Transcript Cultivating Cultural Competence in Behavioral Health

ADDRESSING
Culturally Competent Clinical
Interviews
“It is said that we are spirits on a human journey. In
this journey, health and well-being are a result of
the complex interplay between the physical world
(i.e., our bodies), our mental processes (our
thoughts and emotions), our environment (our
family, culture, etc.), and the spiritual forces outside
of us and the spiritual learned practices that
become part of us. This perspective is sometimes
referred to as the relational world view.”
Terry Cross (1998, p. 1). Spirituality & Mental Health: A Native American
Perspective. Focal Point, 15(2), pp. 1-4.
Caveats
• What I have to Offer
– Educator/practitioner
• My perspective is limited by my
sociopolitical location
– Am engaged in learning
– Will make mistakes
– Please remind me about strengths!
Integrate Diversity
– From now on I expect you to integrate
diversity more thoroughly into assessment
& service planning, especially:
• With clients who don’t have an immediate awareness
of their “culture” or do not see its relevance
• Without stereotyping clients
• By going beyond race/ethnicity & religion & “cultural
preferences” as dimensions of diversity
Cultural Competence More Than
Cultural Preferences
Multiple Dimensions of Cultural
Competence
Culture & Assessment
Historical & Modern Context for
Assessment & Service Planning
• Clients strengths/challenges related to:
– Local, State, National, & Global Events
– Oppression
– Privilege
– Accessibility of services
– Stigma
Identity & Identity Development
in Context
• The importance of names
• Honoring identities (allowing for selfdefinition)
• Intersectionality of identity
• Expression of identity context-dependent
Asking Good Questions
(Hays, 2001)
• Establish respect and rapport (respeto)
• Use knowledge/experience to formulate
questions & hypotheses
• Framing open-ended questions
– Providing a client-centered rationale
– Using your knowledge of client’s culture
– Using the client’s language
– Using self-disclosure (personalismo)
ADDRESSING Cultural
Complexities in Practice
Cultural Complexities
Appear as:
• Internalized beliefs &
attitudes
• External resources &
barriers
• Behaviors
– Decisions
– Actions and…
Feelings/emotions!
ADDRESSING Framework
(Hays, 2001)
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Age & generational influences
Developmental disabilities & acquired
Disabilities
Religion & Spiritual Orientation
Ethnicity
Socioeconomic Status
Sexual Orientation
Indigenous Heritage
National Origin
Gender
Age & Generational Influences
Age & Generational Influences
• Intergenerational resources
• Intergenerational conflict
• Suicide risks vary by age (related to
developmental crises, exacerbated by
substance abuse, psychopathology, &
social isolation)
• Timeline
Developmental & Acquired
Disabilities
Developmental & Acquired
Disabilities
(Olkin, 2002)
• 15% of U.S. population are people with
disabilities
• 66% of people with disabilities
unemployed
• Largest minority group [hidden] in U.S.
• Topic of disability neglected by graduate
programs
– If offered, focus on medical model
Disability a Minority Status (Olkin, 2002)
Similarities
• Experience prejudice,
stigma, oppression
• Experience barriers to
accessing services
• Not automatically
included – marginalized
by majority group
• Underrepresented
• Underserved
• Have to “appear happy &
grateful”
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Dissimilarities
Separate may be equal
Often the only one in their
family (like LGB)
Non-adaptive
environment at home
Often include pain,
fatigue, and muscle
weakness
Often require adaptive
equipment etc.
Costly
Developmental & Acquired
Disabilities: Three Models
(Olkin, 2002, p. 133)
• Moral Model (most common worldwide)
– Disability:
• Is a defect, result of immorality, a test of faith, a
curse
• Elicits shame in the person and the family
• “God gives us only what we can bear” “Things like
this only happen for a reason” “What did I do to
serve this?”
(Olkin, 2002, p. 133)
• Implications of Moral Model:
– Acceptance of disability on spiritual grounds
– May embrace a greater sense of purpose in
relation to the disability
– May assume a special relationship with God
– May experience acute shame and
ostracization
– May hide the disability or the person with the
disability
(Olkin, 2002, p. 133)
• Medical Model (Most common model in U.S.)
