by any single agency. Be- havioral health service providers can reach larger numbers of underserved populations by team- ing with others who have complementary missions and, at times, greater funding, such as other behavioral health agencies and programs dealing with welfare-to-work services, homelessness, or HIV/AIDS. Additional collaboration to increase use includes sending culturally competent counselors to work at another agency or community group on at least a part-time basis, training community members or other agency personnel to provide brief interventions or referral ser- vices, and supporting the establishment of mutual-help groups with translated/adapted litera- ture in neighborhood locations. • Co-locating community services (creating a one-stop facility): Co-locating with other agencies is often highly desirable, as it can facilitate connections among various community services that clients need and provide an easy central location to access these services (e.g., a substance abuse intensive outpatient treatment program, a service agency, and a com- munity outpatient mental health program offered at one location). For culturally diverse people, the process of accessing services across agencies can be complex because of the need to obtain linguistically and culturally appropriate services and to overcome other barriers, such as eco- nomic challenges, issues surrounding eligibility, or the cumbersome repetition of completing forms for each agency. An effective one-stop facility ensures close coordination between each agency that participates while also ensuring client confidentiality. Co-location with a community- based organization that already has solid, positive visibility in the community and a culturally competent workforce can help improve the outreach and treatment efforts of behavioral health organizations that have had difficulty connecting with the communities that they serve. • Eliciting support from the community and employing outreach workers: It is often easier and more persuasive for people who abuse substances or need mental health services to receive in- formation and be encouraged to seek treatment by persons who are ethnically similar to them and speak the same language as they do. This is especially important for new immigrants, who do not yet know their way around the new country and could be unsure of whom they can trust. When possible, outreach workers should be of similar cultural origin as the population being served and should be familiar with the community where they are working. This allows them to explain the advantages of treatment in culturally appropriate ways, speak the appropriate lan- guage or dialect, address the concerns of community members, and respect clients’ priorities and issues. Outreach efforts can forge connections with important members of the community who encourage people with mental and substance use disorders and their families to seek treatment. These efforts are particularly important with new immigrants who may face legal and language barriers or may have a limited understanding of contemporary medicine and treatment possibilities. For example, lay people trained as promotores de salud (promoters of health) have been successful in reaching Latino migrant workers (Azevedo and Bogue 2001). • Supplying support services: Providers can use a variety of means to make treatment accessible to culturally diverse clients. One strategy is to provide transportation from clients’ neighbor- hoods to the provider site. In many areas, people must travel long distances to receive culturally appropriate services. This limits the number of people able to receive treatment, especially

(Continued on the next page.)

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Advice to Administrators: Improving Outreach and Access to Care (continued) individuals with incomes too low to support travel. In addition, lengthy travel requirements re- duce the chances of a person in the early stages of change with low motivation reaching a coun- selor who can help increase motivation and move the person toward recovery. Other strategies are the inclusion of child care and language services within the program. In addition, home-based outpatient treatment and telemedicine strategies can work, particularly for rural populations. • Selecting culturally appropriate strategies to provide community education: Certain forms of outreach are more likely to be successful in some populations than in others. For example, in Chinese and Korean communities, community fairs are often an excellent way to publicize treat- ment services. Notices in community newspapers, on radio and television channels, on billboards, and in stores in the languages spoken locally can reach other potential clients. The person chosen to deliver or represent the messages in such situations should be someone familiar with the community and likely to inspire trust. Some agencies serving American have expe- rienced success in publishing a monthly newsletter that is sent to individual American Indians and agencies serving the Native American community.

racial communities, particularly those whose accurate information and referral to appropri- members may find it difficult to seek services ate mutual-help or community groups. on their own. For example, see Community- Regarding fiscal planning and funding op- Defined Solutions for Latino Mental Health portunities, some HHS initiatives support Care Disparities (Aguilar-Gaxiola et al. 2012). outreach through integrated care. For exam- From the outset, effective outreach and im- ple, the Health Resources and Services proved access to care should include formal Administration (HRSA) Center for Integrated and informal contacts with community organ- Health Solutions (CIHS) promotes the devel- izations, spiritual leaders, and media. Providers opment of integrated primary and behavioral can learn from these contacts about the behav- health services to better address the needs of ioral health concerns in the community, spe- individuals with mental health and substance cial considerations for working with members use concerns. Resources are available to help of the community, cultural impediments to physicians screen for behavioral health prob- treatment, and cultural resources to aid treat- lems and refer individuals to appropriate ment and recovery. treatment. SAMHSA’s Center for Substance Unfortunately, many providers lack sufficient Abuse Treatment has a Targeted Capacity funding to offer the level of outreach services Expansion Program that offers grants in needed by the communities they serve. Be- support of outreach to specific populations. cause they are overwhelmed already, the issue The challenges outlined in this chapter are of outreach to underserved populations is burdensome but can be overcome. Many often seen as a low priority, which can cause organizations have been able to develop cul- these providers to send people in need of tural competence over time (for a historical treatment away, disappointed and disheart- perspective of one organization’s journey, see ened. However, thoughtful and strategic use of Exhibit 4-7). A well-defined and organized community resources can result in more mem- plan, coupled with a consistent organizational bers of underserved populations receiving the commitment, will enable organizations to treatment they need and deserve. At mini- initiate and accomplish the tasks necessary to mum, outreach enables providers to offer promote culturally responsive services.

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Exhibit 4-7: Cultural Competence Initiative Across Time in One Organization Late 1980s • The executive director and board endorse the need to pursue cultural competence and outline agency goals. • An agency cultural competence committee forms to help develop policies, procedures, and a cultural competence plan. Community and client representation is established. • A senior staff member is hired to oversee the organization’s efforts to diversify staff. Early 1990s • The executive director, board of directors, and advisory board endorse the need to pursue culturally competent practices throughout the organization. • General goals are established and senior management and staff members begin educating the staff on cultural competence.

Mid 1990s • Culturally competent clinical standards are developed and implemented. • Initial vision, mission, and value statements are modified to include cultural competence. • Training for management and clinical supervisors incorporates cultural competence in practice. • The agency begins a community cultural assessment and introduces a client satisfaction survey to gain feedback on current implementation of culturally responsive practices and to guide fu- ture direction and focus. • Ongoing clinical supervisor training on cultural competence is initiated. • The cultural competence committee develops recommendations for job descriptions and perfor- mance appraisals to reflect cultural competence skills and responsibilities.

Late 1990s • Individuals and families who receive services are now involved in focus groups, orientations, and trainings. • Partnerships with other agencies to promote cultural competence throughout the community are more strongly encouraged. • A curriculum to train all staff members in the foundations of cultural competence is developed and implemented.

2000s • Across the organization, clinical and administrative programs engage in cultural competence review and goal-setting. • The mission statement is redefined to formally acknowledge the organization’s values of respect for cultural differences, recovery, and advocacy.

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Behavioral Health 5 Treatment for Major Racial and Ethnic Groups

IN THIS CHAPTER John, 27, is an American Indian from a Northern Plains Tribe. He recently entered an outpatient treatment program in a midsized • Introduction Midwestern city to get help with his drinking and subsequent low • Counseling for African mood. John moved to the city 2 years ago and has mixed feelings and Black Americans about living there, but he does not want to return to the reserva- • Counseling for Asian tion because of its lack of job opportunities. Both John and his Americans, Native counselor are concerned that (with the exception of his , Hawaiians, and Other Sandy, and a few neighbors) most of his current friends and Pacific Islanders coworkers are “drinking buddies.” John says his friends and family • Counseling for Hispanics on the reservation would support his recovery—including an and Latinos and a best friend from school who are both in recovery—but his • Counseling for Native contact with them is infrequent. Americans • Counseling for White John says he entered treatment mostly because his drinking was Americans interfering with his job as a bus mechanic and with his relationship with his girlfriend. When the counselor asks new group members to tell a story about what has brought them to treatment, John explains the specific event that had motivated him. He describes having been at a party with some friends from work and watching one of his coworkers give a bowl of beer to his dog. The dog kept drinking until he had a seizure, and John was disgusted when peo- ple laughed. He says this event was “like a vision;” it showed him that he was being treated in a similar fashion and that alcohol was a poison. When he first began drinking, it was to deal with bore- dom and to rebel against strict parents whose Pentecostal Christian beliefs forbade alcohol. However, he says this vision showed him that drinking was controlling him for the benefit of others. Later, in a one-on-one session, John tells his counselor that he is afraid treatment won’t help him. He knows plenty of people back

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home who have been through treatment and healing, help-seeking behavior, and treatment still drink or use drugs. Even though he expectations and preferences. Adopting Sue’s doesn’t consider himself particularly - (2001) multidimensional model in developing al, he is especially concerned that there is cultural competence, this chapter identifies nothing “Indian” about the program; he dis- cultural knowledge and its relationship to likes that his treatment plan focuses more on treatment as a domain that requires proficien- changing his thinking than addressing his cy in clinical skills, programmatic develop- spiritual needs or the fact that drinking has ment, and administrative practices. This been a poison for his whole community. chapter focuses on patterns of substance use and co-occurring disorders (CODs), beliefs John’s counselor recognizes the importance of about and traditions involving substance use, connecting John to his community and, if beliefs and attitudes about behavioral health possible, to a source of traditional healing. treatment, assessment and treatment consider- After much research, his counselor is able to ations, and theoretical approaches and treat- locate and contact an Indian service organiza- ment interventions across the major racial and tion in a larger city nearby. The agency puts ethnic groups in the United States. him in touch with an older woman from John’s Tribe who resides in that city. She, in Introduction turn, puts the counselor in touch with another member of the Tribe who is in recovery and Culture is a primary force in the creation of a had been staying at her house. This man person’s identity. Counselors who are culturally agrees to be John’s sponsor at local 12-Step competent are better able to understand and meetings. With John’s permission, the counse- respect their clients’ identities and related lor arranges an initial family therapy session cultural ways of life. This chapter proposes that includes his new sponsor, the woman who strategies to engage clients of diverse racial serves as a local “clan mother,” John’s - and ethnic groups (who can have very differ- friend, and, via telephone, John’s uncle in ent life experiences, values, and traditions) in recovery, mother, and brother. With John’s treatment. The major racial and ethnic groups permission and the assistance of his new in the United States covered in this chapter sponsor, the counselor arranges for John and are African Americans, Asian Americans some other members of his treatment group to (including Native Hawaiians and other Pacific attend a sweat lodge, which proves valuable in Islanders), Latinos, Native Americans (i.e., helping John find some inner peace as well as Alaska Natives and American Indians), and giving his fellow group members some insight White Americans. In addition to providing into John and his culture. epidemiological data on each group, the chap- To provide culturally responsive treatment, ter discusses salient aspects of treatment for counselors and organizations must be commit- these racial/ethnic groups, drawing on clinical ted to gaining cultural knowledge and clinical and research literature. This information is skills that are appropriate for the specific racial only a starting point in gaining cultural and ethnic groups they serve. Treatment pro- knowledge as it relates to behavioral health. viders need to learn how a client’s identifica- Understanding the diversity within a specific tion with one or more cultural groups culture, race, or ethnicity is essential; not all influences the client’s identity, patterns of information presented in this chapter will substance use, beliefs surrounding health and apply to all individuals. The material in this chapter has a scientific basis, yet cultural beliefs,

102 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Multidimensional Model for Developing Cultural Competence: Cultural Knowledge of Behavioral Health

traditions, and practices change with time and environmental context affects behavioral are not static factors to consider in providing health. However, to provide a framework for services for clients, families, or communities. understanding many diverse cultural groups, some generalizations are necessary; thus, broad Although these broad racial/ethnic categories categories are used to organize information in are often used to describe diverse cultural this chapter. Counselors are encouraged to groups, the differences between two members learn as much as possible about the specific of the same racial/ethnic group can be greater populations they serve. Sources listed in than the differences between two people from Appendix F provide additional information. different racial/ethnic groups (Lamont and Small 2008; Zuckerman 1998). It is not possi- Counseling for African and ble to capture every aspect of diversity within each cultural group. Behavioral health workers Black Americans should acknowledge that there will be many individual variations in how people interact According to the 2010 U.S. Census definition, with their environments, as well as in how African Americans or Blacks are people whose

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origins are “in any of the black racial groups of consumption as they grow older (Center for Africa” (Humes et al. 2011, p. 3). The term Substance Abuse Treatment [CSAT] 1999a; includes descendants of African slaves brought Galvan and Caetano 2003). Rates of overall to this country against their will and more substance use among African Americans vary recent immigrants from Africa, the Caribbean, significantly by age. Several researchers have and South or Central America (many individ- observed that despite Black youth being less uals from these latter regions, if they come likely than White American youth to use from Spanish-speaking cultural groups, iden- substances, as African Americans get older, tify or are identified primarily as Latino). The they tend to use at rates comparable with term “Black” is often used interchangeably those of White Americans (Watt 2008). This with African American, although sometimes increase in substance use with age among the term “African American” is used specifi- Blacks is often referred to as a crossover effect. cally to describe people whose families have th However, Watt (2008), in her analysis of 4 been in this country since at least the 19 years of National Survey on Drug Use and century and thus have developed distinct Health (NSDUH) data (1999–2002), found African American cultural groups. “Black” can that when controlling for factors such as drug be a more inclusive term describing African exposure, , employment, education, Americans as well as more recent immigrants income, and family/social support, the cross- with distinct cultural backgrounds. over effect disappeared for Blacks ages 35 and Beliefs About and Traditions older; patterns for drug and heavy alcohol use Involving Substance Use among Black and White American adults remained the same as for Black and White In most African American communities, American adolescents (i.e., White Americans significant alcohol or drug use may be socially were significantly more likely to use substanc- unacceptable or seen as a sign of weakness es). Watt concludes that systemic issues, such (Wright 2001), even in communities with as lower incomes and education levels, and limited resources, where the sale of such sub- other factors, such as lower marriage rates, stances may be more acceptable. Overall, contribute to substance use among Black African Americans are more likely to believe adults. Additional research also suggests that that drinking and drug use are activities for exposure to discrimination increases willing- which one is personally responsible; thus, they ness to use substances in African American may have difficulty accepting alcohol youth and their parents (Gibbons et al. 2010). abuse/dependence as a disease (Durant 2005). When comparing African Americans with Substance Use and Substance Use other racial and ethnic groups, NSDUH data Disorders from 2012 suggest that they are somewhat To date, there has not been much research more likely than White Americans to use illicit analyzing differences in patterns of substance drugs and less likely than White Americans to use and abuse among different groups of use alcohol. They also appear to have an inci- Blacks, but there are indications that some dence of alcohol and drug use disorders simi- gender differences exist. For example, alcohol lar to that seen in White Americans consumption among African American wom- (Substance Abuse and Mental Health Services en increases as they grow older, but Caribbean Administration [SAMHSA] 2013d). Crack Black women report consistently low alcohol cocaine use is more prevalent among Blacks

104 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups than White Americans or Latinos, whereas Some preliminary evidence suggests that rates of abuse of , , African Americans are less likely to develop most , and prescription drugs are drug use disorders following initiation of use lower (SAMHSA 2011a). use (Falck et al. 2008), yet more research is needed also appears to be a more serious problem, to identify variables that influence the devel- albeit affecting a relatively small group, among opment of drug use disorders. Even though African Americans than among members of African Americans seem less likely than other racial/ethnic groups. White Americans to develop alcohol use disorders, a number of older studies have There appear to be some other differences in found that they more frequently experience how African Americans use substances com- liver cirrhosis and other alcohol-related health pared with members of other racial/ethnic problems (Caetano 2003; Polednak 2008). In groups. For example, Bourgois and Schonberg tracking 25 years of data, Polednak (2008) (2007) observed that among people who inject- found that the magnitude of difference has ed heroin in , White Americans decreased over time; nonetheless, health dispar- tended to administer the drug quickly whether ities continue to exist for African Americans in or not they could find a vein, which led them terms of access to and quality of care, which to inject into fat or muscle tissue and resulted can affect a number of health problems in a higher rate of abscesses. However, African (Agency for Healthcare Research and Quality Americans who injected heroin were more 2009; Smedley et al. 2003). methodical and took the time to find a vein, even if it took multiple attempts. This, in turn, Mental and Co-Occurring often resulted in using syringes that were Disorders already bloodied and increased their chances of contracting HIV/AIDS and other blood- A number of studies have found biases that borne diseases. African Americans who inject- result in African Americans being overdiag- ed heroin were significantly more likely to also nosed for some disorders and underdiagnosed use than were White Americans for others. African Americans are less likely who injected heroin (Bourgois et al. 2006). than White Americans to receive treatment for anxiety and mood disorders, but they are African American patterns of substance use more likely to receive treatment for drug use have changed over time and will likely contin- disorders (Hatzenbuehler et al. 2008). In one ue to do so. Based on treatment admission study evaluating posttraumatic stress disorder data, admissions of African Americans who (PTSD) among African Americans in an injected heroin declined by 44 percent during outpatient mental health clinic, only 11 per- a 12-year period, whereas admissions declined cent of clients had documentation referring to by only 14 percent among White Americans PTSD, even though 43 percent of the clients (Broz and Ouellet 2008). Additionally, during showed symptoms of PTSD (Schwartz et al. this period, the peak age for African Americans 2005). Black immigrants are less likely to be who injected heroin increased by 10 years, yet diagnosed with mental disorders than are it decreased by 10 years for White Americans. Blacks born in the United States (Burgess et This suggests that the decrease in injectable al. 2008; Miranda et al. 2005b). heroin use among African Americans was largely due to decreased use among younger African Americans are more likely to be individuals. diagnosed with schizophrenia and less likely to be diagnosed with affective disorders than

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White Americans, even though multiple African Americans are less likely than White studies have found that rates of both disorders Americans to report lifetime CODs (Mericle among these populations are comparable et al. 2012). However, limited research indi- (Baker and Bell 1999; Bresnahan et al. 2000; cates that, as with other racial groups, there are Griffith and Baker 1993; Stockdale et al. 2008; differences across African American groups in Strakowski et al. 2003). African Americans are the screening and symptomatology of CODs. about twice as likely to be diagnosed with a Seventy-four percent of African Americans psychotic disorder as White Americans and who had a past-year major depressive episode more than three times as likely to be hospital- were identified as also having both alcohol and ized for such disorders. These differences in use disorders (Pacek et al. 2012). diagnosis are likely the result of clinician bias Miranda et al. (2005b) found that American- in evaluating symptoms (Bao et al. 2008; born Black women were more than twice as Trierweiler et al. 2000; Trierweiler et al. likely to be screened as possibly having depres- 2006). Clinicians should be aware of bias in sion than African- or Caribbean-born Black assessment with African Americans and with women, but this could reflect, in part, differ- other racial/ethnic groups and should consid- ences in acculturation (see Chapter 1). How- er ways to increase diagnostic accuracy by ever, research findings strongly suggest that reducing biases. For an overview of mental cultural responses to some disorders, and health across populations, refer to Mental possibly the rates of those disorders, do vary Health United States, 2010 (SAMHSA among different groups of Blacks. Differences 2012a). do not appear to be simply reflections of differences in acculturation (Joe et al. 2006). In some African American communities, For a review of African American health, see incidence and prevalence of trauma exposure Hampton et al. (2010). and PTSD are high, and substance use ap- pears to increase trauma exposure even further Treatment Patterns (Alim et al. 2006; Breslau et al. 1995; Curtis- African Americans may be less likely to re- Boles and Jenkins-Monroe 2000; Rich and ceive mental health services than White Grey 2005). Black women who abuse sub- Americans. In the Baltimore Epidemiologic stances report high rates of sexual abuse Catchment Services Area study conducted (Ross-Durow and Boyd 2000). Trauma histo- during the 1980s, African Americans were less ries can also have a greater effect on relapse for likely than White Americans to receive mental African American clients than for clients from health services. However, at follow-up in the other ethnic/racial groups (Farley et al. 2004). early 1990s, African American respondents There are few integrated approaches to trau- were as likely as White Americans to receive ma and substance abuse that have been evalu- such services, but they were much more likely ated with African American clients, and to receive those services from general practi- although some have been found effective at tioners than from mental health specialists reducing trauma symptoms and substance (Cooper-Patrick et al. 1999). Stockdale et al. use, the extent of that effectiveness is not (2008) analyzed 10 years of data from the necessarily as great as it is for White National Ambulatory Medical Care Survey; Americans (Amaro et al. 2007; Hien et al. they found significant improvements in diag- 2004; SAMHSA 2006). nosis and care for mental disorders among African Americans in psychiatric settings

106 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

between 1995 and 2005, but they also found SAMHSA, CBHSQ 2011; Schmidt et al. that disparities persisted in the diagnosis and 2006). Data analyzed by Perron et al. (2009) treatment of mental disorders in primary care indicate that among African Americans with settings. Fortuna et al. (2010) suggest that lifetime diagnoses of drug use disorders, 20.8 persistent problems exist in the delivery of percent had received some type of treatment, behavioral health services, as evidenced by as defined broadly to include resources such as lower retention rates for treating depression. pastoral counseling and mutual-help group attendance. This made them more likely to Even among people who enter substance have received treatment than White Ameri- abuse treatment, African Americans are less cans (15.5 percent of whom received treat- likely to receive services for CODs. A study of ment) or Latinos (17.3 percent of whom administrative records from substance abuse received treatment). Although data indicate and mental health treatment providers in New that African Americans were less likely to Jersey found that African Americans were receive services from private providers, they significantly more likely than White Americans also indicate that African Americans were to have an undetected co-occurring mental more likely to use more informal services (e.g., disorder, and, if detected, they were signifi- pastoral counseling, mutual help). cantly less likely than White Americans or Latinos to receive treatment for that disorder Although most major studies have found that (Hu et al. 2006). Among persons with sub- race is not a significant factor in receiving stance use disorders and co-occurring mood or treatment, African Americans report lengthier anxiety disorders, African Americans are waiting periods, less initiation of treatment, significantly less likely than White Americans more barriers to treatment participation (e.g., to receive services (Hatzenbuehler et al. 2008). lack of childcare, lack of insurance, lack of African Americans who do receive services for knowledge about available services), and CODs are more likely to obtain them through shorter lengths of stay in treatment than do substance abuse treatment programs than White Americans (Acevedo et al. 2012; mental health programs (Alvidrez and Brower and Carey 2003; Feidler et al. 2001; Havassy 2005). Grant 1997; Hatzenbuehler et al. 2008; Marsh et al. 2009; SAMHSA 2011c; Schmidt et al. According to the Treatment Episode Data 2006). In SAMHSA’s 2010 NSDUH, 33.5 Sets (TEDS) from 2001 to 2011, African percent of African Americans who had a need American clients entering substance abuse for substance abuse treatment but did not treatment most often reported alcohol as their receive it in the prior year reported that they primary substance of abuse, followed by mari- lacked money or the insurance coverage to pay juana. However, gender differences are evident, for it (SAMHSA, CBHSQ 2011). Economic indicating that women report a broader range disadvantage does leave many Africans Amer- of substances as their primary substance of icans uninsured; approximately 16.1 percent of abuse than men do (SAMHSA, Center for non-Latino Blacks had no coverage in 2004 Behavioral Health Statistics and Quality (Schiller et al. 2005). [CBHSQ], 2013). Most recent research sug- gests that African Americans are about as Likewise, some researchers have found that likely to seek and eventually receive substance African Americans are less likely than White abuse treatment as are White Americans Americans to receive needed services or an (Hatzenbuehler et al. 2008; Perron et al. 2009; appropriate level of service (Alegria et al.

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2011; Bluthenthal et al. 2007; Marsh et al. value and use of specialized behavioral health 2009). For example, African Americans and services among some African Americans may Latinos are less likely than White Americans limit service use. Hines-Martin et al. (2004) to receive residential treatment and are more found a positive relationship between famili- likely to receive outpatient treatment, even arity and use of mental health services among when they present with more serious substance African Americans. Additionally, factors such use problems (Bluthenthal et al. 2007). Other as social and familial prejudices (Ayalon and studies have found that African Americans Alvidrez 2007; Mishra et al. 2009; Nadeem et with severe substance use or CODs were less al. 2007) and fears relating to past abuses of likely to enter or receive treatment than White African Americans within the mental health Americans with equally severe disorders system (Jackson 2003) can contribute to the (Schmidt et al. 2006, 2007). lack of acceptance and subsequent use of these services. An essential step in decreasing dis- African Americans are overrepresented among parity in behavioral health services among people who are incarcerated in prisons and African Americans involves conducting cul- jails (for review, see Fellner 2009), and a sub- turally appropriate mental health screenings stantial number of those who are incarcerated and using culturally sensitive instruments and (64.1 percent of jail inmates in 2002) have evaluation tools (Baker and Bell 1999). substance use disorders (Karberg and James 2005) and mental health problems (SAMHSA Beliefs and Attitudes About 2012a). However, according to Karberg and Treatment (James 2005), African Americans with sub- stance dependence disorders who were in jail According to 2011 NSDUH data, African in 2002 were less likely than White Americans Americans were, next to Asian Americans, or Latinos to participate in substance abuse the least likely of all major ethnic and racial treatment while under correctional supervision groups to state a need for specialized sub- (32 percent of African Americans participated stance abuse treatment (SAMHSA, CBHSQ compared with 37 percent of Latinos and 45 2013a). Still, logistical barriers may pose a percent of White Americans). In the 2010 greater challenge for African Americans than TEDS survey, African Americans entering for members of other major racial and ethnic treatment were also less likely than Asian groups. For example, 2010 NSDUH data Americans, White Americans, Latinos, Native regarding individuals who expressed a need Hawaiians/Pacific Islanders, or American for substance abuse treatment but did not Indians in the same situation to be referred to receive it in the prior year indicate that treatment through the criminal justice system African Americans were more likely than (SAMHSA, CBHSQ 2012). Notwithstand- members of other major ethnic/racial groups ing, African Americans are more likely to be to state that they lacked transportation to the referred to treatment from criminal justice program or that their insurance did not cover settings rather than self-referred or referred by the cost of such treatment (SAMHSA other sources (Delphin-Rittmon et al. 2012) 2011a). African Americans experience several challenges in accessing behavioral health Beyond issues related to diagnosis and care treatment, including fears about the therapist that can prevent African Americans from or therapeutic process and concerns about accessing mental health services, research discrimination and costs (Holden et al. 2012; suggests that a lack of familiarity with the

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Holden and Xanthos 2009; Williams et al. Most importantly, providers need to demon- 2012). strate multicultural experience. In a study comparing outcomes among Black and White Longstanding suspicions regarding established clients at community mental health centers, healthcare institutions can also affect African the only clinician factor that predicted more Americans’ participation in, attitudes toward, favorable outcomes was clinicians’ general and outcomes after treatment (for review, see experiences and relationships with people Pieterse et al. 2012). Historically, the mental from racial/ethnic and cultural groups other health system has shown bias against African than their own (Larrison et al. 2011). Americans, having been used in times past to control and punish them (Boyd-Franklin and Treatment Issues and Karger 2012; Jackson 2003). After controlling Considerations for socioeconomic factors, African Americans are significantly more likely to perceive the African American clients generally respond healthcare system as poor or fair and signifi- better to an egalitarian and authentic relation- cantly more likely to believe that they have ship with counselors (Sue 2001). Paniagua been discriminated against in healthcare (1998) suggests that in the initial sessions with settings (Blendon et al. 2007). Attitudes to- African American clients, counselors should ward psychological services appear to become develop a collaborative client–counselor rela- more negative as psychological distress in- tionship. Counselors should request personal creases (Obasi and Leong 2009). In many information gradually rather than attempting African American communities, there is a to gain information as quickly as possible, persistent belief that social and treatment avoid information-gathering methods that services try to impose White American values, clients could perceive as an interrogation, pace adding to their distrust of the treatment sys- the session, and not force a data-gathering tem (Larkin 2003; Solomon 1990). agenda (Paniagua 1998; Wright 2001). Coun- selors must also establish credibility with African Americans, even when receiving the clients (Boyd-Franklin 2003). same amount of services as White Americans, are less likely to be satisfied with those services Next, counselors should establish trust. Self- (Tonigan 2003). However, recent evidence disclosure can be very difficult for some clients suggests that, once engaged, African American because of their histories of experiencing clients are at least as likely to continue partici- racism and discrimination. These issues can be pation as members of other ethnic/racial exacerbated in African American men whose groups (Harris et al. 2006). Because distrust of experience of racism has been more severe or the healthcare system can make it more diffi- who have had fewer positive relationships with cult to engage African American clients ini- White Americans (Reid 2000; Sue 2001). tially in treatment, Longshore and Grills Counselors, therefore, need to be willing to (2000) recommend culturally congruent moti- address the issue of race and to validate African vational enhancement strategies to address American clients’ experiences of racism and its African American clients’ ambivalence about in their lives, even if it differs from treatment services. Providers also need to craft their own experiences (Boyd-Franklin 2003; culturally responsive health-related messages Kelly and Parsons 2008). Moreover, racism for African Americans to improve treatment and discrimination can lead to feelings of engagement and effectiveness (Larkin 2003). anger, anxiety, or depression. Often, these feelings are not specific to any given event;

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rather, they are pervasive (Boyd-Franklin et al. overview of core guiding principles in work- 2008). Counselors should explore with clients ing with African American clients. the psychological effects of racism and develop approaches to challenge internal negative Theoretical Approaches and messages that have been received or generated Treatment Interventions through discrimination and prejudice (Good- Research suggests that culturally congruent ing 2002). interventions are effective in treating African Additional methods that may enhance en- Americans (Longshore and Grills 2000; gagement and promote participation include Longshore et al. 1998a; Longshore et al. peer-supported interventions and strategies 1998b; 1999). Although there are conflicting that promote empowerment by emphasizing results on the effectiveness of motivational strengths rather than deficits (Paniagua 1998; interviewing among African American clients Tondora et al. 2010; Wright 2001). It is (Montgomery et al. 2011), some motivational important to explore with clients the interventions have been found to reduce sub- strengths that have brought them this far. stance use among African Americans What personal, community, or family (Bernstein et al. 2005; Longshore and Grills strengths have helped them through difficult 2000). Longshore and Grills (2000) describe a times? What strengths will support their culturally specific motivational intervention recovery efforts? Exhibit 5-1 gives an for African Americans involving both peer and professional counseling that makes use of the core African American value of commu- Exhibit 5-1: Core Culturally nalism by addressing the ways in which the Responsive Principles in Counseling African Americans individual’s substance abuse affects his or her whole community. The motivational program According to Schiele (2000), culturally respon- affirms “the heritage, rights, and responsibili- sive counseling for African American clients ties of African Americans…using interaction involves adherence to six core principles: 1. Discussion of clients’ substance use should styles, symbols and values shared by members be framed in a context that recognizes the of the group” (Longshore et al. 1998b, p. 319). totality of life experiences faced by clients So too, African American music, artwork, and as African Americans. food can help programs create a welcoming 2. Equality is sought in the therapeutic coun- and familiar atmosphere, as is the case for selor–client relationship, and counselors are less distant and more disclosing. other racial and ethnic groups when familiar 3. Emphasis is placed on the importance of cultural symbols appear in the clinical setting. changing one’s environment—not only for the good of clients themselves, but also for Many of the interventions developed for the greater good of their communities. substance abuse treatment services in general 4. Focus is placed on alternatives to sub- have been evaluated with populations that stance use that underscore personal rituals, were at least partly composed of African cultural traditions, and spiritual well-being. Americans; many of these interventions are as 5. Recovery is a process that involves gaining power in the forms of knowledge, spiritual effective for African Americans as they are for insight, and community health. White Americans (Milligan et al. 2004; To- 6. Recovery is framed within a broader con- nigan 2003). One intervention that appears to text of how recovery contributes to the work better for African American (and Latino) overall healing and advancement of the clients than for White American clients— African American community. perhaps because it focuses on improving

110 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

client–counselor communication—is node- Another therapy that has been evaluated with link mapping (visual representation using African American clients and found effective information diagrams, fill-in-the-blank graph- is supportive–expressive , which ic tools, and client-generated diagrams or reduces substance use and improves psycho- visual maps). This approach was associated logical functioning for individuals in metha- with lower rates of substance use, better treat- done maintenance (Woody et al. 1987; Woody ment attendance, and better counselor ratings et al. 1995). Medications for substance abuse of motivation and confidence among African can also work well with African American Americans than among White Americans clients. In one large study, African Americans (Dansereau et al. 1996; Dansereau and were more likely than Latinos or White Simpson 2009). Americans to indicate that they found metha- done helpful (Gerstein et al. 1997), and in In addition, cognitive–behavioral therapy another study, they reported greater perceived (CBT) has certain distinct advantages for quality of life as a result of participation in a African American clients; it fosters a collabo- program (Geisz 2007). Schroeder et rative relationship and recognizes that clients al. (2005) also reported that African Americans are experts on their own problems (Kelly and in a methadone program had significantly Parsons 2008). Maude-Griffin et al. (1998) fewer adverse medical events (e.g., infections, compared CBT and 12-Step facilitation for a gastrointestinal complaints) than did White group of mostly African American (80 per- American participants. African Americans cent) men who were homeless and found that who were being treated for cocaine depend- CBT achieved significantly better abstinence ence remained in treatment significantly outcomes, except among those who considered longer than did other African Americans if themselves very religious (these individuals they received disulfiram (Milligan et al. 2004). had better outcomes with 12-Step facilitation). A review of cultural adaptations of evidence- Other interventions that use CBT principles based practices is given by Bernal and have also been effective with African American Domenech Rodriguez (2012). For an over- populations. For example, a number of studies view of gender-specific treatment considera- have evaluated contingency management tions for mental and substance use disorders approaches with predominantly African among African American men and women, American client populations, finding that this see Shorter-Gooden (2009). model was effective at reducing cocaine and illicit use, improving employment Family therapy outcomes for clients in methadone mainte- African American clients appear more likely nance (Silverman et al. 2002; Silverman et al. to stay connected with their families through- 2007), reducing substance use during and after out the course of their addiction. For instance, treatment, and improving self-reported quality Bourgois et al. (2006) reported that in compar- of life (Petry et al. 2004; Petry et al. 2005; Petry ing African American and White American et al. 2007). The Living in the Balance inter- individuals who injected heroin, African vention, which uses psychoeducation and CBT Americans appeared to be more likely to techniques, has also been evaluated with a maintain contact with their extended families. mostly African American sample and has been Some research also suggests that African shown to improve treatment retention and Americans with substance use disorders are reduce substance use (Hoffman et al. 1996). more likely to have family members with

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histories of substance abuse, suggesting an Advice to Counselors: Strengths of even greater need to address substance abuse African American Families within the family (Brower and Carey 2003). African American kinship bonds have historically Strong family bonds are important in African been sources of strength. Although substance abuse lessens the strength of the family and American cultural groups. African American can erode relationships, counselors can use the families are embedded in a complex kinship inherent strengths of the family to benefit network of biologically related and unrelated clients and their families (Boyd-Franklin and persons. Hence, counselors should be willing Karger 2012; Larkin 2003; Reid 2000). Bell- to expand the definition of family to a more Tolliver et al. (2009) and Hill (1972) suggest that strengths of African American family life include: extended kinship system (Boyd-Franklin • Strong bonds and extensive kinship. 2003; Hines and Boyd-Franklin 2005). Clients • Adaptability of family roles. need to be asked how they define family, • A strong family hierarchy. whom they would identify as family or “like • A strong work orientation. family,” who resides with them in their homes, • A high achievement orientation. • A strong religious orientation. and whom they rely on for help. Hines and Boyd-Franklin (2005) discuss the importance of both blood and nonblood kinship networks system. Network therapy, which involves for African American families. To build a clients’ extended social networks, has also been support network for African American clients, found to improve substance use outcomes for counselors should by asking clients to African American clients when added to identify people (whether biological kin or not) standard treatment (Keller and Galanter who would be willing and able to support 1999). Likewise, the family team conference their recovery and then ask clients for permis- model can be a useful approach, given that it sion to contact those people and include them also engages both families and communities in in the treatment process. the helping process by attempting to stimulate extensive mobilization of activity in the formal Family therapy is often a productive approach and informal relationships in and around cli- to treatment with African Americans (Boyd- ents’ families (State of New Jersey Department Franklin 2003; Hines and Boyd-Franklin of Human Services 2004). 2005; Larkin 2003). However, the extended family can be large and have many ties with Brief structural family therapy and strategic other families in a community; therefore, the family therapy reduce substance use as well, family therapist sometimes needs to take on but research has primarily focused on African other roles to assist with case management or American youth (Santisteban et al. 1997; other activities, including involvement in Santisteban et al. 2003; Szapocznik and community-wide interventions (Sue 2001). In Williams 2000). Multidimensional family reviewing specific family therapy approaches therapy has increased abstinence from sub- for African Americans, Boyd-Franklin (2003) stance use among African American adoles- discusses the use of a multisystem family cents and produced more lasting effects than therapy approach, which incorporates an CBT, but it also has not been evaluated with extended network of relationships that play a adult clients (Liddle et al. 2008). In reviewing part in clients’ lives. Using this model, social specific family programs, Larkin (2003) reports service and other community agencies can be promising preliminary data on a family therapy considered a significant part of the family intervention among African Americans in public housing that addresses substance abuse.

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The program initially engages families via problems to people who are relative . psychoeducation on substance abuse and its African Americans seem less likely to self- effects on the family, followed by a strength- disclose about the past in group settings that based family therapy intervention. Despite the include non-Hispanic Whites (Johnson et al. small sample size, all 10 families admitted to 2011; Richardson and Williams 1990). Con- the program completed treatment, and 7 of 10 sequently, groups composed only of African family members with substance abuse prob- Americans can be more beneficial. Homoge- lems entered recovery and continuing care. nous African American groups can also be Participant surveys indicated that 60 percent good venues for clients to deal with systemic of families preferred multiple-family therapy problems, such as racism and lack of economic over single-family therapy, and 80 percent opportunities in the African American com- preferred services delivered in the housing munity (Jones et al. 2000). project community center to other venues. Mutual-help groups Engaging Moms is another family-oriented A variety of mutual-help groups are available program and intervention developed specifi- for African Americans entering recovery from cally for African American that has substance use and mental disorders. However, been shown to significantly improve treatment most of the literature focuses on 12-Step engagement (Dakof et al. 2003). The interven- groups, including Alcoholics Anonymous tion is designed for women who have children (AA) and Anonymous. Some find and have been identified as cocaine users. The that the 12-Step approach warrants careful program focuses on mobilizing family members consideration with African Americans, who who would be likely to motivate the mothers to can find the concept of powerlessness over enroll and remain in substance abuse treatment. substances of abuse to be too similar to experi- Research has shown no long-term impact, yet ences of powerlessness via discrimination. women who received the intervention were Additionally, the disease concept of addiction significantly more likely to enter treatment (88 presented in 12-Step meetings can be difficult percent of women involved in the program for many African Americans (Durant 2005). versus 46 percent of the control group) and In some instances, the Black community has remain for at least 2 weeks. changed the mutual-help model for substance Group therapy use and mental health to make it more em- powering and relevant to African American Because of the communal, cooperative values participants. For additional information on the held by many African Americans, group ther- 12 Steps for African Americans, visit Alcohol- apy can be a particularly valuable component ics Anonymous World Services (AAWS), AA of the treatment process (Sue and Sue 2013b). for the Black and African American Alcoholic, A strong oral tradition is one of many forms available online (http://www.aa.org/ of continuity with African tradition main- pdf/products/p-51_CanAAHelpMeToo.pdf). tained in the African American experience; therefore, speaking in groups is generally Despite their emphasis on the concept of acceptable to African American clients. How- powerlessness, 12-Step programs are significant ever, Bibb and Casimer (2000) note that Black support systems for many African Americans. Caribbean Americans can be less comfortable In AA’s 2011 membership survey, 4 percent of with the group process, particularly the re- members identified their race as Black quirement that they self-disclose personal (AAWS 2012). Analysis of 2006–2007

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NSDUH data showed that African Americans express a greater degree of comfort with shar- were less likely to use mutual-help groups in ing in meetings, and they are more likely to the past year for substance use (about 11 engage in AA services and state that they had percent did) than White Americans (about 67 a spiritual awakening as a result of AA partic- percent did) or Latinos (about 16 percent did; ipation (Bibb and Casimer 2000; Kaskutas et SAMHSA 2013d). However, the National al. 1999; Kingree 1997). Epidemiologic Survey on Alcohol and Related Research suggests that African Americans Conditions (NESARC) survey did find that who attend 12-Step programs have higher African Americans who had a lifetime drug levels of affiliation than White Americans in use disorder diagnosis and had sought help the same programs (Kingree and Sullivan were more than three times as likely to have 2002). However, they are less likely to have a attended mutual-help meetings as were White sponsor or to read program materials (Kaskutas Americans or Latinos (Perron et al. 2009). et al. 1999), and their abstinence appears to be Several other surveys suggest that African less affected by meeting attendance (Timko et Americans with alcohol-related problems are al. 2006). Other research has found that at least as likely to participate in AA as White African Americans who participate in 12-Step Americans and that greater problem severity is groups report an increase in the number of associated with increased likelihood of partici- people within their social networks who sup- pation (Kingree and Sullivan 2002). Of the port their recovery efforts (Flynn et al. 2006). participants who attended mutual-help group Other mutual-help groups for African sessions for mental health in the past year, Americans are available, particularly faith- approximately 10 percent were Black or Afri- based programs to support recovery from can American, 75 percent were White Ameri- mental illness and substance use disorders and can, and 11.4 percent were Latino (SAMHSA to aid individuals in the process of transition- 2010). ing from correctional institutions. For exam- Durant (2005) observes that African American ple, the has been involved in 12-Step participants tend to participate differ- successful substance abuse recovery efforts, ently in meetings where participants are most- especially for incarcerated persons (Sanders ly White Americans than in meetings where 2002; White and Sanders 2004). most participants are African American. In Traditional healing and some areas, there are 12-Step meetings that complementary methods are largely or entirely composed of African American members, and some African In general, African Americans are less likely to American clients feel more comfortable par- make use of popular alternative or comple- ticipating in these meetings. Mutual-help mentary healing methods than White Ameri- groups can be particularly helpful for African cans or Latinos (Graham et al. 2005). Americans who consider themselves religious. However, the African American culture and Maude-Griffin et al. (1998) found that indi- history is steeped in healing traditions passed viduals who identified as highly religious did down through generations, including herbal significantly better when receiving 12-Step remedies, root medicines, and so forth (Lynch facilitation than when receiving CBT, but that and Hanson 2011). The acceptance of tradi- pattern was reversed for those who did not tional practices by African American clients consider themselves highly religious. Other and their families does not necessarily indicate studies have found that African Americans that they oppose or reject the use of modern

114 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups therapeutic approaches or other alternative a central role in education, politics, recreation, approaches. They can accept and use all forms and social welfare in African American com- of treatment selectively, depending on the munities. To date, African Americans report perceived nature of their health problems. the highest percentage (87 percent) of reli- That said, psychological and substance abuse gious affiliation of any major racial/ethnic problems can be seen as having spiritual causes group (Kosmin and Keysar 2009; Pew Forum that need to be addressed by traditional heal- on Religion and Public Life 2008). Even ers or religious practices (Boyd-Franklin though most are committed to various 2003). Moreover, African Americans are much Christian denominations (with the Baptist and more likely to use religion or spirituality as a African Methodist Episcopal churches ac- response to physical or psychological problems counting for the largest percentages), a growing (Cooper et al. 2003; Dessio et al. 2004; number of African Americans are converts to Graham et al. 2005; Nadeem et al. 2008). Islam, and many recent immigrants from Africa to the United States are also Muslims African American cultural and religious insti- (Boyd-Franklin 2003; Pew Forum on Religion tutions (see advice box below) play an im- and Public Life 2008). portant role in treatment and recovery, and African Americans who use spirituality or Relapse prevention and recovery religion to cope with health problems are nearly African Americans appear to be responsive to twice as likely as other African Americans to continuing care participation and recovery also make use of complementary or alterna- activities associated with substance use and tive medicine (Dessio et al. 2004). Likewise, mental disorders, yet research is very limited. African American churches and mosques play According to NESARC data (Dawson et al.

Advice to Counselors: The Role of African American Religious Institutions in Treatment and Recovery Within African American communities, religious institutions and clergy often function as service providers as well as counselors (Boyd-Franklin 2003; Reid 2000; Taylor et al. 2000). It is not uncom- mon for African Americans to approach clergy first when faced with their own or family members’ mental health or substance abuse problems, but many African American clergy members believe they are not well-prepared to address those problems (Neighbors et al. 1998; Sexton et al. 2006). According to NESARC data, African Americans are twice as likely as Latinos and nearly three times as likely as White Americans to receive pastoral counseling for their drug use (Perron et al. 2009).

For many African Americans in recovery, churches play a significant role in helping them maintain abstinence (Perron et al. 2009). Beyond pastoral counseling, research suggests that other means of engagement within the church can lead to recovery. For example, participation in religious services has been associated with significantly better outcomes for African American men in continuing care following court-mandated treatment (Brown et al. 2004). Stahler et al. (2007) also report successful use of peer mentors drawn from churches for African American women in treatment, marked by significantly fewer drug-positive urine samples in the 6 months following treatment.

