A TreATmenT ImprovemenT proTocol
Improving Cultural
Competence
TIP 59
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
1 Choke Cherry Road
Rockville, MD 20857
TIP 59
Improving Cultural
Competence
A TreATmenT ImprovemenT proTocol
Improving Cultural Competence
Acknowledgments
This publication was produced by The CDM Group, Inc., under the Knowledge Application
Program (KAP) contract 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, Ed.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
Communications, SAMHSA, HHS.
Electronic Access and Copies of Publication
This publication may be ordered or downloaded from SAMHSA’s Publications Ordering Web
page at 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
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 Culture? .................................................................................................................... 11
What Is Race? ......................................................................................................................... 13
What Is Ethnicity? ................................................................................................................. 15
What Is Cultural Identity? .................................................................................................... 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 Families With Treatment and Evaluation Processes . 59
Step 3: Endorse Collaboration in Interviews, Assessments, and Treatment Planning ........... 60
Step 4: Integrate Culturally Relevant Information 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
Language 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 Americans ...................................................................... 103
Counseling for Asian Americans, Native Hawaiians, and Other Pacific Islanders .............. 116
Counseling for Hispanics and Latinos ................................................................................. 128
Counseling for Native Americans......................................................................................... 138
Counseling for White Americans ......................................................................................... 150
Chapter 6—Drug Cultures 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 Acculturation .................................... 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 Diversity 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: Education 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 Worldview ......................................................................................... 43
Exhibit 2-3: ACA Counselor Competencies: Counselor s' Awareness of Their
Own Cultural Values and Biases....................................................................................... 46
Exhibit 2-4: ACA Counselor Competencies: Awareness of Clients' Worldviews ................. 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 African Americans ..... 110
Exhibit 5-2: Lifetime Prevalence of Substance Use Disorders According to Ethnic
Subgroup and Immigration 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 Drug Culture .................................................................... 164
Exhibit 6-3: The Values and Beliefs of a Heroin Culture .................................................... 166
Exhibit 6-4: Music and Drug Cultures ................................................................................ 166
Exhibit 6-5: The Rituals 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 time the panel was
convened and may no longer reflect the individual’s current affiliation.
Chair
Felipe González Castro, M.S.W., Ph.D.
Professor
Department of Psychology
Arizona State University
Tempe, AZ
Co-Chairs
Loretta J. Bradley, M.A., Ph.D.
Professor
Department of Educational Psychology
Texas Tech University
Lubbock, TX
Jacqueline P. Butler, M.S.W., CCDC,
LISW
Professor of Clinical Psychiatry
Substance Abuse Division
College of Medicine
University of Cincinnati
Cincinnati, OH
Flanders Byford, M.S.W., LCSW
Oklahoma City-County Health Department
Oklahoma City, OK
Ting-Fun May Lai, M.S.W., CSW,
CASAC
Director
Chinatown Alcoholism Center
Hamilton-Madison House
New York, NY
Workgroup Leaders
Virgil A. Gooding, Sr., M.A., M.S.W.,
LISC
Clinical Director
Foundation II, Inc.
Cedar Rapids, IA
Ford H. Kuramoto, D.S.W.
President
National Asian Pacific American Families
Against Substance Abuse
Los Angeles, CA
Harry Montoya, M.A.
President/Chief Executive Officer
Hands Across Cultures
Española, NM
Onaje M. Salim, M.A., NCAC-II, CCS
Director
Cork Institute Southeast Addiction
Technology Transfer Center
Morehouse School of Medicine
Atlanta, GA
Panelists
Barbara Lee Aragon, M.S.W.
Academic Fellow
Department of Health Services
North Highlands, CA
vii
Improving Cultural Competence
Debra A. Claymore, M.Ed.Adm.
D. Claymore & Associates, Inc.
Loveland, CO
E. Daniel Edwards, D.S.W.
Director
Ethnic Studies Program
University of Utah
Salt Lake City, UT
Tonda L. Hughes, M.S.N., Ph.D., FAAN
Associate Professor
College of Nursing
University of Illinois at Chicago
Chicago, IL
David Mathews, M.A., Ph.D.
Director of Adult Services
Kentucky River Community Care, Inc.
Jackson, KY
Anthony (Tony) Taiwai Ng, M.D.
Consultant
Washington, DC
Barry Pilson, Ph.D.
Adjunct Professor
School of Social Work
Tulane University
Metairie, LA
Rafaela R. Robles, Ed.D.
Director
Technology Transfer Center
Caribbean Basin/Hispanic Addiction
Centro de Estudios en Adicción
Universidad Central del Caribe
Bayamon, PR
Gloria M. Rodriguez, D.S.W.
Research Scientist
Division of Addiction Services
New Jersey Department of Health and Senior
Services
Trenton, NJ
Ann S. Yabusaki, M.Ed., M.A., Ph.D.
Director
Coalition for a Drug-Free Hawaii
Honolulu, HI
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.
Adjunct Professor
University of North Carolina at Wilmington
Carolina Beach, NC
Jacqueline Butler, M.S.W., LISW, LPCC,
CCDC III, CJS
Professor of Clinical Psychiatry
College of Medicine
University of Cincinnati
Cincinnati, OH
Deion Cash
Executive Director
Community Treatment and Correction
Center, Inc.
Canton, OH
Debra A. Claymore, M.Ed.Adm.
D. Claymore & Associates, Inc.
Loveland, CO
Carlo C. DiClemente, Ph.D.
Chair
Department of Psychology
University of Maryland Baltimore County
Baltimore, MD
Catherine E. Dube, Ed.D.
Independent Consultant
Brown University
Providence, RI
Jerry P. Flanzer, D.S.W., LCSW, CAC
Chief of Services
Division of Clinical and Services Research
National Institute on Drug Abuse
National Institutes of Health
Bethesda, MD
Michael Galer, D.B.A.
Independent Consultant
Westminster, MA
Renata J. Henry, M.Ed.
Director
Division of Alcoholism, Drug Abuse and
Mental Health
Delaware Department of Health and Social
Services
New Castle, DE
Joel Hochberg, M.A.
President
Asher & Partners
Los Angeles, CA
Jack Hollis, Ph.D.
Associate Director
Center for Health Research
Kaiser Permanente
Portland, OR
ix
Improving Cultural Competence
Mary Beth Johnson, M.S.W.
Director
Addiction Technology Transfer Center
University of Missouri—Kansas City
Kansas City, MO
Eduardo Lopez, B.S.
Executive Producer
EVS Communications
Washington, DC
Holly A. Massett, Ph.D.
Academy for Educational Development
Washington, DC
Diane Miller, Ph.D.
Chief
Scientific Communications Branch
National Institute on Alcohol Abuse
and Alcoholism
National Institutes of Health
Bethesda, MD
Harry B. Montoya, M.A.
President/Chief Executive Officer
Hands Across Cultures
Española, NM
Richard K. Ries, M.D.
Director/Professor
Outpatient Mental Health Services
Dual Disorder Programs
Seattle, WA
Gloria M. Rodriguez, D.S.W.
Research Scientist
Division of Addiction Services
New Jersey Department of Health and Senior
Services
Trenton, NJ
Everett Rogers, Ph.D.
Center for Communications Programs
Johns Hopkins University
Baltimore, MD
Jean R. Slutsky, P.A., M.S.P.H.
Director
Center for Outcomes and Evidence
Agency for Healthcare Research and Quality
Rockville, MD
Nedra Klein Weinreich, M.S.
President
Weinreich Communications
Canoga Park, CA
Clarissa Wittenberg
Director
Office of Communications and
Public Liaison
National Institute of Mental Health
National Institutes of Health
Bethesda, MD
Consulting Members of the KAP
Expert Panel
Paul Purnell, M.A
Social Solutions, L.L.C.
Potomac, MD
Scott Ratzan, M.D., M.P.A., M.A.
Academy for Educational Development
Washington, DC
Thomas W. Valente, Ph.D.
Director, Master of Public Health Program
Department of Preventive Medicine
School of Medicine
University of Southern California
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 Internet 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 nation. 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, people in need of behavioral health services. We are grateful to all who have joined with us
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
clinical skills is vital to the effectiveness of
behavioral health services. According to the
U.S. Department of Health and Human
Services (HHS), cultural competence “refers to
the ability to honor and respect the beliefs,
languages, interpersonal styles, and behaviors of
individuals and families receiving services, as
well as staff members who are providing such
services. Cultural competence is a dynamic,
ongoing developmental process that requires a
long-term commitment and is achieved over
time” (HHS 2003a, p. 12). It has also been
called “a set of behaviors, attitudes, and policies
that . . . enable a system, agency, or group of
professionals to work effectively in cross-
cultural situations” (Cross et al. 1989, p. 13).
This Treatment Improvement Protocol (TIP)
uses Sue’s (2001) multidimensional model for
developing cultural competence. Adapted to
address cultural competence across behavioral
health settings, this model serves as a frame-
work for targeting three organizational levels
of treatment: individual counselor and staff,
clinical and programmatic, and organizational
and administrative. The chapters target specif-
ic racial, ethnic, and cultural considerations
along with the core elements of cultural com-
petence highlighted in the model. These core
elements include cultural awareness, general
cultural knowledge, cultural knowledge of
behavioral health, and cultural skill develop-
ment. The primary objective of this TIP is to
assist readers in understanding the role of
culture in the delivery of behavioral health
services (both generally and with reference to
specific cultural groups). This TIP is organized
into six chapters and begins with an introduc-
tion to cultural competence. The following
subheadings provide a summary of each chap-
ter and an overview of this publication.
Introduction to Cultural
Competence
Why is the development of cultural compe-
tence and culturally responsive services
important in the behavioral health field?
Culturally responsive skills can improve client
engagement in services, therapeutic relation-
ships between clients and providers, and
treatment retention and outcomes. Cultural
competence is an essential ingredient in de-
creasing disparities in behavioral health.
The development of cultural competence can
have far-reaching effects not only for clients,
but also for providers and communities. Cul-
tural competence improves an organization’s
sustainability by reinforcing the value of diver-
sity, flexibility, and responsiveness in address-
ing the current and changing needs of clients,
communities, and the healthcare environment.
Culturally responsive organizational strategies
and clinical services can help mitigate organi-
zational risk and provide cost-effective treat-
ment, in part by matching services to client
xv
Improving Cultural Competence
needs more appropriately from the outset. So
too, culturally responsive organizational poli-
cies and procedures support staff engagement
in culturally responsive care by establishing
access to training, supervision, and congruent
policies and procedures that enable staff to
respond in a culturally appropriate manner to
clients’ psychological, linguistic, and physical
needs.
What is the process of becoming culturally
competent as a counselor or culturally
responsive as an organization?
Cultural
competence is not acquired in a limited
timeframe or by learning a set of facts about
specific populations; cultures are diverse and
continuously evolving. Developing cultural
competence is an ongoing process that begins
with cultural awareness and a commitment to
understanding the role that culture plays in
behavioral health services. For counselors, the
first step is to understand their own cultures as
a basis for understanding others. Next, they
must cultivate the willingness and ability to
acquire knowledge of their clients’ cultures.
This involves learning about and respecting
client worldviews, beliefs, values, and attitudes
toward mental health, help-seeking behavior,
substance use, and behavioral health services.
Behavioral health counselors should incorpo-
rate culturally appropriate knowledge, under-
standing, and attitudes into their actions (e.g.,
communication style, verbal messages, treat-
ment policies, services offered), thereby con-
veying their cultural competence and their
organizations’ cultural responsiveness during
assessment, treatment planning, and the
treatment process.
What is culture?
Culture is the conceptual
system developed by a community or society
to structure the way people view the world. It
involves a particular set of beliefs, norms, and
values that influence ideas about relationships,
how people live their lives, and the way people
organize their world. Culture is not a definable
entity to which people belong or do not be-
long. Within a nation, race, or community,
people belong to multiple cultural groups and
negotiate multiple cultural expectations on a
daily basis. These expectations, or cultural
norms, are the spoken or unspoken rules or
standards for a given group that indicate
whether a certain social event or behavior is
appropriate or inappropriate. The word “cul-
ture” is sometimes applied to groups formed
on the basis of age, socioeconomic status,
disability, sexual orientation, recovery status,
common interest, or proximity. Counselors
and administrators should understand that
each client embraces his or her culture(s) in a
unique way and that there is considerable
diversity within and across races, ethnicities,
and culture heritages. Other cultures and
subcultures often exist within larger cultures.
What are race and ethnicity?
Race is often
referred to as a biological category based on
genetic traits like skin color (HHS 2001), but
there are no reliable means of identifying race
through biological criteria. Despite its limita-
tions, the concept of race is important to
discussions of cultural competence. Race—
when defined as a social construct to describe
people with shared physical characteristics—
can have tremendous social significance. The
term ethnicity is often used interchangeably
with race, although by definition, ethnicity—
unlike race—implies a certain sense of belong-
ing. It is generally based on shared values,
beliefs, and origins rather than shared physical
characteristics. With the exception of its final
chapter, which examines drug cultures, this
TIP focuses on the major racial and ethnic
groups identified by the U. S. Census Bureau
within the United States: African and Black
Americans, Asian Americans (including Na-
tive Hawaiians and other Pacific Islanders),
Hispanics and Latinos, Native Americans, and
White Americans.
xvi
Executive Summary
What constitutes cultural identity?
Cultural
identity, in the simplest terms, involves an
affiliation or identification with a particular
group or groups. An individual’s cultural
identity reflects the values, norms, and
worldview of the larger culture, but it is de-
fined by more than these factors. Cultural
identity includes individual traits and attrib-
utes shaped by race, ethnicity, language, life
experiences, historical events, acculturation,
geographic and other environmental influ-
ences, and other forces. Thus, no two individ-
uals will possess exactly the same cultural
identity even if they identify with the same
cultural group(s). Cultural identities are not
static; they develop, evolve, and change across
the life cycle.
This TIP explores cultural identity and its
influence on assessment, treatment planning,
and therapeutic and healing practices. The
introduction it provides to the cross-cutting
factors of race, ethnicity, and culture will help
counselors gain knowledge about the many
forces that shape cultures, communities, and
the lives of clients, including, but not limited
to, families and kinships, gender roles, socioec-
onomic status, religion, education, immigra-
tion, and migration.
What core assumptions serve as the foun-
dation of this TIP?
The consensus panel
developed several core assumptions upon
which to structure the content of this TIP:
• An understanding of race, ethnicity, and
culture (including one’s own) is necessary
to appreciate the diversity of human dy-
namics and to treat clients effectively.
• Incorporating cultural competence into
treatment improves therapeutic deci-
sionmaking and offers alternative ways to
define and plan a treatment program firm-
ly directed toward progress and recovery.
• Organizational commitment to supporting
culturally responsive treatment services,
including adequate allocation of resources,
reinforces the importance of sustaining
cultural competence in counselors and
other clinical staff.
• Advocating culturally responsive practices
increases trust within the community,
agency, and staff.
• Achieving cultural competence requires
the participation of racially and ethnically
diverse groups and underserved popula-
tions in the development and implementa-
tion of treatment approaches and training
activities.
• Consideration of culture is important at all
levels of operation and in all stages of
treatment and recovery.
Core Competencies for
Counselors and Other
Clinical Staff
Cultural competence has come to mean more
than a discrete skill set or knowledge base;
cultural competence also requires self-
evaluation on the part of the practitioner.
Culturally competent counselors are aware of
their own culture and values, and they
acknowledge their own assumptions and
biases about other cultures. Moreover, cultur-
ally competent counselors strive to understand
how these assumptions affect their ability to
provide culturally responsive services to clients
from similar or diverse cultures.
Counselors should begin the process of be-
coming culturally competent by identifying
and exploring their cultural heritage and
worldview along with their clinical worldview,
uncovering how these views shape their per-
ceptions of and during the counseling process.
In addition to understanding themselves and
how their culture and values can affect the
therapeutic process, culturally competent
counselors possess a general understanding of
xvii
Improving Cultural Competence
the cultures of the specific clients with whom
they work. Counselors should also understand
how individual cultural differences affect
substance abuse, health beliefs, help-seeking
behavior, and perceptions of behavioral health
services. Culturally competent counselors:
• Frame issues in culturally relevant ways.
• Allow for complexity of issues based on
cultural context.
• Make allowances for variations in the use
of personal space.
• Are respectful of culturally specific mean-
ings of touch (e.g., hugging).
• Explore culturally based experiences of
power and powerlessness.
• Adjust communication styles to the cli-
ent’s culture.
• Interpret emotional expressions in light of
the client’s culture.
• Expand roles and practices as needed.
Chapter 2 addresses counselors’ core cultural
competencies and presents clinical activities,
including clinical supervision tools. The key
areas explored include cultural awareness and
cultural identity development, the cultural lens
of counseling, key components of cultural
knowledge for behavioral health counselors,
and specific counseling skills that support
culturally responsive services.
Culturally Responsive
Evaluation and Treatment
Planning
The role of culture should be considered
during initial intakes and interviews, in
screening and assessment processes, and in the
development of treatment planning. Culturally
responsive treatment can only occur when the
making of clinical and programmatic decisions
includes culturally relevant information and
practices and is endorsed and supported by
clinical staff, clinical supervisors, and the
organization as a whole. Chapter 3 presents
culturally responsive evaluation and treatment
planning as a series of nine steps.
Step 1: Engage clients. Because the intake
meeting is often the first encounter clients
have with the behavioral health system, it is
vital that they leave the meeting feeling un-
derstood and hopeful. Counselors should try
to establish rapport with clients before launch-
ing into a series of questions.
Step 2: Familiarize clients and family
members with the evaluation and treatment
process. Often, clients and family members
are not familiar with treatment jargon, the
treatment program, the facility, or the expecta-
tions of treatment; furthermore, not all clients
will have had an opportunity to express their
own expectations or apprehension. Clinical
and other treatment staff must not assume
that clients already understand the treatment
process. Instead, they need to take sufficient
time to talk with clients (and their families, as
appropriate) about how treatment works and
what to expect from treatment providers.
Step 3: Endorse a collaborative approach in
facilitating interviews, conducting assess-
ments, and planning treatment. Counselors
should educate clients about their role in
interview, assessment, and treatment planning
processes. From first contact, they should
encourage clients and their families to partici-
pate actively by asking questions, voicing
specific treatment needs, and being involved in
treatment planning. Counselors should allow
clients and family members to give feedback
on the cultural relevance of the treatment plan.
Step 4: Obtain and integrate culturally
relevant information and themes. By explor-
ing culturally relevant themes, counselors will
better understand each client and will be
better equipped to develop a culturally in-
formed evaluation and treatment plan. Areas
xviii
Executive Summary
to explore include immigration and migration
history, cultural identity, acculturation status,
health beliefs, healing practices, and other
information culturally relevant to the client.
Step 5: Gather culturally relevant collateral
information.
Such information is a powerful
tool in assessing clients’ presenting problems,
understanding the influence of cultural factors
on clients, and gathering resources to support
treatment endeavors. By involving others in the
early phases of treatment, providers will likely
obtain more external support for each client’s
engagement in treatment services. Counselors
can obtain supplemental information (with
client permission) from family members, medi-
cal and court records, probation and parole
officers, community members, and so on.
Step 6: Select culturally appropriate screen-
ing and assessment tools.
In selecting eval-
uation tools, counselors should note the
availability of normative data for the popula-
tions to which their clients belong, the inci-
dence of test item bias, the role of
acculturation in understanding test items, and
the adaptation of testing materials to each
client’s culture and language.
Step 7: Determine readiness and motiva-
tion for change.
Although few studies focus
on the use of motivational interviewing with
specific cultural groups, its theories and strate-
gies may be more culturally appropriate for
most clients than other approaches. Through
reflective listening, motivational interviewing
focuses on helping clients explore ambivalence
toward change, decisions, and subsequent
treatment. It is a nonconfrontational, client-
centered approach that reinforces clients as the
experts on what will work and supports the
key idea that change is a process.
Step 8: Provide culturally responsive case
management.
Many core competencies for
counselors are also relevant to case managers.
