Cultural Competency in Behavioral Health

This text-based course is an edited transcript of the webinar, Cultural Competency in Behavioral Health, presented by Sophie Nathenson, PhD.

Learning Outcomes

After this course, participants will be able to:

• Describe the concepts of cultural competency, cultural humility, and culturally competent behavioral healthcare.
• Explain three types of culturally based mental health disparities in the United States.
• Explain three evidenced-based approaches to improve health equity through culturally responsive care.

Risks and Limitations

There are a few notable risks and limitations in this presentation. It does not contain a comprehensive list of techniques or approaches for practicing culturally competent care, nor does it contain an inventory of cultural customs or attributes of any group. Any data presented is subject to change over time, population, and methods. The concepts in this presentation have differing and evolving definitions and applications across disciplines.

Introduction

I will start by introducing the sociological perspective, which I am trained in, and the social and cultural drivers of health and health disparities. Then, we'll move to defining cultural competency and related concepts. We will discuss the rationale for cultural competency in the behavioral health fields and for a systemic sociological view of cultural competency. Then, we will discuss the central components of cultural competency: knowledge, attitudes, awareness, and skills. To preface this, when defining cultural competency, we distinguish cultural competency from simply competency.

Defining Cultural Competency

Culture is a way of life. It includes a worldview, values (what is considered good or bad), beliefs (what is considered to be true), customs, and norms of behavior (the expected ways of behaving). Culture is very much related to the health and well-being of individuals. It is something to look at when it comes to health outcomes, including mental health. Competence can be defined as the ability to perform a task; when we talk about cultural competency, it includes knowledge as a foundation, awareness, attitudes, and skills to navigate the cultural concerns and problems that clients may present. Essentially, this means the ability to work with a variety of individuals across cultures, and be able to address cultural concerns, things that are culturally based or have to do with some of the bigger picture influences on that individual. 

Many times, we'll think of cultural competency not as simply the ability to perform a task or a knowledge base, a set of facts to be learned. Rather, more as qualities, some of which you may already have, and some of which can be developed over time in a continual process across the entire life course. Defining culturally competent care, it means clinicians can work with diverse clients, with a different cultural background, with variation in their responses based on this awareness of cultural differences.

A Sociological Perspective

To bring a sociological perspective to cultural competency, it is a slightly different perspective that training on specific cultural customs, and everything that makes this culture different from that culture. Instead, we are taking a bigger picture, societal of perspective. I am a medical sociologist, not a healthcare professional, and not a behavioral health professional. I'm coming from this perspective, where we're studying underlying social conditions that affect the health status of an entire group. This could be an entire society of people. And specifically, we're looking at inequalities; in sociology, as compared to psychology which studies individual differences, we are comparing group differences. This is not to say that people in a certain group are similar to each other. When we compare groups, we're looking at the health status of that group as a whole. If we see significant differences in life expectancy, physical illnesses, and mental health issues between one group versus another, what that tells us is that there may be something at a broader level within a community, within a society, that may be driving that inequality, or that difference.

When we look at the research on diverse populations, diverse is defined as non-dominant races. In the U.S., white individuals are the "dominant race." Looking at diverse populations and their perspectives, there's often a mention that being aware of systemic issues on the part of the clinician does impact the therapeutic relationship. We're going to zero in on that idea. Understanding some of the social context, even at the broadest country level and even on the global level--that knowledge and awareness impacts the relationship that you have with the client.

In our society, we have documented health disparities, and they've existed and persisted over a very long period of time. These inequities sparked the need for cultural competency. As our country becomes more diverse, as we get hip to the fact that culture does have an effect on health, these disparities and these inequities are deemed important to address. When looking at the whole health status of an entire population--again, that could be a country, county, a city, neighborhood, client base, patient population of a specific healthcare organization--if there are massive disparities, the health status of that entire group is going to go down. It causes decreases in the quality of life of many individuals. It also creates very poor metrics in terms of patient outcomes. It costs a lot more money. There are all sorts of negative impacts. Cultural competency, as a concept, is about creating more awareness and providing more knowledge to potentially reduce these disparities by providing better and more appropriate care (Phelan & Link, 2013).