Counselors working with African American clients should prepare to include churches, mosques, or other faith communities in the therapeutic process, and they should develop a list of appropriate spiritual resources in the community. Treatment providers may consider involving African American clergy in treatment programs to improve clergy members’ understanding of behavioral health prob- lems and treatments and to better engage clients and their families. Programs can conduct outreach with local faith-based institutions and clergy to facilitate treatment referrals (Taylor et al. 2000).

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2005), African Americans in recovery from secure resources and appropriate support when were more than twice as needed, or engage in coping behaviors condu- likely as White Americans to maintain absti- cive to maintaining recovery. Counselors can nence rather than just limiting alcohol con- help clients practice coping skills by role- sumption or changing drinking patterns. In playing, even if clients are confident that they another study analyzing the use of continuing can manage difficult or high-risk situations. care following residential treatment in the U.S. Department of Veterans Affairs care system, Counseling for Asian African American men were significantly Americans, Native more likely than White Americans to partici- pate in continuing care (Harris et al. 2006). Hawaiians, and Other Other research evaluating continuing care for Pacific Islanders African American men who had been man- dated to outpatient treatment by a parole or Asian Americans, per the U.S. Census Bureau probation office found that participants as- definition, are people whose origins are in the signed to a continuing care intervention were , Southeast Asia, or the Indian sub- almost three times as likely to be abstinent and continent (Humes et al. 2011). The term in- five times less likely to be using any drugs on a cludes East Asians (e.g., Chinese, Japanese, and weekly basis during the 6-month follow-up ), Southeast Asians (e.g., period compared with those who did not Cambodian, Laotian, and Vietnamese receive continuing care (Brown et al. 2004). Americans), , Asian Indians, and In evaluating appropriate relapse prevention Central Asians (e.g., Mongolian and Uzbek strategies for African American clients, Americans). In the 2010 Census, people who Walton et al. (2001) found that African identified solely as Asian American made up American clients leaving substance abuse 4.8 percent of the population, and those who treatment reported fewer cravings, greater use identified as Asian American along with one of coping strategies, and a greater belief in or more other races made up an additional 0.9 their self-efficacy. However, they also expected percent. Census data includes specific infor- to be involved in fewer sober leisure activities, mation on people who identify as Asian Indian, to be exposed to greater amounts of substance Chinese, Filipino, Japanese, Korean, use, and to have a greater need for continuing Vietnamese, and “other Asians.” The largest care services (e.g., housing, medical care, Asian populations in the United States are assistance with employment). Walton notes , , that these findings could reflect a tendency of Asian , Korean Americans, African American clients to underestimate the and Vietnamese Americans. Asian Americans difficulties they will face after treatment; they overwhelmingly live in urban areas, and more report a greater need for resources and greater than half (51 percent) live in just three states exposure to substance use, but they still have a (NY, CA, and HI; Hoeffel et al. 2012). greater belief in their ability to remain free of Not all people with origins in Asia belong to substances. Although an individual’s belief in what is commonly conceived of as the Asian coping can have a positive effect on initially race. Some Asian Indians, for example, self- managing high-risk situations, it also can lead identify as White American. For this reason, to a failure to recognize the level of risk in a among others, counselors should be careful to given situation, anticipate the consequences, learn from their Asian American clients how

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they identify themselves and which national (Iversen 2000; Martin 1975). However, some heritages they claim. Counselors should rec- Asian Americans tend to view illicit substance ognize that clients who appear to be Asian use and abuse as a serious breach of acceptable may not necessarily think of themselves pri- behavior that cannot readily be discussed. marily as persons of Asian ancestry or have a Nonetheless, there are broad differences in deep awareness of the traditions and values of Asian cultures’ perspectives on substance use, their countries of origin. For example, Asian thus requiring counselors to obtain more orphans who have been adopted in the United specific information during intake and subse- States and raised as Americans in White quent encounters. American families may have very little con- Acknowledging a substance abuse problem nection with the cultural groups of their bio- often leads to shame for Asian American logical parents (St. Martin 2005). Counselors clients and their families. Families may deny should not make generalizations across Asian the problem and inadvertently, or even inten- cultures; each culture is quite distinct. tionally, isolate members who abuse substances Little literature on substance use and mental (Chang 2000). For example, some Cambodian disorders, rates of co-occurrence, and treatment and Korean Americans perceive alcohol abuse among Asian Americans focuses on behavioral and dependence as the result of moral weak- health treatment for Native Hawaiians and ness, which brings shame to the family Pacific Islanders; thus, a text box at the end (Amodeo et al. 2004; Kwon-Ahn 2001). of this section summarizes available information. Substance Use and Substance Use Disorders Beliefs About and Traditions According to the 2012 NSDUH, Asian Involving Substance Use Americans use alcohol, cigarettes, and illicit Within many Asian societies, the use of intox- substances less frequently and less heavily than icants is tolerated within specific contexts. For members of any other major racial/ethnic example, in some Asian cultural groups, alco- group (SAMHSA 2013d). However, large hol is believed to have curative, ceremonial, or surveys may undercount Asian American beneficial value. Among pregnant Cambodian substance use and abuse, as they are typically women, small amounts of herbal medicines conducted in English and Spanish only with an alcohol base are sometimes used to (Wong et al. 2007b). Despite the limitations of ensure an easier delivery. Following childbirth, research, data suggest that although Asian similar medicines are generally used to in- Americans use illicit substances and alcohol crease blood circulation (Amodeo et al. 1997). less frequently than other Americans, sub- Some Chinese people believe that alcohol stance abuse problems have been increasing restores the flow of (i.e., the life force). The among Asian Americans. The longer Asian written Chinese character for “” con- Americans reside in the United States, the tains the character for alcohol, which implies more their substance use resembles that of the use of alcohol for medicinal purposes. other Americans. Excessive alcohol use, intox- ication, and substance use disorders are more Some Asian American cultural groups make prevalent among Asians born in the United allowances for the use of other substances. States than among foreign-born Asians living Marijuana, for instance, has been used medici- in the United States (Szaflarski et al. 2011). nally in parts of Southeast Asia for many years

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Among Asian Americans who entered sub- to use illicit drugs, whereas Filipino Americans stance abuse treatment between 2000 and had the highest rate of illicit drug use 2010, methamphetamine and marijuana were (Nemoto et al. 1999). In that same study, the most commonly reported illicit drugs Filipino American immigrants were also (SAMHSA, CBHSQ 2012). Methampheta- significantly more likely to have begun using mine abuse among Asian Americans is partic- substances prior to immigrating than were ularly high in Hawaii and on the West Coast Chinese or Vietnamese immigrants. Other (OAS 2005a). As with other racial and ethnic studies have found that Filipino Americans are groups, numerous factors—such as age, birth more likely to use illicit drugs and to inject country, immigration history, acculturation, drugs than other Asian American populations employment, geographic location, and in- (see review in Nemoto et al. 2002). come—add complexity to any conclusions To date, the largest national study to assess about prevalence among specific Asian cultur- substance use and mental disorders across al groups. Asian Americans who are recent Asian American groups is the NLAAS immigrants, highly acculturated, unemployed, (Takeuchi et al. 2007). This study found that or living in Western states are generally more Filipino American men were 2.38 times more likely than other Asian Americans to abuse likely to have a lifetime substance use disorder drugs or alcohol (Makimoto 1998). For exam- than were Chinese American men, whereas ple, according to the National Latino and the differences among women of diverse Asian Asian American Study (NLAAS), Asians who ethnicities were much smaller. Other research are more acculturated are at greater risk for suggests that Korean Americans are more prescription drug abuse (Watkins and Ford likely to have family histories of alcohol de- 2011). pendence than are Chinese Americans There are variations among particular groups (Ebberhart et al. 2003). of Asians; some Asian cultural groups have Besides the variations across different cultures, different attitudes toward substance use than substance use and abuse among Asian Ameri- others, and these differences tend to be ob- cans is also influenced by age. Substance abuse scured in large-scale surveys. Researchers have appears higher for young Asian Americans found that Korean American college students than for those who are older (possibly reflect- drank more frequently and drank greater ing differences in acculturation). A study quantities than did Chinese American stu- conducted in New York City showed that dents at the same schools and were more likely Asian American junior and senior high school to consider drinking socially acceptable students had the lowest percentage of heavy (Chang et al. 2008). Another study in the drinkers of any ethnic group, but those who District of Columbia and surrounding metro- were heavy drinkers drank twice as much daily politan area compared substance use among as those who did not drink heavily (Makimoto different groups of Southeast Asians (i.e., 1998). Asian American youth, especially im- Cambodian, Laotian, and Vietnamese migrants, tend to start using substances at a Americans); Vietnamese Americans had the later age than members of other ethnic groups, highest rates of alcohol use, but Cambodian which could be a factor in the lower levels of Americans had the highest rates of illicit drug abuse seen among Asian Americans. use (Wong et al. 2007b). Research in San Francisco found Chinese Americans to be less Despite rates of substance use disorders likely than Vietnamese or Filipino Americans among Asian Americans having increased over

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time, research has regularly found that, of all Americans are more likely to present with major racial/ethnic groups in United States, somatic complaints and less likely to present Asian Americans have the lowest rates of with symptoms of psychological distress and alcohol use disorders (Grant et al. 2004; impairment (Hsu and Folstein 1997; Kim et SAMHSA 2012b). This phenomenon has al. 2004; Room et al. 2001; U.S. Department typically been explained in part by the fact of Health and Human Services [HHS] 2001; that some Asians lack the enzyme aldehyde Zhang et al. 1998), even though mental illness dehydrogenase, which chemically breaks down appears to be nearly as common among Asian alcohol (McKim 2003). Thus, high levels of Americans as it is in other ethnic/racial acetaldehyde, a byproduct of alcohol metabo- groups. In 2009, approximately 15.5 percent of lism, accumulate and cause an unpleasant Asians reported a mental illness in the past flushing response (Yang 2002). The alcohol year, but only 2 percent reported past-year flushing response primarily manifests as flush- occurrence of serious mental illness (SAMHSA ing of the neck and face but can also include 2012a). Asian Americans have a lower inci- nausea, headaches, dizziness, and other dence of CODs than other racial/ethnic groups symptoms. because the prevalence of substance use disor- ders in this population is lower. In the 2012 Additional factors that could play a part in NSDUH, 0.3 percent of Asian Americans increasing the likelihood of substance use indicated co-occurring serious psychological disorders among Asian Americans include distress and substance use disorders, and 1.1 experiences of racism and the absence of percent had some symptoms of mental distress ethnic identification. Compared with Asian along with a substance use disorder—the low- Americans who do not have alcohol use disor- est rates of any major racial/ethnic group in the ders, Asian Americans who have alcohol use survey (SAMHSA 2013c). disorders are more than five times as likely to report unfair treatment because of their race Considerable variation in the types of mental and are more than twice as likely to deny disorders diagnosed among diverse Asian strong ethnic identification (Chae et al. 2008). American communities is evident, although it Compared with other racial and ethnic is unclear to what extent this reflects diagnostic groups, Asian Americans who drink heavily and/or self-selection biases. For example, are more likely to have friends or peers who Barreto and Segal (2005) found that Southeast also drink heavily (Chi et al. 1989). Asians were more likely to be treated for major depression than other Asians or mem- Mental and Co-Occurring bers of other ethnic/racial groups; East Asians Disorders were the most likely of all Asian American Overall, health and mental health are not groups to be treated for schizophrenia (nearly seen as two distinct entities by Asian Ameri- twice as likely as White Americans). Traumat- can cultural groups. Most Asian American ic experiences and PTSD can be particularly views focus on the importance of virtue, difficult to uncover in some Asian American maturity, and self-control and find full emo- clients. Although Asian Americans are as tional expression indicative of a lack of ma- likely to experience traumatic events (e.g., turity and self-discipline (Cheung 2009). wars experienced by first-generation immi- Given the potential shame they often associate grants from countries such as Vietnam and with mental disorders and their typically Cambodia) in their lives, their cultural respons- holistic worldview of health and illness, Asian es to trauma can conceal its psychological

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effects. For instance, some Asian cultural year, Asian Americans were also the most groups believe that stoic acceptance is the likely of all major racial/ethnic groups to most appropriate response to adversity (Lee report that they could not afford or had no and Mock 2005a,b). insurance coverage for substance abuse treat- ment (SAMHSA, CBHSQ 2011). Treatment Patterns Beliefs and Attitudes About Treatment-seeking rates for mental illness are low among most Asian populations, with rates Treatment varying by specific ethnic/cultural heritage Compared with the general population, Asian and, possibly, level of acculturation (Abe-Kim Americans are less likely to have confidence in et al. 2007; Barreto and Segal 2005; Lee and their medical practitioners, feel respected by Mock 2005a,b). Asian Americans who seek their doctors, or believe that they are involved help for psychological problems will most in healthcare decisions. Many also believe that likely consult family members, clergy, or tradi- their doctors do not have a sufficient under- tional healers before mental health profession- standing of their backgrounds and values; this als, in part because of a lack of culturally and is particularly true for Korean Americans linguistically appropriate mental health ser- (Hughes 2002). Even so, Asian Americans, vices available to them (HHS 2001; Spencer especially more recent immigrants, seem more and Chen 2004). However, among those Asian likely to seek help for mental and substance Americans who seek behavioral health treat- use disorders from general medical providers ment, the amount of services used is relatively than from specialized treatment providers high (Barreto and Segal 2005). (Abe-Kim et al. 2007). Many Asian American Asian Americans tend to enter treatment with immigrants underuse healthcare services due to less severe substance abuse problems than confusion about eligibility and fears of jeopard- members of other ethnic/racial groups and izing their residency status (HHS 2001). have more stable living situations and fewer As with other groups, discrimination, accul- criminal justice problems upon leaving treat- turation stress, and immigration and genera- ment (Niv et al. 2007). However, for Asian tional status, along with language needs, have Americans involved in the criminal justice a large influence on behavioral health and system, there is a more pronounced relation- treatment-seeking for Asian Americans (Meyer ship between crime and drug abuse than for et al. 2012; Miller et al. 2011). The NLAAS other ethnic and racial groups. In the early found that although rates of behavioral health 1990s, an estimated 95 percent of Asian service use were lower for Asian Americans Americans in California prisons were there who immigrated recently than for the general because of drug-related (Kuramoto population, those rates increased significantly 1994). According to SAMHSA’s 2010 TEDS for U.S.-born Asian Americans; third- data, 48.5 percent of Asian Americans in generation U.S.-born individuals’ rates of ser- treatment were referred by the criminal justice vice use also were relatively high (Abe-Kim et system in that year, compared with 36.4 per- al. 2007). Of those Asian Americans who had cent of African Americans and 36.6 percent of any mental disorder diagnosis in the prior year, White Americans (SAMHSA, CBHSQ 62.6 percent of third-generation Americans 2012). According to 2010 NSDUH data sought help for it in the prior year compared regarding individuals who reported a need for with 30.4 percent of first-generation treatment but did not receive it in the prior Americans.

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Overall, Asian Americans place less value on biopsychosocial explanations for substance use substance abuse treatment than other popula- and mental disorders. Counselors should tion groups and are less likely to use such promote discussions focused on clients’ under- services (Yu and Warner 2012). Niv et al. standing of their presenting problems as well (2007) found that Asian and Pacific Islanders as any approaches the clients have used to entering substance abuse treatment programs address them. Subsequently, presenting prob- in California expressed significantly more lems need to be reconceptualized in language negative attitudes toward treatment and rated that embraces the clients’ perspectives (e.g., an it as significantly less important than did imbalance in yin and yang, a disruption in chi; others entering treatment. Seeking help for Lee and Mock 2005a,b). It is advisable to substance abuse can be seen, in some Asian educate Asian American clients on the role of American cultural groups, as an admission of the counselor/therapist, the purpose of thera- weakness that is shameful in itself or as an peutic interventions, and how particular aspects interference with family obligations (Masson of the treatment process (e.g., assessment) can et al. 2013). Among 2010 NSDUH respond- help clients with their presenting problems ents who stated a need for substance abuse (Lee and Mock 2005a,b; Sue 2001). Asian treatment in the prior year but did not receive American clients who receive such education it, Asian Americans were more likely than participate in treatment longer and express members of all other major racial/ethnic greater satisfaction with it (Wong et al. 2007a). groups to say that they could handle the prob- As with other racial/ethnic groups, Asian lem without treatment or that they did not American clients are responsive to a warm and believe treatment would help (SAMHSA empathic approach. Counselors should realize, 2011c). Combining NSDUH data from 2003 though, that building a strong, trusting rela- to 2011 NSDUH, Asian Americans who tionship takes time. Among Asian American needed but did not receive treatment in the clients, humiliation and shame can permeate past year were the least likely of all major the treatment process and derail engagement ethnic/racial groups to express a need for such with services. Thus, it is essential to assess and treatment (SAMHSA, CBHSQ 2013c). discuss client beliefs about shame (see the Treatment Issues and “Assessing Shame in Asian American Clients” Considerations advice box on the next page). In some cases, self-disclosure can be helpful, but the counse- It is important for counselors to approach lor should be careful not to self-disclose in a presenting problems through clients’ culturally way that will threaten his or her position of based explanations of their own issues rather respect with Asian American clients. than imposing views that could alter their acceptance of treatment. In Asian cultural Asian American clients may look to counse- groups, the physical and emotional aspects of lors for expertise and authority. Counselors an individual’s life are undifferentiated (e.g., should attempt to build client confidence in the physical rather than emotional or psycho- the first session by introducing themselves by logical aspect of a problem can be the focus , displaying diplomas, and mentioning his for many Asian Americans); thus, problems as or her experience with other clients who have well as remedies are typically handled holisti- similar problems (Kim 1985; Lee and Mock cally. Some Asian Americans with traditional 2005a,b). Asian American clients may expect backgrounds do not readily accept Western and be most comfortable with formalism on

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Advice to Counselors: Assessing verbal messages than on the explicit content of Shame in Asian American Clients messages (Hall 1976). Asian Americans often use indirect communication, relying on subtle Shame and humiliation can be significant barri- ers to treatment engagement for Asian Ameri- gestures, expressions, or word choices to con- cans. Gaw (1993) suggests that the presence of vey meaning without being openly confronta- the following factors may indicate that a client tional. Counselors must not only be observant has shame about seeking treatment: of nuances in meaning, but also learn about • The client or a family member is extremely verbal and styles concerned about the qualifications of the counselor. specific to Asian cultural groups (for a review • The client is hesitant to involve others in of guidelines to use when working with Asian the treatment process. Americans, see Gallardo et al. 2012). • The client is excessively worried about confidentiality. Asian American clients appear to respond • The client refuses to cover expenses with more favorably to treatment in programs that private insurance. provide services to other Asian clients. • The client frequently or arrives late for treatment. Takeuchi et al. (1995) found that Asian • Family members refuse to support treat- Americans were much more likely to return to ment. mental health clinics where most clients were • The client insists on having a White Ameri- Asian American than to programs where that can counselor to avoid opening up to an- was not the case (98 percent and 64 percent other Asian. returned, respectively). When demographic • The client refuses treatment even when severe problems are evident. differences were controlled for, those who attended programs that had predominantly Asian clients were 15 times more likely to the part of counselors, especially at the begin- return after the initial visit. Asian Americans ning of treatment and prior to assessment of were also more likely to stay in treatment clients’ needs (Paniagua 1998). Many Asian when matched with an Asian American coun- American clients expect counselors to be selor regardless of the type of program they directive (Leong and Lee 2008). Passivity on attended. Sue et al. (1991) also found that the part of the counselor can be misinterpret- Asian American clients attended significantly ed as a lack of concern or confidence. more treatment sessions if matched with an Counselors who are unaccustomed to working Asian American counselor. with Asian populations will likely encounter Among Asian American women, crucial conflict between their theoretical worldview of strategies include reducing the shame of sub- counseling and the deference to authority and stance abuse and focusing on the promotion of avoidance of confrontation that is common overall health rather than just addressing among more traditional Asian American substance abuse. Such strategies reduce the clients. Some clients can be hesitant to con- chance of a woman and her family seeing tradict the counselor or even to voice their substance abuse as an individual flaw. Home own opinions. Confrontation can be seen as visits, when agreed in advance with the client, something to avoid whenever possible. Fur- can be appropriate in some cases as a way to thermore, many Asian cultural groups have gain the trust of, and show respect for, Asian high-context styles of communication, mean- American women. Asian American women ing that members often place greater im- may not be as successful in mixed-gender portance on nonverbal cues and the context of

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Advice to Administrators: Culturally Responsive Program Development Behavioral health service program administrators can improve engagement and retention of Asian clients by making culturally appropriate accommodations in their programs. The accommodations required will vary according to the specific cultural groups, language preferences, and levels of acculturation in question. The following culturally responsive program suggestions were initially identified for Cambodian clients but can be adapted to match the unique needs of other Asian clients from different ethnic and cultural backgrounds: • Create an advisory committee using representatives from the community. • Incorporate cultural knowledge and maintain flexible attitudes as a counselor. • Use cotherapist teams in which one member is Asian and bilingual. • Provide services in the clients’ primary language. • Develop culturally specific questionnaires for intake to capture information that may be missed by standard questionnaires. • Conduct culturally appropriate assessments of trauma that ask about the traumatic experiences common to the population in question. • Visit client homes to improve family involvement in treatment. • Provide support to families during transitions from and to professional care. • Emphasize traditional values. • Explore client coping mechanisms that draw upon cultural strengths. • Use acupuncture or other traditional practices for detoxification. • Integrate Buddhist ideas, values, and practices into treatment when appropriate. • Emphasize relationship-building; help clients with life problems beyond behavioral health concerns. • Provide concrete services, such as housing assistance and legal help. Sources: Amodeo et al. 2004; Park et al. 2011.

groups if strict gender roles exist whereby be more effective if providers avoid approaches communication is constricted within and out- that target emotional responses and instead side the family; women will likely remain silent use strategies that are more indirect in discuss- or defer to the men in the group (Chang 2000). ing feelings (e.g., saying “that might make For more information on treating women, see some people feel angry” rather than asking Treatment Improvement Protocol (TIP) 51, directly what the client is feeling; Sue 2001). Substance Abuse Treatment: Addressing the Asian Americans often prefer a solution- Specific Needs of Women (CSAT 2009c). focused approach to treatment that provides Theoretical Approaches and them with concrete strategies for addressing Treatment Interventions specific problems (Sue 2001). Even though little research is available in evaluating specific Some Asian cultural groups emphasize cogni- interventions with Asian Americans, clinicians tions. For instance, Asian cultural groups that tend to recommend cognitive–behavioral, have a Buddhist tradition, such as the Chinese, solution-focused, family, and acceptance view behavior as controlled by thought. Thus, commitment therapies (Chang 2000; Hall et they accept that addressing cognitive patterns al. 2011; Iwamasa et al. 2006; Rastogi and will affect behaviors (Chen 1995). Some Asian Wadhwa 2006; Sue 2001). Asian American cultural groups encourage a stoic attitude clients are likely to expect that their counselors toward problems, teaching emotional suppres- take an active role in structuring the therapy sion as a coping response to strong feelings session and provide clear guidelines about (Amodeo et al. 2004; Castro et al. 1999b; Lee what they expect from clients. CBT has the and Mock 2005a,b; Sue 2001). Treatment can

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advantages of being problem focused and time For most Asian Americans, particularly those limited, which will likely increase its appeal for who are less acculturated, successful treatment many Asian Americans who might see other involves the client’s family (Chang 2000; Kim types of therapy as failing to achieve real goals et al. 2004; Rastogi and Wadhwa 2006). Even (Iwamasa et al. 2006). Although specific data in individual treatment, it is important to on the effectiveness of CBT among Asian understand the client’s family and his or her Americans is not available, there is some relationship with its members, the dynamics research indicating that CBT is effective for and style of the family, and the family’s role in treating depressive symptoms in Asians (Dai the client’s substance abuse (Meyer et al. et al. 1999; Fujisawa et al. 2010). In China, a 2012). Particularly among Asian American Chinese Taoist version of CBT has been women, family involvement can be essential developed to treat anxiety disorders and was due to the client’s concern about being re- found to be effective, especially in conjunction sponsive to her family’s needs. Nonetheless, with medication (Zhang et al. 2002). involving the family can be quite difficult, as Family therapy both male and female clients may wish to conceal their substance abuse from their fami- Some Asian Americans, particularly those lies because of the shame that it brings. who are less acculturated, prefer individual therapy to group or family interventions be- Advice to Counselors: Culturally cause it better enables them to save face and Responsive Family Therapy keep their privacy (Kuramoto 1994). Some Guidelines for Asian Families clients may wish to enter treatment secretly so Kim et al. (2004) reviewed references that that they can keep their families and friends provide guidelines for family therapy with from knowing about their problems. Once Korean Americans. They established 11 essen- treatment is initiated, counselors should tial ingredients applicable to Korean and other Asian American groups and families. To pro- strongly reinforce the wisdom of seeking help vide culturally responsive therapy to Asian through statements such as “you show concern Americans, counselors should: for your husband by seeking help” or “you are • Assess support from community and ex- obviously a caring father to seek this help.” tended family systems. • Assess immigration history, if appropriate. The norm in Asian families is that “all prob- • Establish credibility as a professional in the lems (including physical and mental problems) initial meeting with the family. must be shared only among family members”; • Explain the key principles and expectations of family therapy and the family roles (es- sharing with others can cause shame and guilt, pecially elders/decisionmakers) in the pro- exacerbating problems (Paniagua 1998, pp. cess. 59–60). Counselors should expect to take • Enable clients, particularly male elders or more time than usual to learn about clients’ decisionmakers, to save face. situations, anticipate client needs for reassur- • Validate and address somatic complaints. • Be both problem focused and present ance in divulging sensitive information, and focused. frame discussions in a culturally competent • Be directive in guiding therapy. way. For example, counselors can assure cli- • Respect the family’s hierarchy. ents that discussing problems is a step toward • Avoid being confrontational and facilitate resuming their full share of responsibility in interactions that are nonconfrontational. • Reframe problems in positive terms. their families and removing some of the stress their families have been feeling. Source: Kim et al. 2004.

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To engage family members in the client’s group goals in this framework can garner treatment, the counselor first needs to be active participation. Still, in group settings and familiar with the way the family functions. in other instances, Asian American clients Different acculturation levels among individu- may expect a fair amount of direction from the al family members and across generations can group leader. Chen (1995) described leader- affect how the family functions, producing ship of a culturally specific therapy group for significant stress and internal conflict. Also, Chinese Americans, noting that clients expect the counselor must be aware of how gender a group leader to act with authority and give roles and generational status influence the more credence to his or her expertise than to communication patterns and rules within each other group members. If members of the family (e.g., expectations of how a child ad- group belong to the same Asian American dresses a parent, the potential relegation of community, the issue of confidentiality will authority among female family members). loom large, because the community is often Even more than for other clients, it is critical small. Asian cultural groups generally appreci- for Asian Americans to “avoid embarrassing ate education in more formal settings, so the family members in front of each other. psychoeducation groups can work well for The counselor should always protect the Asian Americans. It is possible for a psy- dignity and self-respect of the client and his or choeducational group with Asian American her family” (Paniagua 1998, p. 71). participants to evolve comfortably into group Group therapy therapy. Mutual-help groups Group therapy may not be a good for Asian Americans, as many prefer individual According to 2012 NSDUH data, Asian therapy (Lai 2001; Sandhu and Malik 2001). Americans were less likely than other racial Paniagua (1998, p. 73) suggests that “group and ethnic groups to report the use of mutual- therapy…would be appropriate in those cases help groups in the past year (SAMHSA in which the client’s support system (relatives 2013d). Mutual-help groups can be challeng- and close friends) is not available and an ing for Asian Americans who find it difficult alternative support system is quickly needed.” and shaming to self-disclose publicly. The Some Asian Americans participating in group degree of emotion and candor within these therapy will find it difficult to be assertive in a groups can further alienate traditional Asian group setting, preferring to let others talk. American clients. Furthermore, linguistically They can also abide by more traditional roles appropriate mutual-help groups are not always in this context; men might not want to divulge available for people who do not speak English. their problems in front of women, women can Highly acculturated Asian Americans may feel uncomfortable speaking in front of men, perceive participation in mutual-help groups and both men and women might avoid con- as less of a problem, but nevertheless, Asian tradicting another person in group (especially Americans can benefit from culture-specific an older person). It may not make sense to mutual-help groups where norms of interper- Asian American clients to hear about the sonal interaction are shared. Asian American problems of strangers who are not part of their 12-Step groups are available in some locales. community. It is important for counselors to assess client attitudes toward mutual-help participation Asian Americans are likely to be motivated to and find alternative strategies and resources, work for the good of the group; presenting

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including encouragement to attend without through a variety of culture-specific interven- sharing (Sandhu and Malik 2001). tions. For example, some Southeast Asian cultural groups practice cao gio—massaging Although they are not mutual-help groups in the skin with ointment and hot coins (Chan the traditional sense, mutual aid societies and and Chen 2011). The Chinese have developed associations are important in some Asian enormously complex systems of medical American communities. Some mutual aid treatment over centuries of pragmatic experi- societies have long histories and have provided mentation. Traditional com- assistance ranging from financial loans to help bines plant substances according to precise with childcare and funerals. The Chinese have formulas to have the desired influence on the family associations for people with the same affected organs of the body. Acupuncture last name who share celebrations and offer techniques involve regulating the flow of each other help. Japanese, Chinese, and South energy (qi) through the body by inserting Asians have specific associations for people needles at precise locations called acupuncture from the same province or village. For some points. In traditional Chinese medicine, which Asian American groups, such as Koreans, has influenced traditional medical practices in churches are the primary organizational vehi- other Asian cultural groups, illness is seen as cles for assistance. These social support groups an imbalance of yin and yang; a return to can be important resources for Asian American physical wellness can require introducing clients, their families, and the behavioral elements such as herbs to increase yin or yang health agencies that provide services to them. as needed (Torsch and Ma 2000). Traditional healing and Among less acculturated Asian Americans, complementary methods Western medicine, including Western behav- Asian Americans are twice as likely as other ioral health services, can be insufficient to deal Americans to report making use of acupunc- with a problem such as substance abuse and its ture and traditional healers. Even though there effects on clients and their families. For exam- is considerable variation in their use of com- ple, all health problems for the Hmong plementary and (Hughes (whether physical or psychological) are con- 2002), many Asian Americans highly regard sidered spiritual in nature; if providers ignore traditional healers, herbal preparations, and the clients’ understanding of their problems as other culturally specific interventions as a spiritual maladies, they are unlikely to effect means of restoring harmony and balance. positive change (Fadiman 1997). Even for However, Asian American clients do not more acculturated Asian Americans, the use of always readily disclose the use of traditional traditional healing methods and spirituality medicine to Western treatment providers. Ahn can be a very important aspect of treatment et al. (2006) found that about two-thirds of (see Chan and Chen 2011 for an overview of Chinese and Vietnamese Americans who health beliefs and practices). Such use can spoke no or limited English had used tradi- provide a spiritual connection that helps man- tional medicine, but only 7.6 percent had age feelings that are especially difficult to discussed the use of these therapies with their express to others. Many practices associated Western medical providers. with meditation, , and Eastern religious traditions can help disperse the stress and Traditional treatment to restore physical and anxiety experienced during treatment and emotional balance for Asian Americans occurs recovery. In the United States, there are few

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Behavioral Health Counseling for Native Hawaiians and Other Pacific Islanders The of Native Hawaiians and other Pacific Islanders were the original inhabitants of Hawaii, , Samoa, and other Pacific islands. The population of Native Hawaiians and other Pacific Islanders grew more than three times faster than the total U.S. population from 2000 to 2010. More than half of Native Hawaiian and other Pacific Islanders live in Hawaii and California. The largest Pacific Islander populations in the United States comprise Hawaiians, , and Chamorros—the indigenous people of the Mariana Islands, of which Guam is the largest (Hixson et al. 2012).

Native Hawaiians and other Pacific Islanders make up a relatively small proportion of the total United States population. In the 2010 Census, 540,000 people, or 0.2 percent of the population, reported their race as Native Hawaiian or other Pacific Islander, and another 685,000 people (0.2 percent of the population) stated that they were Native Hawaiian or other Pacific Islander in addition to one or more other races (Hixson et al. 2012). The largest concentration of Native Hawaiians and other Pacific Islanders is in Hawaii, where individuals with at least some of this ancestry made up 23.3 percent of the population.

In 2012, according to NSDUH data, 5.4 percent of Native Hawaiians and other Pacific Islanders interviewed had a substance use disorder in the prior year, and 7.8 percent engaged in current illicit drug use (SAMHSA 2013d). Binge and heavy drinking appear to be relatively high, especially among Native Hawaiian/Pacific Islander women. Data from the 2001–2011 TEDS surveys indicate that the most common primary substances of abuse among Native Hawaiians and other Pacific Islanders entering substance abuse treatment are alcohol, , and methamphetamine (SAMHSA 2013c). Because of its relatively small size, many studies have either ignored or been unable to make conclu- sions about substance use and abuse in this population; other research has grouped Native Hawaiians and other Pacific Islanders together with Asians (more for the sake of convenience than for underlying cultural similarities).

According to NSDUH data, 1.8 percent of adult Native Hawaiians and other Pacific Islanders report- ed serious mental illness. Insufficient data were available to analyze past-year mental illness rates (SAMHSA 2013c). Similar to substance use data, specific mental health data are limited across national studies, primarily because the population has been grouped with Asians. However, the evidence that is available suggests that Native Hawaiians are less likely than other racial/ethnic groups in Hawaii to access treatment services even though they experience higher rates of mental health problems (for a review of health beliefs and practices, see Mokuau and Tauili’ili 2011).

A few examples of culturally specific interventions for Native Hawaiians have been presented in the literature. For example, the Rural Hawai’i Behavioral Health Program, which provides substance abuse and mental health services to Native Hawaiians living in rural areas, incorporates Native Hawaiian beliefs and practices into all areas of the program, emphasizing the value of ‘ohana (family) relations, including the importance of respecting and honoring ancestors and elders and passing on cultural ways to the next generation. Program staff members are trained in Native Hawaiian culture and beliefs, including spirituality and the essential value of graciousness, the honoring of mana (life energy), healing rituals such as pule (prayer), the use of healing herbs, and Native Hawaiian beliefs about the causes of illness, such as wrongdoing and physical disruption (Oliveira et al. 2006).

Ho’oponopono is a form of group therapy used by Native Hawaiians; it involves family members and is facilitated by a Küpuna (elder). A qualitative study by Morelli and Fong (2000) of Ho’oponopono with pregnant or postpartum women with substance use disorders (primarily methamphetamine abuse) reported high client satisfaction and positive outcomes (80 percent were abstinent 2 years after treatment). The Na Wahine Makalapua Project, sponsored by the Hawaii Department of Health’s Alcohol and Drug Abuse Division and SAMHSA’s Center for Substance Abuse Prevention, uses elements of Hawaiian culture to treat women with substance use disorders, such as by having Küpuna counsel younger generations.

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examples of culturally specific treatment pro- abstinence difficult for Asian clients. Counse- grams that focus on Asian religious or spiritual lors should take this into account and address treatment; however, there are programs over- difficulties that can arise for clients with fami- seas, such as the Thai Buddhist treatment lies who have shame about mental illness or center described by Barrett (1997). substance use disorders. To date, there are no indications that standard approaches are un- Asian Americans are much more likely than suitable for Asian American clients. For more members of other racial/ethnic groups to label information on these approaches, see the themselves as secular, agnostic, or atheist planned TIP, Relapse Prevention and Recovery (Kosmin and Keysar 2009; Pew Forum on Promotion in Behavioral Health Services Religion and Public Life 2008). That said, a (SAMHSA planned e). substantial number of Asian Americans still have religious affiliations. About 45 percent Counseling for Hispanics are Protestant; 17 percent, Catholic; 14 per- cent, Hindu; 9 percent, Buddhist; and 4 per- and Latinos cent, Muslim (Pew Forum on Religion and Public Life 2008). More acculturated Asian The terms “Hispanic” and “Latino” refer to Americans are likely to enter treatment people whose cultural origins are in Spain and through medical settings and to be comforta- Portugal or the countries of the Western ble with a medical model for treatment, but Hemisphere whose culture is significantly those who are less acculturated or are foreign- influenced by Spanish or Portuguese coloniza- born can prefer the use of traditional healing tion. Technically, a distinction can be drawn and/or religious traditions and beliefs as part between Hispanic (literally meaning people of their treatment ( Ja and Yuen 1997). Reli- from Spain or its former colonies) and Latino gious institutions can play an important part (which refers to persons from countries ranging in the treatment of some groups of Asian from Mexico to Central and South America Americans. For example, Kwon-Ahn (2001) and the Caribbean that were colonized by notes that many Korean Americans, particu- Spain, and also including Portugal and its larly more recent immigrants, turn to Chris- former colonies); this TIP uses the more tian clergy or church groups for assistance inclusive term (Latino), except when research with family and personal problems, such as specifically indicates the other. The term substance abuse, before seeking professional “Latina” refers to a woman of Latino descent. help. Amodeo et al. (2004) suggest that, in Latinos are an ethnic rather than a racial working with Cambodian immigrants, provid- group; Latinos can be of any race. According ers integrate Buddhist philosophy and practic- to 2010 Census data, Latinos made up 16 es into treatment, and, if possible, partner with percent of the total United States population; Buddhist to facilitate treatment entry they are its fastest growing ethnic group (Ennis or to provide services for clients who choose et al. 2011). Latinos include more than 30 to reside in Buddhist temples. national and cultural subgroups that vary by Relapse prevention and recovery national origin, race, generational status in the United States, and socioeconomic status Little research has evaluated relapse preven- (Padilla and Salgado de Snyder 1992; tion and recovery promotion strategies specifi- Rodriguez-Andrew 1998). According to Ennis cally for Asian Americans. However, issues et al. (2011), of Latinos currently living in the involving shame can make the adjustment to United States (excluding and

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other territories), Mexican Americans are the and Glassman 1999). The authors concluded largest group (63 percent), followed by Central that “losing control” has a different cultural and South Americans (13.4 percent), Puerto meaning for these two groups, which in turn Ricans (9.2 percent), and Cubans (3.5 percent). affects how they use alcohol. Beliefs About and Traditions For many Latino men, drinking alcohol is a Involving Substance Use part of social occasions and celebrations. By contrast, solitary drinking is discouraged and Attitudes toward substance use vary among seen as deviant. Social norms for Latinas are Latino cultural groups, but Latinos are more often quite different, and those who have likely to see substance use in negative terms substance abuse problems are judged much than are White Americans. Marin (1998) more harshly than men. Women can be per- found that Mexican Americans were signifi- ceived as promiscuous or delinquent in meet- cantly more likely to expect negative conse- ing their family duties because of their quences and less likely to expect positive substance use (Hernandez 2000). Amaro and outcomes as a result of drinking than were Aguiar (1995) note that the heavy emphasis White Americans. Similarly, Hadjicostandi on the idealization of motherhood contributes and Cheurprakobkit (2002) note that most to the level of denial about the prevalence of Latinos believe that prescription drug abuse substance use among Latinas. Women who could have dangerous effects (85.7 percent), use injection drugs feel the need to maintain that individuals who abuse substances cause their roles as , mothers, partners, and their whole families to suffer (81.4 percent), community members by separating their drug and that people who use illicit drugs will use from the rest of their lives (Andrade and participate in violent crime (74.9 percent) and Estrada 2003), yet research suggests that act violently toward family members (78.9 substance abuse among women does not go percent). Driving under the influence of alco- unrecognized within the Latino community hol is one of the most serious substance use (Hadjicostandi and Cheurprakobkit 2002). problems in the Latino community. Among families, Latino adults generally show Other research suggests that some Latinos strong disapproval of alcohol use in adoles- hold different alcohol expectancies. When cents of either gender (Flores-Ortiz 1994). comparing drinking patterns and alcohol Adults of both genders generally disapprove of expectancies among college students, Velez- the initiation of alcohol use for youth 16 years Blasini (1997) found that Puerto Rican partic- of age and under (Rodriguez-Andrew 1998). ipants were more likely than other students to Long (1990) also found that even among see increased sociability as a positive expectan- Latino families in which there has been multi- cy related to drinking and sexual impairment generational drug abuse, young people were as a negative expectancy. Puerto Rican partici- rarely initiated into drug abuse by family pants were also significantly more likely to members. However, evidence regarding paren- report abstinence from alcohol. In another tal substance use and its influence on youth study comparing Puerto Ricans and Irish has been mixed; most studies show some Americans, Puerto Rican participants who correlation between parental attitudes toward expected a loss of control when drinking had alcohol use and youth drinking (Rodriguez- fewer alcohol-related problems, whereas Irish Andrew 1998). For instance, research with Americans who expected a loss of control had college students found that family influences a greater number of such problems (Johnson

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had a significant effect on drinking in Latinos Although data are available from a number of but not White Americans; the magnitude of studies regarding Latino drinking and drug this effect was greater for Latinas than for use patterns, more targeted research efforts are Latino men (Corbin et al. 2008). needed to unravel the complexities of sub- stance use and the many factors that affect use, Substance Use and Substance Use abuse, and dependence among subgroups of Disorders Latino origin (Rodriguez-Andrew 1998). For According to 2012 NSDUH data, rates of example, some studies show that Latino men past-month illicit substance use, heavy drink- are more likely to have an alcohol use disorder ing, and binge drinking among Latinos were than are White American men (Caetano lower than for White Americans, Blacks, and 2003), whereas others have found the reverse Native Americans, but not significantly so to be true (Schmidt et al. 2007). Disparities (SAMHSA 2013d). The same data showed in survey results may reflect varying efforts to that 8.3 percent of Latinos reported past- develop culturally responsive criteria (Carle month illicit drug use compared with 9.2 2009; Hasin et al. 2007). The table in Exhibit percent of White Americans and 11.3 percent 5-2 shows lifetime prevalence of substance of African Americans. use disorders among Latinos based on

Exhibit 5-2: Lifetime Prevalence of Substance Use Disorders According to Ethnic Subgroup and Immigration Status

Any Alcohol Drug Ethnic Substance Use Alcohol Dependence, Drug Dependence, Subgroup Disorder, % Abuse, % % Abuse, % % Puerto Ricans (born in the U.S. 15.9 7.7 5.6 4.6 4.3 mainland) Puerto Ricans (born in 11.1 4.6 5.3 4.3 3.6 Puerto Rico) (born in 20.9 6.5 8.2 3.6 5.7 the U.S.) Cuban Americans 6.4 3.4 2.2 2.2 1.9 (foreign-born) Mexican Ameri- cans (born in the 21.4 9.4 7.7 5.8 5.3 U.S.) Mexican Ameri- 7 3.5 2.8 2.0 1.7 cans (foreign-born) Other Latino (born 20.4 10.4 5.3 8.4 5.2 in the U.S.) Other Latino 5.7 3.2 2.2 2.1 1.0 (foreign-born)

Source: Alegria et al. 2008a.