Like counselors, case managers should possess
cultural self-knowledge and a basic knowledge
of other cultures. They should possess traits
conducive to working well with diverse groups
and the ability to apply cultural competence in
practical ways. Case management includes the
use, as necessary, of interpreters who can
communicate well in the specific dialects
spoken by each client and who are familiar
with behavioral health vocabulary relevant to
the specific behavioral health setting in which
service provision will occur. Case managers
should acquire cultural and community
knowledge to assist with the coordination of
social, health, and other essential services and
to secure culturally relevant services in and
outside the treatment facility. Case managers
should also keep a list of culturally appropriate
referral resources to help meet client needs.
Step 9: Integrate cultural factors into
treatment planning.
Counselors should be
flexible in designing a treatment plan to meet
the cultural needs of clients and should inte-
grate traditional healing practices into treat-
ment plans when appropriate, using resources
available in the clients’ cultural communities.
Treatment goals and objectives need to be
culturally relevant, and the treatment envi-
ronment must be conducive to client partici-
pation in treatment planning and to the
gathering of client feedback on the cultural
relevance of the treatment being provided.
Pursuing Organizational
Cultural Competence
Organizational cultural competence is a dy-
namic, ongoing process that begins with
awareness and commitment and evolves into
culturally responsive organizational policies
and procedures. A commitment to improving
cultural competence must include resources to
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
community needs evolve. Chapter 4 presents
20 organizational tasks that support counse-
lors’ development of cultural competence and
improve organizational development of cultur-
ally responsive treatment services.
Beginning with the organization’s vision and
mission statement, administrators and govern-
ing boards need to develop, implement, and
support a strategic planning process that
demonstrates commitment to cultural compe-
tence. Key staff members assigned to oversee
the development of culturally responsive
services act as liaisons and facilitators in estab-
lishing a cultural competence committee and
conducting an organizational self-assessment
of cultural competence. With the involvement
of community members, staff, clients and their
families, board members, and other invested
individuals, the cultural competence commit-
tee supports and oversees organizational self-
assessment, using it to identify strengths and
specific areas for improvement in cultural
responsiveness. Based on the results of the
self-assessment, the committee develops and
implements a cultural competence plan.
An organizational self-assessment helps the
committee prioritize the steps needed to
improve culturally responsive services. The
plan should address strategies for recruiting,
hiring, retaining, and promoting qualified,
diverse staff members; the use of interpreters
or bilingual staff members; staff training,
professional development, and education;
fostering community involvement; facilities
design and operation; development of cultur-
ally appropriate program materials; how to
incorporate culturally relevant treatment
approaches; and development and implemen-
tation of supporting policies and procedures,
including reassessment processes. An organi-
zation’s commitment to and support of cultur-
ally responsive services, including congruent
policies and procedures, will enable counselors
to respond more consistently to clients in a
culturally competent manner.
Behavioral Health
Treatment for Major Racial
and Ethnic Groups
Knowledge of a culture’s attitudes toward
mental illness, substance use, healing, and
help-seeking patterns, practices, and beliefs is
essential in understanding clients’ presenting
problems, developing culturally competent
counseling skills, and formulating culturally
relevant agency policies and procedures.
Treatment providers need to learn and under-
stand how identification with one or more
cultural groups influences each client’s
worldview, beliefs, and traditions surrounding
initiation of use, healing, and treatment.
Chapter 5 provides a review of the literature as
it pertains to specific racial and ethnic groups
identified by the U.S. Census Bureau. After a
brief introduction, the chapter explores each
major racial and ethnic group’s specific pat-
terns of substance use and substance use dis-
orders, help-seeking patterns, beliefs about
and traditions involving substance use, beliefs
and attitudes about treatment, assessment and
treatment considerations (including co-
occurring disorders and culturally specific
disorders), and theoretical approaches and
treatment interventions (including evidence-
based and best practices as well as traditional
healing practices).
Chapter 5 also offers assistance in providing
treatment to African and Black Americans,
Asian Americans (including Native Hawaiian
and other Pacific Islanders), Latinos, Native
Americans, and White Americans. Counse-
lors, clinical supervisors, and administrators
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.
Nonetheless, many forces shape how an indi-
vidual identifies with, is influenced by, or
portrays his/her culture, and numerous subcul-
tures can exist within any culture; thus, gener-
alizations about various population groups
should be avoided.
Drug Cultures and the
Culture of Recovery
This TIP emphasizes the concept that many
subcultures exist within and across diverse
ethnic and racial populations and cultures.
Drug cultures are a formidable example—they
can influence the presentation of mental,
substance use, and co-occurring disorders
while also affecting prevention and treatment
strategies and outcomes. Drug cultures differ
from the types of cultures discussed in the rest
of this TIP, but they do share some common
features. For instance, there is not a single
drug culture in the United States today, but
rather, a number of distinct (although some-
times related) drug cultures that differ accord-
ing to substances used, geographic location,
socioeconomic status, and other factors. Drug
cultures focusing on illicit substances may be
of greater importance in the lives of people
who use substances, but people who use legal
substances, such as alcohol, can also partici-
pate in a drug culture. For example, people
who drink heavily at a bar or fraterni-
ty/sorority house can develop their own drug
culture that works to encourage new people to
use, supports high levels of continued use or
binge use, and reinforces denial.
Understanding the role that drug cultures play
in clients’ lives is particularly important be-
cause these cultures, more than any other
cultural connections, influence clients’ sub-
stance use or abuse and the behaviors in which
they engage to manage mental disorders.
Through drug cultures, people new to using
learn to experience “getting high” as a pleasur-
able activity; they also learn the skills needed
to procure and use drugs effectively and to
avoid the pitfalls of the drug-using lifestyle
(e.g., getting arrested, running out of money to
buy drugs). Perhaps most importantly, the
person who uses gains acceptance from a
group of peers even as mainstream society
increasingly discriminates against him or her
because of his or her substance use or mental
illness. Prejudice from mainstream society may
make ties with the drug culture even stronger;
he or she may feel as if there is no other place
to turn for social and cultural support.
Within a treatment program, an understand-
ing of drug cultures will help providers engage
new clients and recognize the social and cul-
tural bonds that might lead them back to
substance use or other high-risk behaviors that
are contraindicated for individuals who are
being treated for psychological symptoms
and/or mental illness. However, unlike other
types of cultural affiliations, the treatment
provider’s relationship to the drug culture does
not just involve understanding; the provider
must actively work to weaken that connection
and replace it with other experiences that meet
the client’s social and cultural needs. In many
cases, this involves helping the client connect
with a “culture of recovery” to meet those
needs over the long course of recovery.
In sum, this TIP was written to help counse-
lors and organizations provide culturally re-
sponsive services. Practices and procedures
that improve one’s cultural competence will
likely result in better outcomes for clients in
treatment for mental and substance use disor-
ders. Culturally competent counseling can
improve counselor credibility, client satisfac-
tion, and client self-disclosure while increasing
clients’ willingness to continue in treatment.
xxi
IN THIS CHAPTER
• Purpose and Objectives
of the TIP
• Core Assumptions
• What Is Cultural
Competence?
• Why Is Cultural
Competence Important?
• How Is Cultural
Competence Achieved?
• What Is Culture?
• What Is Race?
• What Is Ethnicity?
• What Is Cultural Identity?
• What Are the Cross-
Cutting Factors in Race,
Ethnicity, and Culture?
• As You Proceed
Hoshi was born and grew up in Japan. He has been living in the
United States for nearly 20 years, going to graduate school and
working as a systems analyst, while his family has remained in
Japan. Hoshi entered a residential treatment center for alcohol
dependence where the treatment program expected every client to
notify his or her family members about being in treatment. This
had proven to be a positive step for many other clients and their
families in this treatment program, where the belief was that con-
tact with family helped clients become honest about their sub-
stance abuse, reconnect with possibly estranged relatives, and take
responsibility for the decision to seek treatment.
He was reluctant, but staff members persuaded Hoshi to comply
with program expectations. He wrote to his family, describing his
current life and explaining his need for treatment. It was not until
weeks later, after he had been discharged from residential treat-
ment and was participating in the program’s continuing care pro-
gram, that he received a reply. Staff members were shocked to learn
that Hoshi’s parents had disowned him because he had “shamed”
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
Introduction to Cultural
Competence
1
Improving Cultural Competence
own worldviews as well as those of their cli-
ents will be able to work more effectively with
clients who have substance use and mental
disorders. Even when culture is not a con-
scious consideration in providing interventions
and services, it is a dynamic force that often
influences client responses to treatment and
subsequent outcomes. Although outcome
research is limited, culturally responsive be-
havioral health counseling results in greater
counselor credibility, better client satisfaction,
more client self-disclosure, and greater will-
ingness among clients to continue with coun-
seling (Goode et al. 2006; Lie et al. 2011;
Ponterotto et al. 2000). This Treatment
Improvement Protocol (TIP) examines the
significance of culture in substance abuse
patterns, mental health, treatment-seeking
behaviors, assessment and counseling process-
es, program development, and organizational
practices in behavioral health services.
Purpose and Objectives of
the TIP
This TIP is intended to help counselors and
behavioral health organizations make progress
toward cultural competence. Gaining cultural
competence, like any important counseling
skill, is an ongoing process that is never com-
pleted; such skills cannot be taught in any
single book or training session. Nevertheless,
this TIP provides a framework to help practi-
tioners and administrators integrate cultural
factors into their evaluation and treatment of
clients with behavioral health disorders. It also
seeks to motivate professionals and organiza-
tions to examine and broaden their cultural
awareness, embrace diversity, and develop a
heightened respect for people of all cultural
groups. This TIP places significant im-
portance on the role of program management
and organizational commitment in the devel-
opment of cultural competence. Organizational
support allows counselors, case managers, and
administrators to begin to integrate culturally
congruent and responsive services more con-
sistently across the continuum of care—
including outreach and early intervention,
assessment, treatment planning and interven-
tion, and recovery services.
The key objectives of this TIP are helping
readers understand:
• Why it is important for behavioral health
organizations and counselors who provide
prevention and treatment services to con-
sider culture.
• The role culture plays in the treatment
process, both generally and with reference
to specific cultural groups.
Intended Audience
The primary audiences for this TIP are pre-
vention professionals, substance abuse counse-
lors, mental health clinicians, and other
behavioral health service providers and admin-
istrators. Those who work with culturally
diverse populations will find it particularly
useful, though all behavioral health workers—
regardless of their client populations—can
benefit from an awareness of the importance
of culture in shaping their own perceptions as
well as those of their clients. Secondary audi-
ences include educators, researchers, policy-
makers for treatment and related services,
consumers, and other healthcare and social
service professionals who work with clients
who have behavioral health disorders.
Structure of the TIP
This TIP focuses on the essential ingredients
for developing cultural competence as a coun-
selor and for providing culturally responsive
services in clinical settings as an organization.
Chapter 1 defines cultural competence, pre-
sents a rationale for pursuing it, and describes
the process of becoming culturally competent
and responsive to client needs. The chapter
2
Chapter 1—Introduction to Cultural Competence
highlights the consensus panel’s core assump-
tions. It introduces a framework, adapting
Sue’s (2001) multidimensional model of cul-
tural competence as the guiding model across
chapters. The initial chapter ends with a broad
overview of the concepts integral to an under-
standing of race, ethnicity, and culture.
Chapter 2 addresses the development of cul-
tural awareness and describes core competen-
cies for counselors and other clinical staff,
beginning with self-knowledge and ending
with skill development. It covers behaviors and
skills for cultivating cultural competence as
well as attitudes conducive to working effec-
tively with diverse client populations.
Chapter 3 provides guidelines for culturally
responsive clinical services, including inter-
viewing skills, assessment practices, and treat-
ment planning.
Chapter 4 provides organizational strategies to
promote the development and implementation
of culturally responsive practices from the top
down, beginning with organizational self-
assessment of current services and continuing
through implementation and oversight of an
organizational plan targeting initiatives to
improve culturally responsive services.
Chapter 5 provides a general introduction for
each major racial and ethnic group, providing
specific cultural knowledge related to sub-
stance use patterns, beliefs and attitudes to-
ward help-seeking behavior and treatment,
and an overview of research- and practice-
based treatment approaches and interventions.
Chapter 6 closes the TIP with an exploration
of the concept of “drug culture”—the relation-
ship between the drug culture and mainstream
culture, the values and rituals of drug cultures,
how people “benefit” from participation in
drug cultures, and the role of the drug culture
in substance abuse treatment.
Terminology
Throughout the TIP, the term substance abuse
is used to refer to both substance abuse and
substance dependence. This term was chosen
partly because substance abuse treatment
professionals commonly use the term sub-
stance abuse to describe any excessive use of
addictive substances. In this TIP, the term
refers to use of alcohol as well as other sub-
stances of abuse. Readers should attend to the
context in which the term occurs to determine
what possible range of meanings it covers; in
most cases, however, the term will refer to all
varieties of substance use disorders described
by the Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5;
American Psychiatric Association, 2013).
Throughout the TIP, the term behavioral
health refers to a state of mental/emotional
being and/or choices and actions that affect
wellness. Behavioral health problems include
substance abuse or misuse, alcohol and drug
addiction, psychological distress, suicide, and
mental and substance use disorders. This
includes a range of problems, from unhealthy
stress to diagnosable and treatable diseases like
serious mental illness and substance use disor-
ders, which are often chronic in nature but
from which people can and do recover. The
term is also used in this TIP to describe the
service systems encompassing the promotion
of emotional health, the prevention of mental
and substance use disorders, substance use and
related problems, treatments and services for
mental and substance use disorders, and re-
covery support. Behavioral health conditions,
taken together, are the leading causes of disa-
bility burden in North America; efforts to
improve their prevention and treatment will
benefit society as a whole. Efforts to reduce
the impact of mental and substance use disor-
ders on communities in the United States,
such as those described in this TIP, will help
achieve nationwide improvements in health.
3
Improving Cultural Competence
Core Assumptions
The consensus panel developed assumptions
that serve as the fundamental platform of this
TIP. Assumptions were derived from clinical
and administrative experiences, available
empirical evidence, conceptual writings, and
program and treatment service models.
Assumption 1:
The focus of cultural compe-
tence, in practice, has historically been on
individual providers. However, counselors will
not be able to sustain culturally responsive
treatment without the organization’s commit-
ment to support and allocate resources to
promote these practices. Organizations that
value diversity and reflect cultural competence
through congruent policies and procedures are
more likely to be successful in the ever-
changing landscape of communities, treatment
services, and individual client needs.
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.
Before counselors begin to probe the cultures,
races, and ethnicities of their clients and use
this information to improve client treatment,
the consensus panel recommends first that
counselors examine and understand their own
cultural histories, racial and ethnic heritages,
and cultural values and beliefs. This applies to
all practitioners regardless of race, ethnicity, or
cultural identity. Beyond that, clinicians
should clearly identify the influences of their
own cultural experiences on the counseling
relationship. In other words, each counselor
must understand, embrace, and, if warranted,
reexamine and adjust his or her own world-
view to practice in a culturally competent
manner. So too, all support staff, clinicians,
administrators, and policymakers—including
those not from the mainstream culture—
must become educated and convinced of the
importance of cultural competence in the
delivery of effective behavioral health services.
Assumption 3:
Incorporating cultural compe-
tence into treatment improves therapeutic
decision-making and offers alternate ways to
define and plan a treatment program that is
firmly directed toward progress and recov-
ery—as defined by both the counselor and
client. Using culturally responsive practices is
essential and provides many benefits for or-
ganizations, staff, communities, and clients.
Assumption 4:
Consideration of culture is
important at all levels of operation—
individual, programmatic, and organization-
al—across behavioral health treatment set-
tings. It is also important in all activities and
at every treatment phase: outreach, initial
contact, screening, assessment, placement,
treatment, continuing care and recovery ser-
vices, research, and education. Because organi-
zations and systems have their own internal
cultures, it is vital that treatment facilities,
training and educational programs on
substance-related and mental disorders and
treatment processes, and licensing agencies
and accrediting bodies incorporate culturally
responsive practices into their curricula, stand-
ards, criteria, and requirements.
Assumption 5:
Achieving cultural compe-
tence in an organization requires the partici-
pation of racially and ethnically diverse groups
and underserved populations in the develop-
ment and implementation of culturally re-
sponsive practices, program structure and
design, treatment strategies and approaches,
and staff professional development. Culturally
congruent interventions cannot be successfully
applied when generated outside a community
or without community participation. Clients,
potential clients, their families, and their com-
munities should be invited to participate in the
development of a cultural competence plan (an
4
Chapter 1—Introduction to Cultural Competence
organization’s plan to improve cultural compe-
tence and to provide culturally responsive
services) and, subsequently, the design of
culturally relevant treatment services and
organizational policies and procedures.
Assumption 6:
Public advocacy of culturally
responsive practices can increase trust among
the community, agency, and staff. The com-
munity is thus empowered with a voice in
organizational operations. Advocacy can
further function as a secondary form of public
education and awareness as well as outreach.
High collective participation allows treatment
to be viewed as of and for the community.
What Is Cultural
Competence?
In 1989, Cross et al. provided one of the more
universally accepted definitions of cultural
competence in clinical practice: “A set of
congruent behaviors, attitudes, and policies
that come together in a system, agency, or
among professionals and enable the system,
agency, or professionals to work effectively in
cross-cultural situations” (p. 13).
Since then, others have interpreted this defini-
tion in terms of a particular field or attempted
to refine, expand, or elaborate on earlier con-
ceptions of cultural competence. At the root
of this concept is the idea that cultural compe-
tence is demonstrated through practical
means—that is, the ability to provide effective
services. Bazron and Scallet (1998) defined
culturally responsive services as those that are
“responsive to the unique cultural needs of
bicultural/bilingual and culturally distinct
populations” (p. 2). The Office of Minority
Health (OMH 2000) merged several existing
definitions to conclude that:
Cultural and linguistic competence is a set of
congruent behaviors, attitudes, and policies
that come together in a system, agency, or
among professionals that enables effective
work in cross-cultural situations. ‘Culture’ re-
fers to integrated patterns of human behavior
that include the language, thoughts, communi-
cations, actions, customs, beliefs, values, and
institutions of racial, ethnic, religious, or social
groups. ‘Competence’ implies having the ca-
pacity to function effectively as an individual
and an organization within the context of the
cultural beliefs, behaviors, and needs presented
by consumers and their communities. (p. 28)
Numerous evolving definitions and models of
cultural competence reflect an increasingly
complex and multidimensional view of how
race, ethnicity, and culture shape individu-
als—their beliefs, values, behaviors, and ways
of being (see Bhui et al. 2007 for a systemic
review of cultural competence models in
mental health). In this TIP, Sue’s (2001)
multidimensional model of cultural compe-
tence guides its overall organization and the
specific content of each chapter. The model
was adapted to fit the unique topic areas
addressed by this TIP (Exhibit 1-1) and to
target essential elements of cultural compe-
tence in providing behavioral health services
across three main dimensions, as shown in the
cube. (Note: Each subsequent chapter displays
a version of this cube shaded to emphasize the
focus of that chapter.)
Dimension 1: Racially and
Culturally Specific Attributes
Exhibit 1-1 and this TIP focus on main popu-
lation groups as identified by the U.S. Census
Bureau (Humes et al. 2011), but this dimen-
sion is inclusive of other multiracial and cul-
turally diverse groups and can also include
sexual orientation, gender orientation, socioec-
onomic status, and geographic location. There
are often many cultural groups within a given
population or ethnic heritage. For simplicity,
these groups are not represented on the actual
model, and it is assumed that the reader
acknowledges the vast inter- and intragroup
variations that exist in all population, ethnic,
5
Improving Cultural Competence
and cultural groups. Refer to Chapters 5 and 6
to gain further clinical knowledge about spe-
cific racial, ethnic, and cultural groups.
Dimension 2: Core Elements of
Cultural Competence
This dimension includes cultural awareness,
cultural knowledge, and cultural skill devel-
opment. To provide culturally responsive
treatment services, counselors, other clinical
staff, and organizations need to become aware
of their own attitudes, beliefs, biases, and
assumptions about others. Providers need to
invest in gaining cultural knowledge of the
populations that they serve and obtaining
specific cultural knowledge as it relates to
help-seeking, treatment, and recovery. This
dimension also involves competence in clinical
skills that ensure delivery of culturally appro-
priate treatment interventions. Several chap-
ters capture the ingredients of this dimension.