From the sociological perspective, to wrap this up, we’re including the social context that goes beyond biomedical and psychological factors contributes to the manifestation of certain behaviors and disorders. When we include that social context in the mix, we acknowledge those other factors, and we can then address some of those factors that may be causing problems within a client. We'll talk more about that throughout this presentation.

Disparities Research

Taking a super broad brush of disparities research, I'll first say of the different social factors, age, race, gender, and socioeconomic status are the most studied regarding their effect on health outcomes. In cultural competency trainings and literature, there's often a focus primarily on race. Many different social factors are in the mix. We’ll look at some of the main kinds of domains of disparities, which are differences in any kind of health outcome; anything that we can measure that has to do with health. For example, Asian and Native American populations tend to have a higher prevalence of mental disorders. Black and Latinx populations tend to have a greater lifetime persistence of mental disorders.

In terms of access, minorities have fewer visits to mental healthcare services, are less likely to initially fill prescriptions for psychiatric disorders, and have higher dropout rates. This is controlling for other factors that may affect dropouts, such as language barriers, socioeconomic status, and the ability to pay for services. Tribal communities have less access and are less likely to access services. In terms of care quality, Black and Latinx individuals are less likely to receive guideline-based care, and Asians have a lower standard of care. These are very broad variables in terms of disparities, but an entire presentation could be dedicated to these disparities in a very wide variety of outcomes that have to do with mental health.

Mental Health Inequity

In terms of inequity, we differentiate between health disparities and health inequities. Health disparities are simply differences in health outcomes by group, but health inequities are disparities that are due to policy, system, practice, and access injustices. A lot of this has to do with a misdistribution of resources or a distribution that negatively affects certain groups more than others. It can be things like discrimination and racism at the individual or the system level. All of this is wrapped up into producing health inequities.

Looking at some data from the Substance Abuse and Mental Health Services Administration, SAMHSA, 69% of Black and 67% of Latinx adults were found to not be receiving any treatment for their mental health problems. 42% of Black adults and 44% of Latinx adults were not receiving treatment for serious psychiatric disorders. Shockingly, 88% of Black adults and 89% of Latinx adults were not receiving any treatment for substance abuse disorders. This paints a picture for you initially, at how different mental health access outcomes are. We can talk about why, like reverse engineering, as to what is going on at the system level to produce and contribute to this inequity. And how cultural competency can begin to address this, starting with the one-on-one level. Again, there are other social risk factors, such as gender, gender identity, sexuality, disability, and socioeconomic status, with inequities found when comparing those groups (Substance Abuse and Mental Health Services Administration, 2018).

This is important to consider that, again, while individuals in a certain social group or social status are not necessarily similar to each other in terms of individual similarities,  we're looking at the fact that these social statuses essentially lend themselves to differences in how your experience of the world is within a certain societ,y and that there are differences there.
Now, moving to the field of psychology and psychiatry. There are plenty of researchers, scholars, and people who practice in these fields that are calling for action taken to reduce disparities and to encourage cultural competency. This is not just something that is applied to healthcare, and it's also not new. We are at a point in society where public awareness of health disparities and health inequity has gone up significantly. Part of that is from events that happened during the pandemic. Everyone's at home tuning into the same news. Experiencing--at very different levels-- events at the societal level, and there is more awareness. When the concept of cultural competency entered the lexicon in healthcare 20, 30 years ago, it was not a new concept then either. It was just new on the scene in healthcare.