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immigration status and ethnic subgroup than men in the same age group across other (Alegria et al. 2008a). racial/ethnic populations. Among diverse Latino cultural groups, differ- Latino youth appear to start using illicit drugs ent patterns of alcohol use exist. For example, at an earlier age than do members of other some older research suggests that Mexican major ethnic/racial groups. Cumulative data American men are more likely to engage in from 28 years of the Monitoring the Future binge drinking (having five or more drinks at Study show Latino eighth graders as having one time; drinking less frequently, but in higher rates of heavy drinking, marijuana use, higher quantities) than other Latinos but use cocaine use, and heroin use than African or alcohol less frequently (Caetano and Clark White Americans in the same grade. Among 1998). There are also differences regarding the youth in grade 12, the rates of use among abuse of other substances. Among Latinos Latino and White American students are entering substance abuse treatment in 2006, more similar, but Latinos still had the highest heroin and methamphetamine use were espe- rates of crack cocaine and injected heroin use cially high among Puerto Ricans and Mexican ( Johnston et al. 2003). Americans, respectively. Other research has Patterns of substance use and abuse vary based found that Puerto Ricans are more likely to on Latinos’ specific cultural backgrounds. inject drugs and tend to inject more often Among Latinos, rates of past-year alcohol during the course of a day than do other dependence were higher among Puerto Rican Latinos (Singer 1999). and Mexican American men (15.3 percent and Patterns of substance use are also linked to 15.1 percent, respectively) than among gender, age, socioeconomic status, and accul- South/Central American or Cuban American turation in complex ways (Castro et al. 1999a; men (9 percent and 5.3 percent, respectively). Wahl and Eitle 2010). For instance, increased Among Latinas, past-year alcohol dependence frequency of drinking is associated with great- rates were significantly higher for Puerto er acculturation for Latino men and women, Rican women (6.4 percent) than for Mexican yet the drinking patterns of Latinas are affect- American (2.1 percent), Cuban American (1.6 ed significantly more than those of Latino percent), or South/Central American (0.8 men (Markides et al. 2012; Zemore 2005). percent) women (Caetano et al. 2008). Age appears to influence Latino drinking Mental and Co-Occurring patterns somewhat differently than it does for Disorders other racial/ethnic groups. Research indicates that White Americans often “age out” of As with other populations, it is important to heavy drinking after frequent and heavy alco- address CODs in Latino clients, as CODs hol use in their 20s, but for many Latinos, have been associated with higher rates of drinking peaks between the ages 30 and 39. treatment dropout (Amodeo et al. 2008). Latinos in this age range have the lowest There are also reports of diagnostic bias, sug- abstention rates and the highest proportions gesting that some disorders are underreported of frequent and heavy drinkers of any age and others are overreported. Minsky et al. group (Caetano and Clark 1998). In the same (2003) found that, at one large mental health study, Latino men between 40 and 60 years of treatment site in New Jersey, major depression age had higher rates of substance use disorders was overdiagnosed among Latinos, especially Latinas, whereas psychotic symptoms were

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sometimes ignored. Among Latinos with linguistically and/or culturally appropriate CODs, other mental disorders preceded the services (SAMHSA 2011c). They were about development of a substance use disorder 70 twice as likely to state the former and four percent of the time (Vega et al. 2009). times as likely to state the latter as members of the group that was the next most likely to Overall, research indicates fewer mental disor- make such statements. ders and CODs among Latinos than among White Americans (Alegria et al. 2008a; Vega A significant problem prohibiting participa- et al. 2009). However, data from the 2012 tion in substance abuse treatment among NSDUH indicate that the magnitude of the Latinos is the lack of insurance coverage to difference may be decreasing; 1.2 percent of pay for treatment. In SAMHSA’s 2010 Latinos had both serious mental illness and NSDUH, 32 percent of Latinos who needed substance use disorders in the prior year, as did but did not receive substance abuse treatment White Americans, similar to the rate seen in the past year reported that they lacked mon- among African Americans (0.9 percent; ey or insurance coverage to pay for it compared SAMHSA 2013c). When any mental disorder with 29.5 percent of White Americans and symptoms co-occurring with a substance use 33.5 percent of African Americans disorder diagnosis were evaluated, Latinos had (SAMHSA 2011c). Other national surveys a slightly higher rate of co-occurrence (3.4 also found that Latinos with self-identified percent) than did African Americans (3.3 drinking problems were significantly more percent; SAMHSA 2013c). Rates of mental likely than either White Americans or African disorders and CODs also vary by Latino Americans to indicate that they did not seek subgroup (Alegria et al. 2008a), and accultura- treatment because of logistical barriers, such as tion can play a confounding, but inconsistent, a lack of funds or being unable to obtain role in the identification and development of childcare (Schmidt et al. 2007). CODs in Latino populations (Alegria et al. Latinos with substance use disorders are about 2008a; Vega et al. 2009). as likely to enter substance abuse treatment Treatment Patterns programs as White Americans (Hser et al. 1998; Perron et al. 2009; Schmidt et al. 2006). Barriers to treatment entry for Latinos in- Latinos tend to enter treatment at a younger clude, but are not limited to, lack of Spanish- age than either African Americans or White speaking service providers, limited (Marsh et al. 2009). There are also proficiency, financial constraints, lack of cul- significant differences in treatment-seeking turally responsive services, fears about immi- patterns among Latino cultural groups. For gration status and losing custody of children example, Puerto Ricans who inject heroin are while in treatment, negative attitudes toward much more likely to participate in methadone providers, and discrimination (Alegria et al. main-tenance and less likely to enter other 2012; Mora 2002). Among all ethnic/racial less-effective detoxification programs than groups included in the 2010 NSDUH, Lati- are Dominicans, Central Americans, and nos were the most likely to report that they other Latinos (Reynoso-Vallejo et al. 2008). had a need for treatment but did not receive it The researchers note, however, that this could because they could not find a program with be due partially to the fact that Puerto Ricans, the appropriate type of treatment or because compared with other Latinos, have a greater there were no openings in programs that they awareness of treatment options. wished to attend, which may reflect a lack of

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Beliefs and Attitudes About 1998; Perron et al. 2009; Schmidt et al. 2006). Treatment Latinos who receive substance abuse treatment also report less satisfaction with the services In general, Latino attitudes toward health care they receive than White or African Americans are shaped by a lack of access to regular quality (Wells et al. 2001). Even when receiving a care, including inability to afford it (see review level of substance abuse treatment services of health beliefs and help-seeking behaviors comparable to those received by White and among Mexican Americans and African Americans, Latinos are more likely to dwelling in the United States in Rogers 2010). be dissatisfied with treatment (Tonigan 2003). DeNavas-Walt et al. (2006) found that Lati- nos are less likely to have health insurance Treatment Issues and (32.7 percent were uninsured in 2005) than Considerations either non-Latino White Americans (11.3 percent were uninsured) or African Americans Latino clients’ responsiveness to therapy is (19.6 percent were uninsured). They are also influenced not only by counselor and program less likely to have had a regular place to go for characteristics, but also by individual charac- conventional medical care (Schiller et al. teristics, including worldview, degree of accul- 2005). Lack of knowledge about available turation, gender orientation, religious beliefs, services can be a major obstacle to seeking and personality traits. As with other cultural services (Vega et al. 2001). In their review, groups, efforts to establish clear communica- Murguia et al. (2000) identified several factors tion and a strong therapeutic alliance are that influence the use of medical services, essential to positive treatment outcomes including cultural health beliefs, demographic among Latino clients. Foremost, counselors barriers, level of acculturation, English profi- should recognize the importance of—and ciency, accessibility of service providers, and integrate into their counseling style and ap- flexibility of intake procedures; they found proach—expressions of concern, interest in that many Latinos only seek medical care for clients’ families, and personal warmth (person- serious illnesses. alismo; Ishikawa et al. 2010). Research on substance abuse indicates that Counselors and clinical supervisors need to be Latinos who use illicit drugs appear to have educated about culturally specific attributes relatively unfavorable attitudes toward treat- that can influence participation and clinical ment and perceive less need for treatment than interpretation of client behavior in treatment. do illicit drug users among every other major For instance, some Latino cultural groups view ethnic and racial group but Native Americans time as more flexible and less structured; thus, (Brower and Carey 2003). However, in the rather than negatively interpreting the client’s 2011 NSDUH, Latinos were more likely than behavior regarding the keeping of strict White Americans, African Americans, or schedules or appointment times, counselors Asian Americans to indicate that they had a should adopt scheduling strategies that pro- need for substance abuse treatment in the vide more flexibility (Alvarez and Ruiz 2001; prior year but did not receive it (SAMHSA Sue 2001). However, counselors should also 2012b). Other studies have found that Latinos advise Latino clients of the need to take rele- with substance use disorders are about as likely vant actions with the aim of arriving on time to enter substance abuse treatment programs for each appointment or group session. Coun- as other racial and ethnic groups (Hser et al. selors should try to avoid framing noncompli- ance in Latino clients as resistance or anger. It

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is often, instead, a pelea nonga (relaxed fight) (Field and Caetano 2010). Available literature showing both a sense of being misunderstood and research highlight four main themes sur- and respeto (respect that also encompasses a rounding general counseling issues and pro- sense of duty) for the counselor’s authority grammatic strategies for Latinos, as follows. (Barón 2000; Medina 2001). Socializing the client to treatment: Latino Unfortunately, many providers who work with clients are likely to benefit from orientation Latino cultural groups continue to have mis- sessions that review treatment and counseling perceptions and can even see culture as a processes, treatment goals and expectations, hindrance to effective treatment rather than as and other components of services (Organista a source of potential strength (Quintero et al. 2006). 2007). For instance, in treating the alcohol Reassurance of confidentiality: Regardless of problems of Latinas, many counselors believe the particular mode of therapy, counselors that they should not incorporate endorsement should explain confidentiality. Many Latinos, of traditional and possibly harmful cultural especially undocumented workers or recent patterns into the services they provide (Mora immigrants, are fearful of being discovered by 2002). However, other counselors note that authorities like the United States Citizenship the transformative value of the most positive and Immigration Services and subsequently aspects of Latino cultural groups can be em- deported back to their countries of origin phasized: strength, perseverance, flexibility, (Ramos-Sanchez 2009). and an ability to survive (Gloria and Peregoy 1996). Respecting women’s choices can mean Client–counselor matching based on gen- supporting empowerment to pursue new roles der: To date, research does not provide con- and make new choices free of alcohol, guilt, sistent findings on client–counselor matching and discrimination (Mora 2002). For others, it based on similarity of Latino ethnicity. How- can mean reinvigorating the positivity of ever, client–counselor matching based on Latina culture to promote abstinence while gender alone appears to have a greater effect respecting and maintaining traditional family on improving engagement and abstinence roles for women (Gloria and Peregoy 1996). among Latinos than it does for clients of other ethnicities (Fiorentine and Hillhouse 1999). Because some research has found that Latinos have higher rates of treatment dropout than Client–program matching: Matching clients other populations (Amaro et al. 2006), pro- to ethnicity-specific programs appears to grams working with this population should improve outcomes for Latinos. Takeuchi et al. consider ways to improve retention and out- (1995) found that only 68 percent of Mexican comes. Treatment retention issues for Latinos American clients in programs that had a can be similar to those found for other popu- majority of White American clients returned lations (Amodeo et al. 2008), but culturally after the first session compared with 97 per- specific treatment has been associated with cent in those programs where the majority of better retention for Latinos (Hohman and clients were Mexican American. Galt 2001). Research evaluating ethnic match- ing with brief motivational interventions also Theoretical Approaches and found more favorable substance abuse treat- Treatment Interventions ment outcomes at 12-month follow-up when Overall, research evaluating cultural adoption clients and providers were ethnically matched of promising or evidence-based practices in

134 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

treatment specifically for Latinos is scarce Family therapy (Carvajal and Young 2009). For instance, Family therapy is often recommended for empirical literature evaluating CBT specifical- treating Latinos with substance use disorders ly for substance abuse and substance use dis- (Amaro et al. 2006; Barón 2000; Hernandez orders in Latinos is quite limited. Still, a 2000). Although there is little research evalu- number of authors recommend CBT for ating the effectiveness of family therapy for Latinos in mental health and substance abuse adults, both multidimensional family therapy treatment settings because it is action oriented, (Liddle 2010) and brief strategic family thera- problem focused, and didactic (Alvarez and py (Santisteban et al. 1997; Santisteban et al. Ruiz 2001; Organista 2006; Organista and 2003; Szapocznik and Williams 2000) have Muñoz 1998). CBT’s didactic component can been found to reduce substance use and im- educate Latinos about disorders and frame prove psychological functioning among Latino therapy as an educational (and hence less youth. The term familismo refers to the cen- shameful) experience. However, Organista’s trality of the family in Latino culture and can (2006) review of available research on CBT include valuing and protecting children, re- for mental disorders among Latinos suggests specting the elderly, preserving the family that this approach is not always as effective name, and consulting with one another before with Latinos as it is with other populations. making important decisions. As highlighted in Other effective interventions include contin- the case study of a Puerto Rican client on the gency management and motivational inter- next page, counselors must consider the poten- viewing; see the review by Amaro et al. (2006) tially pivotal roles families can play in support- for more on these interventions. Methadone ing treatment and recovery. Latino families are maintenance, too, has been associated with likely to have a strong sense of obligation and long-term reductions in the use of alcohol as commitment to helping their members, in- well as heroin and other illicit drugs among cluding those who have substance use disor- Mexican Americans with opioid use disorders, ders. Even so, the level of family support for although 33 percent of the original cohort people who have substance use or mental died before the 22-year longitudinal study disorders varies among Latinos depending on concluded (Goldstein and Herrera 1995). country of origin, level of acculturation, degree Another therapeutic intervention that can of family cohesion, socioeconomic status, and improve outcomes for Latino clients is node- factors related to substance use (Alegria et al. link mapping (visual representation using 2012). For example, Reynoso-Vallejo et al. information diagrams, fill-in-the blank graph- (2008) concluded that significantly higher ic tools, and client-generated diagrams or rates of homelessness found among people visual maps), which has been associated with from Central American countries who inject- lower levels of opioid and cocaine use, better ed heroin compared with other Latinos could treatment attendance, and higher counselor stem from lower levels of tolerance for injec- ratings of motivation and confidence for tion drug use among their families. Latinos in methadone maintenance treatment For counselors who lack cultural understand- (Dansereau et al. 1996; Dansereau and Simp- ing, it can be easy to simply label and judge son 2009). For a review of Latino outcome families’ behavior as enabling or codependent. studies in health, substance abuse, and mental Instead, counselors should move away from health in social work, refer to Jani and col- labeling the behavior and focus more on help- leagues (2009). ing families recognize how their behavior can

135 Improving Cultural Competence

Case Study: A Puerto Rican Client Anna is a 27-year-old woman who was born in New York and self-identifies as Puerto Rican. She has a 12th-grade education, is unemployed, and lives with her parents, her 4-year-old daughter, and a nephew. Anna is separated from her partner, who is also her daughter’s father. She entered treat- ment as a result of feeling depressed ever since her partner physically assaulted her because she refused to use heroin (the event that sparked their separation). She states, “I want to be clean and take care of my family.” At intake, she had just undergone detoxification and had stopped using alcohol, crack cocaine, and heroin.

Anna states that she feels guilty about her drug use and the way it caused her to neglect her family. She has been having serious problems with her mother, who is critical of her substance use, but believes that her mother is important in her recovery because of the structure she provides at home. She describes her father as a very important figure with whom she enjoys spending time. Her father had stopped drinking 9 years before and is very supportive of her abstinence. He is willing to help in any way he can but has been very sick lately and was diagnosed with prostate cancer. Her father had never received treatment for his drinking problem, and her mother believes that Anna should be able to stop just like her father did. As she describes her situation in treatment, Anna’s vergüenza (shame) and sense of hopelessness is very evident. She fears her father’s death and her mother’s subsequent rejection of her for not helping out.

Anna’s treatment includes family therapy to restructure communication patterns, rules, expecta- tions, and roles. For family sessions, either her mother or both parents participate, depending on her father’s physical condition. Initially, her parents displayed a tendency to focus on the problems of the past, but the counselor directed them to focus on changes needed to help Anna’s recovery. The counselor has also worked with other family members to rally support and use their strengths while also clarifying perceptions, feelings, and behaviors that will help them function as a family unit. Anna’s counselor recognizes that, within the context of her culture, her reliance on her family can be used to aid her recovery and that her family, as defined by Anna, can be used as a support system. Source: Medina 2001. Adapted with permission.

affect one member’s substance abuse and how of the rules of the system. Otherwise, mem- best to handle it. The advice box on the next bers could see group therapy as oppressive. page provides general therapeutic guidelines Facilitators in groups consisting mostly of for working with Latino families. Latino clients must establish trust, responsibil- Group therapy ity, and loyalty among members. In addition, acculturation levels and language preferences Little information is available concerning should be assessed when forming groups so Latinos’ preferences in behavioral health that culturally specific or Spanish-speaking services, but a study evaluating mental health groups can be made available if needed. treatment preferences for women in the Unit- Mutual-help groups ed States found that Latinas were significantly more likely to prefer group treatment Findings on the usefulness of 12-Step groups (Nadeem et al. 2008). According to Paniagua for Latino clients are inconsistent. Member- (1998), the use of group therapy with Latino ship surveys of AA indicate that Latinos clients should emphasize a problem-focused comprise about 5 percent of AA membership approach. Group leaders should allow mem- (AAWS 2012). Latinos who received inpatient bers to learn from each other and resist func- treatment were less likely to attend AA than tioning as a content expert or a representative White Americans (Arroyo et al. 1998). Rates

136 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Advice to Counselors: Family Therapy of engagement than for White American Guidelines for Latino Families participants (Hoffman 1994; Tonigan et al. 1998). For some Latinos, 12-Step groups can • Provide bilingual services. • Use family therapy as a primary method of appeal to religious and spiritual beliefs. Her- treatment. nandez (2000) suggests that mutual-help • Assess cultural identity and acculturation groups composed solely of Latinos make it level for each family member. easier for participants to address the cultural • Determine the family’s level of belief in context of substance abuse. Some Latino 12- traditional and complementary healing practices; integrate these as appropriate. Step groups do not hold that substance abuse • Discuss the family’s beliefs, history, and is a biopsychosocial problem, instead concep- experiences with standard American be- tualizing the disorder as a weakness of charac- havioral health services. ter that must be corrected. Hoffman (1994) • Explore migration and immigration experi- studied Latino 12-Step groups in Los Angeles ences, if appropriate. • Provide additional respect to the father or and observed that, in addition to a more father figure in the family. traditional form of AA, there were groups that • Interview family members or groups of practiced terapia dura (i.e., rough therapy), family members (e.g., children) separately which often uses a confrontational approach to allow them to voice concerns. and endorses family values related to machismo • Generate solutions with the family. Do not force changes in family relationships. (e.g., by reinforcing that overcoming substance • Provide specific, concrete suggestions for abuse rather than drinking is manly). Howev- change that can be quickly implemented. er, these groups were not overly welcoming of • Focus on engaging the family in the first female members and gay men. In such cases, session using warmth and personalismo. gay Latino men and Latinas can benefit from Sources: Bean et al. 2001; Hernandez 2005; attending 12-Step groups that are not cultur- Lynch and Hanson 2011. ally specific or that do not use terapia dura. Traditional healing and of mutual-help participation among people complementary methods with drug use disorders are also lower for Latinos (Perron et al. 2009). Language can In a study of the use of alternative and com- present a barrier to mutual-help group partici- plementary medical therapies, Latinos were pation for Spanish-speaking Latinos; however, less likely to use medical alternatives than Spanish-language meetings are held in some were White Americans (Graham et al. 2005). locations. Counselors should consider the However, those who did use such approaches appropriateness of 12-Step participation on a were more likely to do so because they could case-by-case basis (Alvarez and Ruiz 2001). not afford standard medical care (Alegria et al. For example, Mexican American men who 2012). As in other areas, the use of comple- identify with attitudes of machismo can feel mentary and traditional medicine likely varies uncomfortable with the 12-Step approach. according to acculturation level and country of Concern about divulging family issues in public origin. For instance, the use of faith and reli- can cause hesitation to address substance- gious practices to cope with mental and emo- related problems in public meetings. tional problems is significantly more common among foreign-born Latinos than among For Latinos who do participate in 12-Step those born in the United States (Nadeem et al. programs, findings suggest higher rates of 2008; Vega et al. 2001). abstinence, degree of commitment, and level

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Many Latinos place great importance on the Data are lacking on long-term recovery for practice of Roman Catholicism. Yamamoto Latinos. Given the many obstacles that block and Acosta (1982) describe the central tenets accessibility to treatment for Latinos, continu- of Latino Catholicism as sacrifice, charity, and ing care planning can benefit from greater use forgiveness. These beliefs can hinder assertive- of informal or peer supports. For example, ness in some Latinos, but they can also be a White and Sanders (2004) recommend the source of strength and recovery. Traditionally, use of a recovery management approach with Latinos have been Catholic, although several Latinos. They point to an early example of the Protestant and evangelical groups have con- East Harlem Protestant Parish’s work, which verted millions of Latinos to their religions helped Puerto Rican individuals recovering since the 1970s. Some Latinos also believe in from heroin dependence connect to social syncretistic religions (e.g., Santería or clubs and religious communities that sup- Curanderismo) or practices derived from them ported recovery. Latinos use community and and make use of a variety of traditional heal- family support in addition to spirituality to ing practices and rituals to heal mental and address mental disorders (Lynch and Hanson spiritual ailments (Lefley et al. 1998; Sandoval 2011; Molina 2001). Castro et al. (2007) also 1979). Among Puerto Ricans, espiritismo note that family support systems can be espe- () is a popular traditional healing cially important for Latinos in recovery. system successfully used to address mental health issues (Lynch and Hanson 2011; Moli- Counseling for Native na 2001). Some Mexican Americans rely on Americans curanderos, folk healers who address problems that might be framed as psychological (Falicov There are 566 federally recognized American 2005, 2012). For a review of culturally respon- Indian Tribes, and their members speak more sive interventions with Latinos, refer to than 150 languages (U.S. Department of the Gallardo and Curry (2009). Interior, Indian Affairs 2013a); there are Relapse prevention and recovery numerous other Tribes recognized only by states and others that still go unrecognized by There are no substantial studies evaluating the government agencies of any sort. According to use of relapse prevention and recovery promo- the 2010 U.S. Census (Norris et al. 2012), the tion with Latinos, yet literature suggests that majority (78 percent) of people who identified they would be appropriate and effective for as American Indian or Alaska Native, either this population (Blume et al. 2005; Castro et alone or in combination with one or more al. 2007). Overall, Latinos can face somewhat other races, lived outside of American Indian different triggers for relapse relating to accul- and Alaska Native areas. Approximately 60 turative stress or the need to uphold particular percent of the 5.2 million people who identi- cultural values (e.g., personalismo, machismo; fied as American Indian or Alaska Native, Castro et al. 2007), which can lead to higher alone or in combination with one or more rates of relapse among some Latino clients. other races, reside in urban areas (Norris et al. For example, in a study of relapse patterns 2012). The category of Alaska Natives in- among White American and Latino individu- cludes four recognized Tribal groups— als who used methamphetamine, Brecht et al. Alaskan Athabascan, , Eskimo, and (2000) found that Latino participants relapsed Tingit-Haida—along with many other inde- more quickly than White American pendent communities (Ogunwole 2006). participants.

138 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Native Americans who belong to federally among Native Americans, see the planned TIP, recognized Tribes and communities are mem- Behavioral Health Services for American Indians bers of sovereign Indian nations that exist and Alaska Natives (SAMHSA planned a). within the United States. On lands belonging to these Tribes and communities, Native Beliefs About and Traditions Americans are able to govern themselves to a Involving Substance Use large extent and are not subject to most state Few American Indian Tribes and no Alaska laws—only to federal legislation that is specif- Natives consumed alcoholic beverages prior to ically designated as applying to them (Henson contact with non-Native people, and those 2008). Although health care (including sub- who did used alcohol primarily for special stance abuse treatment) is provided to many occasions and ceremonies. Most Tribes first Native Americans by Indian Health Services encountered the use of alcohol when they (IHS), Tribal governments do have the option encountered European settlers and traders. of taking over those services. Counselors Because of this lack of experience with alco- working with these populations should re- hol, few Native Americans had a context for member that Native Americans, by virtue of drinking besides what they learned from these their membership in sovereign Tribal entities, non-Natives, who at the time drank in large have rights that are different from those of quantities and often engaged in binge drink- other Americans; this distinguishes them from ing. Although patterns of alcohol consump- members of other ethnic/racial groups. tion in the mainstream population of the American Indians live in all 50 states; the United States changed over time, they re- states with the largest populations of Ameri- mained relatively the same in the more isolat- can Indians are Oklahoma, California, and ed Native American communities. According Arizona. The 2000 Census allowed people to to an NSDUH report on American Indian identify, for the first time, as a member of and Alaska Native adults, binge drinking more than one race. Of persons who checked continues to be a significant problem for these two or more races, nearly one in five indicated populations. Both binge drinking and illicit that they were part American Indian or Alaska drug use is higher among Native Americans Native (U.S. Census Bureau 2001a,b). than the national average (30.2 percent versus 23 percent and 12.7 percent versus 9.2 percent, Behavioral health service providers should respectively; SAMHSA 2013d). recognize that Native American Tribes repre- sent a wide variety of cultural groups that American Indian drinking patterns vary a differ from one another in many ways (Duran great deal by Tribe. Tribal attitudes toward et al. 2007). Alaska Natives who live in coastal alcohol influence consumption in complicated areas have very different customs from those ways. For example, in communities, inhabiting interior areas (Attneave 1982). The excessive drinking was acceptable if done in a diversity of Native American Tribes notwith- group or during a social activity. However, standing, they also share a common bond of solitary drinking (even in lesser amounts) was respect for their cultural heritages, histories, considered to be deviant (Kunitz et al. 1994). and spiritual beliefs, which are different from Kunitz et al. (1994) observed that during the those of mainstream American culture. For 1960s, binge drinking was acceptable among more information on the treatment and pre- the Navajo during public celebrations, whereas vention of substance abuse and mental illness any drinking was considered unacceptable among the neighboring Hopi population,

139 Improving Cultural Competence

wherein regular drinkers were shunned or, in show that Alaska Natives are significantly some cases, expelled from the community. more likely to abstain than are other Alaskans Hopi individuals who did drink tended to do (Wells 2004). so alone or moved off the reservation to bor- The most common pattern of abusive drink- der towns where heavy alcohol use was com- ing among American Indians appears to be mon. The ostracism of Hopi drinkers seemed binge drinking followed by long periods of to lead to even greater levels of abuse, given abstinence (French 2000; May and Gossage that there were much higher death rates from 2001). A similar pattern is seen among Alaska alcoholic cirrhosis among the Hopi than Natives (Seale et al. 2006; Wells 2004). As an among the Navajo. example, the Urban Indian Health Institute Native American recovery movements have (2008) found that binge drinking was signifi- often viewed substance abuse as a result of cantly more common among the Native between Native and Western American population (with 21.3 percent cultures, seeing substances of abuse as weapons engaging in binge drinking in the prior 30 that have caused further loss of traditions days compared with 15.8 percent of non- (Coyhis and White 2006). To best treat this Native Americans) and that, among those who population, substance abuse treatment provid- drank, 40.7 percent of Native American par- ers need to expand their perspectives regarding ticipants engaged in binge drinking compared substance abuse and dependence and must with 26.9 percent of non-Natives. embrace a broader view that explores the There are a number of historical reasons for spiritual, cultural, and social ramifications of the development of binge drinking among substance abuse (Brady 1995; Duran 2006; Native Americans. The existence of dry reser- Jilek 1994). vations (which can limit the times when indi- Substance Use and Substance Use viduals are able to get alcohol), high levels of Disorders poverty, lack of availability (e.g., in remote Alaska Native villages), a history of trauma, According to 2012 NSDUH data, American and the loss of cultural traditions can all con- Indian and Alaska Native peoples have the tribute to the development and continuation highest rates of substance use disorders and of this pattern of drinking. Native Americans binge drinking (SAMHSA 2013d). Although are also more likely than members of other rates of substance abuse are high among major racial/ethnic groups to have had their Native Americans, so too are rates of absti- first drink before the age of 21 or before the nence. American Indians and Alaska Natives age of 16, which also may shape drinking are more likely to report no alcohol use in the patterns (SAMHSA 2011c). past year than are members of all other major racial and ethnic groups (OAS 2007). The However, data on heavy and binge drinking do American Indian Services Utilization and not reflect the same pattern of alcohol con- Psychiatric Epidemiology Risk and Protective sumption for all Native American Tribes. One Factors Project (-SUPER PFP) also found analysis of alcohol dependence among mem- that rates of lifetime abstinence from alcohol bers of seven different Tribes found rates of for American Indians in the study were signif- dependence varying from 56 percent of men icantly higher than lifetime abstinence rates and 30 percent of women in one Tribe to 1 among the general population (Beals et al. percent of men and 2 percent of women in 2003). Data on alcohol consumption also another (Koss et al. 2003). Other research

140 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups confirms significant differences in alcohol use diagnosis of an alcohol use disorder (Gilman among diverse Native American communities et al. 2008). Illicit drug use is also more com- (O’Connell et al. 2005; Whitesell et al. 2006). mon for Native Americans than for members of other major racial/ethnic groups. In addition to alcohol, methamphetamine and abuse are major concerns for a num- Among Native Americans entering treatment ber of Native American communities. None- in 2010, alcohol use disorders alone or in theless, there are considerable regional conjunction with drug use disorders were the differences in patterns and prevalence of drug most pressing substance-related problem, with use (Miller et al. 2012). According to the cannabis and other than heroin being National Congress of American Indians the next most common primary substances of (2006), 74 percent of Tribal police forces abuse. One of the largest studies on American ranked methamphetamine as the drug causing Indian substance use and abuse to date, the the most problems in their communities. AI-SUPER PFP, found that 31.2 percent of Methamphetamine abuse can be even more American Indians met criteria for a lifetime serious for Native Americans living in rural diagnosis of a substance use disorder, and 13.4 areas than for those in urban areas, but it is percent met criteria for a past-year diagnosis also a serious problem for growing numbers of (Beals et al. 2003). The study found that rates American Indians, especially women, entering of alcohol use disorders were high among men treatment in urban areas (Spear et al. 2007). from the three Tribes represented but varied to a greater degree among women across American Indians and Alaska Natives are Tribes (Mitchell et al. 2003). more likely to report having used inhalants at some time during their lives, but use tends to American Indians have high rates of certain peak in 8th grade and then decrease (Miller et diseases and conditions. In particular, the al. 2012). In some Native American communi- incidence of diabetes is increasing among ties (e.g., on the Kickapoo reservation in Tex- Native Americans, and approximately 38 as), inhalants have been a major drug of abuse percent of elder Native Americans have diabe- for adults as well as youth. During the early tes (Moulton et al 2005). Diabetes is also 1990s, about 46 percent of the adult popula- associated with both substance use disorders tion on that reservation were thought to abuse and depression in this population (Tann et al. inhalants (Fredlund 1994). Although more 2007). Other health problems associated with recent data are not available, reports from the alcohol use include fetal alcohol syndrome, area suggest that inhalant abuse remains a cirrhosis, and depression. significant problem (Morning Star 2005). Mental and Co-Occurring Rates of substance use disorders appear to be Disorders higher in individuals who consider themselves exclusively Native American than for those According to the 2012 NSDUH, 28.3 percent who identify as more than one race/ethnicity, of American Indians and Alaska Natives but even when surveys ask whether people are report having a mental illness, with approxi- of mixed race, those who report themselves to mately 8.5 percent indicating serious mental be partially Native American still have high illness in the past year (SAMHSA 2013c). rates of substance use disorders (OAS 2007). Native Americans were nearly twice as likely Native Americans are about 1.4 times more to have serious thoughts of suicide as members likely than White Americans to have a lifetime of other racial/ethnic populations, and more

141 Improving Cultural Competence

than 10 percent reported a major depressive Treatment Patterns episode in the past year. Common disorders Despite a number of potential barriers to include depression, anxiety, and substance use. treatment (Venner et al. 2012), Native Ameri- As with other groups, substance use disorders cans are about as likely as members of other among Native Americans have been associated racial/ethnic groups to enter behavioral health with increased rates of a variety of different programs. According to data from the 2003 mental disorders (Beals et al. 2002; Tann et al. and 2011 NSDUH (SAMHSA, CBHSQ 2007; Westermeyer 2001). The 2012 NSDUH 2012), Native Americans were more likely to revealed that 14 percent of Native Americans have received substance use treatment in the reported both past-year substance use disor- past year than persons from other racial/ethnic ders and mental illness. Among those who groups (15.0 percent versus 10.2 percent). reported mental illness, nearly 5 percent re- Other studies indicate that about one-third of ported several mental illnesses co-occurring Native Americans with a current substance use with substance use disorders (SAMHSA disorder had received treatment in the prior 2013c). year (Beals et al. 2006; Herman-Stahl and Chong 2002). The 2012 NSDUH reported Native American communities have experi- that approximately 15 percent of Native enced severe historical trauma and discrimina- Americans received mental health treatment tion (Brave Heart and DeBruyn 1998; Burgess (SAMHSA 2013c). et al. 2008). Studies suggest that many Native Americans suffer from elevated exposure to Native Americans were least likely of all major specific traumas (Beals et al. 2005; Ehlers et al. ethnic/racial groups to state that they could not 2006; Manson 1996; Manson et al. 2005), and find the type of program they needed and were they may be more likely to develop PTSD as a the next least likely after Native Hawaiians and result of this exposure than members of other other Pacific Islanders to state that they did not ethnic/racial groups. PTSD comparison rates know where to go or that their insurance did taken from the AI-SUPER PFP study and not cover needed treatment. Among Native the National Comorbidity Study show that Americans who identified a need for treat- 12.8 percent of the Southwest Tribe sample ment in the prior year but did not enter treat- and 11.5 percent of the Northern Plains Tribe ment, the most commonly cited reasons for sample met criteria for a lifetime diagnosis of not attending were lack of transportation, lack PTSD compared with 4.3 percent of the of time, and concerns about what one’s neigh- general population (Beals et al. 2005). Trauma bors might think (SAMHSA 2011c). histories and PTSD are so prevalent among Many Native Americans, especially those Native Americans in substance abuse treat- residing on reservations or other Tribal lands, ment that Edwards (2003) recommends that seek mental health and substance abuse treat- assessment and treatment of trauma should be ment through Tribal service providers or IHS a standard procedure for behavioral health (Jones-Saumty 2002; McFarland et al. 2006). programs serving this population. For exam- However, an analysis using multiple sources ple, Native American veterans with substance found that 67 percent of Native Americans use disorders are significantly more likely to entering substance abuse treatment over the have co-occurring PTSD than the general course of a year did so in urban areas, and the population of veterans with substance use majority of those urban-based programs were disorders (Friedman et al. 1997). not operated by IHS (McFarland et al. 2006).

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The same research also found that Native beliefs about treatment providers that can Americans were somewhat more likely than influence not only willingness to participate in the general treatment-seeking population to treatment services, but also the level of trust enter residential programs. clients have for providers. Counselors and other behavioral health workers must develop Native Americans were more likely to enter ongoing relationships within local Native treatment as a result of criminal justice refer- American communities to gain knowledge of rals than were White Americans or African the unique attributes of each community, to Americans: 47.9 percent of American Indians show investment in the community, and to and Alaska Natives entering public treatment learn about community resources (Exhibit 5- programs in 2010 were court-ordered to 3). Identifying and developing resources with- treatment compared with 36.6 percent of in Native communities can help promote White Americans and 36.4 percent of African culturally congruent relationships. Americans (SAMHSA, CBHSQ 2012). The lack of recognition of special needs and Exhibit 5-3: Native Americans and knowledge of Native American cultures within Community behavioral health programs may be the main Many Native Americans believe that recovery reasons for low treatment retention and un- cannot happen for individuals alone and that deruse of help-seeking behaviors among their entire community has become sick. Native Americans (LaFromboise 1993; Sue Coyhis calls this the “healing forest” model: and Sue 2013e). one cannot take a sick from a sick forest, heal it, and put it back in the same environ- Beliefs and Attitudes About ment expecting that it will thrive. Instead, the Treatment community must embrace recovery. Today, community development models are Duran et al. (2005) evaluated obstacles to being implemented in American Indian and treatment entry among American Indians on Alaska Native communities to address preven- three different reservations; most frequently tion and treatment issues for mental and sub- mentioned were the perception that good- stance use disorders as well as related issues, such as suicide prevention (Edwards and quality or suitable services were unavailable Egbert-Edwards 1998; HHS 2010; May et al. and the perceived need for individuals to be 2005). Using these models, communities move self-reliant. They also found social relation- toward greater commitment to social problem- ships to be extremely important in overcoming solving and the development of effective, these barriers. Jumper-Thurman and Plested culturally congruent strategies relevant to their Tribes or villages. According to Edwards et al. (1998) reported that focus groups of American (1995), community approaches often lead to: Indian women listed mistrust as one of the • A reduction of substance use. primary barriers for seeking treatment. This is • Breaking intergenerational cycles of alco- due, in part, to the women’s belief that they hol abuse. would encounter people they knew among • Increased community support. • The strengthening of individual and group treatment agency staff; they also doubted the cultural identity. confidentiality of the treatment program. • Leadership development. • Increased interpersonal and inter-Tribal Treatment Issues and problem-solving skills and . Considerations For an example, see Jumper-Thurman et al. Each Tribe and community will likely have (2001). different customs, healing traditions, and

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To provide culturally responsive treatment, They also, for the most part, have a holistic providers need to understand the Native view of health that incorporates physical, American client’s Tribe; its history, traditions, emotional, and spiritual elements (Calabrese worldview, and beliefs; the dimensions of its 2008), individual and community healing substance abuse problem and other communi- (Duran 2006; McDonald and Gonzalez 2006), ty problems; the incidence of trauma and and prevention and treatment activities abuse among its members; its traditional (Johnston 2002). For many, culture is the path healing practices; and its intrinsic strengths. to prevention and treatment. Providers who work with Native Americans However, not all Native Americans have a but do not have an understanding of their need to develop stronger connections to their cultural identity and acculturation patterns are communities and cultural groups. As Brady at a distinct disadvantage (Ponterotto et al. (1995) cautions, culture is complex and chang- 2000). Before beginning any treatment, pro- ing, and a return to the values of a traditional viders should routinely seek consultation with culture is not always desired. An initial inquiry knowledgeable professionals who are experi- into each client’s connection with his or her enced in working with the specific Tribal culture, cultural identity, and desire to incor- group in question (Duran 2006; Edwards and porate cultural beliefs and practices into Egbert-Edwards 1998; Straits et al. 2012) and treatment is an essential step in culturally should conduct thorough client assessments competent practice. When appropriate, pro- that evaluate cultural identity (see Appendix F viders can help facilitate the client’s reconnec- and Chapter 2 for resources). Some Native tion with his or her community and cultural American persons have a strong connection to values as an integral part of the treatment their cultures and others do not; some identify plan. In addition, treatment providers need to with a blend of American Indian cultural adapt services to be culturally responsive. In groups called pan-Indianism or inter-Tribal doing so, outcomes are likely to improve not identity. Still others are comfortable with a only for Native American clients, but for all dual identity that embraces both Native and clients within the program. Fisher et al. (1996) non-Native cultural groups. modified a therapeutic community in Alaska Native Americans often approach the begin- to incorporate Alaska Native spiritual and ning of a relationship in a calm, unhurried cultural practices and found that retention manner, and they may need more time to rates improved for White and African Ameri- develop trust with providers. Concerns about can clients as well as Alaska Native clients confidentiality can be an important issue to participating in the program. address with Native American clients, espe- In working with Native American clients, cially for those in small, tightly-knit commu- providers should be prepared to address spirit- nities. For providers, it is very important to uality and to help clients access traditional make clear to clients that what they say to the healing practices. Culturally responsive treat- counselor will be held in confidence, except ment should involve community events, group when there is an ethical duty to report. activities, and the ability to participate in Native American cultural groups generally ceremonies to help clients achieve balance and believe that health is nurtured through balance find new insight (Calabrese 2008). Stronger and living in harmony with nature and the attachment to Native American cultural community (Duran 2006; Garrett et al. 2012). groups protects against substance use and

144 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups abuse; therefore, strengthening this connection client strengths and empowerment, recognize is important in substance abuse treatment the need to accept personal responsibility for (Duran 2006; Moss et al. 2003; Spicer 2001; change, and make use of learning styles that Stone et al. 2006). many Native Americans find culturally ap- propriate (Heilbron and Guttman 2000; Theoretical Approaches and McDonald and Gonzalez 2006). Motivational Treatment Interventions interviewing is also recommended for Native Some clinicians caution that a model of coun- American clients. In a small study, Villanueva seling that requires self-disclosure to relative et al. (2007) found that all treatment modali- strangers can be counterproductive with Native ties resulted in improvements at 15-month American clients. Other authors recommend follow-up, but clients who received motiva- CBT and social learning approaches for tional enhancement therapy reported signifi- Native American clients, as such approaches cantly fewer drinks per drinking day during typically have less , focus on prob- the 10- to 15-month posttreatment follow-up lem-solving and skill development, emphasize period. Venner et al. (2006) wrote a manual for motivational interviewing with Native Advice to Counselors: Counseling American clients. Native Americans Family therapy When working with Native American clients, Family involvement in treatment leads to providers should: • Use active listening and reflective re- better outcomes for Native Americans at the sponses. time of discharge from treatment (Chong and • Avoid interrupting the client. Lopez 2005). Research also suggests that • Refrain from asking about family or per- family and community support can have a sonal matters unrelated to substance abuse significant effect on recovery from substance without first asking the client’s permission to inquire about these areas. use disorders for this population ( Jones- • Avoid extensive note-taking or excessive Saumty 2002; Paniagua 1998). Family therapy questioning. can be quite helpful and perhaps even essential • Pay attention to the client’s stories, experi- for American Indian clients (Coyhis 2000), ences, dreams, and rituals and their rele- especially when other social supports are vance to the client. . • Recognize the importance of listening and lacking ( Jones-Saumty 2002) focus on this skill during sessions. American Indians place high value on family • Accept extended periods of silence during sessions. and extended family networks; restoring or • Allow time during sessions for the client to healing family bonds can be therapeutic for process information. clients with substance use disorders. Moreo- • Greet the client with a gentle (rather than ver, Native American clients are sometimes firm) handshake and show hospitality (e.g., by offering food and/or beverages). less motivated to engage in “talk therapy” and • Give the client ample time to adjust to the more willing to participate in therapeutic setting at the beginning of each session. activities that involve social and family rela- • Keep promises. tionships ( Joe and Malach 2011). Treatment • Offer suggestions instead of directions approaches should remain flexible and in- (preferably more than one to allow for cli- ent choice). clude clients’ families when appropriate. Counselors should be able to recognize what Sources: Aragon 2006; Trimble et al. 2012. constitutes family, family constellations, and

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family characteristics. The Native American adapted, group therapy can be very beneficial concept of family can include elders, others and culturally congruent. It is important, from the same clan, or individuals who are not however, to determine Native American clients’ biologically related. In many Tribes, all mem- level of acculturation before recommending bers are considered relatives. Families can be Western models of group therapy, as less matrilineal (i.e., kinship is traced through the acculturated Native clients are likely to be less female line) and/or matrilocal (i.e., married comfortable with group talk therapy (Mail and couples live with wife’s parents). Shelton 2002). Group therapy for Alaska Natives should also be nonconfrontational and When families do enter treatment, they may focus on clients’ strengths. initially prefer to focus on a concrete problem, but not necessarily on the most significant Group therapy can incorporate Native family issue. Discussion of a clearly defined American traditions and rituals to make it presenting problem enables families to assess more culturally suitable. For example, the the therapeutic process and better understand talking circle is a Native tradition easily what is expected of them in treatment. Provid- adapted for behavioral health treatment. In ers should be aware that the entire clan and/or this tradition, the members of the group sit in Tribe could know about a given client’s treat- a circle. An eagle feather, stone, or other sym- ment and progress. Family therapy models bolic item is passed around, and each person such as network therapy, which makes use of speaks when he or she is handed the item. support structures outside the immediate Based on a review of the literature, Paniagua family and which were originally developed (1998) recommends that providers using for Native American families living in urban group therapy with Native American clients: communities, can be particularly effective with • Earn support or permission from Tribal Native clients, especially when they have been authorities before organizing group therapy. cut off from their home communities because • Consult with Native professionals. of substance abuse or other issues. For more • If group members , invite respected information on network therapy and similar Tribal members (e.g., traditional healers or approaches, see TIP 39, Substance Abuse elders) to participate in sessions. Treatment and Family Therapy (CSAT 2004b). Mutual-help groups Group therapy Native American peoples have a long history Although researchers and providers once of involvement in mutual-help activities that viewed group therapy as ineffective for Ameri- predates the 12-Step movement (Coyhis and can Indian clients (Paniagua 1998), opinion White 2006). Depending on acculturation, has shifted to recognize that, when appropri- availability of a community support network, ately structured, group therapy can be a pow- and the nature of their presenting problems, erful treatment component (Garrett 2004; Native American clients may be more likely to Garrett et al. 2001; Trimble and Jumper- solicit help from significant others, extended Thurman 2002). Garrett (2004) notes that family members, and community members. many Native American Tribes have traditional Contemporary manifestations of Native healing practices that involve groups; for many American mutual-help efforts include adapta- of these cultural groups, healing needs to occur tions of the 12 Steps (Exhibit 5-4) and of 12- within the context of the group or community Step meeting rituals and practices (Coyhis and (e.g., in talking circles). Thus, if properly White 2006). Another modified element of

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Exhibit 5-4: The Lakota Version of the 12 Steps The Lakota Tribe has adapted the 12 Steps to suit its particular belief system as follows: 1. I admit that because of my dependence on alcohol, I have been unable to care for myself and my family. 2. I believe that the can help me to regain my responsibilities and model the life of my forefathers (ancestors). 3. I rely totally on the ability of the Great Spirit to watch over me. 4. I strive every day to get to know myself and my position within the nature of things. 5. I admit to the Great Spirit and to my Indian and the weaknesses of my life. 6. I am willing to let the Great Spirit help me correct my weaknesses. 7. I pray daily to the Great Spirit to help me correct my weaknesses. 8. I make an effort to remember all those that I have caused harm to and, with the help of the Great Spirit, achieve the strength to try to make amends. 9. I do make amends to all those Indian brothers and sisters that I have caused harm to whenever possible through the guidance of the Great Spirit. 10. I do admit when I have done wrong to myself, those around me, and the Great Spirit. 11. I seek through purification, prayer, and meditation to communicate with the Great Spirit as a child to a father in the Indian way. 12. Having addressed those steps, I carry this brotherhood and steps to sobriety to all my Indian brothers and sisters with alcohol problems and together we share all these principles in all our daily lives.