Chapter 1 provides an overview of cultural
competence and concepts, Chapter 2 provides
an indepth look at the role and effects of the
counselor’s cultural awareness and identity
within the counseling process, Chapter 3
provides an overview of cultural considerations
and essential clinical skills in the assessment
and treatment planning process, and Chapter
5 specifically addresses the role of culture
across specific treatment interventions.
Dimension 3: Foci of Culturally
Responsive Services
This dimension targets key levels of treatment
services: the individual staff member level, the
Exhibit 1-1: Multidimensional Model for Developing Cultural Competence
6
Chapter 1—Introduction to Cultural Competence
clinical and programmatic level, and the or-
ganizational and administrative level. Inter-
ventions need to occur at each of these levels
to endorse and provide culturally responsive
treatment services, and such interventions are
addressed in the following chapters. Chapter 2
focuses on core counselor competencies;
Chapter 3 centers on clinical/program attrib-
utes in interviewing, assessment, and treat-
ment planning that promote culturally
responsive interventions; and Chapter 4 ad-
dresses the elements necessary to improve
culturally responsive services within treatment
programs and behavioral health organizations.
What Are Health Disparities?
A health disparity is a particular type of health difference 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.
Why Is Cultural
Competence Important?
Foremost, cultural competence provides clients
with more opportunities to access services that
reflect a cultural perspective on and alternative,
culturally congruent approaches to their pre-
senting problems. Culturally responsive ser-
vices will likely provide a greater sense of
safety from the client’s perspective, supporting
the belief that culture is essential to healing.
Even though 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 (including his-
torical and generational events), acculturation,
discrimination, and bias, and such services also
allow them to examine how these impacts
relate to or affect their mental and physical
health. Culturally responsive practice recog-
nizes the fundamental importance of language
and the right to language accessibility, includ-
ing translation and interpreter services. For
clients, culturally responsive services honor the
beliefs that culture is embedded in the clients’
language and their implicit and explicit com-
munication styles and that language-
accommodating services can have a positive
effect on clients’ responses to treatment and
subsequent engagement in recovery services.
The Affordable Care Act, along with growing
recognition of racial and ethnic health dispari-
ties and implementation of national initiatives
to reduce them (HHS 2011b), necessitates
enhanced culturally responsive services and
cultural competence among providers. Most
behavioral health studies have found dispari-
ties in access, utilization, and quality in behav-
ioral health services among diverse ethnic and
racial groups in the United States (Alegria et
al. 2008b; Alegria et al. 2011; HHS 2011b; Le
Cook and Alegria 2011; Satre et al. 2010).
The lack of cultural knowledge among provid-
ers, culturally responsive environments, and
diversity in the workforce contribute to dis-
parities in healthcare. Even limited cultural
competence is a significant barrier that can
translate to ineffective provider–consumer
communication, delays in appropriate treat-
ment and level of care, misdiagnosis, lower
rates of consumer compliance with treatment,
and poorer outcome (Barr 2008; Carpenter-
Song et al. 2011; Dixon et al. 2011). Increas-
ing the cultural competence of the healthcare
workforce and across healthcare settings is
crucial to increasing behavioral health equity.
Additionally, adopting and integrating cultur-
ally responsive policies and practices into
7
Improving Cultural Competence
behavioral health services provides many
benefits not only for the client, but also for the
organization and its staff. Foremost, it increas-
es the likelihood of sustainability. Cultural
competence supports the viability of services
by bringing to the forefront the value of diver-
sity, flexibility, and responsiveness in organiza-
tions and among practitioners. Beyond the
necessity of adopting culturally responsive
practices to meet funding, state licensing,
and/or national accreditation requirements,
cultural competence essential in organizational
risk management (the process of making and
implementing decisions that will optimize
therapeutic outcomes and minimize adverse
effects upon clients and, ultimately, the organ-
ization). For instance, implementing culturally
responsive services is likely to increase access
to care and improve assessment, treatment
planning, and placement. So too, it is likely to
enhance effective communication between
clients and treatment providers, thus decreas-
ing risks associated with misunderstanding the
clients’ presenting problems or the needs of
clients with regard to appropriate referrals for
evaluation or treatment.
Organizational investment in improving
cultural competence and increasing culturally
responsive services will likely increase use and
cost effectiveness because services are more
appropriately matched to clients from the
beginning. A key principle in culturally re-
sponsive practices is engagement of the com-
munity, clients, and staff. As organizations
establish community involvement in the ongo-
ing implementation of culturally responsive
services, the community will be more aware of
available treatment services and thus will
become more likely to use them as its in-
volvement with and trust for the organization
grows. Likewise, clients and staff are more apt
to be empowered and invested if they are
involved in the ongoing development and
delivery of culturally responsive services. Cli-
ent and staff satisfaction can increase if organ-
izations provide culturally congruent
treatment services and clinical supervision.
An organization also benefits from culturally
responsive practices through planning for,
attracting, and retaining a diverse workforce
that reflects the multiracial and multiethnic
heritages and cultural groups of its client base
and community. Developing culturally respon-
sive organizational policies includes hiring and
promotional practices that support staff diver-
sity at all levels of the organization, including
board appointments. Increasing diversity does
not guarantee culturally responsive practices,
but it is more likely that doing so will lead to
broader, varied treatment services to meet
client and community needs. Organizations
are less able to ignore the roles of race, ethnici-
ty, and culture in the delivery of behavioral
health services if staff composition at each
level of the organization reflects this diversity.
Culturally responsive practice reinforces the
counselor’s need for self-exploration of cultur-
al identity and awareness and the importance
of acquiring knowledge and skills to meet
clients’ specific cultural needs. Cultural com-
petence requires an understanding of the
client’s worldview and the interactions be-
tween that worldview and the cultural identi-
ties of the counselor and the client in the
therapeutic process. Culturally responsive
practice reminds counselors that a client’s
worldview shapes his or her perspectives,
The Enhanced National Standards for
Culturally and Linguistically Appropriate
Services in Health and Health Care (OMH
2013) are meant to reduce and eliminate
disparities, improve quality of care, and
promote health equality by establishing a
blueprint for health and the organization
of health care (see Appendix C or visit
http://www.thinkculturalhealth.hhs.gov).
8
Chapter 1—Introduction to Cultural Competence
beliefs, and behaviors surrounding substance
use and dependence, illness and health, seek-
ing help, treatment engagement, counseling
expectations, communication, and so on.
Cultural competence includes addressing the
client individually rather than applying gen-
eral treatment approaches based on assump-
tions and biases. It also can counteract a
potentially omnipotent stance on the part of
counselors that they know what clients need
more than the clients themselves do. Cultural
competence highlights the need for counselors
to take time to build a relationship with each
of their clients, to understand their clients, and
to assess for and access services that will meet
each client’s individual needs.
The importance and benefit of cultural com-
petence does not end with changes in organi-
zational policies and procedures, increases in
program accessibility and tailored treatment
services, or enhancement of staff training. In
programs that prioritize and endorse cultural
competence at all levels of service, clients, too,
will have more exposure to psychoeducational
and clinical experiences that explore the roles
of race, ethnicity, culture, and diversity in the
treatment process. Treatment will help clients
address their own biases, which can affect
their perspectives and subsequent relationships
with other clients, staff members, and individ-
uals outside of the program, including other
people in recovery. Culturally responsive
services prepare clients not only to embrace
their own cultural groups and life experiences,
but to acknowledge and respect the experienc-
es, perspectives, and diversity of others.
How Is Cultural
Competence Achieved?
Cultural groups are diverse and continuously
evolving, defying precise definitions. Cultural
competence is not acquired merely by learning
a given set of facts about specific populations,
changing an organization’s mission statement,
or attending a training on cultural compe-
tence. Becoming culturally competent is a
developmental process that begins with
awareness and commitment and evolves into
skill building and culturally responsive behav-
ior within organizations and among providers.
Cultural competence is the ability to recognize
the importance of race, ethnicity, and culture
in the provision of behavioral health services.
Specifically, it is awareness and acknowledg-
ment that people from other cultural groups
do not necessarily share the same beliefs and
practices or perceive, interpret, or encounter
similar experiences in the same way. Thus,
cultural competence is more than speaking
another language or being able to recognize
the basic features of a cultural group. Cultural
competence means recognizing that each of
us, by virtue of our culture, has at least some
ethnocentric views that are provided by that
culture and shaped by our individual interpre-
tation of it. Cultural competence is rooted in
respect, validation, and openness toward
someone whose social and cultural back-
ground is different from one’s own (Center for
Substance Abuse Treatment [CSAT] 1999b).
Nonetheless, cultural competence literature
highlights how difficult it is to appreciate
cultural differences and to address these dif-
ferences effectively, because many people tend
to see things solely from their own culture-
bound perspectives. For counselors, specific
cognitions, attitudes, and behaviors character-
ize the path to culturally competent counsel-
ing and culturally responsive services. Exhibit
1-2 depicts the continuum of thoughts and
behaviors that lead to cultural competence in
the provision of treatment. The “stages” are
not necessarily linear, and not all people begin
with a negative impression of other cultural
groups—they may simply fail to recognize
differences and diverse ways of being. For
9
Improving Cultural Competence
Exhibit 1-2: The Continuum of Cultural Competence
Stage 1: Cul
tural 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 organizational culture
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 subject 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
most people, the process of becoming cultural-
ly competent is complex, with movement back
and forth along the continuum and with
feelings and thoughts from more than one
stage sometimes existing concurrently.
What Is Culture?
Culture is defined by a community or society.
It structures the way people view the world. It
involves the particular set of beliefs, norms,
and values concerning the nature of relation-
ships, the way people live their lives, and the
way people organize their environments.
Culture is a complex and rich concept. Under-
standing it requires a willingness to examine
and grasp its many elements and to compre-
hend how they come together. Castro (1998)
identified the elements generally agreed to
constitute a culture as:
• A common heritage and history that is
passed from one generation to the next.
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.
11
Improving Cultural Competence
• Shared values, beliefs, customs, behaviors,
traditions, institutions, arts, folklore, and
lifestyle.
• Similar relationship and socialization
patterns.
• A common pattern or style of communica-
tion or language.
• Geographic location of residence (e.g.,
country; community; urban, suburban, or
rural location).
• Patterns of dress and diet.
Although these criteria cannot be strictly
applied to every cultural group, they do suffi-
ciently define cultures so that groups are
distinguishable to their members and to others
(Castro 1998). Note that these criteria apply
more or less equally well to cultural groups
based on nationality, ethnicity, region (e.g.,
Southern, Midwestern), profession, and social
interests (Exhibit 1-3 reviews common char-
acteristics of culture).
However, culture is not a definable entity to
which people belong or do not belong. Within
a nation, race, or community, people belong to
multiple cultural groups, each with its own set
of cultural norms (i.e., spoken or unspoken
rules or standards that indicate whether a
certain behavior, attitude, or belief is appropri-
ate or inappropriate).
The word “culture” can be applied to describe
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 myths.
• Religion and spirituality.
• 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, stereotypes, 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 legitimacy (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-
bility, sexual orientation, geographic location,
membership in self-help support groups, and
so forth. In this TIP, with the exception of the
drug culture, the focus is on cultural groups
that are shaped by a dynamic interplay among
specific factors that shape a person’s identity,
including race, ethnicity, religion, socioeco-
nomic status, and others.
What Is Race?
Race is often thought to be based on genetic
traits (e.g., skin color), but there is no reliable
means of identifying race based on genetic
information (HHS 2001). Indeed, 85 percent
of human genetic diversity is found within any
“racial” group (Barbujani et al. 1997). Thus,
what we perceive as diverse races (based largely
on selective physical characteristics, such as
skin color) are much more genetically similar
than they are different. Moreover, physical
characteristics ascribed to a particular racial
group can also appear in people who are not in
that group. Asians, for example, often have an
epicanthic eye fold, but this characteristic is
also shared by the Kung San bushmen, an
African nomadic Tribe (HHS 2001).
Although it lacks a genetic basis, the concept
of race is important in discussing cultural
competence. Race is a social construct that
describes people with shared physical charac-
teristics. It can have tremendous social signifi-
cance in terms of behavioral health services,
social opportunities, status, wealth, and so on.
The perception that people who share physical
characteristics also share beliefs, values, atti-
tudes, 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. The major
racial groupings designated by the U.S. Census
Bureau—African American or Black, White
American or Caucasian, Asian American,
American Indian/Alaska Native, and Native
Hawaiian/Pacific Islander—are limiting in
that they are categories developed to describe
identifiable populations that exist currently
within the United States. The U.S. Census
defines Hispanics/Latinos as an ethnic group
rather than a racial group (see the “What Is
Ethnicity?” section later in this chapter).
Racial labels do not always have clear meaning
in other parts of the world; how one’s race is
defined can change according to one’s current
environment or society. A person viewed as
Black in the United States can possibly be
viewed as White in Africa. Racial categories
also do not easily account for the complexity
of multiracial identities. An estimated 3 per-
cent of United States residents (9 million
individuals) indicated in the 2010 Census that
they are of more than one race (Humes et al.
2011). The percentage of the total United
States population who identify as being of
mixed race is expected to grow significantly in
coming years, and some estimate that it will
rise as high as one in five individuals by 2050
(Lee and Bean 2004).
White Americans constitute the largest racial
group in the United States. In the 2010
Census, 72 percent of the United States popu-
lation consisted of non-Hispanic Whites, a
classification that has been used by the Census
Bureau and others to refer to non-Hispanic
people of European, North African, or Middle
Eastern descent (Humes et al. 2011). The U.S.
Census Bureau predicts, however, that White
Americans will be outnumbered by persons of
color sometime between the years 2030 and
2050. The primary reasons for the decreasing
proportion of White Americans are immigra-
tion patterns and lower birth rates among
Whites relative to Americans of other racial
backgrounds (Sue and Sue 2003b).
Whites are often referred to collectively as
Caucasians, although technically, the term
13
Improving Cultural Competence
refers to a subgroup of White people from the
Caucasus region of Eastern Europe and West
Asia. To complicate matters, some Caucasian
people—notably some Asian Indians—are
typically counted as Asian (U.S. Census
Bureau 2001a). Many subgroups of White
Americans (of European, Middle Eastern, or
North African descent) have had very differ-
ent experiences when immigrating to the
United States.
African Americans, or Blacks, are the second
largest racial group in the United States, mak-
ing up about 13 percent of the United States
population in 2010 (Humes et al. 2011).
Although most African Americans trace their
roots to Africans brought to the Americas as
slaves centuries ago, an increasing number are
new immigrants from Africa and the Caribbe-
an. The terms African American and Black
are used synonymously at times in literature
and research, but some recent immigrants do
not consider themselves to be African
Americans, assuming that the designation
only applies to people of African descent born
in the United States. The racial designation
Black, however, encompasses a multitude of
cultural and ethnic variations and identities
(e.g., African Caribbean, African Bermudian,
West African, etc.). The history and experi-
ence of African Americans has varied consid-
erably in different parts of the United States,
and the experience of Black people in this
country varies even more when the culture and
history of more recent immigrants is consid-
ered. Today, African American culture embod-
ies elements of Caribbean, Latin American,
European, and African cultural groups. Not-
ing this diversity, Brisbane (1998) observed
that “these cultures are so unique that practices
of some African Americans may not be un-
derstood by other African Americans…there
is no one culture to which all African
Americans…belong” (p. 2).
The racial category of Asian is defined by the
U.S. Census Bureau (2001a) as people “having
origins in any of the original peoples of the
Far East, Southeast Asia, or the Indian sub-
continent including, for example, Cambodia,
China, India, Japan, Korea, Malaysia, Pakistan,
the Philippine Islands, Thailand, and Vietnam”
(p. A-3). In the 2010 census, Asian Americans
accounted for 4.8 percent of the total United
States population, or 5.6 percent when biracial
or multiracial Asians were included (Hoeffel
et al. 2012). For those who identified with
only one Asian group, 23 percent of Asian
Americans were Chinese; 19 percent, Asian
Indian; 17 percent, Filipino; 11 percent,
Vietnamese; 10 percent, Korean; and 5 per-
cent, Japanese. Asian Americans comprised
about 43 ethnic subgroups, speaking more
than 100 languages and dialects (HHS 2001).
The tremendous cultural differences among
these groups make generalizations difficult.
Until recently, Asian Americans were often
grouped with Pacific Islanders (collectively
called Asians and Pacific Islanders, or APIs)
for data collection and analysis. Beginning
with the 2000 Census, however, the Federal
Government recognized Pacific Islanders as a
distinct racial group. As a result, this TIP does
not combine Asians with Pacific Islanders.
Nonetheless, remnants of the old classification
system are evident in research based on the
API grouping. Where possible, the TIP uses
data solely for Asians; however, in some cases,
the only research available is for the combined
API grouping.
Native American is a term that describes both
American Indians and Alaska Natives. Racially,
Native Americans are related to Asian peoples
(notably, those from Siberia in Russia), but
they are considered a distinct racial category
by the U.S. Census Bureau, which further
stipulates that people categorized in this
fashion have to have a “Tribal affiliation
14
Chapter 1—Introduction to Cultural Competence
or community attachment” (U.S. Census Bu-
reau 2001a, p. A-3). There are 566 federally
recognized American Indian or Alaska Native
Tribal entities (U.S. Department of the Interior,
Indian Affairs 2013a), but there are numerous
other Tribes recognized only by States and still
others that go unrecognized by any govern-
ment agency. These Tribes, despite sharing a
racial background, represent a widely diverse
group of cultures with diverse languages,
religions, histories, beliefs, and practices.
What Is Ethnicity?
The term ethnicity is sometimes used inter-
changeably with “race,” although it is im-
portant to draw distinctions between the two.
According to Yang (2000), ethnicity refers to
the social identity and mutual sense of belong-
ing that defines a group of people through
common historical or family origins, beliefs,
and standards of behavior (i.e., culture). In
some cases, ethnicity also refers to identifica-
tion with a clan or group whose identity can
be based on race as well as culture. Some
Latinos, for example, self-identify in terms of
both their ethnicity (e.g., their Cuban herit-
age) and their race (e.g., whether they are dark
or light skinned).
Because Latinos can belong to a number of
races, the Census Bureau defines them as an
ethnic group rather than a race. In 2010,
Latinos comprised 16 percent of the United
States population (Ennis et al. 2011). They are
the fastest growing ethnic group in the United
States; between 2000 and 2010, the number of
Latinos in the country increased 43 percent, a
rate nearly four times higher than that for the
total population (Ennis et al. 2011). By 2050,
Latinos are expected to make up 29 percent of
the total population (Passel and Cohn 2008).
Nearly 60 percent of Latino Americans were
born in the United States, but Latinos also
account for more than half of the nation’s
foreign-born population (Larsen 2004;
Ramirez and de la Cruz 2003). Foreign-born
Latinos include legal immigrants, some of
whom have succeeded in becoming natural-
ized American citizens, as well as undocu-
mented or illegal immigrants to the United
States. Approximately three-quarters (74
percent) of the Nation’s unauthorized immi-
grant population are Hispanics, mostly from
Mexico (Passel and Cohn 2008).
The terms “Hispanic” and “Latino” refer to
people whose cultural origins are in Spain or
Portugal or the countries of the Western
Hemisphere whose culture is significantly
influenced by Spanish or Portuguese coloniza-
tion. Regional and political differences exist
among various groups as to whether they
prefer one term over the other. The literature
currently uses both terms interchangeably, as
both terms are widely used and refer generally
to the same Latin-heritage population of the
United States. That said, a distinction can
technically be drawn between Hispanic (liter-
ally meaning people from Spain or its former
colonies) and Latino (which refers to persons
whose origins lie in countries ranging from
Mexico to Central and South America and
the Caribbean, which were colonized by
Spain, and including Portugal and its former
colonies as well). For that reason, this TIP uses
the more inclusive term Latino, except when
research specifically indicates the other. The
term Latinas is used to refer specifically to
women who are a part of this cultural group.
Ethnicity differs from race in that groups of
people can share a common racial ancestry
yet have very different ethnic identities.