This goes back to 1970. "We are asking white psychiatrists to become increasingly aware of how their everyday practices continue to perpetuate institutional white racism in psychiatry." Looking at the sociological: "it means a significant reduction in economic barriers to psychiatric care, and it means relinquishing negative stereotypes" (Sabshin et al.,1970). Moving on to 1985, it's referred to as "an ethical obligation that cross-cultural skills are placed on a level of parity with other specialized therapeutic skills" (Ridley, 1985), part of the ethics of being a provider; to have the skills to serve a variety of clients and to be aware of the issues that may be disproportionately affecting these individuals. The APA (2002) says to "take precautions to ensure that their providers' potential biases, the boundaries of their competence, and the limitations of their expertise do not lead to, or condone unjust practices." In order to do these things and engage in actions according to these calls for action, there has to be first a knowledge of cultural differences in the social context, then trickling down to what that means for individual care and that therapeutic alliance.

Components of Cultural Competency

Now, we will go over the components of cultural competency and get more in-depth, especially with knowledge, the foundation, bringing in the social context of it all. The components of cultural competency are knowledge, attitudes, awareness, and skills. Number one: knowledge. I'm adding here an understanding of the context and the relevant issues. There are other definitions of the knowledge component of cultural competency that may be more specifically about knowing and learning about specific cultures. This is important. It can open your mind to the variation and the cultural implications to care and to all sorts of aspects of diagnosis and health philosophy, the subjective nature of different illnesses, the practices and the treatment, philosophies among different cultures. We don't want to build up this knowledge base so that we stereotype. That's part of the understanding of those cultural differences. We're building on that definition of knowledge of different cultures, to make sure that the knowledge domain includes inquiring about these cultural issues impacting the client and getting that information specific to that individual client (Sue et al., 2009).

Attitudes: this can be your attitude towards diversity in general. It can include empathy, non-judgment, and the therapeutic alliance wrapped up in that domain. Next is awareness: understanding one's own biases. Self-awareness is the practice of reflecting on where you're coming from and where your culture fits into the mix. Finally, we have skills. This can include assessment and your ability to use culturally sensitive interventions. All of these components exist at the personal, agency or organizational level, the community level, and the societal level. It's not just the one-on-one. It can be as broad as society in general; the knowledge, attitudes, awareness, and skills (Sue et al., 2009).

There are other key terms and terms to know, in part because culture can be very closely associated with ethnicity or race, and it's much broader than that. Ethnicity refers to cultural heritage and traditions: shared history, nationality, country of origin, religious affiliation, beliefs, and belonging to a particular faith. Race is a conglomeration of similar physical characteristics, but that's where we associate race within society. There's a very important distinction here where it could be seen as a biological set of differences, genetic differences, but we have the research to demonstrate that two people of the same race, physically, may have actually more differences than two people who do not look alike in terms of their race.
From a sociological perspective, we look at race as a social construction, not as something biological, because the differences by race that we see in how people are treated in society, their health outcomes, and their well-being as a whole are different. There's a different social experience and a different social context. A social construction is how we define race here. Identity could be at the individual, the group, or the universal level. Someone's personal identity, how they identify, and aspects of culture they identify with are part of their core identity. Multiculturalism refers to appreciating diversity, understanding group identities and cultural differences, and welcoming that.

Getting into the knowledge component of cultural competency, we have knowledge of cultural differences, differences in customs, differences in health philosophies, behaviors, health-improving behaviors, and norms. These all affect mental health. Everything that we're talking about in terms of disparities, these components of culture and cultural competency, all affect mental health, and are documented factors and drivers of mental health outcomes. Cultural factors in mental health outcomes could be related to things like barriers to mental health care. It could be about the role of the social context that we live in. Social context is the broader set of norms, values, and beliefs in broader society. It's how people are portrayed in the media, it's the political climate, it's the economic situation of a certain society  or smaller community. It’s everything that's going on outside the individual, the things that affect us collectively and affect people in different sectors of society with different social statuses differently.

The culture of mental healthcare, the bias, or the limitations of interventions is an interesting topic because it has to do with the fact that our diagnosis and our treatment in behavioral health and healthcare have a culture to them. They're not necessarily objective in the grand scheme of things. They are also culturally based, and they're often looked at as objective because they're driven by scientific discoveries and the like. They also have a culture to them. It's very significant.