Source: CSAT 1999b, p. 56. Reprinted from material in the public domain.

the 12 Steps is use of a circular, rather than a considerable number also continue to partici- linear, path to healing. The circle is important pate in traditional 12-Step groups. In the AI- to American Indian philosophy, which sees the SUPER-PFP, 47 percent of Northern Plains great forces of life and nature as circular Tribe respondents and 28.8 percent of South- (Coyhis 2000). In addition, staff members of west Tribe respondents with a past-year sub- the White Bison program have also rewritten stance use disorder reported 12-Step group the AA “Big Book” from a Native American attendance in the prior year (Beals et al. 2006). perspective (Coyhis and Simonelli 2005). The Mohatt et al. (2008b) found that more Alaska principles of the 12 Steps, which involve using Natives in recovery reported participation in the group or community to provide support 12-Step groups than in substance abuse treat- and motivation while emphasizing spiritual ment. In Venner and Feldstein’s (2006) re- reconnection, appeal to many Native Ameri- search with American Indians in recovery, 84 cans who see treatment as social in nature and percent of respondents had attended some who view addiction as a spiritual problem. mutual-help meetings. The Native American Wellbriety movement is Traditional healing and a modern, indigenous mutual-help program complementary methods that has its roots in 12-Step groups but incor- Native American peoples have a range of be- porates Native American spiritual beliefs and liefs about health care—from traditional beliefs cultural practices (Coyhis and Simonelli 2005; to strong support for modern science—and Coyhis and White 2006; White Bison, Inc. may use a number of strategies when address- 2002; also see http://www.whitebison.org). ing health problems. Traditional healing prac- Although the Wellbriety movement is popular tices are often used in conjunction with modern with many Native Americans in recovery, a medicine. For example, American Indians

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traditionally view all things as deeply inter- 2002; White 2000). The sweat lodge, in par- connected. Disruption of the physical, mental, ticular, is frequently used in substance abuse spiritual, or emotional sides of a person can treatment settings (Bezdek and Spicer 2006; result in illness. A Native American client may Schiff and Moore 2006). consult a medical doctor to address part of the Alaskan behavioral health programs have problem and a traditional healer to help regain developed recovery camps to provide a treat- balance and harmony. ment setting that incorporates Native beliefs The use of traditional healing for substance and seasonal practices (e.g., Old Minto Family abuse and mental health problems is fairly Recovery Camp: common among Native Americans (Herman- http://www.tananachiefs.org/ health- Stahl and Chong 2002; Herman-Stahl et al. services/old-minto-family-recovery-camp- 2003). For example, among Native American new/). Recovery camps are based on the mod- individuals who reported a substance use el of traditional Native Alaskan fishing camps disorder in the past year, 57.4 percent of those and provide a context in which clients can from a Southwest Tribe and 31.7 percent from learn about traditional practices, such as suste- a Northern Plains Tribe used traditional heal- nance activities. Another program, the Village ers or healing practices (Beals et al. 2006). In a Sobriety Project, incorporates traditional survey of American Indians from three differ- Yup’ik and Cup’ik Eskimo traditions of hunt- ent Arizona Tribes, 27.4 percent stated that ing, chopping wood, berry picking, and taking they had used traditional healers and/or heal- tundra walks (Mills 2003). See Niven (2010) ing practices to help with mental health prob- for a review of client-centered, culturally lems (Herman-Stahl and Chong 2002). responsive behavioral health techniques for Overall, many Native Americans believe that use with Alaska Natives. culture is the primary avenue of healing and It is difficult to measure the effectiveness of that connecting with one’s culture is not only a Native American healing practices using means of prevention, but also a healing treat- ment (Bassett et al. 2012) There are a number of potential pitfalls that can occur when trying to integrate Each Native American culture has its own Native spiritual and cultural practices into specific healing practices, and not all of those treatment. Cultural groups are complex practices are necessarily appropriate to adapt systems; removing pieces of them for to behavioral health treatment settings. How- implementation as part of a treatment ever, many traditional healing activities and program can be a disservice to the culture as well as the clients (Kunitz et al. 1994; ceremonies have been made accessible during Moss et al. 2003); a breach of customs treatment or effectively integrated into treat- and traditions; and a sign of disrespect for ment settings (Castro et al. 1999b; Coyhis the community and Tribe, Tribal lead- 2000; Coyhis and White 2006; Mail and ership, and Native American practices. It Shelton 2002; Sue 2001; White 2000). These is important to take the time to build practices include dances (such as the relationships and seek consultation with Plains Indians’ sun dance and the ’s Tribal elders, and other Tribal leaders to gourd dance), the four circles (a model for ensure that the best and most appropriate conceptualizing a harmonious life), the talking steps are taken in creating a culturally relevant and responsive treatment circle, sweat lodges, and other purification model and program. practices (Cohen 2003; Mail and Shelton

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Western standards and practices. Limited or (Garrity 2000). In 2001, roughly 20 percent of inconsistent funding, migration patterns, American Indians identified as Baptist, 17 culturally incompetent or incongruent evalua- percent as Catholic, 17 percent as having no tion practices, and abuses incurred during or religious preference, and 3 percent as following after data collection are major confounding a Tribal religion (Kosmin et al. 2001). variables that have limited knowledge on the The relative importance of religion can also effectiveness of incorporating traditional vary among diverse Native American commu- practices into Western approaches to the nities. Before pursuing traditional methods, treatment of substance abuse and mental assessment of clients’ spiritual orientation is illness. Nonetheless, Mail and Shelton (2002) important. Spirituality is a personal issue that reviewed earlier literature on the use of “indig- treatment providers must respect; clients enous therapeutic interventions” for alcohol should choose which spiritual and cultural abuse and dependence and suggest that a methods to incorporate into treatment. Pro- number of these interventions have been of viders should also be wary of an obsession value to Native Americans with substance use with their clients’ cultural activities, which may disorders. Other authors have concurred be considered intrusive (LaFromboise et al. (Coyhis and White 2006; Sabin et al. 2004). 1993). Checking with community resources Regardless of whether a program adapts spe- on the subject and asking the client “What cific Native American healing practices, pro- feels right for you?” are appropriate steps to viders working with this population should take in identifying whether traditional healing recognize that spirituality is central to its practices will have therapeutic value. Providers values and is perceived as an integral part of should consult with Native healers or Tribal life itself. It is through spiritual experiences leaders about the appropriateness of using a that Native Americans believe they will find particular practice as part of behavioral health meaning in life. Some Native languages have services. Rather than using traditional healing words that refer to spirituality as “walking methods themselves, counselors may wish to around” or “living the path.” In many cases, the refer clients to a Native American healer in spiritual traditions of Native Americans are the community or in the treatment program. not (and have never been) conceived of as a Relapse prevention and recovery religion, but rather as a set of beliefs and practices that pervades every aspect of daily Despite limited data on long-term recovery life (Deloria 1973). for Native Americans who have substance use disorders, a few studies have found high rates Despite religion and spirituality often playing of relapse following substance abuse treatment important roles in recovery from mental and (see review in Chong and Herman-Stahl substance use disorders for Native Americans, 2003). White and Sanders (2004) recommend providers should not assume that only indige- that long-term recovery plans for Native nous spirituality is relevant. The majority of Americans make use of a recovery manage- Native Americans do not practice their tradi- ment rather than a traditional continuing care tional spirituality exclusively, and Christian approach. Such an approach emphasizes the religious institutions like the Native American use of informal recovery communities and Church and Pentecostal churches have been traditional healing approaches to provide instrumental in helping many Native Ameri- extended monitoring and support for Native cans overcome substance use disorders Americans leaving treatment.

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Researchers have conducted interviews with of the population in the 2010 Census; Mather both American Indians (Bezdek and Spicer et al. 2011). 2006) and Alaska Natives (Hazel and Mohatt White Americans, like other large ethnic and 2001; Mohatt et al. 2008; People Awakening cultural groups, are extremely heterogeneous Project 2004) who have achieved extended in historical, social, economic, and personal periods of recovery. Bezdek and Spicer (2006) features, with many (often subtle) distinctions identified two key tasks for American Indians among subgroups. Perhaps because White entering recovery. First, they need to learn how Americans have been the majority in the to respond to family and friends who drank United States, it is sometimes forgotten how with them and to those who supported their historically important certain distinctions recovery. Next, they have to find new ways to between diverse White American ethnic deal with boredom and negative feelings. By heritages have been (and continue to be, for accomplishing these tasks, Native clients can some). Conversely, many White American build new social support systems, develop people prefer not to see themselves as such effective coping strategies for negative feelings, and instead identify according to their specific and achieve long-term recovery. The People ethnic background (e.g., as Irish American). Awakening Project found that, among Alaska For similar reasons, certain cross-cutting Natives who had a substantial period of recov- cultural issues (see Chapter 1) like geographic ery, the development of active, culturally ap- location, sexual orientation, and religious propriate coping strategies was essential (e.g., affiliation are important in defining the cul- distancing themselves from friends or family tural orientations of many White Americans. who drank heavily, getting involved in church, doing community service, praying; Hazel and Beliefs About and Traditions Mohatt 2001; Mohatt et al. 2008; People Involving Substance Use Awakening Project 2004). Historically, use of alcohol was accepted Counseling for White among White/European cultural groups because it provided an easy way to preserve Americans fruit and grains and did not contain bacteria that might be found in water. Over time, the According to the 2010 U.S. Census definition, production and consumption of alcohol be- White Americans are people whose ancestors came an often-integral part of cultural activi- are among those ethnic groups believed to be ties, which can be seen in the way some White the original peoples of Europe, the Middle cultural groups take particular pride in nation- East, or (Humes et al. 2011). al brands of alcoholic beverages (e.g., Scotch The racial category of White Americans whisky, French wine; Abbott 2001; Hudak includes people of various ethnicities, such as 2000). A number of European cultural groups , , Polish (e.g., French, Italian) traditionally believed Americans, and Anglo Americans (i.e., people that daily alcohol use was healthy for both with origins in England), among others. Many mind and body (Abbott 2001; Marinangeli Latinos will also identify racially (if not ethni- 2001), and for others (e.g., English, Irish), the cally) as White American. Non-Latino White bar or was the traditional center of com- Americans constitute the largest racial group munity life (O’Dwyer 2001). Despite some in the United States (making up 63.7 percent variations in cultural attitudes toward appro- priate drinking practices, alcohol has been and

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remains the primary recreational substance for often more accepting of prescription medica- Whites in the United States. Predominant tion abuse and less likely to perceive prescrip- attitudes toward drinking in the United States tion medications as potentially harmful more closely reflect those of Northern Europe; (Hadjicostandi and Cheurprakobkit 2002). alcohol use is generally accepted during cele- Despite illicit drug use now being as common brations and recreational events, and, at such among White Americans as people of color, times, excessive consumption is more likely to White Americans still tend to perceive drug be acceptable. use as an activity that occurs outside their Typically, White European cultural groups families and communities. In a 2001 survey, accept alcohol use as long as it does not inter- only 54 percent of White Americans ex- fere with responsibilities, such as work or pressed concern that someone in their family family, or result in public drunkenness (Hamid might develop a drug abuse problem compared 1998). However, among certain groups of with 81 percent of African Americans (Pew White Americans (usually defined by religious Research Center for the People and the Press beliefs), the use of alcohol or any other intoxi- 2001). In the same survey, White Americans cant is considered immoral (van Wormer expressed less concern about drug abuse in 2001). These religious beliefs, combined with their neighborhoods than did other racial and concerns about the effects of problematic ethnic groups. However, in terms of seeing drinking patterns (especially among men in drugs as a national problem, White Americans the frontier; White 1998), became the impetus and other racial and ethnic groups are in closer for the early 19th-century creation of the agreement. Perhaps as a result of this misper- Temperance Movement and culminated in the ception about the prevalence of drug use in passing of the 18th Amendment to the United their homes and communities, White States Constitution, which enacted Prohibition. American parents are less likely to convey Although the Temperance Movement is no disapproval of drug use to their children than longer a major political force, belief in the African American parents (National Center moral and social value of abstinence continues on Addiction and Substance Abuse 2005) and to be strong among some segments of the much more likely than Latino or African White American population. American parents to think that their children have enough information about drugs (Pew Illicit drug use, on the other hand, has histori- Research Center for the People and the Press cally been demonized by White American 2001). cultural groups and seen as an activity engaged in by people of color or undesirable subcul- There are also differences in how White Amer- tures ( and Whitebread 1970; Hamid icans, Latinos, and African Americans perceive 1998; Whitebread 1995). For example, White drug and alcohol . White Americans Americans typically link drug use to per- are less likely than African Americans, but ceived threat of crime—particularly crimes more likely than Latinos, to state that they perpetrated by people of color (Hamid 1998; believe a person can recover fully from addic- Whitebread 1995). Attitudes have changed tion (Office of Communications 2008). How- over time, but White American cultural ever, White Americans are more likely than groups continue to enforce strong cultural African Americans to indicate that substance prohibitions against most types of illicit drug use disorders should be treated as diseases use. At the same time, White Americans are (Durant 2005).

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Substance Use and Substance Use White Americans who use heroin are less likely Disorders than people who use heroin from all other major racial/ethnic groups except African According to 2012 NSDUH data, rates of Americans to have injected the drug past-year substance use disorders were higher (SAMHSA 2011c). White Americans are also for White Americans than for Native more likely than members of other major Hawaiians, other Pacific Islanders, and Asian racial/ethnic groups, except Native Hawaiians Americans; rates of current alcohol use were and other Pacific Islanders (for whom esti- higher than for every other major ethnic/racial mates may not be accurate), to have tried group (SAMHSA 2013d). Alcohol has tradi- ecstasy. Except for Native Americans (some of tionally been the drug of choice among White whom may use the for Americans of European descent; however, not religious purposes), they are also more likely all European cultural groups have the same than other racial/ethnic groups to have tried drinking patterns. Researchers typically con- hallucinogens (SAMHSA 2011c). Research trast a Northern/Eastern European pattern, in confirms that prescription drug misuse is which alcohol is consumed mostly on week- more common among White Americans than ends or during celebrations, with that of African Americans or Latinos (Ford and Southern Europe, in which alcohol is con- Arrastia 2008; SAMHSA 2011c), and they are sumed daily or almost daily but in smaller more likely to have used prescription opioids quantities and almost always with food. The in the past year and to use them on a regular Southern European pattern involves more basis. regular use of alcohol, but it is also associated with less alcohol-related harm overall (after Comparative studies indicate that White controlling for total consumption; Room et al. Americans are more likely than all other major 2003). The pattern of White Americans typi- racial/ethnic groups except Native Americans cally follows that of Northern and Eastern to have an alcohol use disorder (Hasin et al. Europe, but individuals from some ethnic 2007; Perron et al. 2009; Schmidt et al. 2007). groups maintain the Southern European White Americans are at a greater risk of having pattern. severe alcohol withdrawal symptoms (such as tremens) than are African Americans White Americans, on average, begin drinking or Latinos with alcohol use disorders (Chan et and develop alcohol use disorders at a younger al. 2009). So too, White Americans are more age than African Americans and Latinos likely than African Americans or Latinos to (Reardon and Buka 2002). White Americans meet diagnostic criteria for a drug use disorder are more likely to have their first drink before at some point during their lives (Perron et al. the age of 21 and to have their first drink 2009). Overall, substance use disorders vary before the age of 16 than members of any considerably across and within non-European other major racial/ethnic group except Native White American cultural groups. For example, Americans (SAMHSA 2011c). Some data rates of substance abuse treatment admissions suggest that White Americans begin using in Michigan from 2005 suggest that substance illicit drugs at an earlier age than African use disorders may be considerably lower for Americans (Watt 2008) and that the mean age Arab Americans than other White Americans for White Americans who inject heroin has (Arfken et al. 2007). decreased (Broz and Ouellet 2008).

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Mental and Co-Occurring Americans and about 60 percent lower for Disorders Asian Americans (Grant et al. 2005). A simi- lar pattern exists for major depressive disorder About 20 percent of White Americans report- (Hasin et al. 2005). ed some form of mental illness in the past year, and they were more likely to have past-year Treatment Patterns serious psychological distress than other popu- White Americans are more likely to receive lation groups excluding Native Americans mental health treatment or counseling than (SAMHSA 2012a). other racial/ethnic groups (SAMHSA 2012b). White Americans appear to be more likely White Americans are more likely than African than Latinos or Asian Americans to have Americans to receive substance abuse treat- CODs (Alegria et al. 2008a; Vega et al. 2009) ment services from a private physician or and more likely to have concurrent serious other behavioral health or primary care profes- psychological distress and substance use disor- sional (Perron et al. 2009). Among White ders (SAMHSA 2011c). White Americans American clients entering substance abuse with CODs are also more likely to receive treatment programs in 2010, alcohol (alone or treatment for both their substance use and in conjunction with illicit drugs) was most mental disorders than are African Americans often the primary substance of abuse, followed with CODs (Alvidrez and Havassy 2005; by heroin and cannabis. However, findings are Hatzenbuehler et al. 2008), but they are per- inconsistent concerning the relative frequency haps less likely to receive treatment for their with which White Americans enter substance substance use disorder alone (Alvidrez and abuse treatment. Some studies have found that Havassy 2005). White Americans are more White Americans are more likely to receive likely to receive family counseling and mental needed behavioral health services than both health services while in substance abuse treat- African Americans and Latinos (Marsh et al. ment and less likely to have unmet treatment 2009; Wells et al. 2001). In contrast, other needs (Marsh et al. 2009; Wells et al. 2001). In studies have found that African Americans addition, White Americans are significantly with an identified need are somewhat more less likely than Latinos or African Americans likely to enter treatment for drug use disorders to believe that antidepressants are addictive and about as likely to receive treatment for (Cooper et al. 2003). alcohol use disorders when compared with White Americans (Hatzenbuehler et al. 2008; The most common mental disorders among Perron et al. 2009; SAMHSA, CBHSQ 2012; White Americans are mood disorders (par- Schmidt et al. 2006). ticularly major depression and bipolar I disor- der) and anxiety disorders (specifically Beliefs and Attitudes About , including social , and general- Treatment ized ; Grant et al. 2004b). Among White Americans, these disorders are White Americans appear to be generally more prevalent than in any other ethnic/racial accepting of behavioral health services. They groups save Native Americans (Grant et al. have better access to health care and are more 2005; Hasin et al. 2005). For example, rates of a likely to use services than people of color, but lifetime diagnosis of generalized anxiety disor- this varies widely based on socioeconomic der are about 40 percent lower for African status and cultural affiliation. Most treatment Americans and Latinos than for White services have historically been developed for

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White American populations, so it is not opposed to being in partial remission or drink- surprising that White Americans are more ing without symptoms of alcohol dependence likely than other racial/ethnic groups to be (Dawson et al. 2005). satisfied with treatment services (Tonigan 2003). Treatment Issues and Considerations Still, attitudes differ among certain cultural subgroups of White Americans. For example, Most major treatment interventions have been Russian immigrants from the former Soviet evaluated with a population that is largely or Union have a longstanding distrust of mental entirely White American, although the role of health systems and hence may avoid substance White American cultural groups is rarely abuse treatment (Kagan and Shafer 2001). considered in evaluating those interventions. Other groups who have a strong family orien- For example, as Straussner (2001) notes, “the tation, such as Italian Americans or Scotch- paradox of writing about substance abusers of Irish Americans, might avoid treatment that European background is that they are a group asks them to reveal family secrets (Giordano that is believed to be the group for whom the and McGoldrick 2005; Hudak 2000). traditional alcohol and other drug treatment models have been developed, and yet they are According to 2010 NSDUH data regarding a group whose unique treatment needs and people who recognized a need for substance treatment approaches have rarely been ex- abuse treatment in the prior year but did not plored” (p. 165). Very few evaluations of receive it, White Americans were more likely treatment strategies and interventions (wheth- than members of other major racial/ethnic er based on research or clinical observation) groups to state that it was because they had no have taken into account ethnic and cultural time for treatment, that they were concerned differences among White American clients, what their neighbors might think, that they and therefore it is generally not possible to did not want others to know, and/or that they make culturally responsive recommendations were concerned about how it might affect for specific subgroups of White Americans. their jobs (SAMHSA 2011c). Other research confirms that White Americans are significant- Culturally responsive treatment for many ly more likely to avoid treatment due to fear of White Americans will involve helping them what others might think or because they are in rediscover their cultural backgrounds, which denial (Grant 1997). White Americans may sometimes have been lost through acculturation also have different attitudes toward recovery, at and can be an important part of their long- least regarding alcohol use disorders, than do term recovery. Giordano and McGoldrick members of other ethnic/racial groups. Ac- (2005) note that ethnic identity and culture cording to NESARC data on people who can be more important for some White met criteria for a diagnosis of alcohol de- Americans “in times of stress or personal pendence at some point during their lives, crisis,” when they may want to “return to White Americans were more likely than familiar sources of comfort and help, which African Americans, Latinos, or other non- may differ from the dominant society’s norms” Latinos to have achieved remission from that (p. 503). Appendix B provides information on disorder but were also less likely than African instruments for assessing cultural identifica- Americans or other non-Latinos (but not tion. For an overview of challenges in main- Latinos) to currently abstain from drinking, as taining mental health, access to health care,

154 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

and help-seeking among White Americans, ethnic heritages, and there is no approach that see Downey and D’Andrea (2012). is effective for all White Americans in family therapy (Hanson 2011). Hierarchical families, Theoretical Approaches and such as German American families, may Treatment Interventions expect the counselor to be authoritative, at Overall, the optimum treatment approach least in the initial sessions (Winawer and with White Americans is a comprehensive Wetzel 2005), although a more egalitarian one; the more tools in the toolkit, the greater German American family might not respond the chance of success (McCaul et al. 2001). well to such imperatives. In the same vein, one Within-group differences arise regarding client of French background could readily education level, socioeconomic status, gender, accept direct and clear therapeutic assign- and other factors, which must be considered. ments that contain measurable goals (Abbot Providers can, however, assume that most 2001), whereas another French American well-accepted treatment approaches and inter- client may value counseling that is more pro- ventions (e.g., CBT, motivational interviewing, cess oriented. Thus, it is imperative to assess 12-Step facilitation, contingency management, the cultural identification of clients and their pharmacotherapies) have been tested and families, along with the treatment needs that evaluated with White American clients. best match their cultural worldviews. Still, treatment is not uniformly appropriate In some White American families, there is a even for White Americans. Approaches may longstanding culture of drinking. Attempts at need modification to suit class, ethnic, reli- abstinence can be perceived by family mem- gious, and other client traits. Providers should bers as culturally inappropriate. In other fami- establish not only the client’s ethnic back- lies, there is deep denial about alcohol abuse or ground, but also how strongly the person dependence, especially when talking about identifies with that background. Few clinicians substance use to those outside the family. For have made observations on best therapeutic example, some Polish American families can approaches for members of particular White be resistant to the idea that drinking is the American cultural/ethnic subgroups. cause of family problems (Folwarski and Smolinski 2005) and sometimes believe that Family therapy to admit an alcohol problem, especially to In White American families, individuals are someone outside the family, signals weakness. generally expected to be independent and self- Group therapy reliant; as a result, families in therapy can have trouble adjusting to work that focuses more on Standard group therapies developed for men- communication processes than specific prob- tal health and substance abuse treatment lems or content (McGill and Pearce 2005). programs have generally been used and evalu- Van Wormer (2001) notes that many White ated with White American populations. For Americans need help addressing communica- details on group therapy in substance abuse tion issues. In family therapy, useful approach- treatment, see TIP 41, Substance Abuse Treat- es include those that encourage open, direct, ment: Group Therapy (CSAT 2005c). and nonthreatening communication. Mutual-help groups There is no singular description that fits Mutual-help groups, of which AA is the most White American families within or across prevalent, have a largely White American

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membership (AAWS 2008; Atkins and Traditional healing and Hawdon 2007). In a 2011 survey, 87 percent complementary methods of AA members indicated their race as White Only 12 percent of White Americans consider (AAWS 2012). In research with largely White themselves atheist, agnostic, or secular without populations, AA participation has been found a religious affiliation, meaning that, as a group, to be an effective strategy for promoting White Americans are more religious than recovery from alcohol use disorders (Dawson Asian Americans but less so than Latinos or et al. 2006; McCrady et al. 2004; Moos and African Americans (Pew Forum on Religion Moos 2006; Ritsher et al. 2002; Weisner et al. and Public Life 2008). As with other groups, 2003). Other mutual-help groups, such as White Americans belong to many different Self-Management and Recovery Training, religions, although the vast majority belong to Secular Organizations for Sobriety/Save Our various Christian denominations, with approx- Selves, and Women for Sobriety, also have imately 57 percent identifying as Protestant predominately White American membership and 25.9 percent as Catholic (National Center and are based on Western ideas drawn from on Addiction and Substance Abuse, 2001). psychology (Atkins and Hawdon 2007; White White Americans also make up 91 percent of 1998). practitioners of Judaism in the United States, The appeal of mutual-help groups among 14 percent of followers of Islam, and 32 per- White Americans rests on the historical ori- cent of the American Buddhist population gins of this model. The 12-Step model was (Kosmin et al. 2001). For more religious originally developed by White Americans White Americans, pastoral counseling or based on European ideas of spirituality, faith, prayer can be useful aids in the treatment of and group interaction. Although the model substance use disorders. However, White has been adopted worldwide by different Americans are significantly less likely to use cultural groups (White 1998), the 12-Step prayer as a method of coping (Graham et al. model works especially well for White ethnic 2005). White Americans are more likely than groups, including Irish Americans, Polish members of other major racial/ethnic groups Americans, , and Scotch- to use complementary or alternative medical Irish Americans, because it incorporates therapies, such as herbal medicine, acupunc- Western cultural traditions involving spiritual ture, chiropractors, massage therapy, yoga, and practice, public , and the use of special diets (Graham et al. 2005). anonymity to protect against humiliation Relapse prevention and recovery (Abbott 2001; Gilbert and Langrod 2001; Hudak 2000; McGoldrick et al. 2005; Taggart Factors that promote recovery for White 2005). Americans include the learning and use of coping skills (Litt et al. 2003; Litt et al. 2005; In addition to mutual-help groups for sub- Maisto et al. 2006). Even though some research stance abuse, numerous recovery support suggests that White Americans are less likely groups, Internet resources, Web-based com- to use coping skills than African Americans munities, and peer support programs are (Walton 2001) and have lower levels of self- available to promote mental health recovery. efficacy upon leaving treatment (Warren et al. Many resources are available through the 2007), the development of these skills and of National Alliance on Mental Illness self-efficacy is important in managing relapse (http://www.nami.org). risks and in maintaining recovery. Counselors

156 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

may offer psychoeducation on the value of 2002; McIntosh and McKeganey 2000; coping strategies, specific skills to manage Rumpf et al. 2002). Other important factors stressful situations or environments, and op- include continuing care, the development of portunities to practice these skills during substitute behaviors (i.e., reliance on healthy treatment. Some coping skills or strategies or positive activities in lieu of substance use), may be more important than others in manag- the creation of new caring relationships that ing high-risk situations, but research suggests do not involve substance use, and increased that greater use of a variety of coping strate- spirituality (Valliant 1983). Valliant (1983) gies is more important than the use of any one and others (e.g., Laudet et al. 2002; McCrady specific skill (Gossop et al. 2002). et al. 2004; Moos and Moos 2006) conclude, based on research with mostly White partici- Social and family supports are also important pants, that mutual-help groups often play an in maintaining recovery and preventing re- important role in maintaining recovery. lapse among White Americans (Laudet et al.

TIPs That Provide Supplemental Information on Topics in This Chapter TIP 34: Brief Interventions and Brief Therapies for Substance Abuse (CSAT 1999a)

TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment (CSAT 1999c)

TIP 39: Substance Abuse Treatment and Family Therapy (CSAT 2004b)

TIP 41: Substance Abuse Treatment: Group Therapy (CSAT 2005c)

TIP 42: Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005d)

TIP 44: Substance Abuse Treatment for Adults in the Criminal Justice System (CSAT 2005b)

TIP 47: Substance Abuse: Clinical Issues in Intensive Outpatient Treatment (CSAT 2006c)

TIP 51: Substance Abuse Treatment: Addressing the Specific Needs of Women (CSAT 2009c)

TIP 57: Trauma-Informed Care in Behavioral Health Services (SAMHSA 2014) Planned TIP: Relapse Prevention and Recovery Promotion in Behavioral Health Services (SAMHSA planned e)

157

Drug Cultures and the 6 Culture of Recovery

IN THIS CHAPTER Lisa is a 19-year-old White college student living in , CA, who was sent to treatment by her parents after failing her • What Are Drug Cultures? college classes and being placed on academic probation. While • The Role of Drug Cultures home on break earlier that year, her parents found pills in her room in Substance Abuse but let her return to school after she promised to stop using. The Treatment academic probation is only part of the reason her parents sent her to treatment. They were also concerned about her recent weight loss, as her older had previously struggled with bulimia. Lisa began using marijuana at age 15 with a cousin. In her first year of high school, she had difficulty fitting in. However, the next year, she became friendly with an clique that helped her define an identity for herself and introduced her to ecsta- sy (3,4-methylenedioxymethamphetamine, or MDMA), metham- phetamine, and various hallucinogens, along with new ideas about politics, music, and art. She has since found similar friends at college and keeps in touch with several members of her high school clique. In treatment, Lisa tells her counselor that she has long felt neglect- ed by her parents, who are too interested in material things. She sees her drug use and that of her friends as a rebellion against the materialistic attitudes of their parents. She also dismisses her fami- ly’s cultural heritage, insisting that her parents only identify as Americans even though they are first-generation Americans with European backgrounds. She talks at length about ways to acquire and prepare relatively unknown hallucinogens, the best music to listen to while using, and how to evaluate the quality of marijuana. Lisa says that she doesn’t believe she has a problem. She thinks that her failing grades reflect her lack of interest in college, which she says she is attending only because people expect it of her. When asked what she would rather be doing, she says she does not have any clearly defined goals and just wants to do “something with art

159 Improving Cultural Competence

This Treatment Improvement Protocol which she notes “isn’t even illegal,” and take (TIP) emphasizes the concept that many other botanical hallucinogens. She is adamant subcultures exist within and across diverse about keeping her friends, who she says have ethnic and racial populations and cultures. been supportive of her and are not materialis- Drug cultures are a formidable example— tic “sellouts” like her parents. these are cultures that can influence the presentation of mental, substance use, Her counselor places a priority on connecting and co-occurring disorders as well as Lisa with other people her age who are in prevention and treatment strategies recovery. She asks a client who graduated from and outcomes. the program and is only a year older than Lisa to accompany her to Narcotics Anonymous (NA) meetings attended mostly by younger people in recovery. The counselor also encour- or music.” Lisa points out that, unlike most of ages Lisa’s friendships with other young peo- her classmates, she doesn’t drink and has ple in the program. When Lisa complains stopped doing addictive drugs like ecstasy and about her parents’ and the materi- methamphetamine, which were responsible for alism of mainstream culture, her counselor her weight loss. She is convinced that she can brings up the spiritual elements of mutual- continue to smoke pot and , help recovery groups and how they provide an

Multidimensional Model for Developing Cultural Competence: Drug Cultures

160 Chapter 6—Drug Cultures and the Culture of Recovery alternative model for interacting with others. What Are Drug Cultures? The counselor begins to help Lisa explore how her drug use may be an attempt to fill her Up to this point, this TIP has focused on unmet emotional and social needs and may cultures based on ethnicity, race, language, and hinder the development of her own interests, national origin. The TIP looks primarily at identity, and goals. those cultural groups because they are the major cultural forces that shape an individual’s Treatment providers should consider how life and worldview. However, there are other cultural aspects of substance use reinforce types of cultural groups (sometimes referred to substance use, substance use disorders, and as subcultures) that are also organized around relapses. Factors to note include clients’ possi- shared values, beliefs, customs, and traditions; ble self-medication of psychological distress or these cultural groups can have, as their core mental disorders. Beyond specific biopsycho- organizing theme, such factors as sexuality, social issues that contribute to the risk of musical styles, political , and so on. substance-related disorders and the initiation For most clients in treatment for substance use and progression of use, counselors and treat- disorders (including those who have a co- ment organizations must continually acquire occurring mental disorder), the drug subcul- knowledge about the ever-changing, diverse ture will likely have affected their substance drug cultures in which client populations may use and can affect their recovery; that is the participate and which reinforce the use of primary rationale for the development of this drugs and alcohol. Moreover, behavioral health unique chapter. Research literature in this service providers and program administrators topic area is considerably limited. need to translate this knowledge into clinical and administrative practices that address and Some people question whether a given drug counter the influence of these cultures within culture is in fact a subculture, but many seem the treatment environment (e.g., by instituting to have all the elements ascribed to a culture policies that ban styles of dress that indicate (see Chapter 1). A drug culture has its own affiliation with a particular drug culture). history (pertaining to drug use) that is usually orally transmitted. It has certain shared values, Adopting Sue’s multidimensional model (2001) beliefs, customs, and traditions, and it has its for developing cultural competence, this chap- own rituals and behaviors that evolve over ter identifies drug cultures as a domain that time. Members of a drug culture often share requires proficiency in clinical skills, program- similar ways of dressing, socialization patterns, matic development, and administrative practic- language, and style of communication. Some es. It explores the concept of drug cultures, the even develop a social hierarchy that gives relationship between drug cultures and main- different status to different members of the stream culture, the values and rituals of drug culture based on their roles within that culture cultures, and how and why people value their ( Jenkot 2008). As with other cultures, drug participation in drug cultures. This chapter cultures are localized to some extent. For exam- describes how counselors can determine a ple, people who use in client’s level of involvement in a drug culture, Hawaii and Missouri could share certain atti- how they can help clients identify and develop tudes, but they will also exhibit regional differ- alternatives to the drug cultures in which they ences. The text boxes in this chapter offer participate, and the importance of assisting examples of the distinct values, languages, clients in developing a culture of recovery.

161 Improving Cultural Competence

rituals, and types of artistic expression associ- Exhibit 6-1: How Drug Cultures Differ ated with particular drug cultures. • There is overlap among members, but drug Many subcultures exist outside mainstream cultures differ based on substance used— society and thus are prone to fragmentation. A even among people from similar ethnic and socioeconomic backgrounds. The drug cul- single subculture can split into three or four ture of heroin use (McCoy et al. 2005; related subcultures over time. This is especially Pierce 1999; Spunt 2003) differs from the true of drug cultures, in which people use drug culture of ecstasy use (Reynolds 1998). different substances, are from different locales, • Drug cultures differ according to geo- or have different socioeconomic statuses; they graphic area; people who use heroin in the Northeast United States are more likely to may also have very different cultural attitudes inhale than inject the drug, whereas the related to the use of substances. Bourgois and opposite is true among people in the Schonberg (2007) described how ethnic and Western United States who use heroin racial differences can affect the drug cultures (Office of Applied Studies [OAS] 2004). of users of the same drugs to the point that • Drug cultures can differ according to other social factors, such as socioeconomic status. even such things as injection practices can The drug culture of young, affluent people differ between Black and White heroin users who use heroin can occasionally mirror the in the same city. Exhibit 6-1 lists of some of drug culture of the street user, but it will al- the ways in which drug cultures can differ so have notable differences (McCoy et al. from one another. 2005; Pierce 1999; Spunt 2003). • Drug cultures (even involving the same Differences in the physiological and psycho- drugs and the same locales) change over logical effects of drugs account for some dif- time; older people from New York who use heroin and who entered the drug culture in ferences among drug cultures. For example, the 1950s or 1960s feel marginalized within the drug culture of people who use heroin is the current drug scene, which they see as typically less frenetic than the drug culture promoting a different set of values involving methamphetamine use. However, (Anderson and Levy 2003). other differences seem to be more clearly related to the historical development of the change factors are quite different. In Missouri, culture itself or to the effects of larger social the low cost and easy production of the drug forces. Cultural and socioeconomic compo- influenced development of a methampheta- nents contributed to the rise in methamphet- mine drug culture. Missouri leads the nation amine use among gay men on the West Coast in the number of methamphetamine labs seized (Reback 1997) and among Whites of lower by police; a disproportionately large number of socioeconomic status in rural Missouri seizures occur in rural areas (Carbone-Lopez et (Topolski and Anderson-Harper 2004). How- al. 2012; Topolski and Anderson-Harper ever, in these two cases, the details of those 2004). The popularity of the drug among How To Identify Key Characteristics of a Drug Culture Counselors and clinical supervisors must acquire knowledge about drug cultures represented within the client population. Drug cultures can change rapidly and vary across racial and ethnic groups, geographic areas, socioeconomic levels, and generations, so staying informed is challenging. Besides needing an understanding of current drug cultures (to help prevent infiltration of related behaviors and attitudes within the treatment environment), counselors also need to help clients understand how such cultures support use and pose dynamic relapse risks.

(Continued on the next page.)

162 Chapter 6—Drug Cultures and the Culture of Recovery

How To Identify and Discuss Key Characteristics of a Drug Culture (continued) Counselors can use this exercise to begin to educate clients about the influence of drug cultures and help them identify the specific behaviors, values, and attitudes that constitute their experience of using alcohol and drugs. It can be a helpful tool in improving clients’ understanding of the reinforcing as- pects of alcohol and drug use beyond physiological effects. In addition, this exercise can be used as a training tool in clinical supervision to help counselors understand the influence and potential reinforc- ing qualities of a drug culture among clients and within the treatment milieu. Materials needed: Diagram handout and pencils. Instructions: • Determine whether this exercise is more appropriate as an individual or group exercise. Assess the newness and variability of recovery within the group constellation. If several group members support recovery-related behavior, conducting this exercise may be a beneficial educational tool and means of intervention with clients who continue to identify mainly with their drug culture. Conversely, if most group members are new or have had difficulty accepting treatment or treatment guidelines, this exercise may be more aptly used as an individual tool. • Attention: In group settings, strict parameters need to be established at the beginning of the session to ensure that the discussion remains centered on attitudes, values, and behaviors sur- rounding drug and alcohol use—not on specific techniques or procedures for using drugs or rit- uals surrounding intake or injection. • Start the discussion by first presenting the idea that drug cultures exist—describing the main elements that constitute culture (refer to Chapter 1 or the categories identified in the “Drug Culture” diagram below). Next, provide examples of how drug culture can support continued use and relapse. Keep in mind that not all clients are engaged in a drug culture. • Following the general introduction, review each block in the diagram and ask clients to provide examples related to their own use and involvement with drugs and alcohol. After discussing their examples, ask them to identify the most significant behaviors, attitudes, and values that re- inforce their use (e.g., a feeling of acceptance or camaraderie). • Counselors can redirect this general discussion to related topics—for example, by identifying behaviors, values, and attitudes likely to support recovery or by shifting from discussion to role- plays that will help clients address relapse risks associated with their drug culture and practice coping skills (e.g., assertiveness or refusal skills to counter the influence of others once they are discharged from the program or to address situations that arise during the course of treatment).

Drug Culture Establishing Trust and Socialization Values Credibility How were you introduced to the What values are upheld or How do you go about culture? devalued in the group? establishing credibility? Gender Roles and Status Rules Relationships In what ways can you obtain Are there spoken and unspoken What gender expectations status or be seen as a success? rules or norms? exist surrounding drug use? Concepts of Sanction, Dress Symbols and Images Punishment, and Conflict Are there specific ways to Are there symbols that represent Mediation dress that show allegiance a particular association with a How does the group deal with to a specific substance or group or substance? in-group conflicts? group? Language & Communication View of Past, Present, Attitudes Are there special verbal or and Future What are common attitudes nonverbal ways to communicate Are there specific beliefs about toward others (nonusers, about substance- the past, present, and/or future? police, etc.)? related activities?

163 Improving Cultural Competence

Whites could be linked to the historical de- shops” from multiple doctors and procures velopment of the methamphetamine trade by drugs for misuse from pharmacies. Although White motorcycle gangs (Morgan and drug cultures typically play a greater role in 1997). On the other hand, most gay men who the lives of people who use illicit drugs, people use the drug report having first used it at who use legal substances—such as alcohol— parties with the expectation of involvement in are also likely to participate in such a culture sexual activity (Hunt et al. 2006). In studies of (Gordon et al. 2012). Drinking cultures can gay men who used methamphetamine, the develop among heavy drinkers at a bar or a main reason for use was to heighten sexual college fraternity or sorority house that works experience (Halkitis et al. 2005; Kurtz 2005; to encourage new people to use, supports high Reback 1997). Morgan and Beck (1997) levels of continued or binge use, reinforces found that increased sexual activity was one denial, and develops rituals and customary reason why certain women and heterosexual behaviors surrounding drinking. In this chap- men used methamphetamine, but it was not as ter, drug culture refers to cultures that evolve important a reason as it was for gay men. from drug and alcohol use. This chapter aims to explain that people who The Relationship Between Drug use drugs participate in a drug culture, and Cultures and Mainstream Culture further, that they value this participation. However, not all people who abuse substances To some extent, subcultures define themselves are part of a drug culture. White (1996) draws in opposition to the mainstream culture. Sub- attention to a set of individuals whom he calls cultures may reject some, if not all, of the values “acultural addicts.” These people initiate and and beliefs of the mainstream culture in favor sustain their substance use in relative isolation of their own, and they will often adapt some from other people who use drugs. Examples of elements of that culture in ways quite different acultural addicts include the medical profes- from those originally intended (Hebdige 1991; sional who does not have to use illegal drug Issitt 2009; Exhibit 6-2). Individuals often networks to abuse prescription medication, or identify with subcultures—such as drug cul- the older, middle-class individual who “pill tures—because they feel excluded from or

Exhibit 6-2: The Language of a Drug Culture One of the defining features of any culture is the language it uses; this need not be an entire lan- guage, and may simply comprise certain jargon or slang and a particular style of communication. The use of slang regarding drugs and drug activity is a well-recognized aspect of drug culture. Not as well-known is the diversity of that language and how it varies across time and place. Rather than coining new words, the language of drug culture often borrows words from mainstream culture and adapts them to new purposes.

For example, Williams (1992) examined the use of Star Trek terminology among people who used crack cocaine in New York during the 1980s. They adopted the persona of members of the Star Trek Enterprise crew in their use of language—such as “going on a mission” when they went looking for cocaine; “beam me up, Scotty” when they wanted to get high; and referring to crack cocaine itself as “Scotty.” Crack cocaine users even created an imaginary book entitled The Book of Tech that they referred to as if it contained important information for people who use and sell crack cocaine (e.g., how to cook freebase cocaine from cocaine hydrochloride). This language (and other terms derived from other sources) helped members of this drug culture recognize other members. People who did not understand the terms used were typically taken advantage of during drug transactions.

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unable to participate in mainstream society. chances of any attempt to change behavior The subculture provides an alternative source (Cohen 1992). The drug culture enables its of social support and cultural activities, but members to view substance use disorders as those activities can run counter to the best normal or even as status symbols. The disorder interests of the individual. Many subcultures becomes a source of pride, and people may are neither harmful nor antisocial, but their celebrate their drug-related identity with other focus is on the substance(s) of abuse, not on members of the culture (Pearson and Bourgois the people who participate in the culture or 1995; White 1996). Social stigma also aids in their well-being. the formation of oppositional values and beliefs that can promote among mem- Mainstream culture in the United States has bers of the drug culture (Exhibit 6-3). historically frowned on most substance use and certainly substance abuse (Corrigan et al. When people with substance use disorders 2009; White 1979, 1998). This can extend to experience discrimination, they are likely to legal substances such as alcohol or delay entering treatment and can have less (including, in recent years, the increased pro- positive treatment outcomes (Fortney et al. hibition against cigarette in public 2004; Link et al. 1997; Semple et al. 2005). spaces and its growing social unacceptability Discrimination can also increase denial and in private spaces). As a result, mainstream step up the individual’s attempts to hide sub- culture does not—for the most part—have an stance use (Mateu-Gelabert et al. 2005). The accepted role for most types of substance use, immorality that mainstream society attaches unlike many older cultures, which may accept to substance use and abuse can unintentionally use, for example, as part of specific religious serve to strengthen individuals’ ties with the rituals. Thus, people who experiment with drug culture and decrease the likelihood that drugs in the United States usually do so in they will seek treatment. highly marginalized social settings, which can The relationship between the drug and main- contribute to the development of substance stream cultures is not unidirectional. Since the use disorders (Wilcox 1998). Individuals who beginning of a definable drug culture, that are curious about substance use, particularly culture has had an effect on mainstream cul- young people, are therefore more likely to tural institutions, particularly through music become involved in a drug culture that en- (Exhibit 6-4), art, and literature. These con- courages excessive use and experimentation nections can add significantly to the attraction with other, often stronger, substances (for a a drug culture holds for some individuals review of intervention strategies to reduce (especially the young and those who pride discrimination related to substance use disor- themselves on being nonconformists) and ders, see Livingston et al. 2012). create a greater risk for substance use escalat- When people who abuse substances are mar- ing to abuse and relapse. ginalized, they tend not to seek access to mainstream institutions that typically provide Understanding Why People Are sociocultural support (Myers et al. 2009). This Attracted to Drug Cultures can result in even stronger bonding with the To understand what an individual gains from drug culture. A marginalized person’s behavior participating in a drug culture, it is important is seen as abnormal even if he or she attempts first to examine some of the factors involved to act differently, thus further reducing the

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Exhibit 6-3: The Values and Beliefs of a Heroin Culture Many core values of illicit drug cultures involve rejecting mainstream society and its cultural values. Stephens (1991) analyzed value statements from people addicted to heroin and extracted the core tenets of this drug culture’s value system. They are: • Antisocial viewpoint—Members of this drug culture share a viewpoint that sees all people as basically dishonest and egocentric; they are especially distrustful of those who do not use heroin. • Rejection of middle-class values—Members denigrate values such as the need for hard work, security, and honesty. • Excitement/hedonism—Members value immediate gratification and the intense pursuit of pleas- ure over more stable and lasting values. • Importance of outward appearances—As much as members of the drug culture may complain about the mainstream culture’s shallowness, they strongly believe in conspicuous consumption and the importance of owning things that give an image of prosperity. • Valence of street addict subcultures—Members of this drug culture value the continued partici- pation of others in the culture, even to the point of expecting individuals who have stopped us- ing to continue to participate in the culture. • Emotional detachment—People involved in this drug culture value emotional aloofness and see emotional involvement with others as a weakness.