Thus, by definition, ethnicity—unlike race—
is an explicitly cultural phenomenon. It is
based on a shared cultural or family herit-
age as well as shared values and beliefs
rather than shared physical characteristics.
15
Improving Cultural Competence
Within a racial group (e.g., Asian, White,
Black, Native American), there are many
diverse ethnicities, and these diverse ethnici-
ties often reflect vast differences in cultural
histories. The White Anglo-Saxon Protestant
peoples of England and Northern Europe
have, for example, many differing cultural
attributes and a very different history in the
United States than the Mediterranean peoples
of Southern Europe (e.g., Italians, Greeks).
What Is 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. All people,
regardless of race or ethnicity, develop a cul-
tural identity (Helms 1995). Cultural identity
is not consistent even among people who
identify with the same culture. Two Korean
immigrants could both identify strongly with
Korean culture but embrace or reject different
elements of that culture based on their par-
ticular life experiences (e.g., being raised in an
urban or rural community, belonging to a
lower- or upper-class family). Cultural groups
may also place different levels of importance
on various aspects of cultural identities. In
addition, individuals can hold two or more
cultural identities simultaneously.
Some of the factors that are likely to vary
among members of the same culture include
socioeconomic status, geographic location,
gender, education level, occupational status,
sexuality, and political and religious affiliation.
For individuals whose families are highly
acculturated, some of these characteristics
(e.g., geographic location, occupation, religion)
can be more important than ethnic culture in
defining their sense of identity. The section
that follows provides more detailed infor-
mation on the most important cross-cutting
factors involved in the creation of a person’s
cultural identity.
What Are the Cross-
Cutting Factors in Race,
Ethnicity, and Culture?
Language and Communication
Language is a key element of culture, but
speaking the same language does not neces-
sarily mean that people share the same cultural
beliefs. For example, English is spoken in
Australia, Canada, Jamaica, India, Belize, and
Nigeria, among other countries. Even within
the United States, people from different re-
gions can have diverse cultural identities even
though they speak the same language. Con-
versely, those who share an ethnicity do not
automatically share a language. Families who
immigrated to this country several generations
earlier may identify with their culture of origin
but no longer be able to speak its language.
English is the most common language in the
United States, but 18 percent of the total
population report speaking a language other
than English at home (Shin and Bruno 2003).
Styles of communication and nonverbal meth-
ods of communication are also important
aspects of cultural groups. Issues such as the
use of direct versus indirect 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, and
amount of eye contact expected are all cultur-
ally defined and reflect very basic ethnic and
cultural differences (Comas-Diaz 2012;
16
Chapter 1—Introduction to Cultural Competence
Franks 2000; Sue 2001). More specifically, the
relative importance of nonverbal messages
varies greatly from culture to culture; high-
context cultural groups place greater im-
portance on nonverbal cues and the context of
verbal messages than do low-context cultural
groups (Hall 1976). For example, most Asian
Americans come from high-context cultural
groups in which sensitive messages are encod-
ed carefully to avoid giving offense.
A behavioral health service provider who lis-
tens only to the literal meaning of words can
miss clients’ actual messages. What is left un-
said, or the way in which something is said,
can be more important than the words used to
convey the message. African Americans have
a relatively high-context culture compared
with White Americans but a somewhat
lower-context culture compared with Asian
Americans (Franks 2000). Thus, African
Americans typically rely to a greater degree
than White Americans on nonverbal cues in
communicating. Conversely, White American
culture is low context (as are some European
cultural groups, such as German and British);
communication is expected to be explicit, and
formal information is conveyed primarily
through the literal content of spoken or writ-
ten messages.
Geographic Location
Cultural groups form within communities and
among people who interact meaningfully with
each other. Although one can speak of a na-
tional culture, the fact is that any culture is
subject to local adaptations. Local norms or
community rules can significantly affect a
culture. Thus, it is important for providers to
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 agreeableness (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
of a homogeneous Mexican culture so much as
the Mexican culture of Los Angeles, CA, or
the Mexican culture of El Paso, TX.
Geographical factors can also have a signifi-
cant effect on a client’s culture. For example,
clients coming from a rural area—even if they
come from different ethnicities—can have a
great deal in common, whereas individuals
from the same ethnicity who were raised in
different geographic locales can have very
different experiences and, consequently, atti-
tudes. For example, although the vast majority
of Asian Americans live in urban areas (95
percent in 2002; Reeves and Bennett 2003), a
particular Asian American client may have
been born in a rural community or come from
a culture (e.g., the Hmong) that developed in
remote areas; the client may retain cultural
values and interests that reflect those origins.
Other clients who currently live in cities may
still consider a rural locale as their home and
regularly return to it. Many Native Americans
who live in urban areas or in communities
adjacent to reservations, for example, travel
regularly back to their home reservations
(Cornell and Kalt 2010; Lobo 2003).
In addition to its potential influence upon
culture, geography can strongly affect sub-
stance use and abuse, mental health and well-
being, and access to and use of health services
(Baicker et al. 2005). In the Substance Abuse
and Mental Health Services Administration’s
(SAMHSA’s) 2012 National Survey on Drug
Use and Health (NSDUH), past-month illicit
drug use rates among individuals ages 12 and
older were 9.9 percent in large metropolitan
areas, 8.3 percent in nonmetropolitan urban-
ized areas, 5.9 percent in less urbanized non-
metropolitan areas, and 4.8 percent in rural
areas (SAMHSA 2013d). In very rural or
remote areas, illicit drug use is likely to be
even less common than in rural areas
(Schoeneberger et al. 2006). Even among
members of the same culture, less substance
use is observed in those who live in more rural
regions. For example, O’Connell and associ-
ates (2005) found that alcohol consumption
was lower for American Indians living on
reservations than for those who were geo-
graphically dispersed (and typically living in
urban areas). Likewise, individuals born or
living in urban areas may be at greater risk for
serious mental illness. In one systematic study,
higher distribution rates of schizophrenia were
found in urban areas, particularly among
people who were born in metropolitan areas
(McGrath et al. 2004).
Worldview, Values, and Traditions
There are many ways of conceptualizing how
culture influences an individual. Culture can
be seen as a frame through which one looks at
the world, as a repertoire of beliefs and prac-
tices that can be used as needed, as a narrative
or story explaining who people are and why
they do what they do, as a set of institutions
defining different aspects of values and tradi-
tions, as a series of boundaries that use values
and traditions to delineate one group of people
from another, and so on. According to Lamont
and Small (2008), such schemata recognize
that culture shapes what people believe (i.e.,
their values and worldviews) and what they do
to demonstrate their beliefs (i.e., their tradi-
tions and practices). Cultural groups define
the values, worldviews, and traditions of their
members—from food preferences to appropri-
ate leisure activities—including use of alcohol
and/or drugs (Bhugra and Becker 2005). Thus,
it is impossible to review and summarize the
variety of cultural values, traditions, and
worldviews found in the United States in this
publication. Providers are encouraged to
speak with their clients to learn about their
worldviews, values, and traditions and to seek
training and consultation to gain specific
18
Chapter 1—Introduction to Cultural Competence
knowledge about clients’ cultural beliefs and
practices.
Family and Kinship
Although families are important in all cultural
groups, concepts of and attitudes toward
family are culturally defined and can vary in a
number of ways, including the relative im-
portance of particular family ties, the family’s
inclusiveness, how hierarchical the family is,
and how family roles and behaviors are de-
fined (McGoldrick et al. 2005). In some cul-
tural groups (e.g., White Americans of Western
European descent, such as German, English),
family is limited to the nuclear family, where-
as in other groups (e.g., African Americans;
Asian Americans; Native Americans; White
Americans of Southern European descent, such
as Italian, Greek), the idea of family typically
includes many other blood or marital relations
(Almeida 2005; Hines and Boyd-Franklin
2005; Marinangeli 2001; McGill and Pearce
2005; McGoldrick et al. 2005). Some cultural
groups clearly define roles for different family
members and carefully prescribe methods of
behaving toward one another based on specific
relationships. For example, in Korean culture,
wives are expected to defer to their in-laws
about many decisions (Kim and Ryu 2005).
Even in cultural groups with carefully defined
roles and rules for family members, family
dynamics may change as the result of internal
or external forces. The process of accultura-
tion, for instance, can significantly affect
family roles and dynamics among immigrant
families, causing the dissolution of longstand-
ing cultural hierarchies and traditions within
the family and resulting in conflict between
spouses or different generations of the family
(Hernandez 2005; Juang et al. 2012; Lee and
Mock 2005a). Information on family therapy
with major ethnic/racial groups is provided in
Chapter 5 of this TIP. Details of the role of
family in treatment and the provision of family
therapy appear in TIP 39, Substance Abuse
Treatment and Family Therapy (CSAT 2004b).
Gender Roles
Gender roles are largely cultural constructs;
diverse cultural groups have different under-
standings of the proper roles, attitudes, and
behaviors for men and women. Even within
modern American society, there are variations
in how cultural groups respond to gender
norms. For example, after controlling for
income and education, African American
women are less accepting than White
American women of traditional American
gender stereotypes regarding public behavior
but more accepting of traditional domestic
gender roles (Dugger 1991; Haynes 2000).
Culturally defined gender roles also appear to
have a strong effect on substance use and
abuse. This can perhaps be seen most clearly
in international research indicating that, in
societies with more egalitarian relationships
between men and women, women typically
consume more alcohol and have drinking
patterns more closely resembling those of men
in the society (Bloomfield et al. 2006). A
similar effect can be seen in research conduct-
ed in the United States with Latino men and
women with varying levels of acculturation to
mainstream American society (Markides et al.
2012; Zemore 2005).
The terms for and definitions of gender roles
can also vary. For example, in Latino cultural
groups, importance is placed on machismo (the
belief that men must be strong and protect
their families), caballerismo (men’s emotional
connectedness), and marianismo (the idea that
women should be self-sacrificing, endure
suffering for the sake of their families, and
defer to their husbands) (Arciniega et al. 2008;
Torres et al. 2002). These strong gender roles
have benefits in Latino culture, such as simpli-
fying and clarifying roles and responsibilities,
19
Improving Cultural Competence
but they are also sources of potential problems,
such as limiting help-seeking behavior or the
identification of difficulties. For example,
because of the need to appear in control, a
Latino man can have difficulty admitting that
his substance use is out of control or that he is
experiencing psychological distress (Castro et
al. 1999a). For Latinas, the difficulties of
negotiating traditional gender roles while
encountering new values through accultura-
tion can lead to increased substance use/abuse
and mental distress (Gil and Vazquez 1996;
Gloria and Peregoy 1996; Mora 2002).
Negotiating gender roles in a treatment set-
ting is often difficult; providers should not
assume that a client’s traditional culture-based
gender roles are best for him or her or that
mainstream American ideas about gender are
most appropriate. The client’s degree of accul-
turation and adherence to traditional values
must be taken into consideration and respect-
ed. Two TIPs explore the relationship of
gender to substance abuse and substance
abuse treatment: TIP 51, Substance Abuse
Treatment: Addressing the Specific Needs of
Women (CSAT 2009c), and TIP 56, Addressing
the Specific Behavioral Health Needs of Men
(SAMHSA 2013a). TIP 42, Substance Abuse
Treatment for Persons With Co-Occurring
Disorders, addresses the relationships among
gender, mental illness, and substance use
disorders (CSAT 2005d).
Socioeconomic Status and
Education
Sociologists often discuss social class as an
important aspect in defining an individual’s
cultural background. In this TIP, socioeco-
nomic status (SES) is used as a category simi-
lar to class—the difference being that
socioeconomic status is a more flexible and
less hierarchically defined concept. SES in the
United States is related to many factors, in-
cluding occupational prestige and education,
yet it is primarily associated with income level.
Thus, SES affects culture in several ways,
namely through a person’s ability to accumu-
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
use resources. Discrimination and historical
racism have led to lasting inequalities in SES
(Weller et al. 2012; Williams and Williams-
Morris 2000). SES affects mental health and
substance use. From 2005 to 2010, adults 45
through 64 years of age were five times more
likely to have depression if they were poor
(National Center for Health Statistics 2012).
Serious mental illness among adults living in
poverty has a prevalence rate of 9.1 percent
(SAMHSA 2010). Some research demon-
strates higher risk for schizophrenia from
lower socioeconomic levels, but other studies
draw no definite conclusion (Murali and
Oyebode 2010). Most literature suggests that
poverty and its consequences, including lim-
ited access to resources, increase stress and
vulnerability among individuals who may
already be predisposed to mental illness. Of-
ten, theoretical discussions explaining a signif-
icant relationship between mental illness and
SES suggest a bidirectional relationship in
which stress from poverty leads to mental
illness vulnerability and/or mental illness leads
to difficulty in maintaining employment and
sufficient income.
Studies have had conflicting results as to
whether people with high or low SES are
more likely to abuse substances (Jones-Webb
et al. 1995). In international studies, increases
in wealth on a societal level have been associ-
ated with increases in alcohol consumption
(Bergmark and Kuendig 2008; Kuntsche et al.
2006; Room et al. 2003). However, other
factors, such as the availability of social sup-
port systems and education, as well as the
individual’s acculturation level, can also play a
role. Karriker-Jaffe and Zemore (2009) found
that, in immigrants, a greater level of accul-
turation was associated with increased heavy
drinking for those with above-average SES
but not for those with lower SES. Besides
lower socioeconomic status, neighborhood
poverty (defined as having a high [≥20 per-
cent] proportion of residents living in poverty)
was associated with binge drinking and higher
rates of substance-related problems, particu-
larly for men (McKinney et al. 2012).
Education is also an important factor related
to SES (Exhibit 1-4). Higher levels of educa-
tion are associated with increased income,
although the degree to which education in-
creases income varies among diverse ra-
cial/ethnic groups (Crissey 2009). Research in
the United States has found that problems
with alcohol are often associated with lower
SES and lower levels of education (Crum
2003; Mulia et al. 2008). However, other
studies have shown that greater frequency of
drinking and number of drinks consumed are
generally associated with higher levels of
education and higher SES (Casswell et al.
2003; van Oers et al. 1999). For example, the
2012 NSDUH showed that adult rates of
past-month alcohol use increased with in-
creasing levels of education; among those with
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 crime; social disorder; community and concentrated poverty; and residential segregation.
Source: Office of Disease Prevention and Health Promotion, HHS 2013.
21
Improving Cultural Competence
less than a high school education, 36.6 percent
were current drinkers, whereas 68.6 percent of
college graduates were current drinkers.
(SAMHSA 2013d). Education can also affect
substance use independently of SES. For
example, lower education levels seem to relate
to heavy drinking independently of socioeco-
nomic status (Kuntsche et al. 2006).
The desperation associated with poverty and a
lack of opportunity—as well as the increased
exposure to illicit drugs that comes from living
in a more impoverished environment—can
also increase drug use (Bourgois 2003). Lower
SES and the concurrent lack of either money
or insurance to pay for treatment are associat-
ed with less access to substance abuse treat-
ment and mental health services (Chow et al.
2003). For example, compared with Medicare
coverage, private insurance coverage increases
the odds twofold that someone who has a
substance use disorder will enter treatment
(Schmidt and Weisner 2005). Thus, lower
SES can have a dramatic effect on recovery.
Immigration and Migration
With the exception of American Indians,
Alaska Natives, Native Hawaiians, and other
Pacific Islanders, the United States is a coun-
try of immigrants. Recent immigrants, even
when they come from diverse ethnic/racial
backgrounds, typically share certain experienc-
es and expectations in common. Often, they
encounter a difficult process of acculturation
(as discussed throughout this chapter). They
can also share concerns surrounding the re-
newal of visas, obtainment of citizenship, or
fears of possible deportation depending on
their legal status. Immigration itself is stressful
for immigrants, though the reasons for mi-
grating and the legal status of the immigrant
affect the degree of stress. For documented
residents, the process of adaptation tends to be
smoother than for those who are undocu-
mented. Undocumented persons may be wary
of deportation, are less likely to seek social
services, and frequently encounter hostility
(Padilla and Salgado de Snyder 1992).
Nonetheless, there are numerous variables that
contribute to or influence well-being, quality
of life, cultural adaptation, and the develop-
ment of resilience (e.g., the capacity to mobi-
lize social supports and bicultural integration;
Castro and Murray 2010). Research suggests
that immigrants may not experience higher
rates of mental illness than nonimmigrants
(Alegria et al. 2006), yet immigration nearly
always includes separation from one’s family
and culture and can involve a grieving process
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 Vietnamese
Americans 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).
22
Chapter 1—Introduction to Cultural Competence
as a result of these losses as well as other
changes, including changes in socioeconomic
status, physical environment, social support,
and cultural practices.
Immigrants who are refugees from war, fam-
ine, oppression, and other dangerous environ-
ments are more vulnerable to psychological
distress (APA 2010). They are likely to have
left behind painful and often life-threatening
situations in their countries of origin and can
still bear the scars of these experiences. Some
refugees come to the United States with high
expectations for improved living conditions,
only to find significant barriers to their full
participation in American society (e.g., lan-
guage barriers, discrimination, poverty). Expe-
riencing such traumatic conditions can also
increase substance use/abuse among some
groups of immigrants (see TIP 57, Trauma-
Informed Care in Behavioral Health Services
[SAMHSA 2014]). Behavioral health services
must assess the needs of refugee populations,
as the clinical issues for these populations may
be considerably different than for immigrant
groups (Kaczorowski et al. 2011).
For immigrant families, disruption of roles
and norms often occurs upon arrival in the
United States (for review, see Falicov 2012).
Generally, youth adopt American customs,
values, and behaviors much more easily and at
higher rates than their parents or older mem-
bers of the extended family. Parental frustra-
tion may occur if traditional standards of
behavior conflict with mainstream norms
acquired by their children. The differences in
parents’ values and expectations and adoles-
cents’ behavior can lead to distress in close-
knit immigrant families. This disruption,
known as the acculturation gap, can result in
increased parent–child conflicts (APA 2012;
Falicov 2012; Telzer 2010). For some youth, it
may contribute to experimentation with alco-
hol and/or illicit drugs—increased accultura-
tion is typically associated with increased
substance use and substance use disorders.
Overall, “old country” or traditional behavioral
norms and expectations for appropriate behav-
ior become increasingly devalued in American
majority culture for members of various immi-
grant groups (Padilla and Salgado de Snyder
1992; Sandhu and Malik 2001). Research
shows that family cohesion and adaptability
decrease with time spent in the United States,
regardless of the amount of involvement in
mainstream culture. This suggests that other
factors may confound the relationship between
family conflict and increased exposure to
American culture (Smokowski et al. 2008).
Advice to Counselors and Clinical
Supervisors: Initial Interview and
Assessment Questions
When working with clients who are recent
immigrants or have immigrated to United States
during their lifetime, the APA (1990) recom-
mends exploring:
• Number of generations in the United States.
• Number of years in the United States.
• Fluency in English (or literacy).
• Extent (or lack) of family support.
• Community resources.
• Level of education.
• Change in social status due to immigration.
• Extent of personal relationships with people
from diverse cultural backgrounds.
Stress due to migration and acculturation.
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,
is a useful resource for clinicians to gain infor-
mation about topics including culture, reset-
tlement experiences, and historical and refugee
background information. This site is also quite
useful for refugees. It provides refugee orienta-
tion materials and guidance in establishing
housing, language, transportation, education,
and community services, among other pressing
refugee concerns.
23
Improving Cultural Competence
Exhibit 1-5: Cultural Identification and Cultural
Change Terminology
Acculturation is the process whereby an individual from one
cultural group learns and adopts elements of another cultural
group, integrating them into his or her original culture. Although
it can refer to any process of cultural integration, it is typically
used to describe the ways in which an immigrant or nonmajority
individual or group adopts cultural elements from the majority or
mainstream culture, as the incentive is typically greater for accul-
turation to occur in this direction (see Lopez-Class et al. 2011 for
a historical review of acculturation concepts).
Assimilation is one outcome of acculturation. It involves the
complete adoption of the ways of life of the new cultural group,
resulting in the assimilated group losing nearly all of its original or
native culture.