Role of Culture in Mental Health

The role of culture in mental health: these are just a couple of the ways that culture affects mental health. First, it can influence how clients present symptoms and their subjective experience. We're keeping in mind that from one culture to another there can be a big difference in the interpretation of what's happening mentally. For example, with depression: if you're in an individualistic society, you may be interpreting that as personal misery and despair. In a more collective society, you may be internalizing things at the group level, and there's less of a focus on the individual. This can seem very different to us in the United States where we're zeroing in on that individual experience.

In terms of diagnoses of mental health conditions, they vary quite widely across cultures--things like attention deficit disorder. The set of behaviors that might be used to diagnose attention deficit disorder, for example, in another culture may be more tolerated and therefore not looked at as an abnormality. That is part of the difference in interpreting and diagnosing different mental health conditions.  Symptomology can be looked at as abnormal in one society, normal in another. Whether we define something as an abnormality or a disorder is culturally based, including our own system here in America where mental illnesses are classified according to Western systems and worldviews. That's just something to be aware of. It can help us have an openness to different cultural elements when it comes to the interpretation and presentation of symptoms related to mental health issues. Just being aware of that can help cultivate that open-mindedness--not to switch your views, but to be able to gather information-- culturally relevant information--from the client that may greatly affect the relationship between provider and client (Hinshaw et al., 2011; Maslowski et al., 1998).

Cultural Factors and Barriers to Behavioral Healthcare

Moving on to more cultural factors and barriers to behavioral healthcare. These are part of that set of factors that are culturally based that drive, or at least influence mental health outcomes. There could be physical barriers and a lack of providers based on a geographical area. We see this in rural communities, but it’s not just rural communities where there's a major lack of providers. There may be a lack of providers with the same background as a client. Oftentimes people who fall into minority populations might have a desire for this, so that the cultural issues are more understandable on the part of the provider.

Cultural mistrust of mental health interventions in general can have to do with historical injustices, cultural appropriateness of intervention, and consideration of the client's values and beliefs. For example, beliefs regarding their spirituality, beliefs associated with their religion, resource barriers, lack of insurance cost, language barriers, transportation barriers, and stigma in help-seeking in terms of mental health. Sometimes there's a stereotype that there's a stigma in certain cultures in terms of seeking services, but in actuality, it's an economic barrier, not a stigma.

Racism and Mental Health

Racism is an example of the social context and how that can affect mental health. We have an abundance of research on how racism, including discrimination, profiling, and microaggressions, are linked to more emotional distress, PTSD, depression, anxiety, self-esteem issues, and alcohol, and substance misuse. It affects social wellbeing. It can affect educational attainment. It can affect physical well-being. There's a whole scientific discipline called psychoneuroimmunology. This field studies how that social context, which affects your psychology, affects your physical body. We know that the experience of discrimination over time is cumulative in terms of its effect on both mental health and physical health. You have that release of cortisol that can help you in the short term and harm you when it's a long-term production of cortisol in the body. It can affect the degradation of your body in general, your risk of heart disease, and high blood pressure. It can affect body mass index and poor overall health. All of this gets into the body (Paradies, 2006).

Societal “Structural” Conditions

Looking at societal, or we refer to them as structural conditions, different from social factors and statuses. We're looking at these again in terms of their effect on mental health. Racial segregation, controlling for socioeconomic factors, controlling for the socioeconomic status. By the way, that is a measure that includes your income, your wealth, and your occupation; it can also include education. We can look at the socioeconomic status at the neighborhood level and at the city level. Controlling for that, when we have segregated communities, it can influence and contribute to mental health outcomes.

By the way, in the field of medical sociology, one of the assumptions is that health and illness are not randomly distributed across a geographical area or across groups. So, you can imagine a map of a community and almost like a Doppler radar when we see meteorologists present the weather systems. There are hotspots of certain illnesses, certain mental health conditions, physical health conditions. When we map onto that socioeconomic status, but also things like racial segregation, we see those hotspots of illness. That tells us that it's not necessarily random. There are social factors and structural conditions that are related to those outcomes, things like mass incarceration. We know that incarceration very disproportionately affects different groups, adverse childhood experiences, and this can lead to a higher likelihood of interacting with the criminal justice system. If a child has parents that are away, that are incarcerated, this can lead to adverse childhood experiences, which most of you probably know is related to mental health, but also related to physical health, and chronic illnesses in adulthood. Institutional racism and sexism, both historical and contemporary, affects mental health.