These core values (initially examined by Stephens et al. 1976) were taken from a specific drug culture (heroin), but they can be found in many other drug cultures that center on the use of illicit drugs. However, these same values will not be upheld in every drug culture. For instance, the drug culture of people who use MDMA does not appear to value emotional aloofness, but rather to appreciate the drug’s ability to create a feeling of among those who use it (Gourley 2004; Reynolds 1998). Drug cultures involving legal substances (notably alcohol) are less likely to reject the core values of mainstream society and are less likely to be rejected by that society. They will, howev- er, still value excitement/hedonism and the participation of others in the subculture.

Exhibit 6-4: Music and Drug Cultures Since the 1920s, when marijuana use became associated with musicians, there has been a con- nection between certain music subcultures and particular types of substance use (Blake 2007; Gahlinger 2001). As Blackman (1996) notes, “Before the emergence of post-war , there was a direct connection between the development of the popular music—jazz—and the use of illicit drugs in terms of musicians who used drugs, including heroin, cocaine, and cannabis and their narra- tives about these drugs through songs” (p. 137). Early Federal legislation criminalizing marijuana was motivated, in part, by use of the drug by jazz musicians and fear that their example would influence youth (Whitebread 1995).

In recent years, the link between drug culture and music has been exemplified by the importance of MDMA in the music scene (Kotarba 2007; Murguia et al. 2007). Reynolds (1998) credits the development of rave music to MDMA’s ability to create a feeling of intimacy among relative strangers and the way in which people who use it respond to repetitive, up-tempo music. Con- versely, Adlaf and Smart (1997) found that adolescents in Canada typically became involved in the rave music scene after starting to use MDMA and other drugs. Regardless of how the relationship developed, MDMA and rave music are so closely linked that it is hard to tell where the music culture ends and the drug culture begins.

Blackman (1996) states that drug use has become an essential element of youth culture mainly through its association with musical artists. Similarly, Knutagard (1996) observes how different youth cultures, each defined in part by its members’ choices in music and substance use, have made some types of substance use acceptable to many young people. Esan (2007) notes that urban music and drug

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Exhibit 6-4: Music and Drug Cultures (continued) culture have a shared appeal to young people based on their apparently antagonistic relationship to mainstream culture. Since the 1990s, rock group confessional memoirs have become increasingly popular, often depicting a lifestyle and culture of excess and providing explicit details of drug use and methods; consumption-driven, high-risk, or excessive behaviors; tragic consequences of use; and, sometimes, the author’s participation in rehabilitation (Oksanen 2012).

Certain drugs and the drug-dealing lifestyle are featured prominently in different types of music, including (Esan 2007; Schensul et al. 2000) or (a popular form of Mexican and Mexican American border music that tells of the lives of drug traffickers [Edberg 2004]). However, even music that is not overtly concerned with drug use can become connected to a drug culture or to substance use in an individual’s mind. According to White (1996), links between particular songs and the recall of euphoric drug experiences are especially common and may need to be addressed ex- plicitly in treatment. Hearing these songs can act as a trigger for drug use and can, therefore, be a potential cause of relapse. in substance use and the development of Drug cultures serve as an initiating force as substance use disorders. Despite having differ- well as a sustaining force for substance use and ing theories about the root causes of substance abuse (White 1996). As an initiating force, the use disorders, most researchers would agree culture provides a way for people new to drug that substance abuse is, to some extent, a use to learn what to expect and how to appre- learned behavior. Beginning with Becker’s ciate the experience of getting high. As White (1953) seminal work, research has shown that (1996) notes, the drug culture teaches the new many commonly abused substances are not user “how to recognize and enjoy drug effects” automatically experienced as pleasurable by (p. 46). There are also practical matters involved people who use them for the first time in using substances (e.g., how much to take, (Fekjaer 1994). For instance, many people find how to ingest the substance for strongest effect) the taste of alcoholic beverages disagreeable that people new to drug use may not know during their first experience with them, and when they first begin to experiment with drugs. they only learn to experience these effects as The skills needed to use some drugs can be pleasurable over time. Expectations can also be quite complicated, as shown in Exhibit 6-6. important among people who use drugs; those The drug culture has an appeal all its own that who have greater expectancies of pleasure promotes initiation into drug use. Stephens typically have a more intense and pleasurable (1991) uses examples from a number of ethno- experience. These expectancies may play a part graphic studies to show how people can be as in the development of substance use disorders taken by the excitement of the drug culture as (Fekjaer 1994; Leventhal and Schmitz 2006). they are by the drug itself. Media portrayals, Additionally, drug-seeking and other behav- along with singer or music group autobiog- iors associated with substance use have a raphies, that glamorize the drug lifestyle may reinforcing effect beyond that of the actual increase its lure (Manning 2007; Oksanen drugs. Activities such as rituals of use (Exhibit 2012). In buying (and perhaps selling) drugs, 6-5), which make up part of the drug culture, individuals can find excitement that is missing provide a focus for those who use drugs when in their lives. They can likewise find a sense of the drugs themselves are unavailable and help purpose they otherwise lack in the daily need to them shift attention away from problems they seek out and acquire drugs. In successfully might otherwise need to face (Lende 2005). navigating the difficulties of living as a person

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Exhibit 6-5: The Rituals of Drug Cultures Several authors have noted that illicit drug use and alcohol use typically involve ritualized behaviors (Alverson 2005; Carlson 2006; Carnes et al. 2004; Grund 1993; White 1996). The rituals of substance use affect where, when, and how substances are used. Substance-related rituals serve both instru- mental and social functions. Instrumental functions include maximizing drug effects, minimizing negative effects of drug use, and preventing secondary problems. Socially, the rituals display one’s affiliation with the drug culture to other people and help create a sense of community within the culture. Obviously, the social function is more central to group activities than to solitary rituals.

Most drug-related social rituals involve sharing substances or sharing the experience of intoxication. Some drug cultures (e.g., marijuana) encourage the sharing of substances, but even when they are not shared, drugs are often used with other people who use, such as in crack houses and shooting galleries (Bourgois 1998; Grund 1993; Williams 1992). Rituals involving shared substance use and public substance use strengthen the bonds between members of a drug culture and sustain the drug culture. Some social rituals are so important to members of the drug culture that they participate in them even when they have no drugs, such as when marijuana smokers smoke an inert substance (e.g., horse manure, banana peels) together when they have no marijuana (White 1996). Drug use can also be incorporated into other ritualized behaviors, such as sexual activity (Carnes et al. 2004).

Individuals develop their own drug-related rituals through the influence of other members of the culture and also through trial and error. This allows them to determine what works best for them to maximize the drug’s effect and minimize related problems. For example, Grund (1993) found, through observing the rituals surrounding the injection of cocaine and heroin among people in the , that specific rituals governed the timing and administration of the drugs so that heroin lessened the unpleasant side effects of the cocaine. Other recent examples are the combination of energy drinks with alcohol to delay the normal onset of sleepiness (Howland and Rohsenow 2013; Substance Abuse and Mental Health Services Administration [SAMHSA] 2013c) and the combination of with alcohol to intensify euphoric effects (for review of central nervous system use and emergency room information, see SAMHSA 2013b).

Exhibit 6-6: Questions Regarding Knowledge and Skill Demands of Heroin Use

• If first use is by snorting, how is it done (assuming the person has never taken a drug intranasal- ly)? Is there a special technique for using heroin this way? • If first use is by injection, is it best to inject the drug under the skin (skin-popping) or into a vein? • What equipment is required? If one doesn’t have a hypodermic syringe, what other equipment can be substituted to make up a set of “works” or an “outfit”? • How is heroin prepared (cooked) for injection? • What techniques or procedures are used to inject the drug? • What does one do if the needle clogs? • Is there any way to test the purity of the drug? • How much of the drug constitutes a desirable dose? • If more than one person is using and an outfit is being shared, who uses it first? • If sharing, how can the works be cleaned to prevent the transmission of disease? • How does one know if he or she has injected too much? • Are there any unpleasant side effects one should anticipate? • How long will the effects of the drug last? • Is there any way to maximize the drug’s effects? • Is there anything one should not do while high on the drug? • How much time must pass before the drug can be used again? • If a bruise or an abscess develops at the injection site, how can it be hidden and treated (without seeing a physician)?

Source: White 1996.

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who uses drugs, they can gain approval from acceptance is a major reason many young peers who use drugs and a feeling that they are people begin to use drugs, as social acceptance successful at something. can be found with less effort within the drug culture. In some communities, participation in the drug trade—an aspect of a drug culture—is In addition to helping initiate drug use, drug simply one of the few economic opportunities cultures serve as sustaining forces. They sup- available and is a means of gaining the admi- port continued use and reinforce denial that a ration and respect of peers (Bourgois 2003; problem with alcohol or drugs exists. The Simon and Burns 1997). However, drug deal- importance of the drug culture to the person ing as a source of status is not limited to eco- using drugs often increases with time as the nomically deprived communities. In studying person’s association with it deepens (Moshier drug dealing among relatively affluent college et al. 2012). White (1996) notes that as a students at a private college, Mohamed and person progresses from experimentation to Fritsvold (2006) found that the most im- abuse and/or dependence, he or she develops a portant motives for dealing were ego gratifica- more intense need to “seek for supports to tion, status, and the desire to assume an outlaw sustain the drug relationship” (p. 9). In addi- image. tion to gaining social sanction for their sub- stance use, participants in the drug culture Marginalized adolescents and young adults learn many skills that can help them avoid the find drug cultures particularly appealing. pitfalls of the substance-abusing lifestyle and Many individual, family, and social risk factors thus continue their use. They learn how to associated with adolescent substance abuse are avoid arrest, how to get money to support also risk factors for youth involvement with a their habit, and how to find a new supplier drug culture. Individual factors—such as when necessary. feelings of alienation from society and a strong rejection of authority—can cause youth to The more an individual’s needs are met within look outside the traditional cultural institu- a drug culture, the harder it will be to leave tions available to them (family, church, school, that culture behind. White (1996) gives an etc.) and instead seek acceptance in a subcul- example of a person who was initially attracted ture, such as a drug culture (Hebdige 1991; in youth to a drug culture because of a desire Moshier et al. 2012). Individual traits like for social acceptance and then grew up within sensation-seeking and poor impulse control, that culture. Through involvement in the drug which can interfere with functioning in main- culture, he was able to gain a measure of self- stream society, are often tolerated or can be esteem, change his family dynamic, explore his freely expressed in a drug culture. Family sexuality, develop lasting friendships, and find involvement with drugs is a significant risk a career path (albeit a criminal one). For this factor due to additional exposure to the drug individual, who had so much of his life invest- lifestyle, as well as early learning of the values ed in the drug culture, it was as difficult to and behaviors (e.g., lying to cover for parents’ conceive of leaving that culture as it was to illicit activities) associated with it (Haight et conceive of stopping his substance use. al. 2005). Social risk factors (e.g., rejection by peers, poverty, failure in school) can also in- Online Drug Cultures crease young people’s alienation from tradi- One major change that has occurred in drug tional cultural institutions. The need for social cultures in recent years is the development of

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How To Lead an Exercise Examining Benefits, Losses, and the Future Counselors and clinical supervisors can help clients identify reinforcing aspects (besides physiologi- cal effects) of their drug and alcohol use and the losses associated with use, including unmet goals and dreams. The physiological, social, and emotional gains and losses that have transpired during their use (whether or not they associate these losses with their use) can serve as risks for relapse. This exercise works well as an interactive psychoeducational lecture for clients, as a training tool for counselors, and as a group counseling exercise. It can also be adapted for individual sessions.

Materials needed: Group room with sufficient space to move around.

Instructions: • Select an amenable client aware of the losses and consequences associated with his/her use. Later in the exercise, select other clients to give other group members a more direct experience. • Divide the group in two. For large groups, select only 6 to 8 people for each side. Have each subgroup stand on opposite sides of the room facing each other. One group will represent the benefits of use; the other, losses associated with use (see diagram for room set-up). • Rather than using the client’s personal benefits and losses (at least initially), ask group members to brainstorm about their experiences that represent each side. Begin with the side of the room that represents “benefits of use” and ask everyone in the room to name some benefits. Then, assign a specific benefit to each person in the “benefits of use” group and create a one-line message for each (a first-person statement describing the benefit), asking the representative cli- ent to remember the line. For example, if the group named a benefit of use as immediate ac- ceptance from others who use, assign this benefit to one person and create a message to capture it: “I make you feel like you belong,” or “We are family now.” Continue brainstorming until you have assigned six or more benefits. • Next, go to the opposite group that represents the losses associated with use and begin to solicit losses from everyone in the room. Assign a loss to each person in the “loss” group, create a one-line message that coincides with each loss, and then ask an individual to remember each loss message (e.g., “I am the loss of your children,” “I am the loss of your self-respect,” “I am the loss of your health”). In addition, ask the group to name future goals and plans that were curtailed because of use. Assign these losses as well, following the same format (e.g., “I am the loss of a college degree,” “I am the loss of intimate relationships,” “I am the loss of belief in the future”). Note: If you run out of people, you can assign two roles to one person. • At this point, the exercise can already be a powerful experience for many clients. Now, have the person who was originally selected as the client stand facing the “benefits of use” group. Have the client process what it is like to see the benefits of use. You can also have each person in the “benefits of use” group state his or her one-line message to help facilitate this process. Stand with the client as he or she moves to the “loss” group. Again, have the client stand and face this group while asking him or her what it is like to see the losses, including the losses related to goals and the future. Note: It is not important as an exercise to have benefits or losses specific only to this client. It is far better to gain a sample from the entire group so that everyone is in- volved and to maximize the exercise’s effectiveness as a psychoeducational tool. • After the client has stood in front of both groups, ask him or her to move back and forth be- tween each group several times to see what emotional changes occur in experiencing each group. It is important to process this experience as a group. You can invite other members to switch out of their roles and stand in as clients to experience this exercise more directly. Clients are likely to see how seductive the “benefits of use” group can be and how this attraction can lead back to relapse. This exercise may also help clients connect with the losses associated with their use. At times, clients may gain awareness that the very losses associated with their use can also serve as a trigger for use as a means of self-medicating feelings.

(Continued on the next page.)

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How To Lead an Exercise Examining Benefits, Losses, and the Future (continued)

• Allot sufficient time for this psychoeducational lecture—not only to demonstrate the benefits and losses associated with use, but also to enable the group to process their thoughts and feelings.

Group Room Setup

Internet communities organized around drug of whom were from the United States. Re- use (Gatson 2007a; Murguia et al. 2007) and spondents were likely to be young (90 percent drug use facilitation, including information on were under 30), male (76 percent), White (92 use, production, and sales (Bowker 2011; U.S. percent), relatively affluent (58 percent had Department of Justice 2002). Such communi- incomes of $45,000 or more), ties develop around Web sites or discussion employed (41 percent were employed full boards where individuals can describe their time; another 28 percent, part time), and/or in drug-related experiences, find information on school (57 percent were attending school full acquiring and using drugs, and discuss related or part time). According to the 2011 National issues ranging from musical interests to legal Survey on Drug Use and Health, approxi- problems. Many of the Web sites where these mately 0.3 percent of individuals 12 years of online communities develop are originally age or older purchase prescription drugs created to lessen the negative consequences of through the Internet (SAMHSA, 2012b). substance use by informing people about vari- ous related legal and medical issues (Gatson The Role of Drug Cultures 2007b; Murguia et al. 2007). As in other drug in Substance Abuse cultures, users of these Web sites and discus- sion boards develop their own language and Treatment values relating to drug use. Club drugs and hallucinogenics are the most often-discussed Most people seek some kind of social affilia- types of drugs, but online communities involve tion; it is one aspect of life that gives meaning the discussion of all types of licit and illicit to day-to-day existence. Behavioral health substances, including and opioids service providers can better understand and (Gatson 2007a; Murguia et al. 2007; Tackett- help their clients if they have an understand- Gibson 2007). ing of the culture(s) with which they identify. This understanding can be even more im- Murguia et al. (2007) reported on a survey of portant when addressing the role of drug adult (ages 18 and older) participants in one culture in a client’s life because, of all cultural online community. The self-selected survey affiliations, it is likely to be the one most sample included 1,038 respondents, 80 percent intimately connected with his or her substance

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abuse. The drug culture is likely to have had a clients about their relationships, daily activities considerable influence on the client’s behav- and habits relating to substance use, values, iors related to substance use. and views of other people and the world can allow providers to develop a good sense of the Drug Cultures in Assessment and meanings drug cultures hold for clients. Engagement To engage a client in treatment, understanding The first step in understanding the role a drug his or her relationship with a drug culture may culture plays in a client’s life is to assess which be as important as understanding elements of drug culture(s) the client has been involved that client’s racial or ethnic identity. Clients with and his or her level of involvement. There are unlikely to self-identify as members of the are no textbooks that can inform providers drug culture in the same way that they would about the drug cultures in their areas, but identify as an African American or Asian counselors probably know quite a bit about American, for example, but they can still be them already, as they learn much about drug offended or distrustful if they think the provid- cultures through talking with their clients. er or program does not understand how their Counselors who are themselves in recovery lifestyle relates to their substance use. Affilia- may be familiar with some clients’ substance- tion with a drug culture is a source of client using lifestyles and social environments or will identity; the client’s place in the drug culture have insight into how to explore the issue with can be important to his or her self-esteem. clients. They can also educate their colleagues. After the assessment and engagement stage, Providers who have never personally abused the provider’s attitude toward the client’s substances can learn from recovered counse- participation in a drug culture will be signifi- lors as well as from their clients. However, cantly different from his or her attitude to- asking a client point-blank about his or her ward the client’s other cultural affiliations. As involvement in a drug culture is likely to be most providers already know (even if they do answered with a blank stare. Instead, talking to not use the term drug culture), if a client

How To Learn About Clients’ Daily Routines and Rituals One way to gain an understanding of a client’s involvement in a specific drug culture is to learn about his or her daily routines and rituals. Keep in mind that there can be different routines on weekends or specific days of the week; ask about exceptions to the typical daily schedule.

Materials needed: Weekly calendar.

Instructions: • To elicit information about the client’s daily activities, use a cue or anchor to initiate this explora- tion, such as a calendar highlighting each day of a week—Monday through Sunday. • Placing the calendar in front of the client, ask him or her to describe a typical day, beginning with the time that he or she generally wakes up and building on the morning routines (e.g., “What does an average morning look like for you?”). • Encourage the client to provide a specific account of his or her routine rather than a general response. Important information can be obtained by asking the client about feelings or reactions to daily activities as they unfold in the session. • After completing an example of an entire day, ask the client if there are exceptions to this schedule that routinely occur on another day of the week or during the weekend. Once these are processed, it can be beneficial to ask what it was like for him or her to talk about these daily routines.

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(e.g., style of dress, music, language, or com- “The culture of recovery is an informal in which group norms (pre- munication patterns). This can occur through scribed patterns of perceiving, thinking, two basic processes: replacing the element feeling, and behaving) reinforce sobriety with something new that is positively associat- and long-term recovery from addiction.” ed with a culture of recovery (e.g., replacing a (White 1996, p. 222) marijuana leaf keychain with an NA key- chain), and reframing something so that it is no longer associated with drug use or the drug continues to be closely affiliated with the culture (e.g., listening to music that was asso- drug-using life, then he or she is more likely to ciated with the drug culture at a sober dance relapse. The people, places, things, thoughts, with others in recovery; White 1996). The and attitudes related to drug and/or alcohol process will depend on the nature of the cul- use act as triggers to resume use of substances. tural element. Behavioral health service providers need to help their clients weaken and eventually elim- Developing a Culture of Recovery inate their connections to the drug culture. Just as people who are actively using or abus- White (1996) identifies an important issue to ing substances bond over that common experi- address during transition from engagement to ence to create a drug culture that supports treatment—in the process of engaging clients, their continued substance use, people in recov- providers help them identify how their con- ery can participate in activities with others nections to the drug culture prevent them who are having similar experiences to build a from reaching their goals and how the loss of culture of recovery. There is no single drug these connections would affect them if they culture; likewise, there is no single culture of chose to cut ties with the drug culture. recovery. However, large international mutual- Finding Alternatives to Drug help organizations like Alcoholics Anonymous Cultures (AA) do represent the culture of recovery for many individuals (Exhibit 6-7). Even within A client can meet the psychosocial needs previ- such organizations, though, there is some ously satisfied by the drug culture in a number cultural diversity; regional differences exist, for of ways. Strengthening cultural identity can be example, in meeting-related rituals or attitudes a positive action for the client; in some cases, toward certain issues (e.g., use of prescribed the client’s family or cultural peers can serve as psychotropic medication, approaches to a replacement for involvement in the drug spirituality). culture. This option is particularly helpful when the client’s connection to a drug culture is The planned TIP, Relapse Prevention and relatively weak and his or her traditional culture Recovery Promotion in Behavioral Health is relatively strong. However, when this option Services (SAMHSA planned e), provides more is unavailable or insufficient, clinicians must information on using mutual-help groups in focus on replacing the client’s ties with the drug Recovery from mental and substance use culture (or the culture of addiction) with new disorders is a process of change through ties to a culture of recovery. which people improve their health and wellness, live in a self-directed manner, and To help clients break ties with drug cultures, work toward achieving their full potential. programs need to challenge clients’ continued involvement with elements of those cultures (SAMHSA 2011b)

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treatment settings and in long-term recovery. replace the activities, beliefs, people, places, and It contains detailed information about poten- things associated with substance abuse with tial recovery supports that behavioral health new recovery-related associations—the central programs can use to foster cultures of recovery purpose of creating a culture of recovery. among clients and program graduates. Even programs that already recognize the Most treatment programs try to foster a culture need to create a culture of recovery for their of recovery for their clients. Some modalities, clients can make doing so more of a focus in with therapeutic communities being the lead treatment. White (1996) explores ways to do example, focus on this issue as a primary treat- this, including: ment strategy. Even one-on-one outpatient • Teaching clients about the existence of treatment programs typically encourage attend- drug cultures and their potential influence ance at mutual-help groups, such as AA, to in clients’ lives. meet sociocultural recovery needs. Most pro- • Teaching clients about cultures of recovery viders also recognize that clients need to and discussing how elements of the drug

Exhibit 6-7: 12-Step Group Values and the Culture of Recovery For historical reasons, cultures of recovery (like the recovery process in general) in the United States have been greatly influenced by 12-Step groups such as AA and NA (White 1998). These groups provide a clearly defined culture of recovery for a great many people. They provide members with a set of rituals, daily activities, customs, traditions, values, and beliefs.

The 12 Steps and 12 Traditions represent the core principles, values, and beliefs of such groups. Wilcox (1998) defines these values as surrender; faith; acceptance, tolerance, and patience; honesty, openness, and willingness; humility; willingness to examine character defects; taking life one day at a time; and keeping things simple. As seen by comparing these values with those common to the heroin culture described in the “The Values and Beliefs of a Heroin Culture” box earlier in this chap- ter, one of the ways in which 12-Step groups work is by instilling a set of values contrary to those found in drug cultures. However, they also provide members with a new set of values that are in some ways distinct from the values of the mainstream culture that were rejected when the individual began his or her involvement in the drug culture (Wilcox 1998).

Many of the values of AA and other 12-Step groups are embodied in rituals that take place in meet- ings and in members’ daily lives. White (1998) lists four categories: • Centering rituals help members stay focused on recovery by reading recovery literature, han- dling recovery tokens or symbols, and taking regular self-assessments or personal inventories each day. • Mirroring rituals keep members in contact with one another and help them practice sober living together. Attending meetings, telling one’s story, speaking regularly by phone, and using slo- gans (e.g., “keep it simple,” “pass it on”), among others, are mirroring activities. • Acts of personal responsibility include being honest and becoming time-conscious and punctu- al. Activities include the creation of new rituals of daily living related to sleeping, hygiene, and other areas of self-care while also being reliable and courteous. • Acts of service involve performing rituals to help others in recovery. These acts are related to the Twelfth Step, which directs members to carry the message of their spiritual awakening to others who abuse alcohol or are dependent on it, thereby encouraging them to practice the 12 Steps. Acts of service recognize that people in recovery have something of value to offer those still abusing alcohol.

These rituals aid the processes of personal transformation and integration into a new cultural group.

174 Chapter 6—Drug Cultures and the Culture of Recovery

culture can be replaced by elements of a of recovery involves connecting individuals culture of recovery. back to the larger community and to their • Establishing clear boundaries for appro- cultures of origin (Davidson et al. 2008). This priate behavior (e.g., behavior that does can require efforts to educate the community not reflect drug cultures) in the program about recovery as well (e.g., by promoting a and consistently correcting behaviors that recovery month in the community, hosting violate boundaries (e.g., wearing shirts de- recovery walks or similar events, or offering picting pot leaves; displaying gang- outreach to community groups, such as affiliated symbols, gestures, and tattoos). churches or fraternal/benevolent societies). • Working to shape a peer culture within the Programs that do not have a plan for creating program so that longer-term clients and a culture of recovery among clients risk their staff members can socialize new clients to clients returning to the drug culture or hold- a culture of recovery. ing on to elements of that culture because it • Having regular assessments of clients and meets their basic and social needs. In the worst the entire program in which staff members case scenario, clients will recreate a drug cul- and clients determine areas where work is ture among themselves within the program. In needed to minimize cultural attitudes that the best case, staff members will have a plan can undermine treatment. for creating a culture of recovery within their • Involving clients’ families (when appropri- treatment population. ate) in the treatment process so they can support clients’ recovery as well as partici- SAMHSA’s Guiding Principles of pate in their own healing process. Recovery

White (1996) suggests that programs build • Recovery emerges from hope. linkages with mutual-help groups; include • Recovery is person driven. mutual-help meetings in their programs or • Recovery occurs via many pathways. provide access to community mutual-help • Recovery is holistic. Recovery is supported by peers and allies. meetings; and include mutual-help rituals, • • Recovery is supported through relationship symbols, language, and values in treatment and social networks. processes. • Recovery is culturally based and influenced. • Recovery is supported by addressing Other activities that can improve integration trauma. into a recovery culture include SAMHSA’s • Recovery involves individual, family, and Recovery Community Services Program community strengths and responsibility. (http://www.samhsa.gov/grants/2011/ti_11_0 • Recovery is based on respect. 04.aspx), which was developed to provide and More information on the Guiding Principles of evaluate peer-based recovery support services, Recovery is available at the SAMHSA Store and Recovery Community Centers, which (http://store.samhsa.gov/shin/content//PEP12- provide space for recovering people to social- RECDEF/PEP12-RECDEF.pdf). ize, organize, and develop a recovery culture Source: SAMHSA 2012c. (White and Kurtz 2006). Developing a culture

175

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Appendix B—Instruments To Measure Identity and Acculturation

Some researchers have tested the usefulness of complex multidimensional models (Skinner acculturation and identity models with people 2001). The table that begins on the next page who abuse substances. For example, Peña and summarizes the instruments available to colleagues’ racial identity attitude scale was measure acculturation and ethnic identity. found, in a study of African American men in (See also the Center of Excellence for treatment for cocaine dependence, to help Cultural Competence for additional resources counselors better understand the roles that at http://nyculturalcompetence.org). ethnic and cultural identity play in clients’ Other scales have been developed to examine substance abuse issues (Peña et al. 2000). In specific culture-related variables, including 1980, Cuellar and colleagues published their machismo (Cuellar et al. 1995; Fragoso and acculturation rating scale for Mexican Kashubeck 2000), simpatía (Griffith et al. Americans, which conceptualized accultura- 1998), familismo (Sabogal et al. 1987), tradi- tion as progressing across a 5-point continu- tionalism– (Ramirez 1999), and um ranging from Mexican or low acculturated family traditionalism and rural preferences (level 1) to American or high acculturated (Castro and Gutierres 1997). Counselors can (level 5). The mid-level designation of bicul- use acculturation scales to help match patients tural (level 3) was set as the midpoint between to providers, to make treatment plans, and to the two extremes, although various investiga- identify the role of identity in substance abuse. tors have questioned this assumption Although these instruments can be helpful, (Oetting and Beauvais 1990; Sayegh and the counselor must not rely solely on them to Lasry 1993). Since then, scholars have devel- determine the client’s identity or level of oped new ways to conceptualize identity and acculturation. acculturation, ranging from simple scales to

253 Improving Cultural Competence

Acculturation and Ethnic Identity Measures

Instrument Description Cultural Group

African American Accul- This scale measures eight dimensions of African African Americans turation Scale-Revised American culture: (1) traditional beliefs and prac- (Klonoff and Landrine tices, (2) traditional family structure and practices, 2000) (3) traditional socialization, (4) preparation and consumption of traditional foods, (5) preference for African American things, (6) interracial atti- tudes, (7) , and (8) traditional health beliefs and practices. Black Racial Identity This scale measures beliefs or attitudes of Blacks African Americans Attitude Scale—Form B toward both Blacks and Whites using 5-point (Helms 1990) scales. It is available in short and long forms. Cross Racial Identity This scale measures six identity clusters associated African Americans Scale (Worrell et al. with four stages of racial identity development. 2001) Multidimensional Inven- The MIBI measures centrality of Black identity, African Americans tory of Black Identity , and regard for a Black identity. It is (MIBI; Sellers et al. 1997) available online at http://sitemaker.umich.edu/aaril/files/mibiscaleand scoring.pdf. Scale To Assess African This is a 10-item scale that assesses media prefer- African Americans American Acculturation ences, racial bias in relationships, race-related (Snowden and Hines attitudes, and comfort in interacting with other 1999) races. African Self- This scale measures within-group variability in the African Consciousness Scale level of acculturation/cultural identity continuum Americans/African (Baldwin and Bell 1985) (Baldwin and Bell 1985) based on degree of Immigrants Afrocentricity or Nigrescence (White and Parham 1996). It indicates a client’s level of involvement in traditional African American culture or the core African-oriented culture. Native American Accul- The Native American Acculturation scale asks 20 Native Americans turation Scale (Garrett questions to ascertain a client’s level of involve- and Pichette 2000) ment with Native American culture. Rosebud Personal This assessment evaluates components of accul- Native Americans Opinion Survey turation, including language use, values, social (Hoffmann et al. 1985) behaviors, social networks, religious affiliation and practice, home community, education, ancestry, and cultural identification. Asian American Multi- The AAMAS was developed to be easy to use with Asian Americans dimensional Accultura- a variety of Asian American ethnic groups. It tion Scale (AAMAS; Gim includes questions relating to cultural identity, Chung et al. 2004) language use, cultural knowledge, and food preferences. (Continued on the next page.)

254 Appendix B—Instruments To Measure Identity and Acculturation

Acculturation and Ethnic Identity Measures (continued)

Instrument Description Cultural Group

Cultural Adjustment The CADC helps avoid potential problems relating Asian Americans Difficulties Checklist to acculturation by asking about language use, (East Asians) (CADC; Sodowsky and social customs, family interactions, perceptions of Lai 1997) prejudice, friendship networks, and cultural ad- justment. East Asian Acculturation This instrument includes 29 items that assess Asian Americans Measure (Barry 2001) assimilation, level of separation from other Asians, (East Asians) integration, and marginalization. General Ethnicity Ques- The GEQ is an instrument designed to be used Asian Americans tionnaire (GEQ; Tsai et with minor modifications for assessing cultural (although al. 2000) orientation with different cultural groups. There designed to be are original and abridged versions. The original multicultural in includes 75 items asking about language use, orientation) social affiliations, cultural practices, and cultural identification. Suinn-Lew Asian Self- This instrument was modeled after the Accultura- Asian Americans Identity Acculturation tion Rating Scale for Mexican Americans, and Scale (Suinn et al. 1992) research indicates it has high reliability. Ethnocultural Identity This is a 19-item self-report assessment with high Asian Americans Behavioral Index (Yama- validity. and Pacific da et al. 1998) Islanders Internal-External Ethnic The instrument evaluates ethnic friendships and Chinese Identity Measure (Kwan affiliation, ethnocommunal expression, ethnic food Americans 1997) orientation, and family , in order to differentiate three Chinese American identity groups: (1) internal, (2) external, and (3) internal- external undifferentiated. Marín and Marín Accul- This scale is a 12-item instrument that assesses Chinese turation Scale (Marín et three domains: (1) language use, (2) media prefer- Americans al. 1987) ences, and (3) ethnic diversity of social relations. It is available online at http://www.columbia.edu/cu/ssw/projects/pmap/ docs/gupta_acculturation.pdf Behavioral Acculturation These two scales, used in conjunction with one Cuban Americans Scale and Value Accul- another, ask individuals about behaviors and turation Scale (Szapocz- values in order to determine acculturation. If used nik et al. 1978) singly, the behavioral scale is the superior measure for acculturation. Na Mea Hawai’i This is a 34-item scale. An adolescent version is Native Hawaiians (Hawaiian Ways), A available (Hishinuma et al. 2000). Hawaiian Acculturation Scale (Rezentes 1993) (Continued on the next page.)

255 Improving Cultural Competence

Acculturation and Ethnic Identity Measures (continued)

Instrument Description Cultural Group

Abbreviated Multi- The AMAS-ZABB is a multidimensional, bilinear, 42- Latinos dimensional Accul- item scale that evaluates identity, language compe- turation Scale tence, and cultural competence. (AMAS-ZABB; Zea et al. 2003) Acculturation Scale This 12-item acculturation scale, available in English Latinos (Marin et al. 1987) and Spanish, evaluates language use, media prefer- ences, and social activities. It is available online at http://casaa.unm.edu/inst/MARIN%20Short%20Scale. pdf Bicultural Involve- The BIQ assesses language use and involvement in Latinos ment Questionnaire both Latino and mainstream American activities. It (BIQ; Szapocznik et relates two sets of scores to derive a measure of al. 1980) bicultural involvement, with individuals who are highly involved in both cultures scoring highest on the scale. The Bidimensional This 24-item scale asks questions about language use, Latinos Acculturation Scale language proficiency, and media preferences. for Hispanics (Marin and Gamba 1996) Brief Acculturation This scale has only four items, but scores on the scale Latinos Scale for Hispanics have been correlated highly with generation, nativity, (Norris et al. 1996) length of time in the United States, language prefer- ences, and subjective perceptions of acculturation. Multidimensional This measure places adolescents in one of four cate- Latinos Measure of Cultural gories based on language, behavior/familiarity, and Identity for Latinos values/attitudes: (1) bicultural, (2) Latino-identified, (3) (Felix-Ortiz et al. American-identified, and (4) low-level bicultural. 1994) Acculturation Rating The ARSMA-I differentiates between 5 levels of accul- Mexican Scale for Mexican turation: (1) Very Mexican, (2) Mexican-Oriented Americans Americans-I Bicultural, (3) True Bicultural, (4) Anglo-Oriented (ARSMA-I; Cuellar et Bicultural, and (5) Very Anglicized. Established validity. al. 1980) Acculturation Rating This scale is like the ARSMA-I, except that it includes Mexican Scale for Mexican separate subscales to measure multidimensional Americans Americans-II (Cuellar aspects of cultural orientation toward Mexican and et al. 1995) Anglo cultures independently. Cultural Life Style This self-report instrument, available in Spanish and Mexican Inventory (Mendoza English, evaluates five dimensions of acculturation: Americans 1989) intrafamily language use, extrafamily language use, social activities and affiliations, cultural knowledge and activities, and cultural identification and pride. (Continued on the next page.)

256 Appendix B—Instruments To Measure Identity and Acculturation

Acculturation and Ethnic Identity Measures (continued)

Instrument Description Cultural Group

Cultural Life Style This self-report instrument, available in Spanish and Mexican Inventory (Mendoza English, evaluates acculturation on five dimensions: Americans 1989) intrafamily language use, extrafamily language use, social activities and affiliations, cultural knowledge and activities, and cultural identification and pride. Mexican American This 28-item scale evaluates cultural orientation and Mexican Acculturation Scale comfort with ethnic identity. Items ask about language Americans (Montgomery 1992) use, media preferences, cultural activities/traditions, and self-perceived ethnic identity. Padilla’s Padilla’s Acculturation Scale is a 155-item question- Mexican Acculturation Scale naire that assesses cultural knowledge and ethnic Americans (Padilla 1980) loyalties. Bidimensional This scale measures evaluates two major dimensions Mexican Acculturation Scale of acculturation (Hispanic and non-Hispanic) using 12 Americans and for Hispanics (Marín items measuring 3 language-related areas. It has been Central and Gamba 1996) found to have high consistency and validity. Americans Stephenson This is a 32-item instrument that evaluates immersion Multicultural Multigroup in both culture of origin and the of Acculturation Scale the society. (Stephenson 2000) Index of This instrument includes 20 questions that assess Multicultural Acculturation (Ryder interest/participation in one’s “heritage culture” and et al. 2000) “typical American culture” (available online at http://www2.psych.ubc.ca/~dpaulhus/Paulhus_measur es/VIA.American.doc). Bicultural Accultura- Developed for use with first- and second-generation Puerto Rican tion Scale (Cortés Puerto Rican adults, this scale measures involvement Americans and Rogler 1994) in American culture and Puerto Rican culture, but it has limited evidence of validity and reliability. Psychological The items on this scale pertain to the client’s sense of Puerto Ricans on Acculturation Scale psychological attachment to and belonging within the U.S. main- (Tropp et al. 1999) Anglo American and Hispanic/Latino cultures. land Acculturation Scale This 13-item scale evaluates languages proficiency and Cambodian, for Southeast Asians preferences regarding social interactions, cultural Laotian, and (Anderson et al. activities, and food. It includes two subscales for Vietnamese 1993) proficiency in languages, as well as language, social, Americans and food preferences. White Racial Identity This 50-item instrument rates items on a 5-point scale White Americans Attitude Scale (Helms to measure attitudes associated with Helms’s stages of and Carter 1990) racial identity development for Caucasians.

257

Appendix C—Tools for Assessing Cultural Competence

There are numerous assessment tools available for evaluating cultural competence in clinical, training, and organizational settings. These tools are not specific to behavioral health treatment. Though more work is needed in developing empirically supported instruments to measure cul- tural competence, there is a wealth of multicultural counseling and healthcare assessment tools that can provide guidance in identifying areas for improvement of cultural competence. This appendix examines three resource areas: counselor self-assessment tools, guidelines and assess- ment tools to implement and evaluate culturally responsive services within treatment programs and organizations, and forms addressing client satisfaction with and feedback about culturally responsive services. Though not an exhaustive review of available tools, this appendix does pro- vide samples of tools that are within the public domain. For additional resources and cultural competence assessment tools, visit the National Center for Cultural Competence (http://nccc.georgetown.edu) or refer to the University of Michigan Health System’s Program for Multicultural Health (http://www.med.umich.edu/multicultural/). Counselor Self-Assessment Tools Multicultural Counseling Self Efficacy Scale—Racial Diversity Form This 60-item self-report instrument assesses perceived ability to perform various counselor be- haviors in individual counseling with a racially diverse client population. For additional infor- mation on psychometric properties and scoring, refer to Sheu and Lent (2007). Self-Assessment Checklist for Personnel Providing Services and Supports to Children and Youth With Special Health Needs and Their Families This instrument was developed by Tawara D. Goode of the Georgetown University Center for Child and Human Development. This version is adapted with permission from Promoting Cultural Competence and Cultural Diversity in Early Intervention and Early Childhood Settings (June 1989). It is available from the Web site of the National Center for Cultural Competence (http://nccc.georgetown.edu/documents/ChecklistEIEC.pdf). Select A, B, or C for each numbered item listed: A = Things I do frequently B = Things I do occasionally C = Things I do rarely or never

259 Improving Cultural Competence

Physical Environment, Materials and Resources _____ 1. I display pictures, posters, and other materials that reflect the cultures and ethnic back- grounds of children and families served by my program or agency. _____ 2. I [e]nsure that magazines, brochures, and other printed materials in reception areas are of interest to and reflect the different cultures of children and families served by my program or agency. _____ 3. When using videos, films, or other media resources for health education, treatment, or other interventions, I ensure that they reflect the cultures of children and families served by my program or agency. _____ 4. When using food during an assessment, I [e]nsure that meals provided include foods that are unique to the cultural and ethnic backgrounds of children and families served by my program or agency. _____ 5. I [e]nsure that toys and other play accessories in reception areas and those used during assessment are representative of the various cultural and ethnic groups within the local communi- ty and the society in general. Communication Styles _____ 6. For children who speak languages or dialects other than English, I attempt to learn and use key words in their language so that I am better able to communicate with them during as- sessment, treatment, or other interventions. _____ 7. I attempt to determine any familial colloquialisms used by children and families that may have an impact on assessment, treatment, or other interventions. _____ 8. I use visual aids, gestures, and physical prompts in my interactions with children who have limited English proficiency. _____ 9. I use bilingual staff members or trained/certified interpreters for assessment, treatment, and other interventions with children who have limited English proficiency. _____ 10. I use bilingual staff members or trained/certified interpreters during assessments, treatment sessions, meetings, and for other events for families who would require this level of assistance. 11. When interacting with parents who have limited English proficiency I always keep in mind that: _____ Limitation in English proficiency is in no way a reflection of their level of intellec- tual functioning. _____ Their limited ability to speak the language of the dominant culture has no bearing on their ability to communicate effectively in their language of origin. _____ They may or may not be literate in their language of origin or English. _____ 12. When possible, I ensure that all notices and communiqués to parents are written in their language of origin.

260 Appendix C—Tools for Assessing Cultural Competence

_____ 13. I understand that it may be necessary to use alternatives to written communications for some families, as word of mouth may be a preferred method of receiving information. Values and Attitudes _____ 14. I avoid imposing values that may conflict or be inconsistent with those of cultures or ethnic groups other than my own. _____ 15. In group therapy or treatment situations, I discourage children from using racial and ethnic slurs by helping them understand that certain words can hurt others. _____ 16. I screen books, movies, and other media resources for negative cultural, ethnic, or racial stereotypes before sharing them with the children and their parents served by my program or agency. _____ 17. I intervene in an appropriate manner when I observe other staff members or parents within my program or agency engaging in behaviors that show cultural insensitivity, bias, or prejudice. _____ 18. I understand and accept that family is defined differently by different cultures (e.g., extended family members, fictive kin, godparents). _____ 19. I recognize and accept that individuals from culturally diverse backgrounds may desire varying degrees of acculturation into the dominant culture. _____ 20. I accept and respect that male–female roles in families may vary significantly among different cultures (e.g., who makes major decisions for the family, play, and social interactions expected of male and female children). _____ 21. I understand that age and lifecycle factors must be considered in interactions with individuals and families (e.g., high value placed on the decisions of elders or the role of the eldest male in families). _____ 22. Even though my professional or moral viewpoints may differ, I accept the fami- ly/parents as the ultimate decisionmakers for services and supports for their children. _____ 23. I recognize that the meaning or value of medical treatment and health education may vary greatly among cultures. _____ 24. I recognize and understand that beliefs and concepts of emotional well-being vary significantly from culture to culture. _____ 25. I understand that beliefs about mental illness and emotional disability are culturally based. I accept that responses to these conditions and related treatment/interventions are heavily influenced by culture. _____ 26. I accept that religion and other beliefs may influence how families respond to illnesses, disease, disability, and death.