– Disability is
• A physical defect or failure
• Result of pathology
• Result of poor health, bad habits, unhealthy
behavior
• Patients treated as their diagnosis
(Olkin, 2002, p. 133)
• Implications of Medical Model:
– Receive treatment and get “cure” or “relief”
– Reduced shame or stigma
– Trust in medical interventions
– Surge in medical research
– Paternalism and marginalization
– Services provided to, but not by people with
disabilities
(Olkin, 2002, p. 133)
• Social Model (empowerment model)
– Disability
• Is a social construct
• Problems in the environment NOT the
person
• Negative effects from oppression & stigma
• 1970’s “reframe” part of consumer rights
movement - “Nothing about us without us”
(Olkin, 2002, p. 133)
• Implications of Social Model:
– Increased access and influence on policy,
politics, economics, rights, and protections
– Integration of disability with sense identity
– Pride in oneself and in membership with
disability community
– De-pathologizes disability
– Social construct seems immutable
– Hard to change entrenched attitudes
Stigma of Mental Illness
Causes Harm
(Corrigan, 2004)
• Public Stigma
– Blocks acquisition of
good jobs & housing
– Criminalizes mental
illness
– Barrier to health care
– Lack of parity for
insurance benefits
– Avoidance of
services & reduced
compliance
• Self-Stigma
– Internalized prejudice
– Reduced self-esteem
– Diminished selfefficacy
– Shame
– Family shame
– Culturally mediated
– Avoidance of
services & reduced
compliance
Religion & Spiritual Orientation
Religion & Spiritual Orientation
(Walsh, 1998, p. 64)
• Religions are
organized beliefs
systems & include:
• Institutionalized moral
values
• Beliefs about God
• Involvement in a
religious community
• Spirituality is an
overarching construct
& involves:
– Personal beliefs about
the ultimate human
condition or a supreme
being or unity of
nature & universe
– A set of values
– Can be found inside or
outside of formal
religion
Sources of Resilience:
(Walsh, 1998)
• Strength found in sense of community & collaboration
• Meaning attributed to adversity
– Sense of Coherence
– Pathways to Integration
• Hope
– Initiative & invention
– Perseverance
– Encouragement & Confidence
• Humor
• Transcendent Beliefs
– Values & Purpose
– Religion & Spirituality
Religion & Spiritual Orientation
Dalai Lamai (1998, p. 15)
“Religions are like medicine in that the important thing is to
cure human suffering. In the practice of medicine, it is not a
question of how expensive the medicine is; what is
important is to cure the illness in a particular patient.
Similarly, you see, there is a variety of religions with their
different philosophies and traditions. The aim is to cures
the pains and unhappiness of the human mind. Here too, it
is not a question of which religion is superior as such. The
question is which will cure a particular person.”
Every Religion has a Gift
“Every religion has a specific gift to offer
humankind; every religion brings with it a unique
viewpoint which enriches the world. Christianity
stresses love and sacrifice; Judaism, the value of
spiritual wisdom & tradition. Islam emphasizes
universal brotherhood and equality while Buddhism
advocates compassion & mindfulness. The Native
American tradition teaches reverence for the earth
and the natural world surrounding us. Vedanta or
the Hindu tradition stresses the oneness of
existence and the need for direct mystical
experience” (Vrajaprana, 1999, p. 56).
Ethnicity
Ethnicity
(Casas, 1995; Phinney, 1990)
• Group of persons who share a unique
social and cultural heritage.
• Ethnic identity varies along the three
dimensions:
– Cultural norms & values
– Strength, salience, & meaning of cultural
identity
– Experiences & attitudes associated with
minority & majority status in U.S. culture
Ethnic/Cultural Guideposts
• Family life cycle
– Definition of family
– Roles
– Parenting practices
– How decisions made
• Human development (consider Erikson)
– Rituals/markers/milestones
– Attitudes toward change
• Work Life
– definitions of success
Ethnic/Cultural Guideposts
• Meaning & causes of
– Health/wellness
– Illness/mental illness
– Familiarity with behavioral health services/psychotherapy
• Resources
– Coping
– Kinship Networks
– Natural helpers
• Racial/Cultural Identity Development
• White Racial Identity Development
• Biracial Identity Development
Ethnic/Cultural Guideposts
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Immigration history (legal status)
Acculturation/acculturative Stress
Linguistic capabilities & preferences
Experiences of oppression
– Coping with racism, sexism, ableism, antiSemitism, heterosexism
Ethnic/Cultural Guideposts
• Values
– Collectivism/Individualism
– Self-directedness/fatalism
– Duty
– Respect
• Existential themes
– Purpose/meaningfulness
– Isolation
– Loss/Death
Acculturation
(Falicov, 1998, p. 39)
• Individuals gradually lose their culture of
origin as they adopt values & behavior of
new culture
• May experience marginalization by host
culture
– Leads to ACCULTURATIVE STRESS
– Identity conflicts, changing values, linguistic
differences
– Produces secondary conflict
Acculturation
Berry (1980)
• Assimilation
– relinquish ones beliefs & assume beliefs & attitudes of
majority group
• Separation
– Withdraw from dominant culture
• Marginalization
– Cannot identify with own group or majority culture
• Integration (healthiest)
– Ethnic identity and dominant culture integrated
Identity Development
(Tatum, 1997, p. 94)
• According to Janet
Helms, “task for
people of color is to
resist negative
societal messages
and develop an
empowered sense of
self in the face of a
racist society…”
• “…the task for Whites
is to develop a
positive White identity
based on reality and
not on assumed
superiority”
Racial/Cultural Identity
Developmental Tasks
• Move from a White frame of reference to a
positive [racial/cultural] frame of reference
(Cross, 1971).