In general, the social experience based on socioeconomic factors, gender, sexuality, religion, disabilities, and other social statuses that we call social statuses. Much of the time fits into a social hierarchy, which means not necessarily at the individual level, but within a society, there’s a difference in the treatment, the social norms and ways of interacting with people that fall into different groups. Poverty, neighborhood deprivation, and unemployment affect mental health greatly. 
Displacement, loss of culture, and sense of belonging. If a culture is physically displaced, and there are examples that go way far back into history, hundreds of years ago where if a group is displaced, moved to another location, or the culture breaks down, there are higher rates of substance abuse, there are higher rates of overdose. It has a massive effect on the entire group as a whole. Social capital is like capital, only instead of monetary resources, which means more social resources, social cohesion, and the closeness of the group.

Redlining, reduced investment, blocking out people of certain groups accessing loans and resources in general, or employment. That includes services, schools, and hospitals. A neighborhood might have their property taxes, you know, their property values go down and then the schools suffer because that’s where they’re getting their funding. They could go out of business, and they don’t have a school. All of that has a massive effect on a neighborhood, a group, a culture, the built environment, and how a community is structured to foster social interaction and safety. All of those things affect mental health (Cummings et al., 2017).

Structural Racism

Structural racism; a defined by the Aspen Institute as "A system in which public policies, institutional practices, cultural representations, and other norms, work in various, often reinforcing ways to perpetuate racial group inequity, dimensions of our history and culture that have allowed privileges associated with 'whiteness' and disadvantages associated with 'color' to endure and adapt over time." (The Aspen Institute, 2016). Suppose you hear the concept of structural racism or systemic racism. In that case, it's that level above the individual where this is something that has gone on in history and continues today, where there are simply privileges and disadvantages by group.

Structural Competence

Structural competence is a great adjunct to cultural competency. Structural competence is the ability to discern how these downstream clinical symptoms, problems, and diseases are influenced by upstream social determinants of mental health. I'll break that down a little bit in terms of upstream and downstream. Downstream factors are things that may affect a health outcome quickly. They're the things that we're observing -  clinical symptoms, suicidal ideation, or something physical like a heart attack that leads to death. Things that happen downstream are those things that fall into emergency situations. 

Going a little further upstream we have health behaviors; further upstream, the social context, relationships, family situation, home environment. Even further upstream, we have the economic level, political level, and policy level. Problems that are happening at the systemic level are identified as problems in terms of their influence on these health disparities. Recognizing the history of pathologizing responses to trauma, there are truly disturbing aspects of history and how things are medicalized and were medicalized, and pathologized. Things like drapetomania, which was defined as the desire to escape slavery. These illnesses were legitimate diagnosable illnesses, essentially justified inhumane treatment and structural racism, and impacted diagnosis and mental health treatment. In other words, a trauma response to something external was then labeled as a mental illness. When we take that to today, if we're focusing only on that symptomology and we ignore those broader social factors, we could be missing a large part of the story (Metzl & Hansen, 2014; Willoughby, 2018).

Client Perspectives of Culturally Competent Psychotherapy

Looking at client perspectives of culturally competent psychotherapy, these are some important issues: understanding cultural issues, recognizing bias, using the social justice framework, having the desire that their therapists be advocates in terms of social problems, and preference of the same race therapist. As a side note: the outcomes may not always be better--you can rest assured if you are not the same race or of the same culture as your client, it doesn't necessarily mean you’re going to be less effective.

A study showed that a cross-cultural counseling inventory had a greater impact than only the counselor rating form on satisfaction with their provider among minority clients. This shows that there is some evidence of a positive impact of practicing cultural competency. This is also a sidebar, but a very important one (Constantine, 2002; Fuertes et al., 2006).