261 Improving Cultural Competence

_____ 27. I recognize and accept that folk and religious beliefs may influence a family’s reaction and approach to a child born with a disability or later diagnosed with a physical/emotional disa- bility or special health care needs. _____ 28. I understand that traditional approaches to disciplining children are influenced by culture. _____ 29. I understand that families from different cultures will have different expectations of their children for acquiring toileting, dressing, feeding, and other self-help skills. _____ 30. I accept and respect that customs and beliefs about food, its value, preparation, and use are different from culture to culture. _____ 31. Before visiting or providing services in the home setting, I seek information on ac- ceptable behaviors, courtesies, customs, and expectations that are unique to families of specific cultures and ethnic groups served by my program or agency. _____ 32. I seek information from family members or other key community informants that will assist in service adaptation to respond to the needs and preferences of culturally and ethnically diverse children and families served by my program or agency. _____ 33. I advocate for the review of my program’s or agency’s mission statement, goals, policies, and procedures to ensure that they incorporate principles and practices that promote cultural diversity and cultural competence. There is no answer key with correct responses. However, if you frequently responded “C,” you may not necessarily demonstrate values and engage in practices that promote a culturally diverse and culturally competent service delivery system for children with disabilities or special health care needs and their families. Ethnic-Sensitive Inventory (ESI; Ho 1991, reproduced with permission) Here are some statements made by some practitioners with ethnic minority clients. How often do you feel this way when you work with ethnic minority clients? Every statement should be answered by circling one number ranging from 5 (always) to 4 (frequently), 3 (occasionally), 2 (seldom), and 1 (never). In working with ethnic minority clients, I . . . A. Realize that my own ethnic and class background may influence my effectiveness. B. Make an effort to ensure privacy and/or anonymity. C. Am aware of the systematic sources (racism, poverty, and prejudice) of their problems. D. Am against speedy contracting unless initiated by them. E. Assist them to understand whether the problem is of an individual or a collective nature. F. Am able to engage them in identifying major progress that has taken place. G. Consider it an obligation to familiarize myself with their culture, history, and other ethnically related responses to problems.

262 Appendix C—Tools for Assessing Cultural Competence

H. Am able to understand and “tune in” the meaning of their ethnic dispositions, behaviors, and experiences. I. Can identify the links between systematic problems and individual concerns. J. Am against highly focused efforts to suggest behavioral change or introspection. K. Am aware that some techniques are too threatening to them. L. Am able at the termination phase to help them consider alternative sources of support. M. Am sensitive to their fear of racist or prejudiced orientations. N. Am able to move slowly in the effort to actively “reach for feelings.” O. Consider the implications of what is being suggested in relation to each client’s ethnic reality (unique dispositions, behaviors, and experiences). P. Clearly delineate agency functions and respectfully inform clients of my professional expecta- tions of them. Q. Am aware that lack of progress may be related to ethnicity. R. Am able to understand that the worker–client relationship may last a long time. S. Am able to explain clearly the nature of the interview. T. Am respectful of their definition of the problem to be solved. U. Am able to specify the problem in practical, concrete terms. V. Am sensitive to treatment goals consonant to their culture. W. Am able to mobilize social and extended family networks. X. Am sensitive to the client’s premature termination of service. Scoring: The 24 items include four items for each of six treatment phases of client–counselor interaction. The sum of the numbers circled for each item relating to a treatment phase is the score for that phase. The scoring grid is given below.

Scoring Grid for ESI

Process Phase Items Precontact A ______G ______M ______S ______Problem Identification B ______H ______N ______T ______Problem Specification C ______I ______O ______U ______Mutual Goal Formulation D ______J ______P ______V ______Problem Solving E ______K ______Q ______W ______Termination F ______L ______R ______X ______

Source: Ho 1991. Reproduced with permission.

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Evaluating Cultural Competence in Treatment Programs and Organizations Agency Cultural Competence Checklist—Revised Form (Dana 1998, reproduced with permission) Staff and policy attitudes ______Bilingual/bicultural ______Bilingual ______Bicultural ______Culture broker ______Flexible hours/appointments/home visits ______Treatment immediate/day/week ______Indigenous intake ______Match client–staff ______Agency environment reflects culture Total possible = 9 Total obtained = ______Services ______Culture-relevant assessment ______Cultural context for problems ______Cultural-specific intervention model ______Culture-specific services: ___ Prevention ___ Crisis ___ Brief ___ Individual ___ Couple ___ Family ___ Child ___ Outreach ___ Community ___ Education ___ Non-mental health ___ Resource linkage ___ Natural helpers/systems Total possible = 4 Total obtained = ______Total possible services = 13 Total obtained = ______Relationship to community ______Agency operated by minority community ______Agency in minority community ______Easy access ______Uses existing minority community facilities ______Agency ties to minority community ______Community advocate for services ______Community as adviser ______Community as evaluator Total possible = 8 Total obtained = ______

264 Appendix C—Tools for Assessing Cultural Competence

Training ______In-service training for minority staff ______In-service training for nonminority staff Total possible = 2 Total obtained = ______Evaluation ______Evaluation plan/tool ______Clients as evaluators/planners Total possible = 2 Total obtained = ______Enhanced National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care The standards presented in this section were developed by the Office of Minority Health (OMH 2013) in the Centers for Disease Control and Prevention (CDC) and are available online (https://www.thinkculturalhealth.hhs.gov/pdfs/EnhancedNationalCLASStandards.pdf). This section is reproduced from material in the public domain. Note that the Centers for Medicare and Medicaid Services (CMS) have also developed tools to assess linguistic competence and interpreter services as well as guidelines for planning culturally responsive services (see the CMS Web site at http://www.cms.gov). The National Standards for Culturally and Linguistically Appropriate Services (CLAS) are meant to advance health equity, improve quality, and help elimi- nate health disparities by establishing a blueprint for health and health care organizations to: Principal standard 1. Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs. Governance, leadership, and workforce 2. Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources. 3. Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area. 4. Educate and train governance, leadership, and workforce in culturally and linguistically ap- propriate policies and practices on an ongoing basis. Communication and language assistance 5. Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services. 6. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing. 7. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided.

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8. Provide easy-to-understand and multimedia materials and signage in the languages commonly used by the populations in the service area. Engagement, continuous improvement, and accountability 9. Establish culturally and linguistically appropriate goals, policies, and management accounta- bility, and infuse them throughout the organization’s planning and operations. 10. Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into measurement and continuous quality improvement activities. 11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery. 12. Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of popula- tions in the service area. 13. Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness. 14. Create conflict and grievance resolution processes that are culturally and linguistically appro- priate to identify, prevent, and resolve conflicts or complaints. 15. Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public. The Organizational Cultural Competence Assessment Profile The Health Resources and Services Administration (HRSA) developed the Organizational Cultural Competence Assessment Profile from the cultural competence literature, guided by a team of experts. The profile was used during site visits to a variety of healthcare settings. It is an organizing framework and set of specific indicators to assist in examining, demonstrating, and documenting cultural responsiveness in organizations involved in the direct delivery of health care and services. The profile is not intended to be prescriptive; rather, it is designed to be adapted, modified, or applied in ways that best fit within an organization’s context. The profile is presented as a matrix that classifies indicators by critical domains of organizational functioning and by whether the indicators relate to the structures, processes, outputs, or outcomes of the organization. The indicators suggest that assessment of cultural competence should encompass both qualitative and quantitative data and evaluate progress toward achieving results, not just the end results. Alt- hough the profile can be used in whole or in part, the full application enables an organization to assess its level of cultural competence comprehensively. Adapted here from material in the public domain are the matrices for process and capacity/structure measures. For more information, see http://www.hrsa.gov/culturalcompetence/ healthdlvr.pdf. Sample of Process Measures by Domain

Domain Topic Areas Measures/Indicators Communication Interpreter Yearly updated directory of trained interpreters is available within 24 hours for routine situations and within 1 hour or less for urgent situations. Communication Interpreter Percentage of clients with limited English proficiency who have access to bilingual staff or interpretation services.

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266 Appendix C—Tools for Assessing Cultural Competence

Sample of Process Measures by Domain (continued)

Domain Topic Areas Measures/Indicators Communication Linguistically Number of trained translators and interpreters available competent Number of staff proficient in languages of the community organization Communication Language Consumer reading and writing levels of primary languages and ability, dialects is recorded. written and oral, of the consumer Policies and Choice of Contract continuation and renewal with health plan is contingent procedures health plan upon successful achievement of performance targets that demon- network strate effective service, equitable access, and comparability of benefits for populations of racial/ethnic groups. Policies and Staff hiring, Number of multilingual/multicultural staff procedures recruitment Ratio by culture of staff to clients Family and Community Degree to which families participate in key decisionmaking activities: community and • Family participation on advisory committees or task forces participation consumer • Hiring of family members to serve as consultants to provid- participation ers/programs • Inclusion of family members in planning, implementation, and evaluation of activities Communication Translated Allocated resources for interpretation and translation services for materials medical encounters and health education/promotion material. Communication Linguistic Ability to conduct audit of the provider network, which includes the capacity of following components: the provider • Languages and dialects of community available at point of first contact. • Number of trained translators and interpreters available. • Number of clinicians and staff proficient in languages of the community. Communication Provide • Organization has the capacity to disseminate information on information, health care plan benefits in languages of community. education • Organization has the capacity to disseminate information and explanation of rights to enrollees.

Policies and Grievance Organization has structures in place to address cross-cultural ethi- procedures and conflict cal and legal conflicts in health care delivery and complaints or resolution grievances by patients and staff about unfair, culturally insensitive, or discriminatory treatment, or difficulty in accessing services or denial of services.

Policies and Grievance Organization has feedback mechanisms in place to track number of procedures and conflict grievances and complaints and number of incidents. resolution

Policies and Planning Composition of the governing board, advisory committee, other procedures and govern- policymaking and influencing groups, and consumers served re- ance flects service area demographics.

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Sample of Capacity/Structure Measures by Domain

Domain Topic Areas Measures/Indicators Facility charac- Available and • Transportation is available from residential areas to culturally teristics, capaci- accessible competent providers. ty, and services • Organization has the flexibility to conduct home visits and infrastructure community outreach. • Culturally responsive services are available evenings and weekends.

Facility charac- Information Capacity for tracking of access and utilization rates for popula- teristics, capaci- systems tion of different racial/ethnic groups in comparison to the ty, and overall service population. infrastructure Monitoring, Organizational Ability to conduct ongoing organizational self-assessments of evaluation, and assessment cultural and linguistic competence and integration of measures research of access, satisfaction, quality, and outcomes into other organi- zational internal audits and performance improvement pro- grams.

Multiculturally Competent Service System Assessment Guide Reproduced with permission from The Connecticut Department of Children and Families, Office of Multicultural Affairs (2002). Instructions: Rate your organization on each item in Sections I through VIII using the following scale: 1 2 3 4 5 Not at all To a moderate degree To a great degree Suggested Rating Interpretations: #1 and #2: “Priority Concerns”; #3: “Needs Improvement”; #4 and #5: “Adequate” When you have rated all items and assessed each section, please follow the instructions in Sec- tion IX to make an assessment of your program or agency and then formulate a culturally compe- tent plan that addresses the need you feel is a priority. I. Agency demographic data (assessment) A culturally competent agency uses basic demographic information to assess and determine the cultural and linguistic needs of the service area. ____ Have you identified the demographic composition of the program’s service area (from recent census data, local planning documents, statement of need, etc.) which should in- clude ethnicity, race, and primary language spoken as reported by the individuals? ____ Have you identified the demographic composition of the persons served?

268 Appendix C—Tools for Assessing Cultural Competence

____ Have you identified the staff composition (ethnicity, race, language capabilities) in rela- tion to the demographic composition of your service area? ____ Have you compared the demographic composition of the staff with the client de- mographics? II. Policies, procedures and governance A culturally competent agency has a board of directors, advisory committee, or policy-making group that is proportionally representative of the staff, client/consumers, and community. ____ Has your organization appointed executives, managers, and administrators who take responsibility for, and have authority over, the development, implementation, and moni- toring of the cultural competence plan? ____ Has your organization’s director appointed a standing committee to advise management on matters pertaining to multicultural services? ____ Does your organization have a mission statement that commits to cultural competence and reflects compliance with all federal and state statutes, as well as any current Connecticut Commission on Human Rights and Opportunities nondiscriminatory policies and affirma- tive action policies? ____ Does your organization have culturally appropriate policies and procedures communicat- ed orally and/or written in the principal language of the client/consumer to address con- fidentiality, individual patient rights and grievance procedures, medication fact sheets, legal assistance, etc. as needed and appropriately? III. Services/programs A culturally competent agency offers services that are culturally competent and in a language that ensures client/consumer comprehension. A. Linguistic and communication support ____ Has the program arranged to provide materials and services in the language(s) of limited English-speaking clients/consumer (e.g., bilingual staff, in-house interpreters, or a con- tract with outside interpreter agency and/or telephone interpreters)? ____ Do medical records indicate the preferred languages of service recipients? ____ Is there a protocol to handle client/consumer/family complaints in languages other than English? ____ Are the forms that client/consumers sign written in their preferred language? ____ Are the persons answering the telephones, during and after-hours, able to communicate in the languages of the speakers? ____ Does the organization provide information about programs, policies, covered services, and procedures for accessing and utilizing services in the primary language(s) of cli- ent/consumers and families? ____ Does the organization have signs regarding language assistance posted at key locations?

269 Improving Cultural Competence

____ Are there special protocols for addressing language issues at the emergency room, treat- ment rooms, intake, etc.? ____ Are cultural and linguistic supports available for clients/consumers throughout different service offerings along the service continuum? B. Treatment/rehabilitation planning ____ Does the program consider the client/consumer’s culture, ethnicity and language in treat- ment planning (assessment of needs, diagnosis, interventions, discharge planning, etc.)? ____ Does the program involve client/consumers and family members in all phases of treat- ment, assessment, and discharge planning? ____ Has the organization identified community resources (community councils, ethnic cultur- al social entities, spiritual leaders, faith communities, voluntary associations, etc.) that can exchange information and services with staff, client/consumers, and family members? ____ Have you identified natural community healers, spiritual healers, clergy, etc., when appro- priate, in the development and/or implementation of the service plan? ____ Have you identified natural supports (relatives, traditional healers, spiritual resources, etc.) for purposes of reintegrating the individual into the community? ____ Have you used community resources and natural supports to reintegrate the individual into the community? C. Cultural assessments ____ Is the client/consumer’s culture/ethnicity taken into account when formulating a diagno- sis or assessment? ____ Are culturally relevant assessment tools utilized to augment the assessment/diagnosis process? ___ Is the client/consumer’s level of acculturation identified, described, and incorporated as part of cultural assessment? ____ Is the client/consumer’s ethnicity/culture identified, described, and incorporated as part of cultural assessment? D. Cultural accommodations ____ Are culturally appropriate, educative approaches, such as films, slide presentations, or video tapes, utilized for preparation and orientation of client/consumer family members to your program? ____ Does your program incorporate aspects of each client/consumer’s ethnic/cultural heritage into the design of specialized interventions or services? ____ Does your program have ethnic/culture-specific group formats available for engagement, treatment, and/or rehabilitation? ____ Is there provider collaboration with natural community healers, spiritual healers, clergy, etc., where appropriate, in the development and/or implementation of the service plan?

270 Appendix C—Tools for Assessing Cultural Competence

E. Program accessibility ____ Do persons from different cultural and linguistic backgrounds have timely and convenient access to your services? ____ Are services located close to the neighborhoods where persons from different cultures and linguistic backgrounds reside? ____ Are your services readily accessible by public transportation? ____ Do your programs provide needed supports to families of clients/consumers (e.g., meeting rooms for extended families, child support, drop-in services)? ____ Do you have services available during evenings and weekends? IV. Care management ____ Does the level and length of care meet the needs for clients/consumers from different cultural backgrounds? ___ Is the type of care for clients/consumers from different backgrounds consistently and effectively managed according to their identified cultural needs? ____ Is the management of the services for people from different groups compatible with their ethnic/cultural background? V. Continuity of care ____ Do you have letters of agreement with culturally oriented community services and organ- izations? ____ Do you have integrated, planned, transitional arrangements between one service modality and another? ____ Do you have arrangements, financial or otherwise, for securing concrete services needed by clients/consumers (e.g., housing, income, employment, medical, dental, other emergen- cy personal support needs)? VI. Human resources development A culturally competent agency implements staff training and development in cultural compe- tence at all levels and across all disciplines, for leadership and governing entities as well as for management, supervisory, treatment, and support staff. ____ Are the principles of cultural competence (e.g., cultural awareness, language training, skills training in working with diverse populations) included in staff orientation and on- going training programs? ____ Is the program making use of other programs or organizations that specialize in serving persons with diverse cultural and linguistic backgrounds as a resource for staff education and training? ____ Is the program maximizing recruitment and retention efforts for staff who reflect the cultural and linguistic diversity of populations needing services? ____ Has the staff ’s training needs in cultural competence been assessed?

271 Improving Cultural Competence

____ Has the staff attended training programs on cultural competence in the past two years? Describe:______VII. Quality monitoring and improvement A culturally competent agency has a quality monitoring and improvement program that ensures access to culturally competent care. ____ Does the quality improvement (QI) plan address the cultural/ethnic and language needs? ____ Are client/consumers and families asked whether ethnicity/culture and language are appro- priately addressed in order to receive culturally competent services in the organization? ____ Does the organization maintain copies of minutes, recommendations, and accomplish- ments of its multicultural advisory committee? ____ Is there a process for continually monitoring, evaluating, and rewarding the cultural com- petence of staff? VIII. Information/management system ____ Does the organization monitor, survey, or otherwise access, the QI utilization patterns, Against Medical Advice (AMA) rates, etc., based on the culture/ethnicity and language? ____ Are client/consumer satisfaction surveys available in different languages in proportion to the demographic data? ____ Are there data collection systems developed and maintained to track clients/consumers by demographics, utilization and outcomes across levels of care, transfers, referrals, re- admissions, etc.? IX. Formulating a culturally competent plan based on the assessment of your program or agency Focus on the following critical areas of concern as you develop goals for a culturally competent plan for your agency’s service system. Access: Degree to which services to persons are quickly and readily available. Engagement: The skill and environment to promote a positive personal impact on the quality of the client’s commitment to be in treatment. Retention: The result of quality service that helps maintain a client in treatment with continued commitment. Based on an assessment of your agency, determine whether, in your initial plan, you need to direct efforts of developing cultural competency toward one, or a combination, of the above critical areas. Then, structure your agency’s cultural competence plan using the following instruc- tions: 1. Based on the results of this assessment, summarize and describe your organization’s perceived strengths in providing services to persons from different cultural groups. Please provide specific examples. Attach supporting documentation (e.g., Data, Policies, Procedures, etc.)

272 Appendix C—Tools for Assessing Cultural Competence

2. Based on your assessment, summarize and describe your organization’s primary areas consid- ered either “Priority Concerns” (#1 and/or #2), or “Needs Improvement” (#3) in provid- ing services to persons from different cultural groups. 3. Based on your organization’s strengths and needs, prioritize both the organizational goals and objectives addressed in your cultural competence plan. Describe clearly what you will do to provide services to persons who are culturally and linguistically different. 4. Using the developed goals and objectives, please describe in detail the plans, activities, and/or strategies you will implement to assist your organization in meeting each of the goals and ob- jectives indicated. Patient Satisfaction and Feedback on Clinical and Program Culturally Responsive Services

Iowa Cultural Understanding Assessment–Client Form Please indicate your level of agreement with the statements below by circling the number to the right of the statement that best fits your opinion. All responses are confidential. When you have completed the survey, please either use the pre-addressed, stamped envelope to return the survey by mail or place it in the drop box at the facility. Thank you very much for your participation! Demographic Information What is your sex? ____Male ____Female What is your race? ____Alaskan Native ____American Indian ____Asian ____Black or African American ____Native Hawaiian or other Pacific Islander ____White Are you Hispanic or Latino? ____Yes ____No

RESPONSE Strongly Neither Agree Strongly STATEMENT Disagree Disagree Nor Disagree Agree Agree 1. The staff here understands some of the ideas that I, my family, and others 1 2 3 4 5 from my cultural, racial, or ethnic group may have. 2. Staff here understands the im- portance of my cultural beliefs in my 1 2 3 4 5 treatment process. 3. The staff here listens to me and my 1 2 3 4 5 family when we talk to them. 4. If I want, the staff will help me get 1 2 3 4 5 services from clergy or spiritual leaders. 5. The services I get here really help me work toward things like getting a job, taking care of my family, going to 1 2 3 4 5 school, and being active with my friends, family, and community.

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273 Improving Cultural Competence

Iowa Cultural Understanding Assessment–Client Form (continued)

RESPONSE Strongly Neither Agree Strongly STATEMENT Disagree Disagree Nor Disagree Agree Agree 6. The staff here seems to under- stand the experiences and problems I 1 2 3 4 5 have in my past life. 7. The waiting room and/or facility has pictures or reading material that 1 2 3 4 5 show people from my racial or ethnic group. 8. The staff here knows how to use their knowledge of my culture to 1 2 3 4 5 help me address my current day-to- day needs. 9. The staff here understands that I might want to talk to a person from 1 2 3 4 5 my own racial or ethnic group about getting the help I want. 10. The staff here respects my reli- 1 2 3 4 5 gious or spiritual beliefs. 11. Staff from this program comes to my community to let people like me 1 2 3 4 5 and others know about the services they offer and how to get them. 12. The staff here asks me, my family, or others close to me to fill out forms 1 2 3 4 5 that tell them what we think of the place and services. 13. Staff here understands that people of my racial or ethnic group 1 2 3 4 5 are not all alike. 14. It was easy to get information I needed about housing, food, cloth- 1 2 3 4 5 ing, child care, and other social services from this place. 15. The staff here talks to me about the treatment they will give me to 1 2 3 4 5 help me. 16. The staff here treats me with 1 2 3 4 5 respect. 17. The staff seems to understand that I might feel more comfortable 1 2 3 4 5 working with someone who is the same sex as me.

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274 Appendix C—Tools for Assessing Cultural Competence

Iowa Cultural Understanding Assessment–Client Form (continued)

RESPONSE Strongly Neither Agree Strongly STATEMENT Disagree Disagree Nor Disagree Agree Agree 18. Most of the time, I feel I can trust 1 2 3 4 5 the staff here who work with me. 19. The waiting room has brochures or handouts that I can easily under- 1 2 3 4 5 stand that tell me about services I can get here. 20. If I want, my family or friends are included in discussions about the 1 2 3 4 5 help I need. 21. The services I get here deal with the problems that affect my day-to- 1 2 3 4 5 day life such as family, work, money, relationships, etc. 22. Some of the staff here under- stand the difference between their 1 2 3 4 5 culture and mine. 23. Some of the counselors are from 1 2 3 4 5 my racial or ethnic group. 24. Staff members are willing to be flexible and provide alternative 1 2 3 4 5 approaches or services to meet my cultural/ethnic treatment needs. 25. If I need it, there are translators or interpreters easily available to 1 2 3 4 5 assist me and/or my family.

Source: White et al. 2009. Reproduced with permission.

275

Appendix D—Screening and Assessment Instruments

Important Note: The following tables pro- listed in this appendix serve only as a starting vide an overview of selected instruments that point for investigating the appropriateness of screen and assess for substance use disorders available instruments within specific popula- and mental disorders and symptoms. These tions. Citations reflect information about the tables only represent a sample of instruments. effectiveness of the testing measurements as In reviewing the tables, do not assume that the well as research that suggests modifications or instruments have normative data across race reports testing discrepancies among racial and and ethnicities. The citations and information ethnic populations.

Screening and Assessment Instruments for Substance Use Disorders

Instrument Description Clinical Utility Alcohol, Smoking, and The ASSIST (version ASSIST was developed by the World Health Substance Involvement 3.1) has eight items Organization (WHO) as a culturally neutral tool for Screening Test (ASSIST; to screen for use of use in primary and general medical care settings. Humeniuk et al. 2010) tobacco products, This paper-pencil instrument takes 5 to 10 minutes alcohol, and drugs to complete and is designed to be administered by a health worker. ASSIST determines a risk score for each substance; the score starts a discussion with clients about their substance use. For information about the instrument and its availability in other languages, see http://www.who.int/substance_ abuse/activities/assist/en/ Alcohol Use Disorders This 10-item screen- The AUDIT was developed by WHO for use in Identification Test ing questionnaire multinational settings—the original sample includ- (AUDIT; Babor et al. 1992; was developed to ed subjects from Australia, , , Mexico, Saunders et al. 1993) identify people Norway, and the United States (Allen et al. 1997; whose alcohol Saunders et al. 1993). consumption is Populations researched: Latinos (Cherpitel 1999; hazardous or harm- Cherpitel and Bazargan 2003; Cherpitel and Borges ful to their health. 2000; Frank et al. 2008; Reinert and Allen 2007; Volk et al. 1997), northern (Asian) Indians (Pal et al. 2004); Vietnamese (Giang et al. 2005); (Lima et al. 2005), and Nigerians (Adewuya 2005).

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277 Improving Cultural Competence

Screening and Assessment Instruments for Substance Use Disorders (continued)

Instrument Description Clinical Utility Languages available in: Numerous languages, including Spanish (de Torres et al. 2009; Medina- Mora et al. 1998), French (Gache et al. 2005), Mandarin and Cantonese (Leung and Arthur 2000), Nigerian languages (Adewuya 2005), Russian, German, and Korean (Kim et al. 2008). Addiction Severity Index Currently in its 5th Populations researched: African Americans (Drake (McLellan et al. 1980). edition, this instru- et al. 1995; Leonhard et al. 2000; McLellan et al. Available online at ment assesses the 1985), and Northern Plains American Indians (Carise http://www.tresearch.org/ severity of substance and McLellan 1999). index.php/tools/download- use disorders. It has Languages available in: Numerous languages, asi-instruments-manuals/ 200 items distributed including Spanish (Sandí Esquivel and Avila Corrales over seven subscales. 1990; for multimedia version see Butler et al. 2009), French (Daeppen et al. 1996; Krenz et al. 2004), Japanese (Haraguchi et al. 2009), and Chinese (Liang et al. 2008). Alcohol Use Disorder and This structured inter- The AUDADIS has been found reliable in large Associated Disabilities view is administered general-population studies (Grant et al. 1995; Ruan Interview Schedule by nonprofessional et al. 2008). (AUDADIS; Grant and interviewers to diag- Populations researched: African Americans, Hasin 1990). Available nose substance use Latinos, Asians, and Native Americans (Canino et al. online at disorders and assess 1999; Chatterji et al. 1997; Grant et al. 1995; Ruan http://pubs.niaaa.nih.gov/ some co-occurring et al. 2008). publications/audadis.pdf mental disorders. It Languages available in: Chinese and Spanish evaluates acculturation (Canino et al. 1999; Horton et al. 2000; Leung and and racial/ethnic Arthur 2000). orientation. Currently in its 4th edition (AUDADIS-IV). CAGE (Ewing 1984; May- This is a set of four Populations researched: African Americans field et al. 1974) questions used to (Cherpitel 1997; Frank et al. 2008); Latino (Saitz et detect possible al. 1999). alcohol use disorder. Languages available in: Numerous languages, including Spanish, Creole, Chinese, and Japanese. Composite International This structured, The instrument has been well evaluated with inter- Diagnostic Interview- detailed interview national populations from a variety of different Substance Abuse Module diagnoses substance nations and found to have good reliability for most (CIDI-SAM; Cottler 2000) abuse and depend- substances of abuse (Ustün et al. 1997). ence; it is an expand- Populations researched: African Americans (Horton ed version of the et al. 2000) and Brazilians (Quintana et al. 2004; 2007). substance use section Languages available in: Numerous languages, of the CIDI. including Portuguese, Spanish, Arabic, Japanese, Vietnamese, and Malay.

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278 Appendix D—Screening and Assessment Instruments

Screening and Assessment Instruments for Substance Use Disorders (continued)

Instrument Description Clinical Utility Drug Abuse Screening This self-report No significant differences in DAST reliability Test (DAST; Skinner instrument (10- and across race or cultural background were found 1982) 20-item versions) (Yudko et al. 2007). identifies people who Languages available in: Numerous, including are abusing psycho- Spanish for the 10-item DAST (DAST-10; Bedregal active drugs and et al. 2006), Portuguese, Hebrew, Arabic, and measures degree of Thai. related problems. Rapid Alcohol Prob- The RAPS is a five- The RAPS has high sensitivity across both ethnicity lems Screen (RAPS; question test (also and gender (Cherpitel 1997; 2002). It has also Cherpitel 1995, 2000) available in a newer been found to work significantly better than the four-item version, AUDIT for screening African American and Latino the RAPS-4) that men and to be on par with the AUDIT for women combines optimal (Cherpitel and Bazargan 2003). questions from other Populations researched: Mexican Americans instruments. (Borges and Cherpitel 2001); residents of various countries (Argentina, Belarus, , Canada, China, , India, Mexico, Mozambique, Poland, , and Sweden; Cherpitel et al. 2005). Languages available in: Numerous, including Spanish, Chinese, and Portuguese. Short Michigan Alcohol The S-MAST screens Populations researched: African Americans, Arab Screening Test (S- for alcohol use Muslims, American Indians, Asian Indians, and MAST; Selzer et al. disorder. Thai (Al-Ansari and Negrete 1990; Pal et al. 2004; 1975) Nanakorn et al. 2000; Robin et al. 2004). Languages available in: Numerous, including Spanish, French, Thai, and Asian Indian languages. TWEAK (Russell 1994) TWEAK is a five-item Populations researched: Mexican Americans screening instrument (Borges and Cherpitel 2001) and African originally created to Americans (Cherpitel 1997). screen for risky Languages available in: Spanish (Cremonte and drinking during Cherpitel 2008). pregnancy (but has been validated for a range of male and female populations).

279 Improving Cultural Competence

Screening and Assessment Instruments for Mental Disorders and Symptoms

Instrument Description Clinical Utility With Specific Racial/Ethnic Groups Beck Anxiety Inven- The BAI is a 21-item Populations researched: African Americans tory (BAI; Beck and scale that distinguishes (Chapman et al. 2009). Steer 1990) anxiety from depres- Languages available in: Numerous languages, sion. including Spanish (Novy et al. 2001), Arabic, Chinese, Farsi, Korean, and Turkish. Beck Depression The BDI is a 21-item Several versions of the BDI are available with cultur- Inventory (BDI) and instrument used to al specificity. Beck Depression assess the intensity of Populations researched: African Americans (Dutton Inventory, 2nd Edi- depression. et al. 2004; Grothe et al. 2005; Joe et al. 2008), tion (BDI-II; Beck et al. Asian Americans (Carmody 2005; Crocker et al. 1996) 1994), Hmong (Mouanoutoua et al. 1991), Mexican Americans (Gatewood-Colwell et al. 1989), and Latinos (Contreras et al. 2004). Languages available in: Numerous, including Spanish (Azocar et al. 2001; Bonilla et al. 2004; Carmody 2005; Wiebe and Penley 2005), Chinese (Yeung et al. 2002; Zheng and Lin 1991), French, Arabic (Abdel-Khalek 1998; Alansari 2006), Hebrew, and Farsi (Ghassemzadeh et al. 2005). Center for Epidemio- The CES-D is a 20-item May underestimate symptoms in African Americans logical Studies- self-report scale de- (Bardwell and Dimsdale 2001; Cole et al. 2000). Depression Scale signed to measure Populations researched: Latinos (Batistoni et al. (CES-D; Radloff 1977) depressive symptoms. 2007; Garcia and Marks 1989; Posner et al 2001; Reuland et al. 2009; Roberts et al.1990), Asian Indians (Diwan et al. 2004; Gupta et al. 2006), Native Americans (Chapleski et al. 1997), and African Americans (Canady et al. 2009; Makambi et al. 2009; Nguyen et al. 2004). Languages available in: Numerous languages, including Spanish (Reuland et al. 2009), Chinese (Lin 1989), Greek, Korean, and Portuguese. Geriatric Depression Available in 30- and 15- Populations researched: Latinos (Reuland et al. Scale (Sheikh and item forms, this instru- 2009) and Asians (Broekman et al. 2008; Nyunt et Yesavage 1986) ment screens for de- al. 2009). pression in older adults. Languages available in: Available in 30 languages and validated with a number of different popula- tions (available online at http://www.stanford.edu/ ~yesavage/GDS.html). Millon Clinical Multi- Assesses 13 personality Populations researched: African Americans (Calsyn axial Inventory-III disorders (DSM-III-R et al.1991; Craig and Olson 1998) and Latinos (Millon et al. 2009) Axis II disorders) and 9 (Fernández-Montalvo et al. 2006). clinical syndromes Languages available in: Multiple languages, includ- (DSM-III-R Axis I disor- ing Spanish, Korean, Cantonese, and Portuguese. ders); includes scales to assess substance relat- ed problems.

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280 Appendix D—Screening and Assessment Instruments

Instruments To Screen and Assess Mental Disorders and Symptoms (continued)

Minnesota Multiphasic The MMPI-2 Normed for Asian Americans, African Americans, Personality Inventory, measures personali- Latinos, and American Indians (Hathaway et al.1989). 2nd Edition (MMPI-2) ty traits and symp- Populations researched: African Americans (Castro (Butcher et al. 1989) tom patterns. et al. 2008; McNulty et al. 2003; Monnot et al. 2009; Whatley et al. 2003) and Asian Americans (Tsai and Pike 2000; Tsushima and Tsushima 2009). Languages available in: Numerous, including French, Hmong, and Spanish (Velasquez et al. 2000). Mini International This is a short, Populations researched: African Americans (Black Neuropsychiatric Inter- structured, diagnos- et al. 2004). view (M.I.N.I.; Sheehan tic interview that The Major Depressive Episode and Posttraumatic et al. 1998) assesses the most Stress Disorder (PTSD) sections of the M.I.N.I. common mental have been adapted for use in screening for PTSD disorders (including in refugees, and found effective across cultures in substance use a multinational sample (Eytan et al. 2007). disorders). Languages available in: Over 43 languages, including French, Italian (Rossi et al. 2004), Japanese (Otsubo et al. 2005), Spanish, Italian, and Arabic (Amorim et al. 1998; Lecrubier et al. 1997; Sheehan et al. 1997, 1998). Schedules for Clinical The SCAN-2 is a set Populations researched: The SCAN-2 was devel- Assessment in Neuro- of instruments that oped by WHO with an international sample that psychiatry, 2nd Version measure psycho- included participants from , Greece, India, (SCAN-2; Wing et al. pathology and the United States, Nigeria, , Mexico, 1998) behavior associated Spain, and and is intended to be with major mental cross-culturally appropriate (Room et al. 1996). disorders. Languages available in: Chinese (Cheng et al. 2001), Danish, Dutch, English, French, German, Greek, Italian, , Portuguese, Spanish, Thai, Turkish, and Yoruba. Symptom Checklist-90- This 90-item check- The SCL-90R has been normed for adult inpatient R (SCL-90R; Derogatis list evaluates psy- and outpatient psychiatric patients and adult and 1992) chiatric symptoms adolescent nonpatients across a number of ethnic and their intensity in groups (Derogatis 1992). nine different cate- Populations researched: Latinos (Martinez et al. gories and screens 2005) and African Americans (Ayalon and Young for a broad range of 2009). mental disorders. Languages available in: Spanish, French, Armenian, and Persian.

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Appendix E—Cultural Formulation in Diagnosis and Cultural Concepts

of Distress

Cultural Formulation in nant idioms of distress through which symp- toms or the need for social support are com- Diagnosis municated (e.g., “nerves,” possessing spirits, somatic complaints, inexplicable misfortune), Clinicians need to consider the effects of cul- the meaning and perceived severity of the ture when diagnosing clients. The following individual’s symptoms in relation to norms of cultural formulation adopted by the American the cultural reference group, any local illness Psychiatric Association (APA) in the Diagnostic category used by the individual’s family and and Statistical Manual of Mental Disorders, Fifth community to identify a condition (see the Edition (DSM-5; 2013, pp. 749–759) provides “Cultural Concepts of Distress” section of this a systematic outline for incorporating culturally appendix), the perceived causes or explanatory relevant information when conducting a multi- models that the individual and the reference axial diagnostic assessment. Whether or not group use to explain the illness, and current they are credentialed to diagnose disorders, preferences for and past experiences with counselors and other clinical staff can use the professional and popular sources of care. main content areas listed below to guide the interview, initial intake, and treatment planning 3. Cultural factors related to psychosocial processes. (For review, see Mezzich and Caracci environment and level of functioning. Note 2008; for Native American application, specifi- culturally relevant interpretations of social cally Lakota, refer to Brave Heart 2001.) stressors, available social supports, and levels of functioning and disability, including stresses in 1. Cultural identity of the person. Note the the local social environment and the role of person’s ethnic or cultural reference groups. For religion and kin networks in providing emo- immigrants and ethnic minorities, also note tional, instrumental, and informational support. degree of involvement with culture of origin and host culture (where applicable). Also note 4. Cultural elements of the relationship language ability, use, and preference (including between client and clinician. Indicate differ- ). ences in culture and social status between client and clinician, as well as any problems 2. Cultural explanations of the person’s these differences may cause in diagnosis and illness. Identify the following: the predomi-

283 Improving Cultural Competence

treatment (e.g., difficulty communicating in diverse populations, so too are standard diag- the client’s first language, eliciting symptoms noses. Expressions of psychological problems or understanding their cultural significance, are, in part, culturally specific, and behavior negotiating an appropriate relationship or level that is aberrant in one culture can be standard of intimacy, determining whether a behavior is in another. For example, seemingly paranoid normative or pathological). thoughts are to be expected in clients who have migrated from countries with oppressive 5. Overall cultural assessment for diagnosis governments. Culture plays a large role in and care. Conclude cultural formulation by understanding phenomena that might be discussing how cultural considerations specifi- construed as mental illnesses in Western cally influence comprehensive diagnosis and medicine. These cultural concepts of distress care. may or may not be linked to particular DSM- Cultural Concepts of 5 diagnostic criteria (APA 2013). The table that follows lists DSM-5 cultural concepts of Distress distress; other concepts exist that are not recognized in DSM-5. Just as standard screening instruments can sometimes be of limited use with culturally

DSM-5 Cultural Concepts of Distress

Syndrome Description Populations Ataque de Commonly reported symptoms include uncontrollable shouting, Caribbean, nervios attacks of crying, trembling, heat in the chest rising into the head, Latin and verbal or physical aggression. experiences, sei- American, zurelike or fainting episodes, and suicidal gestures are prominent in Latin some attacks but absent in others. A general feature of an ataque Mediterranean de nervios is a sense of being out of control. Ataques de nervios frequently occur as a direct result of a stressful event relating to the family (e.g., death of a close relative, separation or divorce from a spouse, conflict with spouse or children, or witnessing an accident involving a family member). People can experience amnesia for what occurred during the ataque de nervios, but they otherwise return rapidly to their usual level of functioning. Although descrip- tions of some ataques de nervios most closely fit with the DSM-IV description of panic attacks, the association of most ataques with a precipitating event and the frequent absence of the hallmark symp- toms of acute fear or apprehension distinguish them from . Ataques range from normal expressions of distress not associated with a mental disorder to symptom presentations associ- ated with anxiety, mood dissociative, or somatoform disorders. Dhat (jiryan A folk diagnosis for severe anxiety and hypochondriacal concerns Asian Indian in India, skra associated with the discharge of semen, whitish discoloration of prameha in the urine, weakness, and exhaustion. Sri Lanka, shen-k’uei in China)

(Continued on the next page.)

284 Appendix E—Cultural Formulation in Diagnosis and Cultural Concepts of Distress

DSM-5 Cultural Concepts of Distress (continued)

Nervios Refers both to a general state of vulnerability to stress and to a Latin syndrome evoked by difficult life circumstances. Nervios includes a American wide range of symptoms of emotional distress, somatic disturb- ance, and inability to function. Common symptoms include head- aches and “brain aches,” irritability, stomach disturbances, difficulties, nervousness, tearfulness, inability to concentrate, trembling, tingling sensations, and mareos (dizziness with occa- sional vertigo-like exacerbations). Nervios tends to be an ongoing problem, although it is variable in the degree of disability mani- fested. Nervios is a broad syndrome that ranges from cases free of a mental disorder to presentations resembling adjustment, anxie- ty, depressive, dissociative, somatoform, or psychotic disorders. Differential diagnosis depends on the constellation of symptoms, the kind of social events associated with onset and progress, and the level of disability experienced. Shenjing A condition characterized by physical and mental fatigue, head- Chinese shuairuo aches, difficulty concentrating, dizziness, sleep disturbance, and memory loss. Other symptoms include gastrointestinal problems, sexual dysfunction, irritability, excitability, and autonomic nervous system disturbances. Susto An illness attributed to a frightening event that causes the soul to Latino (espanto, leave the body and results in unhappiness and sickness. Individuals American, pasmo, tripa with susto also experience significant strains in key social roles. Mexican, ida, perdida Symptoms can appear days or years after the fright is experi- Central and del alma, or enced. In extreme cases, susto can result in death. Typical symp- South chibih) toms include appetite disturbances, inadequate or excessive American sleep, troubled sleep or dreams, sadness, lack of motivation, and feelings of low self-worth or dirtiness. Somatic symptoms accom- panying susto include muscle aches and pains, headache, stom- achache, and diarrhea. Ritual healings focus on calling the soul back to the body and cleansing the person to restore bodily and spiritual balance. Susto can be related to major depressive disor- der, posttraumatic stress disorder, and somatoform disorders. Similar etiological beliefs and symptom configurations are found in many parts of the world. Taijin This syndrome refers to an individual’s intense fear that his or her Japanese kyofusho body, its parts, or its functions displease, embarrass, or are offen- sive to other people in appearance, odor, facial expressions, or movement. This syndrome is included in the official Japanese diagnostic system for mental disorders.

Source: APA 2013. Used with permission.