• Move towards greater acceptance of one’s
culture and ethnicity (Ruiz, 1990).
• Commitment to eliminating all forms of
oppression.
White Racial Identity Development
• Two Developmental Tasks:
– Abandon individual racism
– Recognize and oppose institutional and
cultural racism.
Biracial Identity
Development
A complicated process in a racially
bifurcated society
Strategies for Resolution of
Bi-Racial Identity
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Acceptance of identity society assigns
Identification with both racial groups
Identification with a single racial group
Identification with a new racial group
Socioeconomic Status
Socioeconomic Status
• More than educational attainment, income, or
occupational prestige
• Reflects access to
– Resources
– Societal control, & influence
• Social valuation identity (class consciousness)
• More powerful predictor of worldview than family
structure, race, religion, national origin, income,
or subjective class status
Poverty associated with:
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Poor health
Impaired productivity
Substandard physical environment
Increased stress and diminished emotional wellbeing
• Family conflict & marital strife
• Shame & stress (Dr. Steven Bezruchka, 2003)
– Class warfare - “There is a war going on right now and it is the rich who are
attacking everybody else.”
– Wealth brings freedom form stress and many more choices
– Culture of poverty and culture of inequality effects health
Sexual Orientation
Sexual Orientation
“an enduring emotional, romantic,
sexual or affectional attraction to
[(an)other person(s)] … that ranges
from exclusively homosexual to
exclusively heterosexual & includes
various forms of bisexuality” (APA,
1998).
Sexual Orientation Identity
Development
(Worthington, et al., 2002)
Sexual orientation identity development is
a term that describes the process of
accepting and recognizing one’s own
sexual identity, typically as straight, gay,
lesbian, or bi-.
Heterosexual Identity Development
(Worthington et al., 2002)
• Influenced by:
– Biology
– Gender norms & socialization
– Religious orientation
– Microsocial context (one’s social circle)
– Culture (including events)
– Systemic homonegativity, sexual prejudice, &
privilege
Lesbian/Gay/Bi-Sexual Identity
Development Lifelong Process
(deMonteflores & Schultz, 1978):
• Adopting a nontraditional identity
• Restructuring ones self-concept
• Altering ones relations with others and
society
• Two levels of coming out
– To oneself
– To others
Indigenous Heritage
Indigenous Heritage
• Those whose ancestors were first to inhabit a
specific area (Herring, 1997, p. 53).
• Culture existing or enduring pre-migration
• Culture existing or enduring from precolonization & pre-subjugation by another
nation-state
– “Fourth world” status – a minority indigenous group
exists within a dominant nation-state
Yellow Bird, 2001, p. 61
“Many Indigenous Peoples are mistakenly called Indians,
American Indians, or Native Americans. They are not
Indians or American Indians because they are not from
India. They are not native Americans because Indigenous
Peoples did not refer to their lands as America until
Europeans arrived and imposed this name on the land.
Indians, American Indians, and Native Americans are
“colonized” and “inaccurate” names that oppress the
identities of First Nations Peoples.”
National Origins
National Origin
• National Identity
• Country or residence
• Primary language
Gender
Gender
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Assigned sex
Socialization in family, community, & culture
Norms & expectations
Roles
Double-standards
Experiences of gender role enforcement
Gender identity development
– Male/female
– Traditional/non-traditional
Transgender
• Multiple self-definitions (e.g., two-spirit people,
transgenderist, drag king/queen, genderblend,
androgyne)
• Any sexual orientation
• 9-point continuum of gender self-concept from female (F) to genderblending/female
predominated (GB/F) to othergendered
(O) to ungendered (U) to bigendered (B) to
GB/male predominating (GB/M) and so on.
Putting It All Together
Multicultural Case
Conceptualization Ability
(Constantine & Ladany, 2000)
• Counselor’s Ability to:
– Comprehend and integrate the impact
of various cultural factors on a client’s
presenting concerns.
– Articulate an appropriate treatment
plan for working with a client based on
this knowledge.