Improving Cultural Competence
Instructor: Dr. Dawn-Elise Snipes, PhD, LPC-MHSP, LMHC
Executive Director: Counselor education
Podcast Host: Counselor Toolbox, Happiness Isn’t Brain Surgery

On-Demand Counseling CEUs are available at

~ Define assumptions about cultural competence
~ Define Race, Ethnicity and Culture
~ Explore the problems with limited cultural competence

~ Assumption 1: Counselors will not be able to sustain culturally responsive treatment without the organization's commitment to it.
~ Assumption 2: An understanding of race, ethnicity, and culture (including one's own) is necessary to appreciate the diversity of human dynamics and to treat all clients effectively
~ Assumption 3: Incorporating cultural competence into treatment improves therapeutic decision-making and offers alternate ways to define and plan a treatment program that is firmly directed toward progress and recovery
~ Assumption 4: Consideration of culture is important at all levels of operation—individual, programmatic, and organizational
~ Assumption 5: Culturally congruent interventions cannot be successfully applied when generated outside a community or without community participation.
~ Assumption 6: Public advocacy of culturally responsive practices can increase trust among the community, agency, and staff.
Cultural Identification
~ Not all clients identify with or desire to connect with their cultures
~ Culturally responsive services offer clients a chance to explore the impact of culture, acculturation, discrimination, and bias, and how these impacts relate to or affect their mental and physical health.
~ The Affordable Care Act, (HHS 2011b) necessitates enhanced culturally responsive services and cultural competence among providers.
Problems with Limited Cultural Competence
~ Limited cultural competence is a significant barrier that can translate to:
~ Ineffective provider–consumer communication
~ Delays in appropriate treatment and level of care
~ Misdiagnosis
~ Lower rates of treatment compliance
~ Clients feeling misunderstood
~ Clients feeling judged
~ Clinicians making inappropriate treatment recommendations
~ Poorer outcome
Culturally Responsive Practice
~ Culturally responsive practice reminds counselors that a client's worldview shapes his or her:
~ Perspectives (How things “should be,” What goals to strive for)
~ Beliefs (ex. Just world, why things happen)
~ Behaviors surrounding addictive behaviors (Alcohol, illicit drugs, sex, gambling, eating disorders)
~ Beliefs about illness and health (East vs. West, God’s punishment vs Natural progression)
~ Seeking help (Airing “dirty laundry,” participation in face to face vs virtual treatment, LEO/Military, elderly)
~ Counseling expectations (LEO/Military, criminally involved)
~ Communication (Openness, methods)
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.
~ Individual Level: Counselors can also operate from this stance, holding a myopic view of “effective” treatment.
~ Stage 2. Cultural Incapacity
~ Organizational Level: Organizational culture may be biased, and clients may view them as oppressive. An agency functioning at cultural incapacity expects clients to conform to generalized services
~ Individual Level: Counselors ignore the relevance of culture while using the dominant client population and/or culture as the norm for assessment, treatment planning, and determination of services.
Continuum cont…
~ 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.
~ 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 subject to the biases of others.
Continuum cont…
~ 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.
~ Individual Level: Counselors acknowledge a need for more training specific to the populations they serve
~ Stage 5. Cultural Competence and Proficiency
~ Organizational Level: Organizations are aware of the importance of integrating services that are congruent with diverse populations.
~ Individual Level: Recognition of the vital need to adopt culturally responsive practices.
~ Race is a social construct that describes people with shared physical characteristics
~ The perception that people who share physical characteristics also share beliefs, values, attitudes, and ways of being can have a profound impact on people's lives regardless of whether they identify with the race to which they are ascribed by themselves or others
~ Racial categories also do not easily account for the complexity of multiracial identities.
~ 3 percent of United States residents are multiracial and that is expected to grow to 20% by 2050
~ Many subgroups of White Americans (of European, Middle Eastern, or North African descent) have had very different experiences when immigrating to the United States.
~ The racial designation Black, however, encompasses a multitude of cultural and ethnic variations and identities i.e. African Caribbean, African Bermudian, West African
~ African American culture embodies elements of Caribbean, Latin American, European, and African cultural groups
~ Asian Americans comprised about 43 ethnic subgroups, speaking more than 100 languages and dialects
~ Native American is a term that describes both American Indians and Alaska Natives
~ There are 566 federally recognized American Indian or Alaska Native Tribal entities
~ Because Latinos can belong to a number of races, the Census Bureau defines them as an ethnic group rather than a race
~ Why not African American, Asian American or Native American?
~ Ethnicity refers to the social identity and mutual sense of belonging that defines a group of people through common historical or family origins, beliefs, and culture
~ Ethnicity differs from race in that groups of people can share a common racial ancestry yet have very different ethnic identities.
~ Ethnicity—unlike race—is an explicitly cultural phenomenon based on a shared cultural or family heritage as well as shared values and beliefs rather than shared physical characteristics.
~ Culture is not a definable entity to which people belong or do not belong.
~ Race or community, people belong to multiple cultural groups, each with its own set of cultural norms
~ The word “culture” can be applied to describe the ways of life of groups formed on the bases of:
~ Age: Babyboomers, Milennials, Gen-X
~ Profession: Lawyers, Therapists, Factory workers
~ Socioeconomic status: Poor, Middle class, Wealthy
~ Disability: Deaf, Blind, Wheelchair, Schizophrenia
~ Sexual orientation: GLBTQ
~ Geographic location: New York City, Nashville, Clarksville
~ Membership in self-help support groups: 12-Step