285

Appendix F—Cultural Resources

General Resources guidelines that reflect current professional practice. The ATA also has online directories Addiction Technology Transfer available. The Directory of Translation and Centers Interpreting Services is an online directory of individual translators and interpreters. The http://www.nattc.org Directory of Language Services Companies is The Addiction Technology Transfer Centers a directory of companies that offer translating Network identifies and advances opportunities or interpreting services. for improving substance abuse treatment. The Center for Research on Ethnicity, Network comprises 14 regional centers as well Culture, and Health as a national office serving the United States and its territories. Regional centers cater to http://www.crech.org unique needs in their areas while supporting Established in 1998 in the University of national initiatives. Improving cultural compe- Michigan’s School of Public Health, the Center tence is a major focus for the Network, which provides a forum for basic and applied public seeks to improve substance abuse treatment by health research on relationships among eth- identifying standards of culturally competent nicity, culture, socioeconomic status, and treatment and generating ways to foster their health. It develop new interdisciplinary adoption in the field. frameworks for understanding these relation- Agency for Healthcare Research ships while promoting effective collaboration and Quality–Minority Health among public health academicians, healthcare providers, and communities to reduce racial http://www.ahrq.gov/research/findings/factsh and ethnic disparities in health care. eets/minority/index.html Community Toolbox: Cultural This site provides research findings, papers, and Competence in a Multicultural press releases related to minority health. World American Translators Association http://ctb.ku.edu/en/table-of- http://www.atanet.org contents/culture/cultural-competence The American Translators Association (ATA) The cultural competence section of this Web offers a certification program that evaluates site provides information (including examples the competence of translators according to and links) on a number of relevant topics, such

287 Improving Cultural Competence

as how to build relationships with people from professionals, families, and consumers on the different cultures, reduce prejudice and racism, panels prepared the document. build organizations and communities that are responsive to people from diverse cultures, and heal the effects of internalized oppression. http://www.diversityrx.org The Cross Cultural Health Care This Web site offers resources relating to Program cross-cultural communication issues in http://www.xculture.org healthcare settings and information on inter- preter practice, legal issues relating to language Since 1992, the Cross Cultural Health Care barriers and access to linguistically appropriate Program (CCHCP) has been addressing services, and the ways language and culture broad cultural issues that affect the health of can affect the use of healthcare services. individuals and families in ethnic minority communities in Seattle and nationwide. Health Resources and Services Through a combination of cultural competen- Administration Culture, Language cy trainings, interpreter trainings, research and Health Literacy Page projects, community coalition building, and http://www.hrsa.gov/culturalcompetence/ other services, CCHCP serves as a bridge between communities and healthcare institu- The Health Resources and Services tions to ensure full access to quality health care Administration Culture, Language and Health that is culturally and linguistically appropriate. Literacy Web site provides links to various Cultural Competence Standards in online resources relating to cultural compe- tence in general and to providing culturally Managed Care Mental Health competent health care to a number of specific Services cultural/ethnic groups. Western Interstate Commission for Higher Instruments for Measuring Education. Cultural Competence Standards in Acculturation, University of Managed Mental Health Care for Four Under- served/Underrepresented Racial/Ethnic Groups. Calgary Boulder, CO: Western Interstate Commission http://www.ucalgary.ca/~taras/_private/Accult for Higher Education, 1998. uration_Survey_Catalogue.pdf The Center for Mental Health Services This document gives information on accul- (CMHS) presents cultural competence stand- turation and cultural identity measures, pre- ards for managed care mental health services to senting many in full. It does not always include improve the availability of high-quality services scoring information but typically provides for four underserved and/or underrepresented questions from each instrument. racial and ethnic groups—African Americans, Latinos, Native Americans, and Asian/Pacific Minority Health Project Islander Americans. With help from the http://www.minority.unc.edu/ Western Interstate Commission for Higher Education Mental Health Program, CMHS The Minority Health Project (MHP) of the convened national panels representing each University of North Carolina’s Gillings School major racial/ethnic group. Mental health of Global Public Health seeks to improve the

288 Appendix F—General Resources quality of racial and ethnic population data, to strengthened and empowered by its diversity. expand the capacity for conducting statistical iMCI’s initiatives aim to increase communica- research and developing research proposals on tion, understanding, and respect among people minority health, and to foster a network of of diverse backgrounds and address systemic researchers in minority health. MHP collabo- cultural issues facing our society. The Institute rates with the Center for Health Statistics accomplishes this through its conferences, Research, the University of North Carolina, the individualized organizational training and National Center for Health Statistics, and the consulting interventions, publications, and Association of Schools of Public Health to leading-edge projects. conduct educational programs and provide information on minority health research and Office of Civil Rights data sources. http://www.hhs.gov/ocr/civilrights/resources/s pecialtopics/lep/ National Center for Cultural Competence The Office of Civil Rights of the U.S. Department of Health and Human Services http://nccc.georgetown.edu investigates complaints, enforces rights, devel- The National Center for Cultural Compe- ops policies, and promulgates regulations to tence’s (NCCC) mission is to increase the ensure compliance with nondiscrimination capacity of health and mental health programs and health information privacy laws. The to design, implement, and evaluate culturally agency offers technical assistance and public and linguistically responsive service delivery education to ensure understanding of and systems. NCCC conducts training, technical compliance with these laws, including the assistance, and consultation; participates in provision of resources and tools to improve networking, linkages, and information ex- services for individuals with limited English change; and engages in knowledge and prod- proficiency. uct development and dissemination. Office of Minority Health The National Center on Minority Resource Center Health and Health Disparities http://minorityhealth.hhs.gov/ http://www.ncmhd.nih.gov The Office of Minority Health (OMH) was The Center’s mission is to promote minority established by the U.S. Department of Health health and reduce health disparities. It is and Human Services in 1985 to advise the particularly useful as a resource for infor- Secretary and the Office of Public Health and mation about health disparities and the best Science on public health policies and programs methods to address them. affecting Native Americans, African Ameri- cans, Asian Americans, Latinos, and Native International MultiCultural Hawaiians and other Pacific Islanders. The Institute mission of OMH is to improve and protect the http://www.imciglobal.org/ health of racial and ethnic minority populations through the development of policies and pro- The International MultiCultural Institute grams that will eliminate health disparities. (iMCI) works with individuals, organizations, and communities to create a society that is The OMH Resource Center (OMHRC) is a national resource and referral service for

289 Improving Cultural Competence

minority health issues. It collects and distrib- less likely to receive quality care than the gen- utes information on various health topics, eral population. It articulates the foundation for including substance abuse, cancer, heart dis- understanding relationships among culture, ease, violence, diabetes, HIV/AIDS, and society, mental health, mental illness, and infant mortality. OMHRC also facilitates services, and also describes how these issues information exchange on minority health affect different racial and ethnic groups. issues, and offers customized database search- es, publications, mailing lists, referrals, and Stanford University Curriculum in the like regarding Native American, African Ethnogeriatrics American, Asian American, Pacific Islander, http://www.stanford.edu/group/ethnoger/ and Latino populations. This online curriculum explores healthcare Substance Abuse and Mental issues for older adults from a variety of cultur- Health Services Administration al groups (with modules on African Americans, Latinos, Native Americans, and http://store.samhsa.gov/ several Asian American populations). The Substance Abuse and Mental Health Services Administration (SAMHSA) is the African and Black Nation’s one-stop resource for information American Resources about substance abuse and mental illness prevention and behavioral health treatment. Congressional Black Caucus The SAMHSA Store Web site provides in- Foundation Health formation on behavioral health topics such as cultural competence, healthcare-related laws, http://www.cbcfinc.org/what-we- and mental health and substance abuse. do/researchandpolicy.html Surgeon General’s Report on Congressional Black Caucus Foundation Mental Health: Culture, Race, and Health’s mission is to empower people of Ethnicity African descent to make better decisions about their health and that of their communi- U.S. Department of Health and Human ties. The Web site provides information about Services. Mental Health: Culture, Race, and public health issues, key legislation on public Ethnicity. A Supplement to Mental Health: A policy issues, health initiatives, and local Report of the Surgeon General. HHS Pub. No. events directly and indirectly relating to the SMA 01-3613. Rockville, MD: U.S. health of people of African descent world- Department of Health and Human Services, wide. It includes a section on substance abuse. Substance Abuse and Mental Health Services Administration, Center for Mental Health National Black Alcoholism and Services, 2001. Addictions Council, Inc. This report highlights the roles that culture http://www.nbacinc.org and society play in mental health, mental The National Black Alcoholism and Addictions illness, and the types of mental health services Council, Inc. (NBAC) is a nonprofit, tax- people seek. The report finds that, although exempt organization of Black individuals effective, well-documented treatments for concerned about alcoholism and drug abuse. mental illnesses are available, minorities are

290 Appendix F—General Resources

NBAC educates the public about the preven- The Asian and Pacific Islander American tion of alcohol and drug abuse and alcoholism Health Forum (APIAHF) is a national advo- and is committed to increasing services for cacy organization that promotes policy, pro- persons who are dependent upon alcohol and gram, and research efforts to improve the their families, providing quality care and treat- health of Asian and Pacific Islander Americans. ment, and developing research models designed APIAHF established the Asian and Pacific for Blacks. NBAC helps Blacks concerned with Islander Health Information Network or involved in the field of alcoholism and drug- (APIHIN) in 1995. APIHIN was developed related issues to exchange ideas, offer services, as an integrated telecommunications infra- and facilitate substance abuse treatment pro- structure that gives Asians and Pacific Is- grams for Black Americans. landers access to health information and resources through local community access National Medical Association points and key provider intermediaries. The http://www.nmanet.org organization supports two mailing lists: API- HealthInfo, which concentrates on Asian and A professional and scientific organization Pacific Islander American health, and API- representing the interests of more than 25,000 SAMH, which deals with issues related to physicians and their patients, the National behavioral health of special interest to the Medical Association (NMA) is the collective Asian and Pacific Islander community. voice of African American physicians and a leading force for parity and justice in medicine National Asian American Pacific and health. Established in 1895, NMA aims Islander Mental Health to prevent diseases, disabilities, and adverse Association health conditions that disproportionately or differentially affect African American and http://www.naapimha.org underserved populations; improve quality and The National Asian American Pacific Islander availability of health care for poor and under- Mental Health Association (NAAPIMHA) served populations; and increase representa- evolved from an Asian American Pacific tion and contributions of African Americans Islander Mental Health Summit sponsored by in medicine. NMA provides educational SAMHSA. NAAPIMHA focuses on five programs and opportunities for scholarly interrelated areas: enhancing collection of exchange, conducts outreach to promote im- appropriate and accurate data; identifying proved public health, and establishes national current best practices and service models; health policy agendas in support of African capacity building, including provision of tech- American physicians and their patients. nical assistance and training of service providers, both professional and paraprofes- Asian American, Native sional; conducting research and evaluation; and Hawaiian, and Other working to engage consumers and families. Pacific Islander Resources National Asian Pacific American Families Against Substance Abuse Asian and Pacific Islander American Health Forum http://www.napafasa.org The National Asian Pacific American Families http://www.apiahf.org Against Substance Abuse is a nonprofit

291 Improving Cultural Competence

membership organization that addresses the sionals trying to address their needs. This Web alcohol, tobacco, and drug issues of Asian site helps bridge the communication barrier by American and Pacific Islander populations; it offering information about and links to re- involves providers, families, and youth in sources for substance abuse prevention, general reaching Asian American and Pacific Islander health information, building cultural pride, and communities to promote health and social research tools, such as databases and bibliog- justice and reduce substance abuse and related raphies. problems. National Alliance for Hispanic Psychosocial Measures for Asian Health American Populations: Tools for http://www.hispanichealth.org Direct Practice and Research The National Alliance for Hispanic Health is http://www.columbia.edu/cu/ssw/projects/pmap the nation’s oldest and largest network of This Web site presents information on psy- Hispanic health and human service providers. chosocial measures (including some related to Alliance members deliver quality services to substance abuse) found to be reliable and valid more than 12 million persons annually. As the with Asian Americans (in general group or for nation’s action forum for Hispanic health and a specific subgroup). well-being, the programs of the Alliance inform and mobilize consumers, support The Vietnamese Community providers in the delivery of quality care, pro- Health Promotion Project mote appropriate use of technology, improve http://www.suckhoelavang.org/main.html the science base for accurate decisionmaking, and promote philanthropy. This project’s mission is to improve the health of Vietnamese Americans. A part of the Uni- National Council of La Raza versity of California–San Francisco School of Institute for Hispanic Health Medicine, the Web site provides information http://www.nclr.org/index.php/issues_and_pr in Vietnamese and English, along with links ograms/health_and_nutrition/hispanic_health to Vietnamese Web sites related to health issues. The Institute for Hispanic Health (IHH) works closely with National Council of La Hispanic and Latino Raza affiliates, government partners, private Resources funders, and Latino-serving organizations to deliver quality health interventions and im- Hispanic/Latino Portal to Drug prove access to and use of quality health pro- motion and disease prevention programs. Abuse Prevention IHH provides culturally responsive and lin- http://www.latino.prev.info guistically appropriate technical assistance and science-based approaches that emphasize The University Prevention Resource public health, rather than disease-specific, Center created this trilingual Web site to serve themes. Themes include behavior change the growing Latino population and those who communication, healthy lifestyle promotion, work with Latinos. Many Latinos face a lan- improving access to quality services, and guage barrier, as do many prevention profes-

292 Appendix F—General Resources

increasing the number and level of Latinos in Health Research, as well as information about health fields. ongoing research projects. National Hispanic Medical Indian Health Service Association http://www.ihs.gov http://www.nhmamd.org The Indian Health Service (IHS) is the prin- Established in 1994, the National Hispanic cipal federal healthcare provider and advocate Medical Association (NHMA) is a nonprofit for Native Americans; it ensures that compre- association representing 36,000 licensed His- hensive, culturally acceptable personal and panic physicians in the United States. Its public health services are available and acces- mission is to improve the health of Latinos sible to Native peoples. Its Web site provides a and other underserved populations. NHMA tour of the IHS and its service areas, adminis- provides policymakers and healthcare provid- trative reports, legislative news, IHS job op- ers with expert information and support in portunities, and healthcare resources targeted strengthening health service delivery to Latino to this group. communities across the Nation. Its agenda National Indian Child Welfare includes expanding access to quality health care; increasing medical education, cultural Association competence, and research opportunities for http://www.nicwa.org Latinos; and developing policy and education to eliminate health disparities for Latinos. The National Indian Child Welfare Associa- tion (NICWA), a comprehensive source of Native American information on American Indian child welfare, works on behalf of Indian children and fami- Resources lies to provide public policy, research, and advocacy; information and training on Indian Centers for American Indian and child welfare; and community development Alaska Native Health services to Tribal governments and programs, http://www.ucdenver.edu/academics/colleges/ State child welfare agencies, and other organi- PublicHealth/research/centers/ zations, agencies, and professionals interested CAIANH/Pages/caianh.aspx in Indian child welfare. NICWA addresses child abuse and neglect through training, The Centers for American Indian and Alaska research, public policy, and grassroots commu- Native Health (CAIANH) at the University nity development. NICWA also supports of Colorado, promote the health and compliance with the Indian Child Welfare Act well-being of American Indians and Alaska of 1978, which seeks to keep American Indian Natives by pursuing research, training, contin- children with American Indian families. uing education, technical assistance, and in- formation dissemination in a biopsychosocial One Sky Center framework that recognizes the unique cultural http://www.oneskycenter.org contexts of this special population. The site provides online access to the group’s journal, One Sky Center aims to improve prevention American Indian and Alaska Native Mental and treatment of substance abuse for Native peoples by identifying, promoting, and dis- seminating effective, evidence-based, culturally

293 Improving Cultural Competence

appropriate substance abuse prevention and development and capacity building, as well as treatment services and practices for applica- program planning and implementation. The tion across diverse Tribal communities. It also Center provides TTA on mental and sub- provides training, technical assistance, and stance use disorders, bullying and violence, products to expand the capacity and quality of suicide prevention, and the promotion of substance abuse prevention and treatment mental health. It offers TTA to federally services for this population. SAMHSA creat- recognized tribes, other American Indian and ed, designed, and funds One Sky Center to Alaska Native communities, SAMHSA Tribal work with all federal and state agencies grantees, and organizations serving Indian providing services to Native Americans. Country. The Web site provides resources across behavioral health topics relevant to SAMHSA’s Tribal Training and Native peoples. Technical Assistance Center White Bison http://beta.samhsa.gov/tribal-ttac http://www.whitebison.org/ The Tribal Training and Technical Assistance This Web site offers resources related to the (TTA) Center uses a culturally relevant, evi- Wellbriety self-help movement for Native dence-based, holistic approach to support Americans, including a discussion board and Native communities in their self- access to the Wellbriety online magazine. determination efforts through infrastructure

294

Appendix G—Glossary

Acculturation typically refers to the socializa- people whose origins are “in any of the black tion process through which people from one racial groups of Africa” (p. A-3). The term culture adopt certain elements from the domi- includes descendants of African slaves brought nant culture in a society. to this country against their will and more recent immigrants from Africa, the Caribbean, American Indian and Alaska Native people and South or Central America (many individ- include those “having origins in any of the uals from these latter regions, if they come original peoples of North and South America from Spanish-speaking cultural groups, iden- (including Central America), and who main- tify or are identified primarily as Latino). The tain tribal affiliation or community attach- term Black is often used interchangeably with ment” (Grieco and Cassidy 2001, p. 2). African American, although for some, the Asians are defined in the United States (U.S.) term African American is used specifically to Census as “people having origins in any of the describe those individuals whose families have original peoples of the Far East, Southeast been in this country since at least the 19th Asia, or the ,” including, century and thus have developed distinctly for example, Cambodia, China, India, Japan, African American cultural groups. Black can Korea, Malaysia, Pakistan, the Philippine be a more inclusive term describing African Islands, Thailand, and Vietnam (Grieco and Americans as well as for more recent immi- Cassidy 2001, p. 2). grants with distinct cultural backgrounds. Biculturalism is “a well-developed capacity to Confianza means trust or confidence in the function effectively within two distinct cul- benevolence of the other person. tures based on the acquisition of the norms, Conformity in Helms’s model of racial iden- values, and behavioral routines of the domi- tity development refers to the tendency of nant culture” and one’s own culture (Castro members of a racial group to behave in con- and Garfinkle 2003, p. 1385). gruence with the values, beliefs, and attitudes Biracial individuals have two distinct racial of their own culture to which they have been heritages, either one from each parent or as a exclusively exposed. result of racial blending in an earlier genera- Cultural competence is “a set of congruent tion (Root 1992). behaviors, attitudes, and policies that . . . ena- Blacks/African Americans are, according to ble a system, agency, or group of professionals the U.S. Census Bureau (2000) definition, to work effectively in cross-cultural situations”

295 Improving Cultural Competence

(Cross et al. 1989, p. 13). It refers to the people on the basis of common origins, shared ability to honor and respect the beliefs, lan- beliefs, and shared standards of behavior guages, interpersonal styles, and behaviors of (culture). individuals and families receiving services, as is “the tendency to view one’s well as staff members who are providing such own culture as best and to judge the behavior services. “Cultural competence is a dynamic, and beliefs of culturally different people by ongoing developmental process that requires a one’s own standards” (Kottak 1991, p. 47). long-term commitment and is achieved over time” (U.S. Department of Health and Health disparity is a particular type of health Human Services [HHS] 2003a, p. 12). difference that is closely linked with social, economic, and/or environmental disadvantage. Cultural competence plans are strategic Health disparities adversely affect groups of plans that outline a systematic organizational people who have systematically experienced approach to providing culturally responsive greater obstacles to health based on their racial services to individuals and to increasing cul- or ethnic group; religion; socioeconomic tural competence among staff at each level of status; gender; age; mental health; cognitive, the organization. sensory, or physical disability; sexual orienta- Cultural diffusion is the process of cultural tion or gender identity; geographic location; or intermingling. other characteristics historically linked to discrimination or exclusion (HHS 2011a). Cultural humility “incorporates a lifelong commitment to self-evaluation and critique” Hembrismo refers to female strength, endur- (Tervalon and Murray-García 1998, p. 123) to ance, courage, perseverance, and bravery redress the power imbalances in counselor– (Falicov 1998). client relationships. Latinos are those who identify themselves in Cultural norms are the spoken or unspoken one of the specific Hispanic or Latino Census rules or standards for a cultural group that categories—Mexican, Puerto Rican, or indicate whether a certain social event or Cuban—as well as those who indicate that behavior is considered appropriate or inappro- they are “other Spanish, Hispanic, or Latino.” priate. Origin can be viewed as the heritage, nation- ality, group, , or country of birth of the Cultural proficiency involves a deep and rich person or the person’s parents or ancestors knowledge of a culture—an insider’s view— before their arrival in the United States. that allows the counselor to accurately inter- pret the subtle meanings of Immersion–emersion is a stage in the identi- (Kim et al. 1992). ty development models of both Cross and Helms during which a transition takes place Culture is the that struc- from satisfaction with the old self to commit- tures the way people view the world—it is the ment to personal change: from immersion in particular set of beliefs, norms, and values that one’s old identity to emerging with a more influence ideas about the nature of relation- mature view of one’s identity (Cross 1995b). ships, the way people live their lives, and the way people organize their world. are those people native to a particular country or region. In the case Ethnicity refers to the social identity and of the United States and its territories, this mutual belongingness that defines a group of

296 Appendix G—Glossary

includes Native Hawaiians, Alaska Natives, Nguzo saba are the seven African American Pacific Islanders, and American Indians. principles celebrated during Kwanzaa: • Umoja is unity with family, community, Institutional racism generally “refers to the nation, and race. policies, practices, and norms that incidentally • Kujichagulia means self-determination to but inevitably perpetuate inequality,” resulting define collective selves, create for collective in “significant economic, legal, political and selves, and speak for collective selves. social restrictions” (Thompson and Neville • Ujima refers to collective responsibility to 1999, p. 167). build and maintain community and solve Language is a culture’s communication sys- problems together. • tem and the vehicle through which aspects of Ujamaa refers to cooperative economics to race, ethnicity, and culture are communicated. build and maintain businesses and to prof- it from them together. Ma chismo is the traditional sense of responsi- • Nia is a sense of purpose to collectively bility Latino men feel for the welfare and build and develop community to restore protection of their families. people to their traditional greatness. • Marianismo is the traditional belief that Kuumba is to always do as much Latinas should be self-sacrificing, endure as possible to leave the community more suffering for the sake of their families, and beautiful and beneficial than it was. • defer to their husbands in all matters. The Imani refers to belief in the community’s Virgin Mary is held up as the model to which parents, teachers, and leaders and in the all women should aspire. righteousness and victory of the struggle. Motivational interviewing is a counseling Organizational cultural competence and style characterized by the strategic therapeutic responsiveness refers to a set of congruent activities of expressing empathy, developing behaviors, attitudes, and policies that enable a discrepancy, avoiding argument, rolling with system, agency, or group of professionals to resistance, and supporting self-efficacy. In work effectively in cross-cultural situations motivational interviewing, the counselor’s (Cross et al. 1989). It is a dynamic, ongoing major tool is reflective listening. process. Multiracial individuals are any racially mixed Orgullo means pride and dignity. people and include biracial people, as well as Personalismo is the use of positive personal those with more than two distinct racial herit- qualities to accomplish a task. ages (Root 1992). Race is a social construct that describes people Native Hawaiians and other Pacific Is- with shared physical characteristics. landers include those with “origins in any of the original peoples of Hawaii, Guam, Samoa, Racism is an attitude or belief that people or other Pacific Islands” (Grieco and Cassidy with certain shared physical characteristics are 2001, p. 2). Other Pacific Islanders include better than others. Tahitians; Northern Mariana Islanders; Reculturation occurs when individuals return Palauans; Fijians; and cultural groups like to their countries of origin after a prolonged Melanesians, Micronesians, or . period in other countries and readapt to the dominant culture.

297 Improving Cultural Competence

Respeto can be translated as respect but also is the acceptance of a part includes elements of both emotional depend- or a trait of one culture into another culture. ence and dutifulness (Barón 2000). White is a form of ethnocentrism Selective perception is, in Helms’s model of and refers to a position of entitlement based racial identity development, the tendency of on a presumed culturally superior status. people early in the process to observe their Whites/Caucasians are people “having ori- environment in ways that generally confirm gins in any of the original peoples of Europe, their pre-existing beliefs. the , or North Africa.” This Simpatía is an approach to social interaction category includes people who indicate their that avoids conflict and confrontation. One race as White or report entries “such as Irish, who is simpático is agreeable and strives to German, Italian, Lebanese, Near Easterner, maintain harmony within the group. Arab, or Polish” (Grieco and Cassidy 2001, p. 2). Syncretism is the result of combining differ- ing systems, such as traditional and introduced cultural traits.

298

Appendix H—Resource Panel

Note: Information given indicates each participant’s affiliation during the time the panel was convened and may no longer reflect the individual’s current affiliation. Ana Anders, M.S.W., LICSW Edwin M. Craft, Dr.P.H. Senior Advisor Program Analyst Special Populations Office Practice Improvement Branch National Institute on Drug Abuse Division of Services Improvement National Institutes of Health Center for Substance Abuse Treatment Bethesda, MD Substance Abuse and Mental Health Services Administration Candace Baker, Ph.D. Rockville, MD Clinical Affairs Manager Lesbian, Gay, Bisexual, and Transgender Christina Currier Special Interest Group Public Health Analyst National Association of Alcoholism and Drug Practice Improvement Branch Abuse Counselors Division of Services Improvement Alexandria, VA Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Carole Chrvala, Ph.D. Administration Senior Program Officer Rockville, MD Board on Neuroscience & Behavioral Health Institute of Medicine Dorynne Czechowicz, M.D. Washington, DC Medical Officer Treatment Development Branch Christine Cichetti Division of Treatment Research and Development Advisor National Institute on Drug Abuse United States Department of Health and National Institutes of Health Human Services Bethesda, MD Washington, DC Janie B. Dargan Cathi Coridan, M.A. Senior Policy Analyst Senior Director for Substance Abuse Office of National Drug Control Policy Programs Executive Office of the President National Mental Health Association Washington, DC Alexandria, VA

299 Improving Cultural Competence

James (Gil) Hill, Ph.D. Richard T. Suchinsky, M.D. Director Associate Chief for Addictive Disorders and Office of Rural Health and Substance Abuse Psychiatric Rehabilitation American Psychological Association Mental Health and Behavioral Sciences Washington, DC Services Department of Veterans Affairs Hendree E. Jones, M.A., Ph.D. Washington, DC Assistant Professor CAP Research Director Jan Towers, Ph.D. Department of Psychiatry and Behavioral Director Sciences Health Policy Johns Hopkins University Center American Academy of Nurse Practitioners Baltimore, MD Washington, DC Guadelupe Pacheco, M.P.A. Jose Luis Velasco Special Assistant to the Deputy Assistant Project Director Secretary National Hispanic Council on Aging Office of Minority Health Washington, DC Department of Health and Human Services Karl D. White, Ed.D. Rockville, MD Public Health Analyst Cecilia Rivera-Casale, Ph.D. Practice Improvement Branch Senior Project Officer Division of Services Improvement Center for Mental Health Services Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Substance Abuse and Mental Health Services Administration Administration Rockville, MD Rockville, MD Deidra , M.D. Jeanean Willis, D.P.M., CDR, USPHS Health Science Administrator Public Health Analyst National Institute on Alcohol Abuse and Office of Minority Health Alcoholism Health Resources and Services Bethesda, MD Administration Rockville, MD Kevin Shipman, M.H.S., LPC Deputy Chief Grants and Program Management Division Special Population Services Washington, DC

300

Appendix I—Cultural Competence and Diversity Network Participants

Note: Information given indicates each participant’s affiliation during the time the network was convened and may no longer reflect the individual’s current affiliation. Elmore T. Briggs, CCDC, NCAC II Terry S. Gock, Ph.D. President/CEO Director SuMoe Partners Pacific Clinics Asian Pacific Family Center Germantown, MD Rosemead, CA African American Workgroup Member Asian/Pacific Islander Workgroup and Lesbian/ Gay/Bisexual/Transgender Workgroup Member Deion Cash Executive Director Renata J. Henry, M.Ed. Community Treatment and Correction Director Center, Inc. Delaware Health and Social Services Canton, OH New Castle, DE African American Workgroup Member African American Workgroup Member Magdalen Chang, Ph.D. Adelaida F. Hernandez, M.A., LCDC Center Manager Youth OSR Services Program Director Haight Ashbury Free Clinics, Inc. S.C.A.N., Inc. San Francisco, CA Laredo, TX Asian/Pacific Islander Workgroup Member Hispanic/Latino Workgroup Member Diana Yazzie Devine, M.B.A. Ford H. Kuramoto, D.S.W. Executive Director President Native American Connections, Inc. National Asian Pacific American Families , AZ Against Substance Abuse Native American Workgroup Member Los Angeles, CA Asian/Pacific Islander Workgroup Member

301 Improving Cultural Competence

Victor Leo, M.S.W., LCSW Tam Khac Nguyen, M.D., CCJS, LMSW Board Chair President Asian/Pacific American Consortium on Sub- Vietnamese Mutual Association, Inc. stance Abuse Polk City, IA Portland, OR Asian/Pacific Islander Workgroup Member Aging Workgroup Member and Asian/Pacific Rick Rodriguez Islander Workgroup Member Manager/Counselor Harry Montoya, M.A. Services United President/CEO Santa Paula, CA Hands Across Cultures Hispanic/Latino Workgroup Member Espanola, NM Mariela C. Shirley, Ph.D. Hispanic/Latino Workgroup Member Assistant Professor Michael E. Neely, Ph.D., MFCC University of North Carolina at Wilmington Administrator Wilmington, NC Integrated Care System Hispanic/Latino Workgroup Member Los Angeles, CA African American Workgroup Member

302

Appendix J—Field Reviewers

Note: Information given indicates each participant’s affiliation during the time the review was conducted and may no longer reflect the individual’s current affiliation. Alan J. Allery, M.Ed., M.H.A. Rodolfo T. Briseno, M.D., M.P.H. Director Facilitator Student Health Services Worker’s Assistance Program–Youth University of North Dakota Advocacy Grand Forks, ND Austin, TX Deborah Altschul, Ph.D. Stephanie Brooks, M.S.W. Assistant Professor/Psychologist Interim Director & Assistant Professor Mental Health Services Research and Programs in Couple & Family Therapy Evaluation Unit College of Nursing and Health Professions Adult Mental Health Division Drexel University Hawaii Department of Health Philadelphia, PA University of Hawaii Jutta H. Butler, B.S.N., M.S. Honolulu, HI Public Health Advisor Diana S. Amodia, M.D. Practice Improvement Branch Medical Director Division of Services Improvement Substance Abuse Treatment Services Center for Substance Abuse Treatment Haight Ashbury Free Clinics, Inc. Substance Abuse and Mental Health Services San Francisco, CA Administration Rockville, MD Ronald G. Black Director, Residential Group Flanders Byford, M.S.W., LCSW Drug Abuse Foundation Licensed Clinical Social Worker Del Ray Beach, FL Oklahoma City County Health Department Oklahoma City, OK Patricia T. Bowman Probation Counselor Maria J. Carrasco, M . P. A Fairfax Alcohol Safety Action Program Director Fairfax, VA Multicultural Action Center Arlington, VA

303 Improving Cultural Competence

Gerhard E. Carrier, Ph.D. Lynn Dorman, Ph.D., J.D. Chair, Mental Health & Addiction Studies President Department of Mental Health Creating Solutions Alvin Community College Portland, OR Alvin, TX Gayle R. Edmunds Carol J. Colleran, CAP, ICADC Director National Director of Older Adult Services Indian Alcoholism Treatment Services Center of Recovery for Older Adults Wichita, KS Hazelden Foundation/Hanley-Hazelden Michele J. Eliason, Ed.S., Ph.D. West Palm Beach, FL Associate Professor Cynthia C. Crone, APN, MNSC The University of Iowa Executive Director Iowa City, IA Center for Addictions Research, Education, Jill Shepard Erickson, M.S.W., ACSW and Services Public Health Advisor College of Medicine, Department of Child and Family Branch Psychiatry and Behavior Health Center for Mental Health Services University of for Medical Sciences Substance Abuse and Mental Health Services Little Rock, AR Administration John P. de Miranda, Ed.M. Rockville, MD Executive Director Elena Flores, M.A., Ph.D. National Association on Alcohol, Drugs, and Associate Professor Disability, Inc. School of Education San Mateo, CA Counseling and Psychology Department Efrain R. Diaz, Ph.D., LCSW University of California, San Francisco Program Supervisor San Francisco, CA Connecticut Department of Mental Health Jo Ann Ford, M.R.C. and Addiction Services Assistant Director Hartford, CT Substance Abuse Resources and Disability Dedric L. Doolin, M.P.A. Issues Deputy Director School of Medicine Area Substance Abuse Council, Inc. Wright State University Cedar Rapids, IA Dayton, OH Donna Doolin, LCSW Maria del Mar Garcia, M.S.W., M.H.S. Director Continuing Education Coordinator Division of Health Care Policy, Addiction & Caribbean Basin and Hispanic Addiction Prevention Services Centro de Estudios en Adicción Kansas Department of Social and Universidad Central del Caribe Rehabilitation Services Bayamon, PR Topeka, KS

304 Appendix J—Field Reviewers

Virgil A. Gooding, Sr., M.A., M.S.W., Susan F. LeLacheur, M.P.H., PA-C LISC Assistant Professor of Health Care Sciences Clinical Director The George Washington University Foundation II, Inc. Washington, DC Cedar Rapids, IA Jeanne Mahoney Maya D. Hennessey, CRADC Director Women’s Specialist Provider’s Partnership-Women’s Health Issues Supervisor, Quality Assurance, Technical American College of Obstetricians and Assistance & Training Gynecologists Office of Special Programs Washington, DC Division of Substance Abuse Michael Mobley, Ph.D., M.Ed. Illinois Department of Human Services and Assistant Professor in Counseling Psychology Substance Abuse Department of Educational, School and Chicago, IL Counseling Psychology Michael W. Herring, LCSW University of Missouri–Columbia Wayne Psychiatric Associates, P.A. Columbia, MO Goldsboro, NC Valerie Naquin, M.A. Deborah J. Hollis, M.A. Vice President Administrator Planning and Development Office of Drug Control Policy Cook Inlet Division of Substance Abuse and Gambling Anchorage, AK Services Paul C. Purnell, M.S. Michigan Department of Community Health President Lansing, MI Social Solutions, LLC Ruth Hurtado, M.H.A. Potomac, MD Public Health Advisor Laura Quiros, M.S.W. Center for Substance Abuse Treatment Program Associate Division of Pharmacologic Therapies Program Planning & Development Department Substance Abuse and Mental Health Services Palladia, Inc. Administration New York, NY Rockville, MD Melissa V. Rael, USPHS Ting-Fun May Lai, M.S.W., CASAC Senior Program Management Officer Director Co-Occurring and Homeless Branch Chinatown Alcoholism Center Division of State and Community Assistance Hamilton-Madison House Center for Substance Abuse Treatment New York, NY Substance Abuse and Mental Health Services Tom Laws Administration Talihina, OK Rockville, MD

305 Improving Cultural Competence

Susanne R. Rohrer, R.N. Ming Wang, L.C.S.W. Nurse Consultant Program Manager Practice Improvement Branch Division of Substance Abuse and Mental Division of Services Improvement Health Center for Substance Abuse Treatment Utah Department of Human Services Substance Abuse and Mental Health Services Salt Lake City, UT Administration Watanabe, M.S.W. Rockville, MD President and CEO Laurie J. Rokutani, Ed.S., NCC, CPP, Asian American Drug Abuse Program, Inc. MAC Los Angeles, CA Training Coordinator Debbie A. Webster Virginia Commonwealth University Community Program Coordinator Mid-America Addiction Technology Transfer Best Practice Team Center Division of Mental Health, Developmental Richmond, VA Disabilities, and Substance Abuse Services LaVerne R. Saunders, B.S.N., R.N., M.S. North Carolina Department of Health and Training Specialist and Consultant Human Services Dorrington & Saunders and Associates Raleigh, NC Framingham, MA Melvin H. Wilson, M.B.A., LCSW-C Gary Q. Tester, MAC, CCDC III-E, OCPS High Intensity Drug Trafficking Area II Coordinator Director Maryland Division of Parole and Probation Ohio Department of Alcohol and Drug Baltimore, MD Addiction Services Ann S. Yabusaki, M.Ed., M.A., Ph.D. Columbus, OH Director Ralph Varela, M.S.W. Coalition for a Drug-Free Hawaii Chief Executive Officer Honolulu, HI Pinal Hispanic Council Eloy, AZ

306

Appendix K—Acknowledgments

Numerous people contributed to the development of this Treatment Improvement Protocol (TIP), including the TIP Consensus Panel (page vii), the Knowledge Application Program (KAP) Expert Panel and Federal Government Participants (page ix), the Resource Panel (Appendix H), the Cultural Competence and Diversity Network Participants (Appendix I), and the Field Reviewers (Appendix J). This publication was produced under KAP, a Joint Venture of The CDM Group, Inc. (CDM), and JBS International, Inc., for the Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment. CDM KAP personnel included Rose M. Urban, M.S.W., J.D., LCSW, CCAC, CSAC, KAP Executive Project Director; Jessica L. Culotta, M.A., KAP Managing Project Co-Director and former Managing Editor; Susan Kimner, Former Managing Project Co-Director; Raquel Witkin, M.S., former Deputy Project Manager; Claudia A. Blackburn, Psy.D., Expert Content Director; Shel Weinberg, Ph.D., Senior Research/Applied Psychologist; J. Gilbert, M.A., Ph.D., Senior Editor/Writer; Deborah Steinbach, M.A., and Janet G. Humphrey, M.A., former Senior Editors/Writers; Claudia Askew, Catalina Bartlett, M.A., Angela Cross, Timothy Ferguson, M.A., Randi Henderson, and Susan Hills, Ph.D., Writers; Angela Fiastro, Junior Editor; Sonja Easley, former Editorial Assistant; Virgie D. Paul, M.L.S., Librarian; and Maggie Nelson, former Project Coordinator.

307

Index

A CODs of, 105–106, 107, 108 AA (Alcoholics Anonymous), 113, 114, 136, cultural identification by, 27 137, 147, 155–156, 173, 174 cultural resources for, 290–291 ACA (American Counseling Association) defined, 14, 103–104, 295 Counselor Competencies, 46, 47, 56 evaluation and treatment planning, 109– acceptance, culturally competent counselors 116, 110, 112, 115 showing, 49 families, concepts of and attitudes about, access to care. See also health insurance cover- 19 age gender issues, 19, 104, 107, 111 by African Americans, 106–108 health disparities, 20 by Asians and Asian Americans, 120 health, illness, and healing, attitudes to- as critical treatment issue, 80 ward, 108–109 by Hispanics and Latinos, 132 as high-context cultural group, 17 by Native Americans, 142–143 historical trauma of, 28, 108, 109–110 outreach strategies, 96–98, 97–98 incarceration rates, 108 for White Americans, 153 Kwanzaa, seven principles of, 297 acculturation, 24–27 mental disorders suffered by, 105–106 asking clients about, 62 organizational cultural competence and, defined, 24, 295 73 five-level model for, 25 power and trust issues, 109–110 generational gap in, 23 recovery and relapse prevention, 115–116 tools for identifying and measuring, 27, religion and spirituality, 114, 115 253, 254–257, 288 substance use and abuse and drug cul- acupuncture, 126 tures, 27, 104–105 adapting intervention strategies to clients’ traditional/alternative healing practices cultural needs, 50, 55, 56, 71–72 and, 114–115 Addiction Technology Transfer Centers, 287 treatment patterns, 106–108 Addressing the Specific Behavioral Health Needs Agency Cultural Competence Checklist, 264– of Men (TIP 56), 20 265 advisory and governing boards, 79 Agency for Healthcare Research and Quality affective/mood disorders, 105–106, 153 (AHRQ), 20, 85, 287 Affordable Care Act, 7 AI-SUPER PFP (American Indian Services African Americans, 14, 103–116 Utilization and Psychiatric Epidemiology Afrocentricity of, 62

309 Improving Cultural Competence

Risk and Protective Factors Project), 140, emotional expression and, 69, 119, 123 141, 142, 147 evaluation and treatment planning for, Alaskan Natives. See Native Americans 121, 121–128, 123 Alcoholics Anonymous (AA), 113, 114, 136, families, role of, 1, 19, 61, 72, 124 137, 147, 155–156, 173, 174 gender issues, 122–123 alcohol abuse. See drug cultures; substance geographic factors, 18 abuse health, illness, and healing, attitudes to- alcohol flushing response, 119 ward, 119, 120–121 alternative healing practices. See tradition- language and communication issues, 17, al/alternative healing practices 54 American Counseling Association (ACA) mental disorders, 57, 119–120 Counselor Competencies, 46, 47, 56 recovery and relapse prevention among, American Indian Services Utilization and 128 Psychiatric Epidemiology Risk and Protec- religion and spirituality, 126–128 tive Factors Project (AI-SUPER PFP), 140, shame and guilt, 1, 117, 119, 121, 122 141, 142, 147 structured approach to counseling often American Indians. See Native Americans preferred by, 55 American Psychiatric Association (APA), 69, substance use and abuse and drug cul- 283 tures, 1, 57, 117–119 American Religious Identification Survey, 30 traditional/alternative healing practices American Translators Association, 287 used by, 126–128 anxiety disorders, 61, 72, 105, 107, 109, 124, trauma, personal or historical, 119–120 126, 142, 153 treatment patterns, 120 APA (American Psychiatric Association), 69, assessment. See evaluation and planning; 283 measurement; self-assessment APIs (Asians and Pacific Islanders), 14. See assimilation, 24 also Asians and Asian Americans; Pacific Association for Multicultural Counseling, 37, Islanders 45 appreciation, as stage in racial and cultural ataque de nervios, 284 identity development, 40 attitudes and behaviors of culturally compe- Arab Americans, 32, 65, 150, 152 tent counselors, 49–50 Asian Indians, 14, 116. See also Asians and avoidance of certain counselor behaviors, 51 Asian Americans Asians and Asian Americans, 14, 116–128. See B also immigrants Baltimore Epidemiologic Catchment Services adopted into White families, 117 Area study (1980s), 106 client–counselor matching, 71 behavioral health CODs, 119–120 critical treatment issues for culturally re- community fairs, 98 sponsive services, 80 complex cultural problems, counselors al- cultural knowledge about, as core compe- lowing for, 51 tency, 48, 48–49 in criminal justice system, 120 defined, 3 cultural resources for, 291–292 Behavioral Health Services for American Indians defined, 295 and Alaska Natives (planned TIP), 139 educational factors, 22

310 Index

behavioral health service providers and coun- evaluation and treatment planning selors. See also core competencies; self- (Zhang Min), 57–58, 62 assessment; self-knowledge, as core compe- group clinical supervision case study tency (Beverly), 72 behaviors to avoid, 51 Hispanics and Latinos (Anna), 136 on continuum of cultural competence, importance of cultural competence 10–11 (Hoshi), 1 diversity of, 4–5, 8 Native Americans (John), 101–102 evaluation and monitoring of staff per- organizational cultural competence formance, 95–96, 96 (Cavin), 73–74 importance of cultural competence for, 2 racial and cultural identity, 41 matching clients with, 71 Caucasians. See White Americans organizational staff development, 75, 90– CBT. See cognitive–behavioral therapy 96, 92–96 CCHCP (Cross Cultural Health Care Pro- professional development tool for super- gram), 288 visor-supervisee discussions, 95 Census Bureau, U.S., racial and ethnic groups, in Sue’s multidimensional model for de- xvi, 13 veloping cultural competence, 6, 6–7 Center for Integrated Health Solutions behaviors and attitudes of culturally compe- (CIHS), 98 tent counselors, 49–50 Center for Mental Health Services (CMHS), biculturalism and mixed cultural identity, 5, 288 24, 57–58, 62, 116–117, 295 Center for Research on Ethnicity, Culture, bipolar disorders, 41, 69, 153 and Health, 287 biracial or , 5, 13, 14, 62, Center for Substance Abuse Treatment 295, 297 (CSAT) Blacks. See African Americans Targeted Capacity Expansion Program, boards, governing and advisory, 79 98 Brief Interventions and Brief Therapies for TIPs. See Treatment Improvement Proto- Substance Abuse (TIP 34), 157 cols Buddhists and Buddhism, 32–33, 123, 128, Central and South Americans, 32, 129, 131, 156 135, 285. See also Hispanics and Latinos change, determining readiness and motivation C for, 69–70 cabellerismo, 19 chibih, 285 Cambodians, 117, 118, 119, 123, 128. See also Chinese, 14, 32, 51, 57, 98, 117, 118, 123, 124, Asians and Asian Americans 125, 126, 285. See also Asians and Asian cao gio, 126 Americans Caribbeans, 104, 106, 113, 128, 284. See also Christians and Christianity, 31, 101, 115, 128, African Americans; Hispanics and Latinos 138, 149, 156 case management, culturally responsive, 70, CIDI (Composite International Diagnostic 70–71, 71 Interview), 68 Case Management Society of America, 71 CIHS (Center for Integrated Health Solu- case studies tions), 98 core competencies (Gil), 35 circles, in Native , 147, drug cultures (Lisa), 159–161 148

311 Improving Cultural Competence

cirrhosis, 105, 140, 141 collateral information of cultural relevance, 64, Civil Rights Movement, 38 64–65, 66–67 clinical issues, culturally framing, 49 committees, organizational, for cultural com- clinical/program attributes. See evaluation and petence, 79–80 treatment planning communication. See language and communi- clinical scales and CODs, 65–68 cation clinical supervisors and clinical supervision. Community-Defined Solutions for Latino Men- See also core competencies tal Health Care Disparities (Aguilar-Gaxiola diversity of, 4–5, 8 et al., 2012), 98 evaluation and monitoring of staff per- community involvement and awareness formance, 95–96, 96 demographic profiles, 84 group clinical supervision case study environmental appropriateness for popu- (Beverly), 72 lations served, 96 importance of cultural competence for, 2, feedback, gathering, 86 93–95, 94 as key culturally responsive practice, 8 mapping racial and cultural identity de- Native American treatment planning and, velopment and, 42 101–102, 143, 144 professional development tool for super- outreach programs, 96–98, 97–98 visor-supervisee discussions, 95 strategies for engaging, 80, 80–81 training content for language services per- Community Toolbox, 287 sonnel, 90 complementary healing practices. See tradi- clinical worldview, 43 tional/alternative healing practices CMHS (Center for Mental Health Services), complex cultural problems, counselors allow- 288 ing for, 51 co-occurring disorders (CODs) Composite International Diagnostic Interview of African Americans, 105–106, 107, 108 (CIDI), 68 of Asians and Asian Americans, 119–120 confianza, 295 clinical scales, culturally valid, 65–68 confidentiality issues, 134, 144 counselor knowledge of cultural distribu- conformity, as stage in racial and cultural tion of, 48–49 identity development, 40, 295 of Hispanics and Latinos, 131–132 Consumer Assessment of Healthcare Provid- immigrants and, 26 ers and Systems Cultural Competence Item of Native Americans, 141–142 Set, 85 Substance Abuse Treatment for Persons With contingency management approaches, 111, Co-Occurring Disorders (TIP 42), 20, 135 157 continuum of cultural competence, 9–11, 10– of White Americans, 153 11 cognitive–behavioral therapy (CBT) core assumptions of cultural competence, xvii, for African Americans, 111 4–5 for Asians and Asian Americans, 123–124 core competencies, xvii–xviii, 3, 36–56. See also for Hispanics and Latinos, 135 self-knowledge, as core competency for Native Americans, 145 adapting intervention strategies to clients’ for White Americans, 155 cultural needs, 50, 55, 56 collaborative approach, 60–61, 109, 111 attitudes and behaviors of culturally com- petent counselors, 49–50