Segmented assimilation describes a more complicated process
of assimilation whereby an immigrant group does not assimilate
entirely with mainstream culture but adopts aspects of other
diverse cultural groups that are themselves outside mainstream
culture (e.g., involvement in the drug culture; see Chapter 6 of
this TIP and Portes et al. 2005).
Biculturalism occurs when an individual acquires the knowledge,
skills, and identity of both his or her culture of origin and the
mainstream/majority culture and is equally (or nearly equally)
capable of social and cultural interaction in both societies.
Enculturation can denote a process whereby an individual adopts
the culture that surrounds him or her (similar to acculturation),
but the term has more recently been used to describe the pro-
cess by which individuals come to value their native cultures and
begin to learn about and adopt their native cultural lifeways.
Sources: LaFromboise et al. 1993; Paniagua 1998; Portes et al.
2005; Smokowski et al. 2008; Stone et al. 2006.
Clients who are migrants (e.g., seasonal work-
ers) pose a particular set of challenges for
treatment providers because of the difficulties
involved in connecting clients to treatment
programs and recovery communities. In the
United States, migrant workers are considered
one of most marginalized and underserved
populations (Bail et al. 2012). Migrants face
many logistical obstacles to treatment-seeking,
such as lack of childcare, insurance, access to
regular health care, and transportation (Hovey
2001; Rosenbaum and Shin 2005). Current
data are limited but suggest high rates of
alcohol use, alcohol use disor-
ders, and binge drinking, often
occurring as a response to
stress or boredom associated
with the migrant lifestyle
(Hovey 2001; Worby and
Organista 2007). In addition,
limited data on migrant men-
tal health reflect mixed find-
ings regarding increased risk
for mental illness or psycho-
logical distress (Alderete et al.
2000). One factor associated
with mental health status is
the set of circumstances lead-
ing up to the migrant worker’s
decision to migrate for em-
ployment (Grzywacz et al.
2006).
Acculturation and
Cultural Identification
Many factors contribute to an
individual’s cultural identity,
and that identity is not a static
attribute. 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.
As a result, 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. For
clients, sorting through these conflicting
cultural expectations and forging a comforta-
ble identity can be an important part of the
recovery process. Some of the more commonly
used terms related to cultural identity are
defined in Exhibit 1-5.
All immigrants undergo some acculturation
over time, but the rate of change varies from
group to group, among individuals, and across
24
Chapter 1—Introduction to Cultural Competence
different periods of history. Earlier theories
suggested that immigrants generally assimilat-
ed within three generations from the time of
immigration and that assimilation was associ-
ated with socioeconomic gains. More recent
scholarship suggests that this is changing
among some cultural groups who may lack the
financial or human capital necessary to suc-
ceed in mainstream society or who may find
that continued involvement in their native or
traditional culture has benefits that outweigh
those associated with acculturation (Portes et
al. 2005; Portes and Rumbaut 2005).
Acculturation typically occurs at varying speeds
for different generations, even within the same
family. Acculturation can thus be a source of
conflict within families, especially when parents
and children have different levels of accultura-
tion (Exhibit 1-6) (Castro and Murray 2010;
Farver et al. 2002; Hernandez 2005). Others
have suggested that acculturation can negative-
ly affect mental health because it erodes tradi-
tional family networks and/or because it results
in the loss of traditional culture, which other-
wise would have a protective function (Escobar
and Vega 2000; Sandhu and Malik 2001).
Many studies have found that increased accul-
turation or factors related to acculturation are
associated with increased alcohol and drug use
and with higher rates of substance use disor-
ders among White, Asian, and Latino immi-
grants (Alegria et al. 2006; Grant et al. 2004a;
Grant et al. 2004b; Vega et al. 2004). Place of
birth is most strongly associated with higher
rates of substance use and disorders thereof.
For example, research suggests a rate of sub-
stance use disorders about three times higher
for Mexican Americans born in the United
States than for those born in Mexico (Alegria
et al. 2008a; Escobar and Vega 2000). Asian
adolescents born in the United States present
a higher rate of past-month alcohol use than
Asian adolescents not born in the United
States (8.7 versus 4.7 percent); however, the
rate of nonmedical use of prescription drugs is
higher among Asian adolescents not born in
the United States than among those born in
the United States (2.7 versus 1.4 percent;
SAMHSA, Center for Behavioral Health
Statistics and Quality 2012).
Acculturation can increase substance
use/abuse, in part because the process of accul-
turation is itself stressful (Berry 1998; Vega et
al. 2004). Mora (2002) asserts that the stress
associated with acculturation has a significant
effect on increasing substance use and abuse
among Latinas; this can be observed most
clearly in the increases in substance use associ-
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
associated with acculturation could also con-
tribute to rates of mental disorders and co-
occurring disorders (CODs), which are higher
among more acculturated groups of immi-
grants (Cherpitel et al. 2007; Escobar and
Vega 2000; Grant et al. 2004a; Organista et al.
2003; Vega et al. 2009; Ward 2008). In fact,
American-born Latinos who have used sub-
stances are three times more likely to have
CODs than foreign-born Latinos who have
used substances (Vega et al. 2009). Research
also suggests that acculturation could interact
with factors such as culture or stress in in-
creasing mental disorders.
Rates of substance use/abuse in the United
States are among the highest in the world
(United Nations, Office on Drugs and Crime
2008, 2012), so for many immigrants, adopt-
ing mainstream American cultural values and
lifestyles can also entail changing attitudes
toward substance use. As an example, Marin
(1998) found that, compared with Whites,
Mexican Americans expected significantly
more negative consequences and fewer posi-
tive ones from drinking, but Marin also found
that the more acculturated the Mexican
American participants were, the more closely
their expectations resembled those of Whites.
Other factors that can contribute to increased
substance use among more acculturated clients
include changes in traditional gender roles,
exposure to socially and physically challenging
inner-city environments (Amaro and Aguiar
1995), and employment outside the home
(often a role-transforming change that can
contribute to increased risk of alcohol depend-
ence). Although much of the research has
focused on the relationship of acculturation to
male substance use/abuse patterns, women can
be even more affected by acculturation. Multi-
ple studies using international samples have
found that the greater the amount of gender
equality in a society, the more similar alcohol
consumption patterns are for men and women
(Bloomfield et al. 2006). Many immigrants to
the United States (where gender equality is
relatively strong) come from societies with less
gender equality and thus with greater prohibi-
tions against alcohol use for women.
Karriker-Jaffe and Zemore (2009) found that
higher levels of acculturation are associated
with increased alcohol consumption only
when combined with above-average SES (and
not with lower SES), suggesting that income
is another factor to consider when evaluating
the effect of acculturation on alcohol use.
There are exceptions to the idea that accul-
turation increases substance use/abuse. Most
notably, immigrants coming from countries
with unusually high levels of drinking do not
necessarily experience a change in their use,
and they may even consume less alcohol and
fewer drugs that they did in their native coun-
tries. Even among those born in the United
States, however, data suggest that greater
identification with one’s traditional culture has
a protective function. For example, in the
National Latino and Asian American Study,
the largest national survey specifically target-
ing these population groups to date, greater
ethnic identification was associated with
significantly lower rates of alcohol use disor-
ders among Asian Americans (Chae et al.
2008), and the use of Spanish with one’s
family was linked with significantly lower
rates of alcohol use disorders in Latinos
(Canino et al. 2008).
Less research is available on the relationship of
acculturation to substance use and substance
use disorders among nonimmigrants, but some
data suggest that a lower level of identification
with one’s native culture is linked with heavier,
lengthier substance use among American
Indians living on reservations (Herman-Stahl
et al. 2003). For some American Indians, more
26
Chapter 1—Introduction to Cultural Competence
involvement in Tribal culture and traditional
spiritual activities is associated with better
posttreatment outcomes for alcohol use disor-
ders (Stone et al. 2006). American Indians
who drink heavily but live a traditional life-
style have better recovery outcomes than those
who do not live a traditional lifestyle (Kunitz
et al. 1994). Likewise, African Americans may
have greater motivation for treatment if they
recognize that they have a drug problem and
also have a strong Afrocentric identity
(Longshore et al. 1998b). Strong cultural or
racial/ethnic identity can have protective
features, whereas acculturation can lead to a
loss of cultural identity that increases sub-
stance abuse and contributes to poorer recov-
ery outcomes for both Native Americans and
African Americans.
Overall, acculturation and cultural identifica-
tion have tremendous implications for behav-
ioral health services. Research has shown an
association between low levels of acculturation
and low usage rates of mainstream healthcare
services. Individuals can feel conflicted about
their identities—wanting to both fit in with
the mainstream culture and retain the tradi-
tions and beliefs of their cultures of origin. For
such clients, sorting through these conflicting
cultural expectations and forging a comforta-
ble identity can be an important part of the
recovery process. Familiarity with cultural
identity formation models and theories of
acculturation (including acculturation meas-
urement methods; see Exhibit 1-7) can help
behavioral health workers provide services
with greater flexibility and sensitivity (see
Appendix B for instruments that measure
aspects of cultural identity and acculturation).
Heritage and History
A culture’s history and heritage explain the
culture’s development through the actions of
members of that culture and also through the
actions of others toward the specific culture.
Providers should be knowledgeable about the
many positive aspects of each culture’s history
and heritage and resourceful in learning how
to integrate these into clinical practice.
Nearly all immigrant groups have experienced
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., friendships 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
places. Their eagerness to assimilate or remain
separate depends greatly on the circumstances
of their immigration (Castro and Murray
2010). Additionally, some immigrants are
refugees from war, famine, natural disasters,
and/or persecution. The depths of suffering
that some clients have endured can result in
multiple or confusing symptoms. For example,
a traumatized Congolese woman could speak
of hearing voices, and it could be unclear
whether these voices suggest an issue requiring
spiritual healing within a cultural framework,
a traumatic stress reaction, or a mental disor-
der involving the onset of auditory hallucina-
tions. Those who have watched close family
members die violently can have “survivor guilt”
as well as agonizing memories. Amodeo et al.
(1997) report that “somatic complaints, in-
cluding trouble sleeping, loss of appetite,
stomach pains, other bodily pains, headaches,
fatigue or lack of energy, memory problems,
mood swings and social withdrawal have been
reported to be among the refugees’ most fre-
quent presenting problems” (p. 70). For an
overview of the impact of trauma, see TIP 57,
Trauma-Informed Care in Behavioral Health
Services (SAMHSA 2014).
Abueg and Chun (1998) caution, however,
that “traumatic experience is not homogenous”
(p. 292). Experiences before, during, and after
migration and/or encampment vary depending
on the country of origin as well as the time
and motivation for migration. Within the
United States, cultural groups such as African
Americans and Native Americans have long
histories of traumatic events, which have had
lasting effects on the descendants of those
who experienced the original trauma. Conse-
quently, past as well as present discrimination
and racism are related to a number of negative
consequences across diverse populations, in-
cluding lower SES, health disparities, and fewer
employment and educational opportunities (see
review in Williams and Williams-Morris
2000).
According to theories of historical trauma, the
traumas of the past continue to affect later
generations of a group of people. This concept
was first developed to explain how the trauma
of the Holocaust continued to affect the de-
scendants of survivors (Duran et al. 1998;
Sotero 2006). In the United States, it has
perhaps been best explored in relation to the
traumas endured by Native American peoples
during the colonization and expansion of the
United States. One can extend this concept
to other groups (e.g., African Americans,
Cambodians, Rwandans) who suffered trau-
matic events like slavery or genocide.
Among Native Americans in treatment for
substance use and/or mental disorders, histori-
cal trauma is an important clinical issue (Brave
Heart et al. 2011; Duran et al. 1998; Evans-
Campbell 2008). Some research indicates that
thinking about historical loss or displaying
symptoms associated with historical trauma
plays into increases in alcohol use disorders,
other substance use, and lower family cohesion
(Whitbeck et al. 2004; Wiechelt et al. 2012).
Brave Heart (1999) theorizes that historical
traumas perpetuate their effects among Native
Americans by harming parenting skills and
increasing abuse of children, which creates a
cyclical pattern—greater levels of mental and
substance use disorders in the next generation
along with continued poor parenting skills.
Specifically, Libby et al. (2008) found that
substance use was involved in the intergenera-
tional transmission of trauma. Additional
research highlights a relationship between
elevated chronic trauma exposure and preva-
lence of both mental and substance use disor-
ders among large samples of American Indian
adults living on reservations (Beals et al. 2005;
Manson et al. 2005).
28
Chapter 1—Introduction to Cultural Competence
Sotero (2006) reviews research on historical
trauma across diverse populations and propos-
es a similar explanation of how deliberately
perpetrated, large-scale traumatic events con-
tinue affecting communities years after they
occur. She argues that the generation that
directly experiences the trauma suffers material
(e.g., displacement), psychological (e.g., post-
traumatic stress disorder), economic (e.g., loss
of sources of income/sustenance), and cultural
(e.g., lost knowledge of traditions and beliefs)
effects. These lasting sequelae of trauma then
affect the next generation, who can suffer in
many similar ways, resulting in poorer coping
skills or in attempts to self-medicate distress
through substance abuse.
Sexuality
Attitudes toward sexuality in general and
toward sexual identity or orientation are cul-
turally defined. Each culture determines how
to conceptualize specific sexual behaviors, the
degree to which they accept same-sex relation-
ships, and the types of sexual behaviors con-
sidered acceptable or not (Ahmad and Bhugra
2010). In any cultural group, diverse views and
attitudes about appropriate gender norms and
behavior can exist. For example, in some Latino
cultural groups, homosexual behavior, espe-
cially among men, is not seen as an identity but
as a curable illness or immoral behavior (Kusnir
2005). In some Latino cultural groups, self-
identifying as other than heterosexual may
provoke a more negative response than engag-
ing in some homosexual behaviors (de Korin
and Petry 2005; Greene 1997; Kusnir 2005).
For individuals from various ethnic/racial
groups in United States, having a sexual iden-
tity different from the norm can result in
increased substance use/abuse, in part because
of increased stress. Additionally, alcohol and
drug use can be more acceptable within some
segments of gay/lesbian/bisexual cultures
(Balsam et al. 2004; CSAT 2001; Mays et al.
2002). As a result of a lack of acceptance
within both mainstream and diverse eth-
nic/racial communities, various gay cultures
have developed in the United States. For some
individuals, gay culture provides an alternative
to their culture of origin, but unfortunately,
cultural pressures can make the individual feel
like he or she has to select which identity is
most important (Greene 1997). However, a
person can be, for example, both gay and
Latino without experiencing any conflicts
about claiming both identities at the same
time. 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.
Heterosexual behaviors are carefully prescribed
by a culture. Typically, these prescriptions are
determined based on gender; behaviors con-
sidered acceptable for men can be considered
unacceptable for women and vice versa. In
addition, cultures define the role of alcohol or
other substances in courtship, sexual behaviors,
and relationships (Room 1996). Other factors
that can vary across cultural groups include the
appropriate age for sexual activity, the rituals
and actions surrounding sexual activity, the use
of birth control, the level of secrecy or open-
ness related to sexual acts, the role of sex
workers, attitudes toward sexual dysfunction,
and the level of sexual freedom in choosing
partners.
Perspectives on Health, Illness,
and Healing
Beliefs, attitudes, and behaviors related to
health, illness, and healing vary across racial,
ethnic, and cultural groups. Many cultural
groups hold views that differ significantly
from those of Western medical practice and
thus can affect treatment (Sussman 2004). The
field of medical anthropology was developed,
29
Improving Cultural Competence
in part, to analyze these differences, and much
has been written about the range of cultural
beliefs concerning health and healing. In
general, 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; and their
remedies (including the use of Western medi-
cines), treatments, and healing practices for
illness (Bhugra and Gupta 2010; Comas-Diaz
2012). In addition, there are complex rules
about which members of a community or
family can make decisions about health care
across cultural groups (Sussman 2004).
In mainstream American society, healthcare
professionals are typically viewed as the only
ones who have real expertise about health and
illness. However, other societies have different
views. For instance, among the Subanun peo-
ple of the Philippines, all members of the
community learn about healing and diagnosis;
when an individual is sick, the diagnosis of his
or her problem is an activity that involves the
whole community (Frake 1961). Cultural
groups also differ in their understanding of the
causes of illness, and many cultural groups
recognize a spiritual element in physical ill-
ness. The Hmong, for example, believe that
illness has a spiritual cause and that healing
may require shamans who communicate with
spirits to diagnose and treat an illness
(Fadiman 1997; Gensheimer 2006).
With respect to mental health, providers
should be aware that any mental disorder or
symptom is only considered a disorder or
problem by comparison with a socially defined
norm. For instance, in some societies, someone
who hears voices can be considered to have
greater access to the spirit world and to be
blessed in some way. Furthermore, there are
mental disorders that only present in a specific
cultural group or locality; these are called
cultural concepts of distress. Appendix E
describes cultural concepts of distress recog-
nized by the DSM-5. Other specific examples
of cultural differences relating to the use of
health care and alternative approaches to
medical diagnosis and treatment are also
presented in Chapter 5.
Religion and Spirituality
Religious traditions or spiritual beliefs are
often very important factors for defining an
individual’s cultural background. In turn,
attention to religion and spirituality during
the course of treatment is one facet of cultur-
ally competent services (Whitley 2012).
Christians, Muslims, Jews, and Buddhists
(among others) can be members of any racial
or ethnic group; in the same vein, people of
the same ethnicity who belong to different
religions sometimes have less in common than
people of the same religion but different
ethnicities. In some cases, religious affiliation
is an especially important factor in defining a
person’s culture. For instance, the American
Religious Identification Survey reported that
47 percent of the respondents who identified
culturally as Jewish were not practicing Jews
(Kosmin et al. 2001).
According to the American Religious Identifi-
cation Survey (Kosmin and Keysar 2009), only
15 percent of Americans identified as not
having a religion; of those, less than 2 percent
identified as atheist or agnostic. In another
survey from the Pew Forum on Religion and
Public Life (2008), 1.6 percent of respondents
stated that they were atheist; 2.4 percent,
agnostic; and 6.3 percent, secular and unaffili-
ated with a religion. Many religions are prac-
ticed in the United States today. This TIP
cannot cover them all in detail in. However,
this TIP does briefly describe the four most
common (by size of self-identified member-
ship) religious traditions.
30
Chapter 1—Introduction to Cultural Competence
Christianity
Christianity, in its various forms, remains the
predominant religion in the United States
today. According to Kosmin and Keysar
(2009), 76 percent of the population in 2008
identified as Christian, with the largest denom-
ination being Catholics (25.1 percent), fol-
lowed by Baptists (15.8 percent). Christianity
encompasses a variety of denominations with
different beliefs and attitudes toward issues
such as alcohol and/or other substance use.
Most mainstream Christian religions support
behavioral health treatment, and many church-
es serve as sites for self-help groups or for
Christian recovery programs. Some Christian
sects, however, are not as amenable to sub-
stance abuse and mental health treatment as
others.
Judaism
Judaism is the second most common religion
in the United States (1.2 percent of the popu-
lation as of 2008; Kosmin and Keysar 2009).
Most Jews believe that they share a common
ancient background. However, the population
has dispersed over time and now exists in
various geographic regions. The majority of
Jews in the United States would be considered
White, but Ethiopian Jews (the Beta Israel)
and members of other African-Jewish com-
munities would likely be seen as African
Americans; the Jewish community from India
(Bene Israel), as Asian Americans; and Jews
who immigrated to the United States from
Latin America, as Latinos. In 2001, approxi-
mately 5 percent of people who identified as
adherents to Judaism (the religion, as opposed
to people who identify as culturally Jewish)
were Latinos, and approximately 1 percent
were African Americans (Kosmin et al. 2001).
Regarding beliefs about and practices sur-
rounding substance use, there are no prohibi-
tions against alcohol use (or other substance
use) in Judaism, but rates of alcohol abuse and
dependence are significantly lower for Jews
than for other populations (Bainwol and
Gressard 1985; Straussner 2001). This could
be partially attributable to genetics, yet there is
also a definite cultural component (Hasin et al.
2002). Conversely, rates of use and abuse of
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).
31
Improving Cultural Competence
other substances are about the same or slightly
higher for Jews in the United States compared
with other populations (Straussner 2001).