Cultural Identity
~ Cultural identity describes an individual's affiliation or identification with a particular group or groups.
~ Cultural identity arises through the interaction of individuals and culture(s) over the life cycle.
~ Cultural identities are not static; they develop and change across stages of the life cycle.
~ People reevaluate their cultural identities and sometimes resist, rebel, or reformulate them over time. (Remember High School; Midlife “crisis”)
Elements which constitute a culture

~ Identity development
~ Rites of passage
~ Broad role of sex and sexuality
~ Images, symbols, and myths
~ Religion and spirituality
~ View, use, and sources of power and authority
~ Role and use of language
~ Ceremonies, celebrations, and traditions
~ Learning modalities, acquisition of knowledge and skills

Elements which constitute a culture
~ Patterns of interpersonal interaction
~ Assumptions, prejudices, stereotypes, and expectations of others
~ Reward or status systems
~ 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

Elements which constitute a culture
~ Patterns and perspectives on gender roles and relationships
~ Means of establishing trust, credibility, and legitimacy
~ Coping 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.

Worldview, Values, and Traditions

~ Culture can be seen as
~ A frame through which one looks at the world
~ A repertoire of beliefs and practices that can be used as needed
~ A narrative or story explaining who people are and why they do what they do
~ A set of institutions defining different aspects of values and traditions
~ A series of boundaries that use values and traditions to delineate one group of people from another
~ Speak with clients about their worldviews, values, and traditions and seek training and consultation to gain specific knowledge about clients' cultural beliefs and practices (Hare Krishna)
Cross-Cutting Factors in Race, Ethnicity, and Culture
~ Verbal and nonverbal communication
~ Appropriate personal space
~ Social parameters for and displays of physical contact
~ Use of silence
~ Preferred ways of moving
~ Meaning of gestures
~ Degree to which arguments and verbal confrontations are acceptable
~ Degree of formality expected in communication
~ Amount of eye contact expected
Verbal and Nonverbal Communication
~ The relative importance of nonverbal messages varies greatly from culture to culture
~ High-context cultural groups place greater importance on nonverbal cues and the context of verbal messages (utility of phone or technology assisted measures)
~ Most Asian Americans come from high-context cultural groups in which sensitive messages are encoded carefully to avoid giving offense.
~ African Americans are between Asian Americans and White Americans in their level of context in communications

Communication cont…
~ A behavioral health service provider who listens only to the literal meaning of words can miss clients' actual messages.
~ What is left unsaid, or the way in which something is said, can be more important than the words used to convey the message.
~ High-context cultural groups may not be appropriate for telemental health except video-based counseling
~ Although, avoid assuming that a client has a particular expectation or expression of nonverbal and verbal communication based solely on race, ethnicity, or cultural heritage