Knowing and Not-Knowing

When we talk about knowledge and gathering all the facts, there are things we may know, but practicing and embracing not knowing, and being open about what you don't know, can be powerful. It's like taking accountability. Oftentimes in our society, if we take accountability, if we show our biases, our lack of knowledge in certain areas, it can be associated with weakness, or you may not think that you're going to be respected.

That is a cultural thing, and breaking that down can be powerful at the individual level. Knowledge can include knowledge of cultural influences on care, the efficacy of care, culturally specific resources, programs and policies, and what’s out there that could help certain groups. If you avoid sensitive topics altogether, it can be detrimental. It can be beneficial and meaningful to have that dialogue. We don't have to know at all. When in doubt, you can ask a client to explain further, and you can always ask about how the social, or political environment may be affecting them personally.

Making the Connection

We're making the connection here: how does this form of knowledge fit into the other components of cultural competency? No matter how wide-ranging your knowledge base, awareness of these broader factors matters to clients, and individual-level care is impacted by understanding this broader context.

Attitudes and Cultural Humility

Knowledge can shape our attitudes. It can help us cultivate awareness, That's a great foundation for the skills you can pick up. Attitudes refer to things like embracing diversity, inquisitiveness, and having a positive attitude towards cultural differences. Practicing cultural humility, as distinct from cultural competency; viewing other mental health paradigms (which could be very different from the paradigm we ascribe to) as having value, emotional intelligence, and avoiding stereotypes. Cultural humility is different than cultural competency, and this is the definition that I gravitate towards in terms of how it could be impactful. It's a lifelong practice of self-evaluation, self-reflection, and self-critique. You're digging deep to understand where you're coming from and your biases. It's about reduced power imbalances. As I just talked about--vulnerability and taking accountability for potential biases and potential harm-- can be very influential in the therapeutic alliance. It also could include advocacy, community outreach, and organizational partnerships. We're looking at competency as more akin to knowledge, whereas cultural humility is more about not knowing (Tervalon & Murray-García, 1998).

Awareness

Having a bias isn't necessarily a bad thing. It's your own values, your own culture, and their impact. Ethnocentrism is looking at your own culture as the standard and looking at other cultures as other, as different. This shows up even in the “DSM-5”: there is an appendix of more culturally based disorders, that are set aside. In contrast, things like anorexia nervosa, for example, are also culture-bound, but is not included in the category of culture-bound illnesses. This is an illness that is more prevalent in Western cultures. Looking at differences in the impact of social issues, we’re simply being aware of institutional and intervention bias. We’re looking at approaches to behavioral health and being aware that they aren't culture-free, and there are cultural differences in engaging with care.

Skills

There are three skills outlined by Cardemil and Battle (2003). You can suspend preconceptions about the client and the family's race and ethnicity. You can recognize that clients may be different from other members of their same racial and ethnic group. You can consider how these differences between the therapists and client could affect psychotherapy. You can acknowledge that power, privilege, racism might also be affecting interaction with clients. Erring on the side of discussion again, you might be in doubt of what the significance is of culture. You can continue to receive ongoing professional development in culturally competent practices (Cardemil & Battle, 2003). This is from 20 years ago. It still applies today.

Anti-Racist Care

Working on the level of addressing some of those social factors, this addresses internalized racism, collective trauma, and emotional regulation. Black psychologist  Kenneth Hardy talks about the concept of the assaulted sense of self. This means that there's an internalization of the externalized racism that happens at the societal and cultural levels. Once that is internalized, it can affect self-esteem. How could this affect therapy? An example is looking at self-esteem issues. Working with that just as an individual thing, versus considering that this may be societally-based. Being aware of that and engaging in discussion with the client may have a positive impact there.