312 Index

behavioral health, cultural knowledge core competencies for counselors and about, 48, 48–49 clinical staff, xvii–xviii, 3, 35–56. See behaviors to avoid, 51 also core competencies case studies, 35, 41 cross-cutting factors, xvii, 16–33, 46–47, clinical issues, framing in culturally rele- 62, 63, 150 vant ways, 49 defined, xv, 5–7, 11, 295–296 complex cultural problems, allowing for, development of, xvi, 9–11, 10–11 51 diversity aiding, 4–5, 8 cross-cutting factors affecting, 46–47 drug cultures, xxi, 3, 159–175. See also knowledge of other cultural groups, 44– drug cultures; substance abuse 47, 45, 47 in evaluation and treatment planning, personal space issues, dealing with, 51–52 xviii–xix, 3, 57–72. See also evaluation power and trust issues, 44, 52 and treatment planning self-assessment tools, 55, 259–63 importance to behavioral health field, xv– skill development, 49–50, 49–55, 51, 53– xvi, 1–2, 7–9 54 at multiple levels of operation, 4 in Sue’s multidimensional model for de- in organizations, xix–xx, 73–99. See also veloping cultural competence, 6, 36, 37 organizational cultural competence touch, awareness of culturally specific public advocacy of, 5 meanings of, 52 purpose and objectives of pursuing, 2 counselors. See behavioral health service pro- for specific racial and ethnic groups, xx– viders and counselors xxi, 3, 101–57. See also racial and ethnic criminal justice system groups; specific groups African Americans in, 108 Sue’s multidimensional model for devel- Asians and Asian Americans in, 120 oping, xv, 5–7, 6, 36, 37, 58, 74, 102, Native Americans in, 143 103, 160, 161 Substance Abuse Treatment for Adults in the terminology used in discussing, 3 Criminal Justice System (TIP 44), 157 Cultural Competence for Health Administra- cross-cultural applicability of diagnostic sys- tion and Public Health, 93 tems, 68–69 cultural competence plans, 81–82, 82, 84, 87, cross-cultural communication, 59 296 Cross Cultural Health Care Program cultural concepts of distress, 30, 69, 284–285 (CCHCP), 288 cultural destructiveness, 10 cross-cutting factors, xvii, 16–33, 46–47, 62– cultural diffusion, 296 63, 150 cultural formulation, 69, 283–284 CSAT. See Center for Substance Abuse cultural humility, 50, 296 Treatment cultural identity, 24–27 Cubans and Cuban Americans, 129, 130, 131. asking clients about, 62 See also Hispanics and Latinos case study, 41 culturagrams, 65, 66–67 defined, xvii, 16 cultural awareness, 38 diagnosis, cultural formulation in, 283 cultural blindness, 10–11 drug culture, as alternative to, 173 cultural competence, xv–xxi, 1–33 mapping, 41, 42 core assumptions of, xvii, 4–5 mixed, 57–58, 62, 116–117 models of, 39, 40

313 Improving Cultural Competence

for Native Americans, 26–27, 144–145 drug cultures, xxi, 3, 159–175. See also sub- self-knowledge of counselors regarding, stance abuse 38, 38–41, 40, 41 of African Americans, 104–105 subcultures, 62–63 of Asians and Asian Americans, 117–119 terminology of, 24 attraction of, 165–169 tools for measuring and identifying, 253, case study (Lisa), 159–161 254–257, 288 cultural identity as alternative to, 173 for White Americans, 39, 154 culture of recovery replacing, xxi, 173, cultural incapacity, 10 173–175, 174, 175 cultural norms, xvi, 12, 45, 48, 52, 60, 296 daily routines and rituals, assessing, 172 Cultural Orientation Resource Center, 23 defined, 161–164 cultural precompetence, 11 differences between, 161, 162 cultural proficiency, 296 evaluation and treatment planning ad- culture, defined, xvi, 11–13, 12, 296 dressing, 171–175, 172 Culture Matters: The Peace Corps Cross-Cultural exercise on benefits, losses, and the fu- Workbook (2012), 52 ture, 170–171 culture of recovery, xxi, 173, 173–175, 174, 175 families and, 169 Cup’ik Eskimo, 148 geographical variations, 161, 162 curanderismo, 138 of Hispanics and Latinos, 129–131, 130 identifying key characteristics of, 162–163 D as initiating and sustaining force for sub- daily routines and rituals of substance abusers, stance abuse, 167, 169 assessing, 172 language and terminology of, 164 dances, sacred, 148 mainstream culture, relationship to, 164– demographic profiles, developing, 84 165 Departments, U.S. See entries at U.S. music and, 165, 166–167 depression, 21, 49, 51, 57, 69, 72, 107, 109, of Native Americans, 139–141 119, 124, 131, 141, 142, 153 online, 169–171 development of cultural competence, xvi, 9–11, rituals of, 167, 168 10–11 SES and, 162, 169 dhat, 284 skills required for certain drug use, diabetes, 49, 141, 290 transmitting, 167, 168 diagnosis, 68–69, 283–285 as subcultural phenomenon, 160, 161–162 Diagnostic and Statistical Manual of Mental Sue’s multidimensional model for devel- Disorders, Fifth Edition (DSM-5), 30, 68, oping cultural competence and, 160, 283, 284–285 161 dissonance, as stage in racial and cultural of White Americans, 150–152 identity development, 40 worldviews, values, and traditions of, 165, distress, cultural concepts of, 30, 69, 284–285 166 diversity DSM-5 (Diagnostic and Statistical Manual of at developmental and organizational lev- Mental Disorders, Fifth Edition), 30, 68, els, 4–5, 8, 90–91 283, 284–285 within racial and ethnic groups, 17–18, 103 Diversity Rx, 288

314 Index

E culturagram, 65, 66–67 East Harlem Protestant Parish, 138 cultural identity and acculturation, de- EBP. See evidence-based practices termining, 62 educational factors, 21–22, 22, 67 diagnosis, 68–69, 283–285 emotional expression, 54–55, 69, 119, 123 distress, cultural concepts of, 30, 69, 284– enculturation, 24 285 engaging clients, 59, 59–60 diversity of population developing, 4–5 Engaging Moms, 113 drug cultures, addressing, 171–175, 172 Enhanced National Standards for Culturally and eliciting client views on their problems, Linguistically Appropriate Services in Health 63 and Health Care (OMH, 2013), 8, 75, 265– engaging clients at initial meeting, 59, 266 59–60 Enhancing Motivation for Change in Substance familiarization of client with process, 59– Abuse Treatment (TIP 35), 69, 70, 157 60 environmental appropriateness for populations families, inclusion of, 1, 59–60, 61, 64–65 served, 96 health, illness, and healing, different cul- epicanthic eye fold, 13 tural attitudes toward, 60, 61, 63, 64 equality, commitment to, 40, 50 for Hispanics and Latinos, 133–138 ESI (Ethnic-Sensitive Inventory), 262–263 immigration history, taking, 23, 61, 66 espanto, 285 integration of culturally relevant issues, espiritismo, 138 61–63, 61–64 ethnic groups. See racial and ethnic groups matching clients and counselors, 71, 134 Ethnic-Sensitive Inventory (ESI), 262–263 motivational interviewing, 70 ethnocentrism, 9, 40, 296, 298 multicultural intake checklist, 64 ethnogeriatrics, 290 for Native Americans, 143, 143–150, 145 evaluation and monitoring one-size-fits-all approach, importance of of organizational cultural competence, 74, avoiding, 58 75, 84–87, 85, 86, 264–273 for Pacific Islanders, 127 of staff performance, 95–96, 96 screening and assessment tools, 65–69, evaluation and treatment planning, xviii–xix, 3, 68, 277, 277–81 57–72 strength-based interviews, 61 adapting intervention strategies to clients’ subcultures, 62–63 cultural needs, 50, 55, 56, 71–72 in Sue’s multidimensional model for de- for African Americans, 109–116, 110, veloping cultural competence, 6, 6–7, 112, 115 58 benefits of cultural competency for, 4 traumatic experiences, 63 case management, 70, 70–71, 71 for White Americans, 154–156 case studies, 57–58, 62, 72 evidence-based practices (EBPs) change, determining readiness and moti- counselors’ cultural sensitivity and, 37 vation for, 69–70 health disparities, reducing, 20 collaborative approach to, 60–61 for Hispanics and Latinos, 134 collateral information of cultural rele- vance, 64, 64–65, 66–67 F cross-cutting factors affecting, 62, 63 families in Asian culture, 1, 19, 61, 72, 124

315 Improving Cultural Competence

counselor’s worldview of, 72 mental disorders and substance abuse is- culturagrams, 66 sues, 20 cultural variations regarding, 19 Substance Abuse Treatment: Addressing the drug cultures and, 169 Specific Needs of Women (TIP 51), 20, gathering culturally relevant collateral in- 123, 157 formation from, 64–65 White Americans and, 19 health, illness, and healing, cultural atti- genetics and race, 13 tudes toward, 30, 60, 61 geographical factors in cultural competence, in Hispanic and Latino culture, 129–130, 17–18, 62–63, 161, 162 135 governance, of organizations, 75, 78–80, 80 immigration and migration issues, 22, 23 governing and advisory boards, 79 inclusion in evaluation and treatment group clinical supervision case study (Beverly), process, 1, 59–60, 61, 64–65 72 in Native American culture, 145–146 group therapy family therapy, 19, 49 for African Americans, 113 for African Americans, 111–113, 113 for Asians and Asian Americans, 125 for Asians and Asian Americans, 124, exercise on benefits, losses, and the fu- 124–125 ture, 170–171 for Hispanics and Latinos, 135–136, 136, for Hispanics and Latinos, 136 137 Ho’oponopono (used by Native Hawai- for Native Americans, 145–146 ians), 127 Substance Abuse Treatment and Family for Native Americans, 146 Therapy (TIP 39), 19, 146, 157 Substance Abuse Treatment: Group Therapy for White Americans, 155 (TIP 41), 155, 157 feedback, gathering, 85, 85–87, 86, 273–275 for White Americans, 155 fetal alcohol syndrome, 141 Filipinos, 14, 118. See also Asians and Asian Americans H fiscal support of organizational cultural com- Hands Across Cultures Corporation, New petence, 96 Mexico, 77–78, 78 flexibility, culturally competent counselors Hawaiians. See Pacific Islanders showing, 50, 55 health disparities four circles, 158 causes of, 20 cultural competence reducing, 7 G defined, 7, 296 gender, 19–20 National Center on Minority Health and acculturation and, 26 Health Disparities, 289 Addressing the Specific Behavioral Health SES and, 21 Needs of Men (TIP 56), 20 health, illness, and healing African Americans and, 19, 104, 107, 111 African American attitudes toward, 108– for Asians and Asian Americans, 122– 109 123 Asian and Asian American attitudes to- client–counselor matching for, 71, 134 ward, 119, 120–121 in Hispanic and Latino culture, 19–20, core competency, cultural knowledge of 129, 134 behavioral health as, 48, 48–49

316 Index

culturagrams, 67 evaluation and treatment planning for, different cultural attitudes toward, 29–30, 133–138 60, 61, 63, 64 family role in culture of, 129–130, 135 Hispanic and Latino attitudes toward, gender roles, 19–20, 129, 134 133 geographic factors, 18 Native American attitudes toward, 143, health, illness, and healing, attitudes to- 147–148 ward, 133 Pacific Islanders’ attitudes toward, 127 language and communication issues, 17 White American attitudes toward, 153– mental disorders, 131–132 154 recovery and relapse prevention, 138 health insurance coverage religion and spirituality of, 137, 138 for African Americans, 107 sexual identity and orientation, 29 for Asians and Asian Americans, 120 substance use and abuse and drug cul- for Hispanics and Latinos, 132, 137 tures, 35–36, 129–131, 130 for Native Americans and Pacific Is- traditional/alternative healing practices, landers, 142 137–138 SES and treatment access, 20, 22 treatment patterns for, 132 Health Resources and Services Administra- history and heritage, 27–29. See also trauma, tion (HRSA) personal or historical Administration Culture, Language and of counselors, 43–44 Health Literacy Page, 288 of organizational cultural competence, 98, CIHS (Center for Integrated Health So- 99 lutions), 98 HIV/AIDS, 105, 290 domains of organizational cultural com- Hmong, 18, 30, 52, 126 petence, 75, 75–76, 266–268 Hogg Foundation for Mental Health, 86 Organizational Cultural Competence As- Holocaust, 28 sessment Profile, 266–268 homosexuality, 29, 162–163 Healthy People 2020, 21 Ho’oponopono, 127 Health and Human Services (HHS). See U.S. Hopi, 139–140 Department of Health and Human Ser- HRSA. See Health Resources and Services vices Administration Helms’s model of racial identity development, humility, culturally competent counselors 298 showing, 50, 296 hembrismo, 296 heritage. See history and heritage I HHS (Health and Human Services). See U.S. IHS (Indian Health Service), 139, 142, 293 Department of Health and Human Ser- iMCI (International MultiCultural Institute), vices 289 high-context versus low-context cultural immersion, as stage in racial and cultural groups, 17, 54 identity development, 40, 296 Hispanics and Latinos, 15, 128–138. See also immigrants, 22–27 immigrants acculturation and cultural identification, CODs of, 131–132 23, 24, 24–27, 25, 27 cultural resources for, 292–293 culturagrams, 66 distress, cultural concepts of, 284–285 Cultural Orientation Resource Center, 23

317 Improving Cultural Competence

evaluation and treatment planning for, Jews and Judaism, 28, 30, 31–32, 156 23, 61, 66 jiryan, 284 family issues, 22, 23 Journey Mental Health Center (JMHC), history and heritage, effects of, 27–28 Wisconsin, 76 initial interview and assessment ques- tions, 23 legal status of, 22, 66–67, 134 K mental disorders and, 22–23 Kickapoo Reservation, Texas, 141 migrant/seasonal workers, 24 Kiowa gourd dance, 148 refugees, 23, 28, 52 Koreans, 14, 16, 19, 61, 98, 117, 118, 120, 124, substance abuse issues, 23, 25–26, 130 126, 128. See also Asians and Asian Ameri- incarceration. See criminal justice system cans Indian Health Service (IHS), 139, 142, 293 Kung San bushmen, 13 Indians. See Asian Indians; Native Americans Kwanzaa, seven principles of, 297 indigenous peoples, 52, 297. See also Native Americans; Pacific Islanders individual counselors. See behavioral health L service providers and counselors Lakota version of the 12 Steps, 147 infrastructure, organizational, 75, 96–98, 97– language and communication, 16–17 98, 99 assessing cultural differences in, 53–54 initial meeting, engaging clients at, 59, 59–60 counselor adjustment of communication institutional racism, 46, 297 style, 52–54 Instruments for Measuring Acculturation culturagrams, 67 (University of Calgary), 288 defined, 297 integration of culturally relevant issues into drug cultures, 164 evaluation and treatment planning, 61–63, emotional expression, 54–55, 69, 119 61–64 examples of cultural differences, 17 integrative awareness, as stage in racial and high-context versus low-context cultural cultural identity development, 40 groups, 17, 54 International MultiCultural Institute (iMCI), improving cross-cultural communication, 289 59 International Statistical Classification of informing clients about language services, Diseases and Related Health Problems, 68 88 interviews. See evaluation and treatment plan- nonverbal communication, 16–17, 54 ning organizational language services (transla- introspection, as stage in racial and cultural tors), 75, 88, 88–90, 90 identity development, 40 translators, 88, 88–90, 90, 287 Iowa Cultural Understanding Assessment, 86, White Americans’ issues with, 155 273–275 Laotians, 118. See also Asians and Asian Islam, 32, 115, 156 Americans Latinos. See Hispanics and Latinos J LEARN mnemonic, 59, 60 jail. See criminal justice system legal status of immigrants, 22, 66–67, 134 Japanese, 1, 14, 32, 126, 285. See also Asians LGBT community, 29, 162–163 and Asian Americans Living in the Balance intervention, 111

318 Index low-context versus high-context cultural models of racial identity, 38 groups, 17, 54 monitoring and evaluation of organizational cultural competence, 74, M 75, 84–87, 85, 86, 264–273 machismo, 19, 137, 297 of staff performance, 95–96, 96 marianismo, 19, 297 Monitoring the Future Study, 131 matching clients, counselors, and programs, mood and affective disorders, 105–106, 153 71, 134 motivation for change measurement determining, 69–70 acculturation and cultural identity, 27, Enhancing Motivation for Change in Sub- 253, 254–257, 288 stance Abuse Treatment (TIP 35), 69, communication styles, cultural differences 70, 157 in, 53–54 motivational interviewing, 70 drug cultures, 162–163 for African Americans, 110 Medicare, 22, 265 defined, 297 mental disorders. See also co-occurring disor- for Hispanics and Latinos, 135 ders; specific conditions for Native Americans, 145 of African Americans, 105–106 Multicultural Counseling Self-Efficacy Scale, of Asians and Asian Americans, 57, 119– 259 120 multicultural intake checklist, 64 cultural differences in understanding of, Multiculturally Competent Service System 30 Assessment Guide, 268–273 diagnosis, 68–69 multiracial or biracial people, 5, 13, 14, 62, gender roles and, 20 295, 297 geographic factors, 18 music and drug cultures, 165, 166–167 of Hispanics and Latinos, 131–132 Muslims, 32, 115, 156 immigrants and, 22–23, 26 mutual-help groups. See also 12-Step pro- of Native Americans, 141–142 grams, under T religion and spirituality, 31 for African Americans, 113–114 SES and, 21 for Asians and Asian Americans, 125–126 trauma-induced, 28–29 for Hispanics and Latinos, 136–137 of White Americans, 153 for Native Americans, 146–147, 147 Mental Health: Culture, Race, and Ethnicity for White Americans, 155–156 (Surgeon General’s report, 2001), 290 methadone programs, 111, 132, 135 Mexicans and Mexican Americans, 18, 25, 26, N 35–36, 128–129, 130, 131, 133, 134, 135, NA (Narcotics Anonymous), 113, 160, 174 137, 138, 167, 285. See also Hispanics and Na Wahine Makalapua Project, 127 Latinos naiveté, as stage in racial and cultural identity MHP (Minority Health Project), 288–289 development, 40 migrant/seasonal workers, 24 narcocorridos, 167 Minority Health Project (MHP), 288–289 Narcotics Anonymous (NA), 113, 160, 174 mission statements, 77–78, 78 National Alliance on Mental Illness, 156 mixed cultural identity/biculturalism, 5, 24, National Ambulatory Medical Care Survey, 57–58, 62, 116–117, 295 106

319 Improving Cultural Competence

National Association of Social Workers, 71 health, illness, and healing, attitudes to- National Center for Cultural Competence ward, 143, 147–148 (NCCC), 86, 259, 289 historical trauma of, 28, 140, 142 National Center on Minority Health and IHS and Tribal service providers, 139, Health Disparities, 289 142, 293 National Comorbidity Study, 142 language and communication issues, 17 National Congress of American Indians, 141 mental disorders of, 141–142 National Epidemiologic Survey on Alcohol monthly newsletters, 98 and Related Conditions (NESARC), 114, motivational interviewing, 70 115, 154 personal space, cultural differences re- National Institute on Minority Health and garding, 51 Health Disparities, 20 recovery and relapse prevention, 148, National Institutes of Health (NIH), 20, 68 149–150 National Latino and Asian American Study religion and spirituality, 102, 144, 149 (NLAAS), 118, 120 substance use and abuse and drug cul- National Survey on Drug Use and Health tures, 26–27, 139–141 (NSDUH) data traditional/alternative healing practices, on African Americans, 104, 108, 114 72, 102, 144, 147–149, 148 on Asians and Asian Americans, 117, treatment patterns, 142–143 119, 120, 121, 125 Wellbriety movement, 49, 147 on Hispanics and Latinos, 132, 133 Navajo, 140 on Native Americans, 139, 140, 142 NCCC (National Center for Cultural Com- on Pacific Islanders, 127 petence), 86, 259, 289 on racial and ethnic groups, 18, 21, 117 nervios, 285 on White Americans, 152, 154 NESARC (National Epidemiologic Survey on Native Americans, 14–15, 138–150 Alcohol and Related Conditions), 114, 115, Behavioral Health Services for American Indians 154 and Alaska Natives (planned TIP), 139 nguzo saba, 297 case study (John), 101–102 NIH (National Institutes of Health), 20, 68 CODs of, 141–142 NLAAS (National Latino and Asian Ameri- community involvement, importance of, can Study), 118, 120 101–102, 143, 144 node-link mapping, 111, 135 complex cultural problems, counselors al- nonverbal communication, 16–17, 54 lowing for, 51 NSDUH. See National Survey on Drug Use confidentiality issues, 144 and Health (NSDUH) data in criminal justice system, 143 cultural identification, importance of, 26– O 27, 144–145 Office of Civil Rights, 289 cultural resources for, 293–294 Office of Minority Health (OMH), 289 defined, 295 definition of cultural competence, 5 evaluation and treatment planning for, Enhanced National Standards for Cultural- 143, 143–50, 145 ly and Linguistically Appropriate Services family in culture of, 145–146 in Health and Health Care (2013), 8, geographic factors, 18 75, 265–266 Resource Center (OMHRC), 289–290

320 Index

staff education and training guidelines, Organizational Cultural Competence Assess- 93, 94 ment Profile (HRSA), 266–268 online drug cultures, 169–171 orgullo, 297 openness, culturally competent counselors orientation sessions, 134 showing, 50 outreach strategies and access to care, 96–98, organizational cultural competence, xix–xx, 97–98 73–99 basic requirements for, 74, 75 P benefits to organization, 8 Pacific Islanders, 14, 116–117, 127. See also case study (Cavin), 73–74 Asians and Asian Americans commitment to, throughout organization, access to care, 142 76–77, 77 client–counselor matching, 71 community involvement in, 8, 80, 80–81, cultural resources for, 291–292 84, 86, 96 defined, 297 continuum of cultural competence, or- evaluation and treatment planning for, ganizations on, 10–11 127 defined, 297 health, illness, and healing, attitudes to- diversity necessary for, 4–5, 90–91 ward, 121, 127 engagement of all parties in, 80, 80–81 substance abuse by, 127 evaluation and monitoring of, 74, 75, 84– pasmo, 285 87, 85, 86, 264–273 peer-supported interventions and strategies, feedback, gathering, 85, 85–87, 86, 273– 110, 113–114. See also group therapy; mutu- 275 al-help groups fiscal support for, 96 pelea nonga, 133–134 governance, 75, 78–80, 80 People Awakening Project, 150 historical perspective on, 98, 99 perdida del alma, 285 HRSA domains of, 75, 75–76 performance evaluation importance of organizational commit- of organizational cultural competence, 74, ment, 2, 4 75, 84–87, 85, 86, 264–273 infrastructure supporting, 75, 96–98, 97– of staff performance, 95–96, 96 98, 99 personal space, 51–52 language services, 75, 88, 88–90, 90 personalismo, 17, 133, 138, 297 mapping racial and cultural identity de- Pew Forum on Religion and Public Life velopment and, 42 (2008), 30 planning, 75, 80–83, 82, 87 planning. See also evaluation and treatment self-assessments, 84–87, 85, 86, 264–273 planning senior management in charge of, 78–79 cultural competence plans, 81–82, 82, 84, strategic planning, 78 87, 296 in Sue’s multidimensional model for de- fiscal support of organizational cultural veloping cultural competence, 6, 6–7, competence, 96 74 organizational cultural competence, 75, values of organization and, 75, 76–78, 77, 80–83, 82, 87 78 plática, 17 workforce and administrative staff devel- policies and procedures, organizational review opment, 75, 90–96, 92–96 of, 82–83

321 Improving Cultural Competence

posttraumatic stress disorder (PTSD), 105, health disparities among, 20 106, 119, 142 health, illness, and healing, cultural atti- power and trust issues, 44, 52, 109–110 tudes toward, 29–30 prejudices, of counselors, 43–44, 44 Jewish, 31 prison. See criminal justice system language and communication issues, 16– procedures and policies, organizational review 17, 17 of, 82–83 mapping racial and cultural identity de- professional development programs, 91, 94 velopment, 41, 42 Prohibition, 151 models of racial identity, 38, 39, 40 Project MATCH, 70 Muslims, 32 promotion strategies for workforce and staff, self-knowledge of counselor regarding ra- 90–91 cial, ethnic, and cultural identities, 38, A Provider’s Introduction to Substance Abuse 39–41, 40, 41 Treatment for Lesbian, Gay, Bisexual, and sexual identity and orientation, 29 Transgender Individuals (CSAT, 2001), 29 sizes and percentages, 13 psychoeducation, 9, 111, 113, 125, 157, 170– in Sue’s multidimensional model for de- 171 veloping cultural competence, 5–6, 6, PTSD (posttraumatic stress disorder), 105, 102, 103 106, 119, 142 U.S. Census Bureau groupings, xvi, 13 public advocacy of cultural competence, 5 worldviews, values, and traditions, differ- Puerto Ricans, 59, 129, 130, 131, 132, 135, ences in, 18–19 136, 138. See also Hispanics and Latinos racial/cultural identity development (R/CID) purification ceremonies, 72, 148 model, 39, 40, 41, 42 racism, 21, 28, 39, 40, 46, 50, 52, 56, 60, 109– 110, 119, 297 R readiness and motivation for change, deter- R/CID (racial/cultural identity development) , 69–70 model, 39, 40, 41, 42 recovery and relapse prevention racial and ethnic groups, xx–xxi, 3, 101–157. for African Americans, 115–116 See also African Americans; Asians and for Asians and Asian Americans, 128 Asian Americans; Hispanics and Latinos; culture of recovery, xxi, 173, 173–175, Native Americans; Pacific Islanders; White 174, 175 Americans for Hispanics and Latinos, 138 Buddhists, 32 for Native Americans, 148, 149–150 case studies, 41, 101–102 Relapse Prevention and Recovery Promotion client–counselor matching, 71, 134 in Behavioral Health Services (planned definitions of race and ethnicity, xvi, 13– TIP), 128, 157, 173–174 16, 15, 296, 297 for White Americans, 156–157 diversity within, 17–18, 103 recovery camps, Native American, 149 ethnic or token representatives, 90–91 recruitment strategies for workforce and staff, families, concepts of and attitudes about, 90–91 19 reculturation, 297–298 gender roles, 19 refugees, 23, 28, 52 geographical variations in, 17–18 relapse prevention. See recovery and relapse global differences in, 13 prevention

322 Index religion and spirituality, 30–33. See also rituals selective perception, 298 of African Americans, 114, 115 self-assessment of Asians and Asian Americans, 126–128 of core competencies, 55, 259–263 Buddhists and Buddhism, 32–33, 123, for counselor training, 93 128, 156 of organizational cultural competence, Christians and Christianity, 31, 101, 115, 84–87, 85, 86, 264–273 128, 138, 149, 156 Self-Assessment Checklist for Personnel culturagrams, 67 Providing Services and Supports to Chil- of Hispanics and Latinos, 137, 138 dren and Youth with Special Health Needs Islam, 32, 115, 156 and Their Families, 55, 259–262 Jews and Judaism, 28, 30, 31–32, 156 self-knowledge, as core competency, 37–45 of Native Americans, 102, 144, 149 ACA Counselor Competencies, 46 of Pacific Islanders, 127 benefits of, 4, 8–9, 37–38 substance abuse and mental illness, treat- case management and, 70 ing, 31 cultural awareness, 38 syncretistic, 138, 298 limitations and abilities, understanding, Taoist version of CBT, 124 44–45 of White Americans, 151, 152 racial, ethnic, and cultural identities, resistance, as stage in racial and cultural iden- identifying, 38, 39–41, 40, 41, 42 tity development, 40 RESPECT mnemonic, 44 respect, culturally competent counselors show- stereotyping, prejudices, and history, 43– ing, 49 44, 44 RESPECT mnemonic, 44 trust and power issues, 44 respeto, 134, 298 worldviews, individual and clinical, 42– retention strategies for workforce and staff, 43, 43, 72 90–91 Self-Management and Recovery Training, 156 rituals sensitivity, culturally competent counselors of cultures of recovery, 174 showing, 50 of drug cultures, 167, 168 SES. See socioeconomic status Rural Hawai’i Behavioral Health Program, sexual identity and orientation, 29 127 shame, 1, 32, 60, 61, 117, 119, 121, 122 shen-k’uei, 284 S shenjing shuairuo, 285 SAMHSA. See Substance Abuse and Mental silence, cultural comfort with, 17 Health Services Administration simpatía, 17, 253, 298 Santería, 138 skra prameha, 284 Save Our Selves, 156 social constructs Schedules for Clinical Assessment in Neuro- gender as, 19 psychiatry (SCAN), 68 race as, 13 schizophrenia, 18, 21, 105–106, 119 socioeconomic status (SES), 20–22 screening and assessment tools, 65–69, 68, acculturation and substance abuse, 26 277, 277–281 culturagrams, 66–67 seasonal/migrant workers, 24 drug cultures and, 162, 169 Secular Organizations for Sobriety, 156 education and, 21–22, 22 segmented assimilation, 24 health disparities and, 20

323 Improving Cultural Competence

health, social determinants of, 21 by Pacific Islanders, 127 solution-focused interventions, 123 religion and spirituality, 31 South and Central Americans, 32, 129, 131, SES and, 21, 22, 26 135, 285. See also Hispanics and Latinos sexual identity and orientation, 29 spirituality. See religion and spirituality by White Americans, 150–152, 155 Standards of Practice for Case Management Substance Abuse and Mental Health Services (Case Management Society of America, Administration (SAMHSA), 290. See also 2010), 71 Health Resources and Services Administra- Standards on Cultural Competence in Social Work tion; National Survey on Drug Use and Practice (National Association of Social Health (NSDUH) data; Treatment Im- Workers, 2001), 71 provement Protocols Stanford University Curriculum in Ethnogeri- guiding principles of recovery, 175 atrics, 290 Targeted Capacity Expansion Program, Star Trek terminology and crack cocaine use, CSAT, 98 164 TTA (Tribal Training and Technical As- stereotyping, by counselors, 43–44, 44 sistance) Center, 293 strategic planning, by organizations, 78 Sue’s multidimensional model for developing strength-based interviews, 61 cultural competence, xv, 5–7, 6, 36, 37, 58, Subanun people, 30 74, 102, 103, 160, 161 subcultures, 62–63, 160, 161–162 suicide, 3, 141, 143 substance abuse. See also co-occurring disor- sun dance, 148 ders; drug cultures; Treatment Improve- supportive-expressive psychotherapy, 111 ment Protocols; 12-Step programs, under T surveys of clients, staff, and community mem- acculturation and, 25 bers, 85, 85–87, 86, 273–275 by African Americans, 27, 104–105 susto, 285 by Asians and Asian Americans, 1, 57, sweat lodges, 102, 148 117–119 syncretistic religions, 138, 298 Buddhism and, 32–33 cultural identification and, 26–27 T culture of recovery and, xxi, 173, 173– taijin kyofusho, 285 175, 174, 175 talking circle, 158 defined, 3 Taoist version of CBT, 124 diagnosing, 68–69 Targeted Capacity Expansion Program, educational factors, 21–22 CSAT, 98 exercise on benefits, losses, and the fu- TEDS (Treatment Episode Data Sets; 2001- ture, 170–171 2011), 107 gender roles and, 20 Temperance Movement, 151 geographic factors, 18 terapia dura, 137 by Hispanics and Latinos, 35–36, 129– TIPs. See Treatment Improvement Protocols 131, 130 touch, culturally specific meanings of, 52 historical trauma leading to, 28 traditional/alternative healing practices immigrants and, 23, 25–26, 130 acupuncture, 126 Islam and, 32 adapting intervention strategies to, 72 Judaism and, 31–32 African Americans and, 114–115 by Native Americans, 26–27, 139–141 Asian Americans and, 126–128

324 Index

cao gio, 126 TIP), 139 circles, in Native American philosophy, Brief Interventions and Brief Therapies for 147, 148 Substance Abuse (TIP 34), 157 complex cultural problems, counselors al- Enhancing Motivation for Change in Sub- lowing for, 51 stance Abuse Treatment (TIP 35), 69, counselor attitudes to, 37 70, 157 counselor awareness of, 49 Relapse Prevention and Recovery Promotion dances, sacred, 148 in Behavioral Health Services (planned in Hispanic and Latino culture, 137–138 TIP), 128, 157, 173–174 mainstream attitudes to, 10 Substance Abuse: Clinical Issues in Intensive of Native Americans, 72, 102, 144, 147– Outpatient Treatment (TIP 47), 157 149, 148 Substance Abuse Treatment: Addressing the organizational attitudes to, 10 Specific Needs of Women (TIP 51), 20, purification ceremonies, 72, 148 123, 157 sweat lodges, 102, 148 Substance Abuse Treatment and Family White Americans and, 156 Therapy (TIP 39), 19, 146, 157 yin/yang balance, 126 Substance Abuse Treatment for Adults in the traditions and values. See worldviews, values, Criminal Justice System (TIP 44), 157 and traditions Substance Abuse Treatment for Persons With training Co-Occurring Disorders (TIP 42), 20, exercise on benefits, losses, and the fu- 157 ture, 170–171 Substance Abuse Treatment: Group Therapy in language services, 89–90 (TIP 41), 155, 157 of workforce and staff, 91, 91–93, 92, 93 Trauma-Informed Care in Behavioral transculturation, 298 Health Services (TIP 57), 23, 28, 157 translators, 88, 88–90, 90, 287 treatment planning. See evaluation and treat- trauma, personal or historical, 28–29 ment planning African American, 28, 108, 109–110 Tribal service providers, 139, 142 Asian or Asian American, 119–120 Tribal Training and Technical Assistance in evaluation and treatment planning, 63, (TTA) Center, SAMHSA, 293 67 tripa ida, 285 Native American, 28, 140, 142 trust and power issues, 44, 52, 109–110 PTSD, 105, 106, 119, 142 TTA (Tribal Training and Technical Assis- of racial and ethnic groups, 28–29, 106 tance) Center, SAMHSA, 293 Trauma-Informed Care in Behavioral 12-Step programs Health Services (TIP 57), 23, 28, 157 for African Americans, 111, 113–114 treatment, attitudes toward. See health, illness, for Asians and Asian Americans, 125 and healing culture of recovery and, 174 Treatment Episode Data Sets (TEDS; 2001- for Hispanics and Latinos, 136–137 2011), 107 for Jewish people, 32 Treatment Improvement Protocols (TIPs) Lakota version, 147 Addressing the Specific Behavioral Health for Native Americans, 49, 102, 146–147, Needs of Men (TIP 56), 20 147 Behavioral Health Services for American for White Americans, 155, 156 Indians and Alaska Natives (planned

325 Improving Cultural Competence

U language and communication issues, 17 undocumented immigrants, 22, 66–67, 134 mental disorders, 153 Urban Indian Health Institute, 140 personal space, cultural differences re- U.S. Census Bureau racial and ethnic groups, garding, 51 xvi, 13 power and trust issues, 52 U.S. Department of Health and Human Ser- recovery and relapse prevention for, 156– vices (HHS). See also Office of Minority 157 Health religion and spirituality, 151, 152 definition of cultural competence, xv substance use and abuse and drug cul- health disparities, defined, 7 tures, 150–152, 155 Healthy People 2020, 21 traditional/alternative healing practices, Mental Health: Culture, Race, and Ethnici- 156 ty (Surgeon General’s report, 2001), treatment patterns, 153 290 White Bison program, 147, 294 Office of Civil Rights, 289 White privilege, 298 U.S. Department of Veterans Affairs, 116 White racial identity development (WRID) model, 39, 40, 41, 42 V WHO (World Health Organization), 68 value statements, of organizations, 77–78, 78 Women for Sobriety, 156 values. See worldviews, values, and traditions World Health Organization (WHO), 68 Veterans Affairs, U.S. Department of, 116 worldviews, values, and traditions veterans, Native American, 142 clinical worldview, 43 Vietnamese, 14, 22, 118, 119, 126, 292. See also of counselors, 42–43, 43, 72 Asians and Asian Americans culturagrams, 66–67 Village Sobriety Project, 148 cultural differences in, 18–19 vision statements, 77–78, 78 of culture of recovery, 174 of drug cultures, 165, 166 W organizational cultural competence and, Wellbriety movement, 49, 147 75, 76–78, 77, 78 White Americans, 13–14, 150–157. See also WRID (White racial identity development) immigrants model, 39, 40, 41, 42 CODs, 153 cultural identities of, 39, 154 Y defined, 298 yin/yang balance, 126 evaluation and treatment planning for, Yup’ik Eskimo, 148 154–156 families, concepts of and attitudes about, 19 gender roles, 19 health, illness, and healing, attitudes to- ward, 153–154

326 SAMHSA TIPs and Publications Based on TIPs What Is a TIP? Treatment Improvement Protocols (TIPs) are the products of a systematic and innovative process that brings together clinicians, researchers, program managers, policymakers, and other federal and non-federal experts to reach consensus on state-of-the-art treatment practices. TIPs are developed under the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Knowledge Application Program (KAP) to improve the treatment capabilities of the Nation’s alcohol and drug abuse treatment service system. What Is a Quick Guide? A Quick Guide clearly and concisely presents the primary information from a TIP in a pocket-sized booklet. Each Quick Guide is divided into sections to help readers quickly locate relevant material. Some contain glossaries of terms or lists of resources. Page numbers from the original TIP are referenced so pro- viders can refer back to the source document for more information. What Are KAP Keys? Also based on TIPs, KAP Keys are handy, durable tools. Keys may include assessment or screening in- struments, checklists, and summaries of treatment phases. Printed on coated paper, each KAP Keys set is fastened together with a key ring and can be kept within a treatment provider’s reach and consulted fre- quently. The Keys allow you, the busy clinician or program administrator, to locate information easily and to use this information to enhance treatment services. Ordering Information Publications may be ordered or downloaded for free at http://store.samhsa.gov. To order over the phone, please call 1-877-SAMHSA-7 (1-877-726-4727) (English and Español). TIP 1 State Methadone Treatment Guidelines— TIP 10 Assessment and Treatment of Cocaine- Replaced by TIP 43 Abusing Methadone-Maintained Patients— TIP 2 Pregnant, Substance-Using Women— Replaced by TIP 43 Replaced by TIP 51 TIP 11 Simple Screening Instruments for Outreach TIP 3 Screening and Assessment of Alcohol- and for Alcohol and Other Drug Abuse and Other Drug-Abusing Adolescents—Replaced Infectious Diseases—Replaced by TIP 53 by TIP 31 TIP 12 Combining Substance Abuse Treatment TIP 4 Guidelines for the Treatment of Alcohol- With Intermediate Sanctions for Adults in and Other Drug-Abusing Adolescents— the Criminal Justice System—Replaced by Replaced by TIP 32 TIP 44 TIP 5 Improving Treatment for Drug-Exposed TIP 13 Role and Current Status of Patient Infants Placement Criteria in the Treatment of Substance Use Disorders TIP 6 Screening for Infectious Diseases Among Quick Guide for Clinicians Substance Abusers—Archived Quick Guide for Administrators TIP 7 Screening and Assessment for Alcohol and KAP Keys for Clinicians Other Drug Abuse Among Adults in the Criminal Justice System—Replaced by TIP 44 TIP 14 Developing State Outcomes Monitoring Systems for Alcohol and Other Drug Abuse TIP 8 Intensive Outpatient Treatment for Alcohol Treatment and Other Drug Abuse—Replaced by TIPs 46 and 47 TIP 15 Treatment for HIV-Infected Alcohol and Other Drug Abusers—Replaced by TIP 37 TIP 9 Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse—Replaced by TIP 42

327 Improving Cultural Competence

TIP 16 Alcohol and Other Drug Screening of TIP 27 Comprehensive Case Management for Hospitalized Trauma Patients Substance Abuse Treatment Quick Guide for Clinicians Case Management for Substance Abuse KAP Keys for Clinicians Treatment: A Guide for Treatment Providers TIP 17 Planning for Alcohol and Other Drug Case Management for Substance Abuse Abuse Treatment for Adults in the Criminal Treatment: A Guide for Administrators Justice System—Replaced by TIP 44 Quick Guide for Clinicians Quick Guide for Administrators TIP 18 The Tuberculosis Epidemic: Legal and Ethical Issues for Alcohol and Other Drug TIP 28 Naltrexone and Alcoholism Treatment— Abuse Treatment Providers—Archived Replaced by TIP 49 TIP 19 Detoxification From Alcohol and Other TIP 29 Substance Use Disorder Treatment for Drugs—Replaced by TIP 45 People With Physical and Cognitive Disabilities TIP 20 Matching Treatment to Patient Needs in Quick Guide for Clinicians Opioid Substitution Therapy—Replaced by Quick Guide for Administrators TIP 43 KAP Keys for Clinicians TIP 21 Combining Alcohol and Other Drug Abuse TIP 30 Continuity of Offender Treatment for Treatment With Diversion for Juveniles in Substance Use Disorders From Institution the Justice System to Community Quick Guide for Clinicians and Quick Guide for Clinicians Administrators KAP Keys for Clinicians TIP 22 LAAM in the Treatment of Opiate TIP 31 Screening and Assessing Adolescents for Addiction—Replaced by TIP 43 Substance Use Disorders TIP 23 Treatment Drug Courts: Integrating See companion products for TIP 32. Substance Abuse Treatment With Legal TIP 32 Treatment of Adolescents With Substance Case Processing Use Disorders Quick Guide for Administrators Quick Guide for Clinicians TIP 24 A Guide to Substance Abuse Services for KAP Keys for Clinicians Primary Care Clinicians TIP 33 Treatment for Stimulant Use Disorders Concise Desk Reference Guide Quick Guide for Clinicians Quick Guide for Clinicians KAP Keys for Clinicians KAP Keys for Clinicians TIP 34 Brief Interventions and Brief Therapies for TIP 25 Substance Abuse Treatment and Domestic Substance Abuse Violence Quick Guide for Clinicians Linking Substance Abuse Treatment and KAP Keys for Clinicians Domestic Violence Services: A Guide for Treatment Providers TIP 35 Enhancing Motivation for Change in Linking Substance Abuse Treatment and Substance Abuse Treatment Domestic Violence Services: A Guide for Quick Guide for Clinicians Administrators KAP Keys for Clinicians Quick Guide for Clinicians TIP 36 Substance Abuse Treatment for Persons KAP Keys for Clinicians With Child Abuse and Neglect Issues TIP 26 Substance Abuse Among Older Adults Quick Guide for Clinicians Substance Abuse Among Older Adults: A KAP Keys for Clinicians Guide for Treatment Providers Helping Yourself Heal: A Recovering Woman’s Substance Abuse Among Older Adults: A Guide to Coping With Childhood Abuse Guide for Social Service Providers Issues Substance Abuse Among Older Adults: Also available in Spanish Physician’s Guide Helping Yourself Heal: A Recovering Man’s Quick Guide for Clinicians Guide to Coping With the Effects of KAP Keys for Clinicians Childhood Abuse Also available in Spanish

328 SAMHSA TIPs and Publications Based on TIPs

TIP 37 Substance Abuse Treatment for Persons TIP 47 Substance Abuse: Clinical Issues in With HIV/AIDS Outpatient Treatment Quick Guide for Clinicians Quick Guide for Clinicians KAP Keys for Clinicians KAP Keys for Clinicians Drugs, Alcohol, and HIV/AIDS: A Consumer TIP 48 Managing Depressive Symptoms in Guide Substance Abuse Clients During Early Also available in Spanish Recovery Drugs, Alcohol, and HIV/AIDS: A Consumer TIP 49 Incorporating Alcohol Pharmacotherapies Guide for African Americans Into Medical Practice TIP 38 Integrating Substance Abuse Treatment and Quick Guide for Counselors Vocational Services Quick Guide for Physicians Quick Guide for Clinicians KAP Keys for Clinicians Quick Guide for Administrators TIP 50 Addressing Suicidal Thoughts and KAP Keys for Clinicians Behaviors in Substance Abuse Treatment TIP 39 Substance Abuse Treatment and Family Quick Guide for Clinicians Therapy Quick Guide for Administrators Quick Guide for Clinicians TIP 51 Substance Abuse Treatment: Addressing the Quick Guide for Administrators Specific Needs of Women Family Therapy Can Help: For People in Quick Guide for Clinicians Recovery From Mental Illness or Addiction Quick Guide for Administrators TIP 40 Clinical Guidelines for the Use of KAP Keys for Clinicians Buprenorphine in the Treatment of Opioid TIP 52 Clinical Supervision and Professional Addiction Development of the Substance Abuse Quick Guide for Physicians Counselor KAP Keys for Physicians Quick Guide for Clinical Supervisors TIP 41 Substance Abuse Treatment: Group Quick Guide for Administrators Therapy TIP 53 Addressing Viral Hepatitis in People With Quick Guide for Clinicians Substance Use Disorders TIP 42 Substance Abuse Treatment for Persons Quick Guide for Clinicians and With Co-Occurring Disorders Administrators Quick Guide for Clinicians KAP Keys for Clinicians Quick Guide for Administrators TIP 54 Managing Chronic Pain in Adults With or KAP Keys for Clinicians in Recovery From Substance Use Disorders TIP 43 Medication-Assisted Treatment for Opioid Quick Guide for Clinicians Addiction in Opioid Treatment Programs KAP Keys for Clinicians Quick Guide for Clinicians You Can Manage Your Chronic Pain To Live a KAP Keys for Clinicians Good Life: A Guide for People in Recovery TIP 44 Substance Abuse Treatment for Adults in From Mental Illness or Addiction the Criminal Justice System TIP 55 Behavioral Health Services for People Who Quick Guide for Clinicians Are Homeless KAP Keys for Clinicians TIP 56 Addressing the Specific Behavioral Health TIP 45 Detoxification and Substance Abuse Needs of Men Treatment TIP 57 Trauma-Informed Care in Behavioral Quick Guide for Clinicians Health Services Quick Guide for Administrators KAP Keys for Clinicians TIP 58 Addressing Fetal Alcohol Spectrum Disorders (FASD) TIP 46 Substance Abuse: Administrative Issues in Outpatient Treatment TIP 59 Improving Cultural Competence Quick Guide for Administrators

329 HHS publication no. (SmA) 14-4849 First printed 2014 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and mental Health Services Administration center for Substance Abuse Treatment