Improving Cultural Competence
Part 2
Instructor: Dr. Dawn-Elise Snipes, PhD, LPC-MHSP, LMHC
Executive Director: Counselor education
Podcast Host: Counselor Toolbox, Happiness Isn’t Brain Surgery

~ Define “Clinical Worldview”
~ Discuss how clinical worldview impacts treatment, case formulation and rapport development
~ Explore questions to consider when developing the case formulation and treatment plan
~ Learn how mapping the client’s cultural views and influences can help clinicians (and clients) develop insights into current struggles and clarify culturally relevant goals

Worldview: The cultural lens of counseling

~ The term “worldview” refers to a set of assumptions that guide how one sees, thinks about, experiences, and interprets the world.
~ Shaped by significant relationships, the individual's environment and life experiences
~ Influences
~ Values, attitudes, beliefs, and behaviors
~ Concept of time
~ Definition of family
~ Organization of priorities and responsibilities
~ Orientation to self/ family/community
~ Religious or spiritual beliefs
~ Ideas about success
~ Etc.
Clinical World View
~ Influenced by education, clinical training, and work experiences
~ Counseling culture reflects
~ Counseling theories (Psychoanalytic, Humanistic, CBT)
~ Techniques and modalities (Individual, group, TAC)
~ General office practices. (Privacy, punctuality, Assessment/Intake)
~ This worldview and their personal cultural worldview shapes the counselor's beliefs pertaining to:
~ The nature of wellness, illness, and healing
~ Interviewing skills and behavior
~ Diagnostic impressions and prognosis.
Clinical World View
~ This worldview, coupled with their personal cultural worldview,
~ It influences
~ the definition of normal versus abnormal behavior
~ the determination of treatment priorities
~ the means of intervention
~ the definitions of successful outcomes
Cultural Awareness and Nonmalfeasance
~ Counselors must engage in self-exploration, critical thinking, and clinical supervision to understand
~ their clinical abilities and limitations regarding the services that they are able to provide,
~ the populations that they can serve
~ the treatment issues that they have sufficient training to address.
~ Cultural competence requires an ability to assess accurately one's clinical and cultural limitations, skills, and expertise.
~ Counselors risk providing services beyond their expertise if they lack awareness and knowledge of the influence of cultural groups on client–counselor relationships, clinical presentation, and the treatment process or if they minimize, ignore, or avoid viewing treatment in a cultural context.
~ Tennessee House Bill 1840
LEARN at Intake
~ Listen to each client from his or her cultural perspective, including perception of the problem and treatment preferences
~ Explain the overall purpose of the interview and intake process.
~ 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.
~ Recommend a course of action through collaboration with the client including how much involvement he or she has in the planning process
~ Negotiate a treatment plan that weaves the client's cultural norms and lifeways into treatment goals, objectives, and steps.
~ Respect—Understand and reflect how respect is shown within given cultural groups through verbal and nonverbal communications.
~ Explanatory model—Devote to understanding how clients perceive their presenting problems issues, their origin, impact and treatment
~ Sociocultural context—Recognize how class, race, ethnicity, gender, education, socioeconomic status etc. 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.
Considerations During Assessment
~ Patterns of substance use and treatment-seeking behavior specific to people of diverse racial and cultural backgrounds.
~ Beliefs about treatment, including expectations and attitudes toward health care and counseling.
~ Community perceptions of behavioral health treatment.
~ Obstacles encountered by specific populations that make it difficult to access treatment, such as geographic distance from treatment services, transportation, childcare, timing (shift work)
~ Patterns of co-occurring disorders and conditions specific to people from diverse racial and cultural backgrounds
~ Culturally appropriate screening and assessment instruments
~ Awareness of common diagnostic biases
Considerations During Assessment
~ Individual, family, and group therapy approaches specific to the racial and cultural backgrounds of diverse clients.
~ Culturally appropriate peer support, mutual-help, and other support groups (e.g., the Wellbriety movement for Native American people).
~ Traditional healing and complementary methods (e.g., use of spiritual leaders, herbs, and rituals).
~ Continuing care and relapse prevention and accessibility of care within their communities.
~ Treatment engagement/retention patterns.
Questions to Consider for Case Conceptualization
~ Does the cultural group in question consider psychological, physical, and spiritual health as separate or unified?
~ How are illnesses and healing practices defined and conceptualized?
~ What are acceptable behaviors for managing stress?
~ How do people in this culture typically express emotions and emotional distress?
~ What behaviors, practices do members of this culture consider to be preventive?
~ What words are used to describe a particular problem?**
~ How do members explain the origins or causes of a particular condition?
~ Are there culturally specific conditions or cultural concepts of distress?
~ Are there specific physiological variations among this population?
~ What are the commonly misdiagnosed symptoms in this population?
~ Where do people from this cultural group typically seek help?

Questions to Consider for Case Conceptualization
~ What traditional healing practices and treatments are endorsed by members of this group?
~ Are there treatments that would typically be unacceptable?
~ Which counseling approaches are more congruent with the client’s beliefs?
~ What are common health inequities for this population?
~ What are acceptable caregiving practices?
~ Do members of this group value caring for family members?
~ Are individuals with specific conditions shunned?
~ What are family member roles in providing health care and decision making?
~ Is discussing consequences of for behaviors or issues acceptable?
~ Is it customary for family members to withhold prognosis from the client?

~ In cultural groups that value the family as much as the individual, it is helpful to address substance abuse in light of its consequences to family or the community.
~ Ask, “How are your family affected by your issue? How do family and community members feel when they see you struggling?”
~ For clients value independence, it can be more effective to point out how their current behaviors and issues undermine their ability to manage their own lives through questions like
~ Ask, “How might your current thoughts and behaviors affect your ability to reach your goals?”
ACT (Not in the TIP)
~ One of the first steps in ACT is to have clients identify
~ Their values
~ Their goals
~ By examining how the clients define what and who is important to them, you can start to gain an understanding of their worldview.
Behaviors for Counselors To Avoid
~ Addressing clients informally until you grasp the clients cultural expectations and preferences.
~ Failing to monitor and adjust to the client's verbal pacing
~ Using counseling jargon
~ Making 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 individual and cultural background

Behaviors for Counselors To Avoid
~ 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
~ how he or she thinks these problems should be addressed.
~ Downplaying the importance of traditional practices and failing to coordinate these services as needed.

Feelings and Culture
~ Feelings are expressed differently across and within cultural groups
~ Expression is influenced by the nature of a given event and the individuals involved in the situation.
~ A certain level of emotional expression can be socially appropriate within one culture yet inappropriate in another.
~ In some cultures, feelings may not be expressed directly.
~ In others some emotions are readily expressed and others suppressed.
~ For example, some people are more comfortable sharing emotions such as sadness while others are more comfortable with anger
~ Some cultures may not perceive that emotional expression is a worthy course of treatment and healing at all.
~ Counselors should not impose a prescribed approach that measures progress and equates healing with the ability to display emotions.
Mapping the Role of Culture
~ Clinicians have to consider the impact of their “Clinical Worldview” as well as their personal worldview on treatment
~ The culturally aware counselor will reflect on the impact of everything from the décor in the lobby to clinic procedures and treatment selection have on the client and make every effort to respect and empower the client to achieve wellness as he or she defines it.
~ It is important to consider the client’s worldview when developing the case formulation
~ Mapping the client’s cultural views and influences can help clinicians (and clients) develop insights into current struggles and clarify culturally relevant goals