We consider care differences, like over-prescribing and mistrust. We can address those issues, taking the time to explain pharmacological treatment, the reasons, the side effects, and we gather information on a wide variety of cultural factors. We'll talk about that in terms of assessment as a culturally competent skill. The American Psychological Association (2020) has deemed racism a pandemic. This is coming late to the party, but nonetheless it is part of bringing awareness of some of these issues. Looking at it as a public health issue, as a mental health issue, as a pandemic that is spreading, that can be addressed. There's a treatment for this pandemic (Cénat, 2020; Ogundare, 2020; Singh, 2019).

Culturally Competent Assessment

Moving into culturally competent assessment, there is in the "DSM" something called the Cultural Formulation Interview. We can use that to gather information related to culture. We're not assuming homogeneity. This set of assessments, and there are lots of different assessments, can gather information on how symptoms may be related to things like racism and socioeconomic issues.

Culturally competent assessment recognizes the impact of these issues, such as mass incarceration and police violence, and how these can affect individuals. It assesses both the individual factors and the collective protective factors, strengths, and resources. Resources could be religious and spiritual, and culturally-based. It could be a culture where there's more social cohesion, or more collectivist, and these can be a strengths and protective factors. For all of the risk factors, there are also protective factors. We're going to look at two frameworks for culturally competent assessment.

• The RESPECTFUL Framework - An acronym of the different aspects of culture (D'Andrea  & Daniels, 2001):
  • R-religious/spiritual identity
  • E-economic class background
  • S- sexual identity
  • P-level of psychological maturity
  • E-ethnic/racial identity
  • C chronological/developmental challenges
  • T- threats to well-being and trauma
  • F-family background and history
  • U-unique physical characteristics
  • L- location of residence and language differences

This is information you may be already collecting; it can serve as a base for conversation and deepen your understanding of your client.

• The ADDRESSING Framework – is similar and also an acronym (Hays, 2001).
  • A- age/generation
  • D- disability status (developmental)
  • D- disability status (acquired)
  • R- religion/spiritual orientation
  • E- ethnicity
  • S- socioeconomic status 
  • S- sexual orientation
  • I- indigenous heritage 
  • N- national origin
  • G- gender

Other Scales and Tools

I mentioned the Cultural Formulation Interview and there is a Trauma Symptoms of Discrimination Scale. Deepening your understanding of discrimination and how that gets into the mind and body is fascinating. There's lots of research on how the social environment gets into the body and is passed on generationally. There's research that, for example, our grandmother's social environment affects our genetics. The field of epigenetic studies this. Consider two generations ago, and what was going on in society two generations ago. It’s pretty bad now, in terms of inequality, but go back two generations. There are other sets of issues that can have an effect on present day, the present generation (Cénat, 2020). Other tools: Everyday Discrimination Scale, UConn Racial/Ethnic Stress and Trauma Survey and, again, the Cultural Formulation Interview.

Communication

Communication applies to any client, but these are some tips when it comes to developing culturally competent skills in communication. You may already do this, but it's food for thought to take into your day-to-day. You can ask clients to describe their identity versus prescribing an identity (again, learning about a culture and then putting that on them or making those assumptions may not be exactly correct). You can ask about ideas, experiences, and beliefs. Consider that cultural and historical factors influence the etiology, symptom presentation, interpretation, how they talk about their mental health issues, and how that interacts with family pressures, cultural pressures, and stigma. The idea that therapy for a long time was associated with something that white individuals did. In your one-on-one communication, just knowing, and not assuming that there’s a universal in terms of symptom presentation and diagnosis. Note in-group differences to avoid inaccurate assessments or racial bias. Again, that's turning the cultural knowledge into a stereotype--avoiding that.

Resisting avoiding gathering information due to discomfort, and moving through discomfort. This applies to all of our relationships, right? When there's a conflict, when there's tension, when there's a power differential--being able to break that down and work through that can lead to a more meaningful connection. You can also consider more structured interviews versus unstructured ones. That relates to that discomfort. If there's a lot of discomfort, needing to know how to start the conversation, how to keep that conversation going, or what to take from it, you can use more structured interviews to gather that information as a starting point.