Because some Jewish people will feel uncom-
fortable in 12-Step groups that meet in
churches and are largely Christian in composi-
tion, mutual-help groups designed specifically
for Jewish people have been developed. The
largest of these is Jewish Alcoholics, Chemi-
cally Dependent Persons and Significant
Others (see http://www.jbfcs.org/programs-
services/jewish-community-services-2/jacs/
for more information). Other Jewish people in
recovery may prefer participating in secular
self-help programs (Straussner 2001). Most
Jewish people support behavioral health
treatment.
Islam
In 2008, roughly 1.3 million people identified
as Muslims in the United States, making it the
third most common religion (Kosmin and
Keysar 2009). Many Americans assume that
all Arabs are Muslim, but the majority of Arab
Americans are Christian; Muslims can come
from any ethnic background (Abudabbeh and
Hamid 2001). Islam is the most ethnically
diverse religion in America, with a member-
ship that is 15 percent White, 27 percent
Black, 34 percent Asian, and 10 percent
Latino (Kosmin et al. 2001).
Attitudes of Muslims toward mental illness
and seeking formal mental health services are
likely to be affected by cultural and religious
beliefs about mental health problems,
knowledge and familiarity with formal ser-
vices, perceived societal prejudice, and the use
of informal indigenous resources (Aloud
2004). Attitudes toward substance use, abuse,
and treatment will likely be shaped by Islam’s
prohibition of the use of alcohol and other
intoxicants. Many Muslim countries have
harsh penalties for the use of alcohol and
other drugs. For these reasons, Muslims
appear to have low rates of substance use
disorders. Despite there being no current data
regarding levels of alcohol and other substance
use among Muslim immigrants in the United
States, Cochrane and Bal (1990) found that, in
a comparison of Sikh, Hindu, Muslim, and
White (probably Christian) men in a British
community, Muslims by far drank the least, yet
those Muslims who consumed the most alco-
hol experienced a greater number of alcohol-
related problems on average. High levels of
alcohol consumption among Muslims who do
drink could be related to feelings of guilt and
shame about their behavior, thus potentially
leading to further abuse and avoidance of
seeking substance abuse treatment when
problems arise (Abudabbeh and Hamid 2001).
Buddhism
In 2008, about 1.2 million Buddhists were
living in the United States (Kosmin and
Keysar 2009). In 2001, according to Kosmin et
al (2001), the majority of Buddhists were
Asian Americans (61 percent), but a signifi-
cant number of White Americans have em-
braced the religion (they make up 32 percent
of Buddhists in the United States), as have
African Americans (4 percent) and Latinos (2
percent). In China and Japan, Buddhism is
often combined with other religious tradi-
tions, such as Taoism or Shintoism, and some
immigrants from those countries combine the
beliefs and practices of those religions with
Buddhism.
Buddhists believe that the choices made in
each life create karma that influences the next
life and can affect behavior (McLaughlin and
Braun 1998). The Fifth Precept of Buddhism
is not to use intoxicating substances, and thus,
the expectation for devout believers is that
they will not use alcohol or other substances of
abuse (Assanangkornchai et al. 2002). In the
United States, no specific substance abuse
treatment programs specialize in treating
32
Chapter 1—Introduction to Cultural Competence
Buddhist clients. Buddhist substance abuse
and mental health treatment programs do
exist in other countries (e.g., Thailand) and
report high outcome rates (70 percent) using
culturally specific practices (e.g., herbal sau-
nas) and religious practices (Barrett 1997).
As You Proceed
This chapter has established the foundation
and rationale of this TIP; reviewed the core
concepts, models, and terminology of cultural
competence; and provided an overview of
factors that are common among diverse racial,
ethnic, and cultural groups. As you proceed, be
aware that diversity occurs not only across
racially and ethnically diverse groups, but
within each group as well—there are cultures
within cultures. Clinicians and organizations
need to develop skills to create an environ-
ment that is responsive to the unique attrib-
utes and experiences of each client, as outlined
earlier in this chapter in the “What Are the
Cross-Cutting Factors in Race, Ethnicity, and
Culture?” section. As you read this TIP, re-
member that many cross-cutting factors influ-
ence the counselor–client relationship, the
client’s presentation and identification of
problems, the selection and interpretation of
screening and assessment tools, the client’s
responsiveness to specific clinical services, and
the effectiveness of program delivery and
organizational structure and planning.
33
IN THIS CHAPTER
• Core Counselor
Competencies
• Self-Assessment for
Individual Cultural
Competence
Gil, a 40-year-old Mexican American man, lives in an upper mid-
dle class neighborhood. He has been married for more than 15
years to his high school sweetheart, a White American woman, and
they have two children. Gil owns a fleet of street-sweeping
trucks—a business started by his father-in-law that Gil has ex-
panded considerably. Of late, Gil has been spending more time at
work. He has also been drinking more than usual and dabbling in
illicit drugs. As his drinking has increased, tensions between Gil
and his wife 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 beer 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 physician 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 divorce him if he did not take
immediate action to deal with his drinking problem, he reluctantly
2
Core Competencies for
Counselors and Other
Clinical Staff
35
Improving Cultural Competence
enrolled in an outpatient treatment program.
Gil, like all people, is a product of his envi-
ronment—an environment that has provided
him with a rich cultural and spiritual back-
ground, a strong male identity, a deep attach-
ment to family and community, a strong work
ethic, and a sense of pride in being able to
support his family. In many Mexican American
cultural groups, illness disrupts family life,
work, and the ability to earn a living. Illness
has psychological costs as well, including
threats to a man’s self-identity and sense of
manhood (Sobralske 2006). Given this back-
ground, Gil would understandably be reluctant
to enter treatment, to accept the fact that his
drinking was a problem or an illness, and to
jeopardize his ability to care for his family and
his company. A culturally competent counselor
would recognize, legitimize, and validate Gil’s
reluctance to enter and continue in treatment.
In an ideal situation, the treatment counselor
would have experience working with people
with similar backgrounds and beliefs, and the
treatment program would be structured to
change Gil’s behavior and attitudes in a man-
ner that was in keeping with his culture and
community. His initial treatment might have
succeeded if the counselor had been culturally
competent and the treatment program had
been culturally responsive.
Like Gil, all clients enter treatment carrying
beliefs, attitudes, conflicts, and problems
shaped by their cultural roots as well as their
present-day realities. As with Gil, many clients
enter treatment with some reluctance and
denial. Research shows that if clients such as
Gil are greeted by a culturally competent
counselor, they are more likely to respond
positively to treatment (Damashek et al. 2012;
Griner and Smith 2006; Kopelowicz et al.
2012; Whaley and Davis 2007). The presence
of counselors of any race or gender who are
culturally competent in responding to the
needs and issues of their clients can greatly
assist client recovery. Gaining regard, respect,
and trust from clients is crucial for successful
counseling outcomes (Ackerman and Hilsen-
roth 2003; Sue and Sue 2003a).
Effective therapy is an ongoing process of
building relational bridges that engender trust
and confidence. Sensitivity to the client’s
cultural and personal perspectives, genuine
empathy, warmth, humility, respect, and ac-
ceptance are the tenets of all sound therapy.
This chapter expands on these concepts and
provides a general overview of the core com-
petencies needed so that counselors may
provide effective treatment to diverse racial
and ethnic groups. Using Sue’s (2001) multi-
dimensional model for developing cultural
competence, the content focuses on the coun-
selor’s need to engage in and develop cultural
awareness; cultural knowledge in general; and
culturally specific skills and knowledge of
wellness, mental illness, substance use, treat-
ments, and skill development.
Core Counselor
Competencies
Since Sue et al. introduced the phrase “multi-
cultural counseling competencies” in 1992,
researchers and academics have elaborated on
the core skill sets that enable counselors to
work with diverse populations (American
Psychological Association [APA] 2002;
Council of National Psychological
Associations for the Advancement of Ethnic
Minority Interests 2009; Pack-Brown and
Williams 2003; Tseng and Streltzer 2004).
Cultural competence has evolved into more
than a discrete skill set or knowledge base; it
also requires ongoing self-evaluation on the
part of the practitioner. Culturally competent
counselors are aware of their own cultural
groups and of their values, assumptions, and
biases regarding other cultural groups. Moreo-
ver, culturally competent counselors strive to
36
Chapter 2—Core Competencies for Counselors and Other Clinical Staff
understand how these factors affect their
ability to provide culturally effective services
to clients.
Given the complex definition of culture and
the fact that racially and ethnically diverse
clients represent a growing portion of the
client population, the need to update and
expand guidelines for cultural competence is
increasing. The consensus panel thus adapted
existing guidelines from the Association of
Multicultural Counseling for culturally re-
sponsive behavioral health services; some of
their key suggestions for counselors and other
clinical staff are outlined in this chapter.
Multidimensional Model for Developing Cultural Competence: Individual Staff
Level
Self-Knowledge
Counselors with a strong belief in evidence-
based treatment methods can find it hard to
relate to clients who prefer traditional healing
methods. Conversely, counselors with strong
trust in traditional healers and culturally ac-
cepted methods can fail to understand clients
who seek scientific explanations of, and solu-
tions to, their substance abuse and mental
health problems. To become culturally compe-
tent, counselors should begin by exploring
their own cultural heritage and identifying
how it shapes their perceptions of normality,
abnormality, and the counseling process.
37
Improving Cultural Competence
Counselors who understand themselves and
their own cultural groups and perceptions are
better equipped to respect clients with diverse
belief systems. In gaining an awareness of their
cultures, attitudes, beliefs, and assumptions
through self-examination, training, and clini-
cal supervision, counselors should consider the
factors described in the following sections.
Cultural awareness
Counselors who are aware of their own cultural
backgrounds are more likely to acknowledge
and explore how culture affects their client–
counselor relationships. Without cultural
awareness, counselors may provide counseling
that ignores or does not address obvious issues
that specifically relate to race, ethnic heritage,
and culture. Lack of awareness can discount
the importance of how counselors’ cultural
backgrounds—including beliefs, values, and
attitudes—influence their initial and diagnos-
tic impressions of clients. Without cultural
awareness, counselors can unwittingly use
their own cultural experiences as a template to
prejudge and assess client experiences and
clinical presentations. They may struggle to
see the cultural uniqueness of each client,
assuming that they understand the client’s life
experiences and background better than they
really do. With cultural awareness, counselors
examine how their own beliefs, experiences,
and biases affect their definitions of normal
and abnormal behavior. By valuing this aware-
ness, counselors are more likely to take the
time to understand the client’s cultural groups
and their role in the therapeutic process, the
client’s relationships, and his or her substance-
related and other presenting clinical problems.
Cultural awareness is the first step toward
becoming a culturally competent counselor.
Racial, ethnic, and cultural identities
A key step in attaining cultural competence is
for counselors to become aware of their own
racial, ethnic, and cultural identities. Although
the constructs of these identities are complex
and difficult to define briefly, what follows is
an overview. Racial identity “refers to a sense
of group or collective identity based on one’s
perception that he or she shares a common
heritage with a particular racial group” (Helms
1990, p. 3). Ethnic and cultural identity is
“often the frame in which individuals identify
consciously or unconsciously with those with
whom they feel a common bond because of
similar traditions, behaviors, values, and be-
liefs” (Chavez and Guido-DiBrito 1999, p.
41). Culture includes, but is not limited to,
spirituality and religion, rituals and rites of
passage, language, dietary habits (e.g., attitudes
toward food/food preparation, symbolism of
food, religious taboos of food), and leisure
activities (Bhugra and Becker 2005).
Aspects of racial, ethnic, and cultural identities
are not always apparent and do not always
factor into conscious processes for the counse-
lor or client, but these factors still play a role
in the therapeutic relationship. Identity devel-
opment and formation help people make sense
of themselves and the world around them. If
Models of Racial Identity
Models of racial identity, often structured in
stages, highlight the process that individuals
undertake in becoming aware of their sense of
self in relation to race and ethnicity within the
context of their families, communities, socie-
ties, and cultural histories. Influenced by the
Civil Rights Movement, earlier racial identity
models in the United States focused on White
and Black racial identity development (Cross
1995; Helms 1990; Helms and Carter 1991).
Since then, models have been created to
incorporate other races, ethnicities, and
cultures.
Although this chapter highlights two formative
racial identity models (see next page), addi-
tional resources highlight racial identity models
that incorporate other diverse groups, includ-
ing those individuals who identify as multiracial
(e.g., see Wijeyesinghe and Jackson 2012).
38
Chapter 2—Core Competencies for Counselors and Other Clinical Staff
positive racial, ethnic, and cultural messages
are not available or supported in behavioral
health services, counselors and clients can lack
affirmative views of their own identities and
may internalize negative messages or feel
disconnected from their racial and cultural
heritages. Counselors from mainstream society
are less likely to be actively aware of their own
ethnic and cultural identities; in particular,
White Americans are not naturally drawn into
examining their cultural identities, as they
typically experience no dissonance when
engaging in cultural activities.
In working to attain cultural competence,
counselors must explore their own racial and
cultural heritages and identities to gain a
deeper understanding of personal develop-
ment. Many models and theories of racial,
ethnic, and cultural development are available;
two common processes are presented below.
Exhibit 2-1 highlights the racial/cultural
identity development (R/CID) model (Sue
and Sue 1999b) and the White racial identity
development (WRID) model (Sue 2001).
Although earlier work focused on a linear
developmental process using stages, current
thought centers on a more flexible process
whereby identification status can loop back to
an earlier process or move to a later phase.
Using either model, counselors can explore
relational and clinical challenges associated
with a given phase. Without an understanding
of the cultural identity development process,
counselors—regardless of race or ethnicity—
can unwittingly minimize the importance of
racial and ethnic experiences. They may fail to
identify cultural needs and secure appropriate
treatment services, unconsciously operate from
a superior perspective (e.g., judging a specific
behavior as ineffectual, a sign of resistance, or a
symptom of pathology), internalize a client’s
reaction (e.g., an African American counselor
feeling betrayed or inadequate when a client of
the same race requests a White American
counselor for therapy during an initial inter-
view), or view a client’s behavior through a veil
of societal biases or stereotypes. By acknowl-
edging and endorsing the active process of
racial and cultural identity development, coun-
selors from diverse groups can normalize their
own development processes and increase their
awareness of clients’ parallel processes of
identity development. In counseling, racial,
ethnic, and cultural identities can be pivotal to
the treatment process in the relationships not
only between the counselor and client, but
among everyone involved in the delivery of the
client’s behavioral health and primary care
services (e.g., referral sources, family members,
medical personnel, administrators). The case
study on page 41 uses stages from the two
models in Exhibit 2-1 to show the interactive
process of racial and cultural identity devel-
opment in the treatment context.
Cultural and racial identities are not static
factors that simply mediate individual identity;
they are dynamic, interactive developmental
processes that influence one’s willingness to
acknowledge the effects of race, ethnicity, and
culture and to act against racism and disparity
across relationships, situations, and environ-
ments (for a review of racial and cultural
identity development, see Sue and Sue 2013c).
For counselors and clinical supervisors, it is
essential to understand the dynamic nature of
cultural identity in all exchanges. Starting with
a personal appraisal, clinical staff members can
begin to reflect—without judgment—on how
their own racial and cultural identities influ-
ence their decisions, treatment planning, case
presentation, supervision, and interactions
with other staff members. Clinicians can map
the interactive influences of cultural identity
development among clients, the clients’ fami-
lies, staff members, the organization, other
agencies, and any other entities involved in the
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
Conformity: Has a positive attitude toward
and preference for dominant cultural values;
places considerable value on characteristics
that represent dominant cultural groups; may
devalue or hold negative views of own race or
other racial/ethnic groups.
Dissonance and Appreciating: Begins to
question identity; recognizes conflicting mes-
sages and observations that challenge be-
liefs/stereotypes of own cultural groups and
value of mainstream cultural groups; develops
growing sense of one’s own cultural heritage
and the existence of racism; moves away from
seeing dominant cultural groups as all good.
Resistance and Immersion: Embraces and
holds a positive attitude toward and prefer-
ence for his or her own race and cultural
heritage; rejects dominant values of society
and culture; focuses on eliminating oppression
within own racial/cultural group; likely to
possess considerable feelings—including
distrust and anger—toward dominant cultural
groups and anything that may represent them;
places considerable value on characteristics
that represent one’s own cultural groups
without question; develops a growing appre-
ciation for others from racially and culturally
diverse groups.
Introspection: Begins to question the psycho-
logical cost of projecting strong feelings
toward dominant cultural groups; desires to
refocus more energy on personal identity
while respecting own cultural groups; realigns
perspective to note that not all aspects of
dominant cultural groups—one’s own ra-
cial/cultural group or other diverse groups—
are good or bad; may struggle with and expe-
rience conflicts of loyalty as perspective
broadens.
Integrative Awareness: Has developed a
secure, confident sense of racial/cultural
identity; becomes multicultural; maintains
pride in racial identity and cultural heritage;
commits to supporting and appreciating all
oppressed and diverse groups; tends to
recognize racism as a societal illness by which
all can be victimized.
Naiveté: Had an early childhood developmental
phase of curiosity or minimal awareness of race;
may or may not receive overt or covert messages
about other racial/cultural groups; possesses an
ethnocentric view of culture.
Conformity: Has minimal awareness of self as a
racial person; believes strongly in the universality
of values and norms; perceives White American
cultural groups as more highly developed; may
justify disparity of treatment; may be unaware of
beliefs that reflect this.
Dissonance: Experiences an opportunity to
examine own prejudices and biases; moves
toward the realization that dominant society
oppresses racially and culturally diverse groups;
may feel shame, anger, and depression about
the perpetuation of racism by White American
cultural groups; and may begin to question
previously held beliefs or refortify prior views.
Resistance and Immersion: Increases awareness
of one’s own racism and how racism is projected
in society (e.g., media and language); likely feels
angry about messages concerning other racial
and cultural groups and guilty for being part of an
oppressive system; may counteract feelings by
assuming a paternalistic role (knowing what is
best for clients without their involvement) or
overidentifying with another racial/cultural group.
Introspection: Begins to redefine what it means
to be a White American and to be a racial and
cultural being; recognizes the inability to fully
understand the experience of others from di-
verse racial and cultural backgrounds; may feel
disconnected from the White American group.
Integrative Awareness: Appreciates racial,
ethnic, and cultural diversity; is aware of and
understands self as a racial and cultural being; is
aware of sociopolitical influences of racism;
internalizes a nonracist identity.
Commitment to Antiracist Action: Commits to
social action to eliminate oppression and disparity
(e.g., voicing objection to racist jokes, taking
steps to eradicate racism in institutions and public
policies); likely to be pressured to suppress efforts
and conform rather than build alliances with
people of color.
Sources: Sue 2001; Sue and Sue 1999b.
40
Chapter 2—Core Competencies for Counselors and Other Clinical Staff
“How To Map Racial and Cultural Identity
Development” box on the next page) as prepa-
ration for counseling, treatment planning, or
clinical supervision, clinicians can gain aware-
ness of the many forces that influence cultur-
ally responsive treatment.
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
(Koltko-Rivera 2004). Starting in early child-
hood, worldview development is facilitated by
significant relationships (particularly with
parents and family members) and is shaped by
the individual’s environment and life experi-
ences, influencing values, attitudes, beliefs, and
behaviors. In more simplistic terms, each
person’s worldview is like a pair of glasses with
colored lenses—the person takes in all of life’s
experiences through his or her own uniquely
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 mother (of Latino/Middle Eastern descent) grew up near Albuquerque, New Mexico.
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 son 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.
41
Improving Cultural Competence
tinted view. Not unlike clients, counselors
enter the treatment process with their own
cultural worldviews that shape their concept of
time; definition of family; organization of
priorities and responsibilities; orientation to
self, family, and/or community; religious or
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 witness
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.
42
Chapter 2—Core Competencies for Counselors and Other Clinical Staff
spiritual beliefs; ideas about success; and so on
(Exhibit 2-2).