~ Individuals from many White/European cultural groups can be uncomfortable with extended silences
~ Native Americans place great emphasis on the value of listening and find extended silences appropriate for gathering thoughts or showing openness
~ Latinos often value genuine communication in relationships and business dealings;
~ Many Latinos also initially engage in small talk to evaluate the relationship and as a prelude to addressing serious issues

~ 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
~ 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.
~ In many Native American and Latino cultural groups, cooperation and agreeableness is valued.
Geographical Factors
~ Geographical factors can also have a significant effect on a client's culture.
~ Clients coming from a rural area—even if they come from different ethnicities—can have a great deal in common (Lake City, FL to Lebanon, TN)
~ Individuals from the same ethnicity who were raised in different geographic locales (i.e. Big city: New York vs. Nashville vs. Miami) can have very different experiences and, consequently, attitudes.
Family and Kinship
~ Concepts of and attitudes toward family are culturally defined and can vary in a number of ways, including
~ the relative importance of particular family ties
~ the family's inclusiveness
~ how hierarchical the family is
~ how family roles and behaviors are defined
~ In some cultural groups family is limited to the nuclear family, whereas in other groups the idea of family typically includes many other blood or marital relations
~ Family dynamics may change as the result of internal or external forces, such as acculturation
Socioeconomic Status and Education

~ SES in the united states is related to:
~ Occupational prestige
~ Education
~ Income level
~ SES affects culture via a person's ability to:
~ Accumulate material wealth
~ Access opportunities
~ Use resources
~ There are many forces at work that pressure a person to alter his or her cultural identity to conform to the mainstream culture's concept of a “proper” identity.
~ People may feel conflicted about their identities—wanting to fit in with the mainstream culture while also wanting to retain the values of their culture of origin. (Religion)
~ Sorting through these conflicting cultural expectations and forging a comfortable identity can be an important part of the recovery process
~ Many studies have found that increased acculturation are associated with higher rates of substance use disorders and mental health issues
~ Attitudes toward sexuality in general and toward sexual identity or orientation are culturally defined.
~ Each culture determines how to conceptualize:
~ specific sexual behaviors
~ the degree to which they accept same-sex relationships
~ the types of sexual behaviors considered acceptable
~ For more information on substance abuse treatment for persons who identify as gay, lesbian, or bisexual, refer to the CSAT (2001) publication, A Provider's Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals.
Perspectives on Health, Illness, and Healing
~ Many cultural groups hold views that differ significantly from those of western medical practice
~ Cultural groups differ in
~ How they define and determine health and illness
~ Who is able to diagnosis and treat an illness
~ Their beliefs about the causes of illness
~ Their remedies
~ There are complex rules about which members of a community or family can make decisions about health care across cultural groups
~ Any mental disorder or symptom is only considered a disorder or problem by comparison with a socially defined norm
~ (More in chapter 5)
Religion and Spirituality
~ Religious traditions or spiritual beliefs are often very important factors for defining an individual's cultural background
~ The American Religious Identification Survey reported that 47 percent of the respondents who identified culturally as Jewish were not practicing Jews
~ Religion is organized, with each religion having its own set of beliefs and practices 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
~ Culture, race and ethnicity are not the same thing.
~ Culturally responsive services take into account the needs and preferences of the individual based upon the cultures to which he or she identifies.
~ It is important to not culturally assign a client based on race, geographic location, religious orientation etc. because not all clients want or choose to identify with their expected cultures.
~ Increased acculturation is associated with poorer mental health outcomes.
~ Culture can have a huge impact on treatment compliance and effects
~ Individual therapy approaches and modalities
~ Appropriateness of group therapy
~ Appropriateness and degree of family involvement
~ Degree of “fit” between therapist and client (LE/Military, Elderly, ED)

The Cultural Orientation Resource Center
~ The Cultural Orientation Resource Center, funded by the U.S. Department of State's Bureau of Population, Refugees, and Migration
~ Provides information about topics including culture, resettlement experiences, and historical and refugee background information.
~ Provides refugee orientation materials and guidance in establishing housing, language, transportation, education, and community services, among other pressing refugee concerns.