Beyond the Individual: Community-Based Interventions

As was mentioned before, cultural competency is a continuum, but it's also a continuum from individual all the way up to the policy level. You can integrate community-based interventions. This might be something that you do, and it might be something at the agency level. Many coalitions in communities have certain goals to address health and social issues in that community. I lived in a small town for many years, and there were many coalitions of people that came from different cultural backgrounds and political ideologies, and there were common goals. For example, ending child abuse or raising the high school graduation rate in the county. Understandably, you have, probably, a heavy workload and a lot going on. Being able to go outside of that, if you do have the time to join those coalitions, you can bring your expertise in the mental health field to interventions, whether that's disseminating mental health information or partnering with those community organizations or coalitions to bring that expertise. You can bring ideas to the table, assist individuals with resources and access, and even provide services. What we're talking about here is meeting people where they're at. If there's a barrier to care, doing something like a pop-up where you're providing some care, or maybe some assessments, similar to pop-up medical care, like a pop-up diabetes clinic or providing oral healthcare.

Policy Recommendations: Education and Research

Now we get into policy recommendations. We have covered the societal view and different societal issues, social factors, systemic issues that affect mental health. How structural issues have a trickle-down effect on clients. How those issues can be embedded, not only in their mind but in their body, and can affect how they are engaging with their mental health.

After looking at that big picture and how that affects individual care, now we’re moving back up to that policy level, which is something that many folks in the mental health fields have called for in terms of engaging more at that policy level as a mental health professional. At the educational level and the workforce level: recruiting, mentoring, and striving for a more diverse workforce. It does matter to have professionals at the table with that lived experience, and have more options for clients to have a provider who is of the same race, or cultural background that, again, may be more understanding of those issues. That’s not to say that there can be an assumption there when two people are of a similar culture. The same skills apply to collecting that information specific to that individual. 

The educational level: inclusion of cultural competency education and looking at different forms of education. I've tried to find evidence of when training works, because the truth is that the disparities we see persist. They're not going away. There is a question, and there is a debate: is cultural competency training making an impact? That's why, personally and professionally, I'm passionate about looking at that big picture, and including cultural humility. The educational practice that is a best practice is experiential learning. Spending time in a certain community with a different culture than you and becoming kind of embedded. Communicating, but mostly listening to people in that group that is different from your background, is very influential in that attitude and awareness piece.

We want to dedicate time and resources for any mandated training. If you're having to go to a training (and you're going to a training right now), having that time, and having resources. If it's happening at the organizational level, it’s putting time and resources behind that. Advocacy for interpreter services, incentivizing buy-in at the leadership and administrative levels, and expanded funding from government agencies and hospital systems to improve cultural competency (McGregor et al., 2019).

At the research level: this is critical as there is an unbelievable dearth and lack of research on the efficacy of therapies on a variety of different cultures and races. Research is needed on these underlying factors that explain these disparities, not just at the individual level. Program evaluation of cultural competency training: as I said, finding where the best practices are. More research on the client experience and more assessment of these other components like humility and empathy, and I would add vulnerability and accountability. Assessing when those skills and qualities are present, what's the effect on the health outcome? More diagnostic research, looking at the reliability and validity of different assessments, increasing studies on diverse populations, more diversity among researchers, and interdisciplinary approaches. As mentioned, those other fields such psychoneuroimmunology added to the research base (Ogedegbe, 2020; Singh, 2019).

Summary

There's a difference between cultural competency and competency, right? Cultural competency is a set of qualities. It's a lifelong practice that includes inner work for us to do. Based on what we know, the quality of the interaction is more important than anything. That's what we want to influence. We can't assume that knowledge of cultural differences automatically translates into more effective interventions (Shim, 2020).

Our general knowledge is very good for understanding that there are cultural differences and systemic inequalities. That's our base, and then we grow into being more comfortable discussing these issues and working on that humility piece. The empathetic inquiry is preferable over extrapolation, or taking your knowledge base and making those assumptions. Finally, a holistic approach to cultural competency also can include outreach, advocacy, and even engagement with policy change. 

Thank you. Your time is appreciated.

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