However, counselors also contend with anoth-
er worldview that is often invisible but still
powerful—the clinical worldview (Bhugra and
Gupta 2010; Tilburt and Geller 2007; Tseng
and Streltzer 2004). Influenced by education,
clinical training, and work experiences, coun-
selors are introduced into a culture that re-
flects specific counseling theories, techniques,
treatment modalities, and general office prac-
tices. This worldview, coupled with their
personal cultural worldview, significantly
shapes the counselor’s beliefs pertaining to the
nature of wellness, illness, and healing; inter-
viewing skills and behavior; diagnostic impres-
sions; and prognosis. Moreover, it influences
the definition of normal versus abnormal or
disordered behavior, the determination of
treatment priorities, the means of intervention,
and the definitions of successful outcomes and
treatment failures.
Foremost, counselors need to remember that
worldviews are often unspoken and inconspic-
uous; therefore, considerable reflection and
self-exploration are needed to identify how
their own cultural worldviews influence their
interactions both inside and outside of coun-
seling. Clinical staff members need to question
how their perspectives are perpetuated in and
shape client–counselor interactions, treatment
decisions, planning, and selected counseling
approaches. In sum, culturally responsive
practice involves an understanding of multiple
perspectives and how these worldviews inter-
act throughout the treatment process—
including the views of the counselor, client,
family, other clients and staff members, treat-
ment program, organization, and other agen-
cies, as well as the community.
Stereotypes, prejudices, and history
Cultural competence involves counselors’
willingness to explore their own histories of
prejudice, cultural stereotyping, and discrimi-
nation. Counselors need to be aware of how
their own perceptions of self and others have
evolved through early childhood influences
and other life experiences. For example, how
were stereotypes of their own races and ethnic
heritages perpetuated in their upbringing?
What myths and stereotypes were projected
onto other groups? What historical events
shaped experiences, opportunities, and percep-
tions of self and others?
Regardless of their race, cultural group, or
ethnic heritage, counselors need to examine
how they have directly or indirectly been
affected by individual, organizational, and
societal stereotypes, prejudice, and discrimina-
tion. How have certain attitudes, beliefs, and
behaviors functioned as deterrents to obtain-
ing equitable opportunities? In what ways
have discrimination and societal biases provid-
ed benefits to them as individuals and as
counselors? Even though these questions can
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
exploring clients’ life experiences and percep-
tions during the treatment process. If counse-
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.
Clinical
Worldview
Individual
Cultural
Worldview
Exhibit 2-2: Counselor Worldview
43
Improving Cultural Competence
Clients can have behavioral health issues and
healthcare concerns associated with discrimi-
nation. If counselors are blind to these issues,
they can miss vital information that influences
client responses to treatment and willingness
to follow through with continuing care and
ancillary services. For example, a counselor
may refer a client to a treatment program
without noting the client’s history or percep-
tions of the recommended program or type of
program. The client may initially agree to
attend the program but not follow through
because of past negative experiences and/or
the perception within his or her racial/ethnic
community that the service does not provide
adequate treatment for clients of color.
All counselors should examine their
stereotypes, prejudices, and emotional
reactions toward others, including
individuals from their own races or cultural
backgrounds and individuals from other
groups. They should examine how these
attitudes and biases may be detrimental to
clients in treatment for substance-related
and mental disorders.
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 Physicians 2003; Campinha-Bacote et al. 2005.
Trust and power
Counselors need to understand the impact of
their role and status within the client–
counselor relationship. Client perceptions of
counselors’ influence, power, and control vary
in diverse cultural contexts. In some contexts,
counselors can be seen as all-knowing profes-
sionals, but in others, they can be viewed as
representatives of an unjust system. Counse-
lors need to explore how these dynamics affect
the counseling process with clients from
diverse backgrounds. Do client perceptions
inhibit or facilitate the process? How do they
affect the level of trust in the client–counselor
relationship? These issues should be identified
and addressed early in the counseling process.
Clients should have opportunities to talk
about and process their perceptions, past
experiences, and current needs.
Practicing within limits
A key element of ethical care is practicing
within the limits of one’s competence. Coun-
selors must engage in self-exploration, critical
thinking, and clinical supervision to under-
stand their clinical abilities and limitations
44
Chapter 2—Core Competencies for Counselors and Other Clinical Staff
regarding the services that they are able to
provide, the populations that they can serve,
and the treatment issues that they have suffi-
cient 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 pro-
cess or if they minimize, ignore, or avoid
viewing treatment in a cultural context.
Some counselors may assume that they have
cultural competence based on having similar
experiences as clients, being from the same
race as clients, identifying as a member of the
same ethnic heritage or cultural group as
clients, or attending training on cultural com-
petence. Other counselors may assume compe-
tence based on their current or prior
relationships with others from the same race
or cultural background as their clients. These
experiences can be helpful and filled with
many potential learning opportunities, but
they do not make an individual eligible or
competent to provide multicultural counseling.
Likewise, the assumption that a person from
the same cultural group, race, or ethnic herit-
age will intrinsically understand a client from
a similar background is operating out of two
common myths: the “myth of sameness” (i.e.,
that people from the same cultural group, race,
or ethnicity are alike) and the myth that “fa-
miliarity equals competence” (Srivastava
2007). The Association for Multicultural
Counseling and Development adopted a set
of counselor competencies that was endorsed
by the American Counseling Association
(ACA) for counselors who work with a mul-
ticultural clientele (Exhibit 2-3). Competen-
cies address the attitudes, beliefs, knowledge,
and skills associated with the counselor’s need
for self-knowledge.
“Become familiar with the community in
which the client lives and the general
cultural norms of the individual client. This
can be accomplished by visiting with
people who know the community well,
attending important community
celebrations and other events, asking
open-ended questions about community
concerns and quality of life, and
identifying community capacities that
affect wellness in the community.”
(Perez and Luquis 2008, p. 177)
Knowledge of Other Cultural
Groups
In addition to an understanding of themselves
and how their cultural groups and values can
affect the therapeutic process, culturally com-
petent counselors work to acquire cultural
knowledge and understanding of clients and
staff with whom they work. From the outset,
counselors need general knowledge and
awareness when working with other cultural
groups in counseling. For example, they should
acknowledge that culture influences commu-
nication patterns, values, gender roles and
socialization, clinical presentations of distress,
counseling expectations, and behavioral norms
and expectations in and outside the counseling
session (e.g. , touching, greetings, gift-giving,
accompaniment in sessions, level of formality
between counselor and client). Counselors
should filter and interpret client presentation
from a broad cultural perspective instead of
using only their own cultural groups or previ-
ous client experiences as reference points.
Counselors also need to invest the time to
know clients and their cultures. Culturally
responsive practice involves a commitment to
obtaining specific cultural knowledge, not
only through ongoing client interactions, but
also through the use of outside resources,
cultural training seminars and programs,
cultural events, professional consultations,
45
Improving Cultural Competence
cultural guides, and clinical supervision.
Counselors need to be mindful that they will
not know everything about a specific popula-
tion or initially comprehend how an individual
client endorses or engages in specific cultural
practices, beliefs, and values. For instance,
some clients may not identify with the same
cultural beliefs, practices, or experiences as
other clients from the same cultural groups.
Nevertheless, counselors need to be as knowl-
edgeable as possible and attend to these cul-
tural attributes—beginning with the intake
and assessment process and continuing
throughout the counseling and treatment
relationship. For a review of content areas
essential in knowing other cultural groups,
refer to the ”What Are the Cross-Cutting
Factors in Race, Ethnicity, and Culture” sec-
tion in Chapter 1. These cultural knowledge
content areas include:
• Language and communication.
• Geographic location.
• Worldview, values, and traditions.
• Family and kinship.
• Gender roles.
• Socioeconomic status and education.
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 cultural racism.
• 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_comp
etencies_and_objectives.pdf). Adapted with permis
sion.
46
Chapter 2—Core Competencies for Counselors and Other Clinical Staff
• Immigration, migration, and acculturation
stress.
• Acculturation and cultural identification.
• Heritage and history.
• Sexuality.
• Religion and spirituality.
• Health, illness, and healing.
Counselors should not make assumptions
about clients’ race, ethnic heritage, or culture
based on appearance, accents, behavior, or
language. Instead, counselors need to explore
with clients their cultural identity, which can
involve multiple identities (Lynch and Hanson
2011). Counselors should discuss what cultural
identity means to clients and how it influences
treatment. For example, a young adult two-
spirited (gay) American Indian man may be
more concerned with having access to tradi-
tional healing practices than to specialized
services for gay men. Counselors and clients
should collaboratively examine presenting
treatment issues and obstacles to engaging in
behavioral health treatment and maintaining
recovery, and they should discuss how cultural
groups and cultural identities can serve as
guideposts in treatment planning.
Exhibit 2-4 lists ACA-endorsed counselor
competencies for knowledge of the worldviews
of clients from diverse cultural groups.
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
Health
Counselors should learn how culture interacts
with health beliefs, substance use, and other
behavioral health issues. They can access litera-
ture and training that address cultural contexts
and meanings of substance use, behavioral and
emotional reactions, help-seeking behavior, and
treatment. Chapter 5 gives information on
culturally responsive behavioral health services
for major ethnic and racial groups. The how-
to box below lists ways to improve one’s cul-
tural knowledge of health issues by acquiring
knowledge in key areas to work successfully
with diverse clients:
• Patterns of substance use and treatment-
seeking behavior specific to people of
diverse racial and cultural backgrounds.
• Beliefs and traditions surrounding sub-
stance use, including cultural norms con-
cerning the use of alcohol and drugs.
• Beliefs about treatment, including expecta-
tions and attitudes toward health care and
counseling.
• Community perceptions of behavioral
health treatment.
• Obstacles encountered by specific popula-
tions that make it difficult to access treat-
ment, such as geographic distance from
treatment services.
• Patterns of co-occurring disorders and
conditions specific to people from diverse
racial and cultural backgrounds (e.g., cul-
turally specific syndromes, earlier onset 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 emotions 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
and substance dependence).
• Assessment and diagnosis, including
culturally appropriate screening and as-
sessment and awareness of common diag-
nostic biases associated with symptom
presentation.
• Individual, family, and group therapy
approaches that hold promise in address-
ing mental and substance-related disorders
specific to the racial and cultural back-
grounds of diverse clients.
• Culturally appropriate peer support,
mutual-help, and other support groups
(e.g., the Wellbriety movement, a cultural-
ly appropriate 12-Step program for Native
American people).
• Traditional healing and complementary
methods (e.g., use of spiritual leaders,
herbs, and rituals).
• Continuing care and relapse prevention,
including attention to clients’ cultural en-
vironments, treatment needs, and accessi-
bility of care within their communities.
• Treatment engagement/retention patterns.
Skill Development
Becoming culturally competent is an ongoing
process—one that requires introspection,
awareness, knowledge, and skill development.
Counselors need to develop a positive attitude
toward learning about multiple cultural
groups; in essence, counselors should commit
to cultural competence and the process of
growth. This commitment is evidenced via
investment in ongoing learning and the pur-
suit of culturally congruent skills. Counselors
can demonstrate commitment to cultural
competence through the attitudes and corre-
sponding behaviors indicated in Exhibit 2-5.
Beyond the commitment to and development
of these fundamental attitudes and behaviors,
counselors need to work toward intervention
strategies that integrate the skills discussed in
the following sections.
Frame issues in culturally relevant
ways
Counselors should frame clinical issues with
culturally appropriate references. For example,
in cultural groups that value the community or
family as much as the individual, it is helpful
to address substance abuse in light of its con-
sequences to family or the community. The
counselor might ask, “How are your family
and community affected by your use? How do
family and community members feel when
they see you high?” For clients who place more
value on their independence, it can be more
effective to point out how substance depend-
ence undermines their ability to manage their
own lives through questions like “How might
your use affect your ability to reach your goals?”
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
to equality
• Proactively addressing racism or bias as it occurs in treatment (e.g., pro-
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
on cultural context
Counselors must take care with suggesting
simple solutions to complex problems. It is
often better to acknowledge the intricacies of
the client’s cultural context and circumstances.
For instance, a Native American single mother
who upholds traditional values could balk at a
suggestion to stop spending time with family
members who drink heavily. Here, the counse-
lor might encourage the woman to broaden
support within her community by connecting
with an elder who supports recovery or by
engaging in a women’s talking circle. Likewise,
a referral for a psychiatric evaluation for major
depression may not be an appropriate initial
recommendation for a Chinese client who
relies on cultural remedies and healing tradi-
tions. An alternative approach would be to
explore the client’s beliefs in healing, develop
steps that respect and incorporate the client’s
help-seeking practices, and coordinate services
to secure a culturally responsive intervention
(Cardemil et al. 2011; Gallardo et al. 2012;
Lynch and Hanson 2011).
Make allowances for variations in
the use of personal space
Cultural groups have different expectations
and norms of propriety concerning how close
people can be while they communicate and
how personal communications can be depend-
ing on the type of relationship (e.g., peers
versus elders). The concept of personal space
involves more than the physical distance
between people. It also involves cultural expec-
tations regarding posture or stance and the use
of space within a given environment. These
cultural expectations, although they are subtle,
can have an impact on treatment. For example,
an Alaska Native may feel more comfortable
sitting beside a counselor, whereas a European
may prefer to be separated from a counselor by
a desk (Sue and Sue 2013a). The use of space
can also be a nonverbal expression of power.
Standing too close to someone can, for exam-
ple, suggest power over them. Standing too far
away or sitting behind a desk can indicate
aloofness. Acceptable or expected degrees of
closeness between people are culturally specific;
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
population. However, counselors should not
predetermine the clients’ expectations; instead,
they should follow the clients’ lead and inquire
about their preferences.
Display sensitivity to culturally
specific meanings of touch
Some treatment and many support groups
have opening or closing traditions that include
holding hands or giving hugs. This form of
touching can be very uncomfortable to new
clients regardless of cultural groups; cultural
prescriptions, including religious beliefs, con-
cerning appropriate touching can compound
this effect (Comas-Diaz 2012). Many cultural
groups use touch to acknowledge or greet
someone, to show respect or convey status or
power, or to display comfort. As counselors, it
is essential to understand cultural norms about
touch, which often are guided by gender and
age, and the contexts surrounding “appropri-
ate” touch for specific cultural groups (Sri-
vastava 2007). Counselors need to devote time
to understanding their clients’ norms for and
interpretations of touch, to assisting clients in
negotiating and upholding their cultural
norms, and to helping clients understand the
context and cultural norms that are likely to
prevail in support and treatment groups.
Explore culturally based experiences
of power and powerlessness
Ideas about power and powerlessness are
influenced by the client’s culture and social
class. What constitutes power and powerless-
ness varies from culture to culture according to
the individual’s gender, age, occupation, ances-
try, religious affiliation, and a host of other
factors. For example, power can be defined in
terms of one’s place within the family, with the
oldest member being the most powerful and
the youngest being the least powerful. Even
the words “power” and “powerlessness” carry
cultural meaning. These words can carry
negative connotations for clients with histories
of discrimination and multiple experiences
with racism, for some women, for indigenous
peoples with histories of colonization, and for
refugees or immigrants who have left oppres-
sive regimes. In this regard, counselors should
use these words carefully. For example, a
Hmong refugee who experienced trauma in
her country of origin could already feel help-
less and powerless over the events that oc-
curred; thus, the concept of powerlessness,
often used in drug and alcohol treatment
programs, can be contraindicated in address-
ing her substance-related disorder. However, a
White American business executive who has
authority over others and a history of financial
influence may need help acknowledging that
he cannot control his substance abuse.
Adjust communication styles to the
client’s culture
Cultural groups all have different communica-
tion styles. Norms for communicating vary in
and between cultural groups based on class,
gender, geographic origins, religion, subcul-
tures, and other individual variations. Counse-
lors should educate themselves as much as
possible regarding the patterns of communi-
cating in the client’s cultural, racial, or ethnic
population while also being aware of his/her
own communication style. For a comprehen-
sive guide in self-assessment and understand-
ing of communication styles, refer to Culture
Matters: The Peace Corps Cross-Cultural
Workbook (Peace Corps Information
Collection and Exchange 2012).
The following are general guidelines for ascer-
taining the client’s communication style:
• Understand the client’s verbal and nonver-
bal ways of communicating. Be aware of
the possible need to move away from
comprehending and interpreting client re-
sponses in conventional professional ways
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-
ings in speech
Does not express or identify
feelings in speech
Self-Disclosure
Frequently Rarely or little
Formality
Informal
Formal in addressing
and showing respec
others
t
(
Continued on the next page.)
53
Improving Cultural Competence
• Styles of communication and nonverbal
methods of communication are important
aspects of cultural groups. Issues such as
the appropriate space to have between
people; preferred ways of moving, sitting,
and standing; the meaning of gestures; and
the degree of eye contact expected are all
culturally defined and situation specific
(Hall 1976). As an example, high-context
cultural groups place greater importance
on nonverbal cues and message context,
whereas low-context cultural groups rely
largely on verbal message content. Most
Asian Americans come from high-context
cultural groups in which sensitive messages
are encoded carefully to avoid offending
others. A provider who listens only to the
content could miss the message. What is
not said can possibly be more important
than what is said.
• Listen to storytelling carefully, as it can be
a way of communicating with the thera-
pist. As in any good therapy, follow the as-
sociations and listen for possible
metaphors to better understand relational
meaning, cognition, and emotion within
the context of the conversation.
Interpret emotional expressions in
light of the client’s culture
Feelings are expressed differently across and
within cultural groups and are influenced by
the nature of a given event and the individuals
involved in the situation. A certain level of
emotional expression can be socially appropri-
ate within one culture yet inappropriate in
another. In some cultural groups, feelings may
not be expressed directly, whereas in other
cultural groups, some emotions are readily
expressed and others suppressed. For example,
expressions of sadness may at first be more
readily shared by some clients in counseling
settings, whereas others may find it more
How To Assess Differences in Communication Styles (continued)
Directness
Verbally explicit
Indirect; subtle; doesn’t
believe in saying everything
Context
Low context; relies more on
words to convey meaning
High context: verbal and
nonverbal cues convey
much of the meaning
Orientation
Orientation to self; use of “I”
statements
Orientation to others, use of
plural and third-person
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.
54
(Bland and Kraft 1998). Always be curious
about the client’s cultural context and be
willing to seek clarification and better un-
derstanding from the client. It is as im-
portant for counselors to access and
engage in cultural consultation to acquire
more specific knowledge and experience.
Chapter 2—Core Competencies for Counselors and Other Clinical Staff
comfortable to express anger as their initial
response. Counselors must recognize that not
all cultures place the same value on verbalizing
feelings. In fact, clients from some cultures
may not perceive that emotional expression is
a worthy course of treatment and healing at
all. Thus, counselors should not impose a
prescribed approach that measures progress
and equates healing with the ability to display
emotions. Likewise, counselors should be
careful not to attribute meaning based on their
own cultural backgrounds or to project their
own feelings onto clients’ experiences. Instead,
counselors need to assist their clients in iden-
tifying and labeling feelings within their own
cultural contexts.
Expand roles and practices
Counselors need to acquire a mindset that
allows for more flexible roles and practices—
while still maintaining appropriate profession-
al boundaries—when working with clients.
Some clients whose culture places considera-
ble emphasis upon and orientation toward
family could look to counselors for advice with
unrelated issues pertaining to other family
members. Other clients may expect a more
prescribed and structured approach in which
counselors give specific recommendations and
advice in the session. For example, Asian
American clients appear to expect and benefit
from a more directive and highly structured
approach (Fowler et al. 2011; Lee and Mock
2005a; Sue 2001; Uba 1994). Still others could
expect that counselors be connected to their
communities through participation in com-
munity events, in working with traditional
healers, or in building collaborative relation-
ships with other community agencies. As
counselors, it is important to understand the
cultural contexts of clients and how this trans-
lates to expectations in the client–counselor
relationship. The appropriate role usually
Results from the counselor’s understanding of
and sensitivity to the values, cultures, and
special needs of the individuals and groups
being served (Sue and Sue 2013d). Counselors
need to adopt an ongoing commitment to
developing skills and endorsing practices that
assist clients in receiving and experiencing the
best possible care. Exhibit 2-6 lists counselor
competencies endorsed by ACA for culturally
appropriate intervention strategies.
Self-Assessment for
Individual Cultural
Competence
Several instruments for evaluating an individ-
ual’s cultural competence have been developed
and are available online. One assessment tool
that has been widely circulated is Goode’s Self-
Assessment Checklist for Personnel Providing
Services and Supports to Children and Youth
With Special Health Needs and Their Families. It
can be adapted for counselors treating adult
clients with behavioral health concerns. This
tool and other additional resources are provid-
ed in Appendix C. For an interactive Web-
based tool on cultural competence awareness,
visit the American Speech-Language-Hearing
Association Web site (http://www.asha.org).
Providing good care goes beyond counse-
lors’ general knowledge, clinical skills, and
approaches; it involves understanding the
multicultural context of clients and of
themselves as counselors. Cultural compe-
tence is an ethical issue requiring counse-
lors to be invested in developing the tools
to provide culturally congruent care—care
that matches the needs and context of the
client. For a review of ethics and ethical
dilemmas in a multicultural context, refer
to Pack-Brown and Williams (2003).
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 net-
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/compet
encies/
cross-cultural_competencies_and_objectives.pdf). Adapted with per
mission.
56
3
Culturally Responsive
Evaluation and
Treatment Planning
IN THIS CHAPTER
• Step 1: Engage Clients
• Step 2: Familiarize Clients
and Their Families With
Treatment and Evaluation
Processes
• Step 3: Endorse
Collaboration in
Interviews, Assessments,
and Treatment Planning
• Step 4: Integrate
Culturally Relevant
Information and Themes
• Step 5: Gather Culturally
Relevant Collateral
Information
• Step 6: Select Culturally
Appropriate Screening
and Assessment Tools
• Step 7: Determine
Readiness and Motivation
for Change
• Step 8: Provide Culturally
Responsive Case
Management
• Step 9: Incorporate
Cultural Factors Into
Treatment Planning
57
Zhang Min, a 25-year-old first-generation Chinese woman, was
referred to a counselor by her primary care physician because she
reported having episodes of depression. The counselor who con-
ducted the intake interview had received training in cultural com-
petence and was mindful of cultural factors in evaluating Zhang
Min. The referral noted that Zhang Min was born in Hong Kong,
so the therapist expected her to be hesitant to discuss her prob-
lems, given the prejudices attached to mental illness and substance
abuse in Chinese culture. During the evaluation, however, the
therapist was surprised to find that Zhang Min was quite forth-
coming. She mentioned missing important deadlines at work and
calling in sick at least once a week, and she noted that her cowork-
ers had expressed concern after finding a bottle of wine in her desk.
She admitted that she had been drinking heavily, which she linked
to work stress and recent discord with her Irish American spouse.
Further inquiry revealed that Zhang Min’s parents, both Chinese,
went to school in England and sent her to a British school in Hong
Kong. She grew up close to the British expatriate community, and
her mother was a nurse with the British Army. Zhang Min came to
the United States at the age of 8 and grew up in an Irish American
neighborhood. She stated that she knew more about Irish culture
than about Chinese culture. She felt, with the exception of her
physical features, that she was more Irish than Chinese—a view
accepted by many of her Irish American friends. Most men she had
dated were Irish Americans, and she socialized in groups in which
alcohol consumption was not only accepted but expected.
Zhang Min first started to drink in high school with her friends.
The counselor realized that what she had learned about Asian
Improving Cultural Competence
Americans was not necessarily applicable to
Zhang Min and that knowledge of Zhang
Min’s entire history was necessary to appreci-
ate the influence of culture in her life. The
counselor thus developed treatment strategies
more suitable to Zhang Min’s background.
Multidimensional Model for Developing Cultural Competence: Clinical/Program
Level
58
Zhang Min’s case demonstrates why thorough
evaluation, including assessment of the client’s
sociocultural background, is essential for treat-
ment planning. To provide culturally responsive
evaluation and treatment planning, counselors
and programs must understand and incorporate
relevant cultural factors into the process while
avoiding a stereotypical or “one-size-fits-all”
approach to treatment. Cultural responsiveness
in planning and evaluation entails being open
minded, asking the right questions, selecting
appropriate screening and assessment instru-
ments, and choosing effective treatment pro-
viders and modalities for each client. Moreover,
it involves identifying culturally relevant con-
cerns and issues that should be addressed to
improve the client’s recovery process.
This chapter offers clinical staff guidance in
providing and facilitating culturally responsive
interviews, assessments, evaluations, and
treatment planning. Using Sue’s (2001) multi-
dimensional model for developing cultural
competence, this chapter focuses on clinical
and programmatic decisions and skills that are
Chapter 3—Culturally Responsive Evaluation and Treatment Planning
important in evaluation and treatment plan-
ning processes. The chapter is organized
around nine steps to be incorporated by clini-
cians, supported in clinical supervision, and
endorsed by administrators.
Step 1: Engage Clients
Once clients are in contact with a treatment
program, they stand on the far side of a yet-to-
be-established therapeutic relationship. It is up
to counselors and other staff members to bridge
the gap. Handshakes, facial expressions, greet-
ings, and small talk are simple gestures that
establish a first impression and begin building
the therapeutic relationship. Involving one’s
whole being in a greeting—thought, body,
attitude, and spirit—is most engaging.
Fifty percent of racially and ethnically diverse
clients end treatment or counseling after one
visit with a mental health practitioner (Sue and
Sue 2013e). At the outset of treatment, clients
can feel scared, vulnerable, and uncertain about
whether treatment will really help. The initial
meeting is often the first encounter clients have
with the treatment system, so it is vital that
they leave feeling hopeful and understood.
Paniagua (1998) describes how, if a counselor
lacks sensitivity and jumps to premature con-
clusions, the first visit can become the last:
Pretend that you are a Puerto Rican taxi driv-
er in New York City, and at 3:00 p.m. on a
hot summer day you realize that you have
your first appointment with the thera-
pist…later, you learned that the therapist
made a note that you were probably depressed
or psychotic because you dressed carelessly
and had dirty nails and hands…would you
return for a second appointment? (p. 120)
To engage the client, the counselor should try
to establish rapport before launching into a
series of questions. Paniagua (1998) suggests
that counselors should draw attention to the
presenting problem “without giving the im-
pression that too much information is needed
to understand the problem” (p. 18). It is also
important that the client feel engaged with
any interpreter used in the intake process. A
common framework used in many healthcare
training programs to highlight culturally
responsive interview behaviors is the LEARN
model (Berlin and Fowkes 1983). The how-to
box on the next page presents this model.
Step 2: Familiarize Clients
and Their Families With
Treatment and Evaluation
Processes
Behavioral health treatment facilities maintain
their own culture (i.e., the treatment milieu).
Counselors, clinical supervisors, and agency
administrators can easily become accustomed
to this culture and assume that clients are used
to it as well. However, clients are typically new
to treatment language or jargon, program
expectations and schedules, and the intake and
treatment process. Unfortunately, clients from
diverse racial and ethnic groups can feel more
estranged and disconnected from treatment
services when staff members fail to educate
them and their families about treatment ex-
pectations or when the clients are not walked
Improving Cross-Cultural Communication
Health disparities have multiple causes. One
specific influence is cross-cultural communication
between the counselor and the client. Weiss
(2007) recommends these six steps to improve
communication with clients:
1. Slow down.
2. Use plain, nonpsychiatric language.
3. Show or draw pictures.
4. Limit the amount of information provided at
one time.
5. Use the “teach-back” method. Ask the client,
in a nonthreatening way, to explain or show
what he or she has been told.
6. Create a shame-free environment that en-
courages questions and participation.
59
Improving Cultural Competence
through the treatment process, starting with
the goals of the initial intake and interview. By
taking the time to acclimate clients and their
families to the treatment process, counselors
and other behavioral health staff members
tackle one obstacle that could further impede
treatment engagement and retention among
racially and ethnically diverse clients.
Step 3: Endorse
Collaboration in
Interviews, Assessments,
and Treatment Planning
Most clients are unfamiliar with the evalua-
tion and treatment planning process and how
they can participate in it. Some clients may
view the initial interview and evaluation as
intrusive if too much information is requested
or if the content is a source of family dishonor
or shame. Other clients may resist or distrust
the process based on a long history of racism
and oppression. Still others feel inhibited from
actively participating because they view the
counselor as the authority or sole expert.
The counselor can help decrease the influence
of these issues in the interview process
through a collaborative approach that allows
time to discuss the expectations of both coun-
selor and client; to explain interview, intake,
and treatment planning processes; and to
establish ways for the client to seek clarifica-
tion of his or her assessment results (Mohatt
et al. 2008a). The counselor can encourage
collaboration by emphasizing the importance
of clients’ input and interpretations. Client
feedback is integral in interpreting results and
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.
60
Chapter 3—Culturally Responsive Evaluation and Treatment Planning
can identify cultural issues that may affect
intake and evaluation (Acevedo-Polakovich et
al. 2007). Collaboration should extend to client
preferences and desires regarding inclusion of
family and community members in evaluation
and treatment planning.
Step 4: Integrate
Culturally Relevant
Information and Themes
By exploring culturally relevant themes,
counselors can more fully understand their
clients and identify their cultural strengths
and challenges. For example, a Korean wom-
an’s family may serve as a source of support
and provide a sense of identity. At the same
time, however, her family could be ashamed
of her co-occurring generalized anxiety and
substance use disorders and respond to her
treatment as a source of further shame be-
cause it encourages her to disclose personal
matters to people outside the family. The
following section provides a brief overview of
suggested strength-based topics to incorpo-
rate into the intake and evaluation process.
Immigration History
Immigration history can shed light on client
support systems and identify possible isolation
or alienation. Some immigrants who live in
ethnic enclaves have many sources of social
support and resources. By contrast, others may
be isolated, living apart from family, friends,
and the support systems extant in their coun-
tries of origin. Culturally competent evalua-
tion should always include questions about the
client’s country of origin, immigration status,
length of time in the United States, and con-
nections to his or her country of origin. Ask
American-born clients about their parents’
country of origin, the language(s) spoken at
home, and affiliation with their parents’ cul-
ture(s). Questions like these give the counselor
important clues about the client’s degree of
acculturation in early life and at present, cul-
tural identity, ties to culture of origin, potential
cultural conflicts, and resources. Specific ques-
tions should elicit information about:
• Length of time in the United States,
noting when immigration occurred or the
number of generations who have resided in
the United States.
• Frequency of returns and psychological
and personal ties to the country of origin.
• Primary language and level of English
proficiency in speaking and writing.
• Psychological reactions to immigration
and adjustments made in the process.
• Changes in social status and other areas as
a result of coming to this country.
• Major differences in attitudes toward
alcohol and drug use from the time of
immigration to now.
Advice to Counselors: Conducting
Strength-Based Interviews
By nature, initial interviews and evaluations can
overemphasize presenting problems and con-
cerns while underplaying client strengths and
supports. This list, although not exhaustive,
reminds clinicians to acknowledge client
strengths and supports from the outset.
Strengths and supports:
• Pride and participation in one’s culture
• Social skills, traditions, knowledge, and
practical skills specific to the client’s culture
• Bilingual or multilingual skills
• Traditional, religious, or spiritual practices,
beliefs, and faith
• Generational wisdom
• Extended families and nonblood kinships
• Ability to maintain cultural heritage and
practices
• Perseverance in coping with racism and
oppression
• Culturally specific ways of coping
• Community involvement and support
Source: Hays 2008.
61
Improving Cultural Competence
Cultural Identity and
Acculturation
As shown in Zhang Min’s case at the begin-
ning of this chapter, cultural identity is a
unique feature of each client. Counselors
should guard against making assumptions
about client identity based on general ethnic
and racial identification by evaluating the
degree to which an individual identifies with
his or her culture(s) of origin. As Castro and
colleagues (1999b) explain, “for each group,
the level of within-group variability can be
assessed using a core dimension that ranges
from high cultural involvement and ac-
ceptance of the traditional culture’s values to
low or no cultural involvement” (p. 515). For
African Americans, for example, this dimen-
sion is called “Afrocentricity.” Scales for Af-
rocentricity have been developed in an attempt
to provide an indicator of an individual’s level
of involvement within the traditional or core
African-oriented culture (Baldwin and Bell
1985; Cokley and Williams 2005; Klonoff and
Landrine 2000). Many other instruments
based on models of identity evaluate accul-
turation and identity. A detailed discussion of
the theory behind such models is beyond the
scope of this Treatment Improvement Proto-
col (TIP); however, counselors should have a
general understanding of what is being meas-
ured when administering such instruments.
The “Asking About Culture and Accultura-
tion” advice box at right addresses exploration
of culture and acculturation with clients. For
more information on instruments that measure
acculturation and/or identity, see Appendix B.
Other areas to explore include the cross-
cutting factors outlined in Chapter 1, such as
socioeconomic status (SES), occupation,
education, gender, and other variables that can
distinguish an individual from others who
share his or her cultural identity. For example,
a biracial client could identify with African
American culture, White American culture, or
both. When a client has two or more ra-
cial/ethnic identities, counselors should assess
how the client self-identifies and how he or
she negotiates the different worlds.
Membership in a Subculture
Clients often identify initially with broader
racial, ethnic, and cultural groups. However,
each person has a unique history that warrants
an understanding of how culture is practiced
and has evolved for the person and his or her
Advice to Counselors: Asking About
Culture and Acculturation
A thoughtful exploration of cultural and ethnic
identity issues will provide clues for determin-
ing cultural, racial, and ethnic identity. There
are numerous clues that you may derive from
your clients’ answers, and they cannot all be
covered in this TIP; this is only one set of
sample questions (Fontes 2008). Ask these
questions tactfully so they do not sound like an
interrogation. Try to integrate them naturally
into a conversation rather than asking one after
another. Not all questions are relevant in all
settings. Counselors can adapt wording to suit
clients’ cultural contexts and styles of commu-
nication, because the questions listed here and
throughout this chapter are only examples:
• Where were you born?
• Whom do you consider family?
• What was the first language you learned?
• Which other language(s) do you speak?
• What language or languages are spoken in
your home?
• What is your religion? How observant are
you in practicing that religion?
• What activities do you enjoy when you are
not working?
• How do you identify yourself culturally?
• What aspects of being ________ are most
important to you? (Use the same term for
the identified culture as the client.)
• How would you describe your home and
neighborhood?
• Whom do you usually turn to for help when
facing a problem?
• What are your goals for this interview?
62
Chapter 3—Culturally Responsive Evaluation and Treatment Planning
family; accordingly, counselors should avoid
generalizations or assumptions. Clients are
often part of a culture within a culture. There
is not just one Latino, African American, or
Native American culture; many variables
influence culture and cultural identity (see the
“What Are the Cross-Cutting Factors in Race,
Ethnicity, and Culture” section in Chapter 1).
For example, an African American client from
East Carroll Parish, LA, might describe his or
her culture quite differently than an African
American from downtown Hartford, CT.
Beliefs About Health, Healing,
Help-Seeking, and Substance Use
Just as culture shapes an individual’s sense of
identity, it also shapes attitudes surrounding
health practices and substance use. Cultural
acceptance of a behavior, for instance, can
mask a problem or deter a person from seek-
ing treatment. Counselors should be aware of
how the client’s culture conceptualizes issues
related to health, healing and treatment prac-
tices, and the use of substances. For example,
in cases where alcohol use is discouraged or
frowned upon in the community, the client
can experience tremendous shame about
drinking. Chapter 5 reviews health-related
beliefs and practices that can affect help-
seeking behavior across diverse populations.
Trauma and Loss
Some immigrant subcultures have experienced
violent upheavals and have a higher incidence
of trauma than others. The theme of trauma
and loss should therefore be incorporated into
general intake questions. Specific issues under
this general theme might include:
• Migration, relocation, and emigration
history—which considers separation from
homeland, family, and friends—and the
stressors and loss of social support that can
accompany these transitions.
• Clients’ personal or familial experiences
with American Indian boarding schools.
• Experiences with genocide, persecution,
torture, war, and starvation.
Advice to Counselors: Eliciting Client
Views on Presenting Problems
Some clients do not see their presenting physi-
cal, 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 the following questions using the clients’
terminology rather than using the word “prob-
lem.” These questions help explore how clients
view their behavioral health concerns:
• I know that clients and counselors some-
times have different ideas about illness and
diseases, so can you tell me more about
your idea of your problem?
• Do you consider your use of alcohol and/or
drugs a problem?
• How do you label your problem? Do you
think it is a serious problem?
• What do you think caused your problem?
• Why do you think it started when it did?
• What is going on in your body as a result of
this problem?
• How has this problem affected your life?
• What frightens or concerns you most about
this problem and its treatment?
• How is your problem viewed in your family?
Is it acceptable?
• How is your problem viewed in your com-
munity? Is it acceptable? Is it considered a
disease?
• Do you know others who have had this
problem? How did they treat the problem?
• How does your problem affect your stature
in the community?
• What kinds of treatment do you think will
help or heal you?
• How have you treated your drug and/or
alcohol problem or emotional distress?
• What has been your experience with treat-
ment programs?
Sources: Lynch and Hanson 2011; Tang and
Bigby 1996; Taylor 2002.
63
Improving Cultural Competence
Step 5: Gather Culturally
Relevant Collateral
Information
A client who needs behavioral health treat-
ment services may be unwilling or unable to
provide a full personal history from his or her
own perspective and may not recall certain
events or be aware of how his or her behavior
affects his or her well-being and that of oth-
ers. Collateral information—supplemental
information obtained with the client’s permis-
sion from sources other than the client—can
be derived from family members, medical and
court records, probation and parole officers,
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
Relocations (current migration pat-
terns)
Losses associated with immigration
and relocation history
English language fluency
Bilingual or multilingual fluency
Individualistic/collectivistic orientation
Racial, ethnic, and cultural identities
Tribal affiliation, if appropriate
Geographic location
Family and extended family concerns
(including nonblood kinships)
Acculturation level (e.g., traditional,
bicultural)
Acculturation stress
History of discrimination/racism
Trauma history
Historical trauma
Intergenerational family history and
concerns
Gender roles and expectations
Birth order roles and expectations
Relationship and dating concerns
Sexual and gender orientation
Health concerns
Traditional healing practices
Help-seeking patterns
Beliefs about wellness
Beliefs about mental illness and mental health
treatment
Beliefs about substance use, abuse, and depend-
ence
Beliefs about substance abuse treatment
Family views on substance use and substance
abuse treatment
Treatment concerns related to cultural differences
Cultural approaches to healing or treatment of
substance use and mental disorders
Education history and concerns
Work history and concerns
SES and financial concerns
Cultural group affiliation
Current network of support
Community concerns
Review of confidentiality parameters and concerns
Cultural concepts of distress (DSM-5*)
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.
64
Chapter 3—Culturally Responsive Evaluation and Treatment Planning
community members, and others. Collateral
information should include culturally relevant
information obtained from the family, such as
the organizational memberships, beliefs, and
practices that shape the client’s cultural identi-
ty and understanding of the world.
As families can be a vital source of infor-
mation, counselors are likely to attain more
support by engaging families earlier in the
treatment process. Although counselor inter-
actions with family members are often limited
to a few formal sessions, the families of racially
and ethnically diverse clients tend to play a
more significant and influential role in clients’
participation in treatment. Consequently,
special sensitivity to the cultural background
of family members providing collateral infor-
mation is essential. Families, like clients,
cannot be easily defined in terms of a generic
cultural identity (Congress 2004; Taylor et al.
2012). Even families from the same racial
background or ethnic heritage can be quite
dissimilar, thus requiring a multidimensional
approach in understanding the role of culture
in the lives of clients and their families. Using
the culturagram tool on the next page in
preparation for counseling, treatment plan-
ning, or clinical supervision, clinicians can
learn about the unique attributes and histories
that influence clients’ lives in a cultural context.
Step 6: Select Culturally
Appropriate Screening
and Assessment Tools
Discussions of the complexities of psychologi-
cal testing, the interpretation of assessment
measures, and the appropriateness of screen-
ing procedures are outside the scope of this
TIP. However, counselors and other clinical
service providers should be able to use assess-
ment and screening information in culturally
competent ways. This section discusses several
instruments and their appropriateness for
specific cultural groups. Counselors should
continue to explore the availability of mental
health and substance abuse screening and
assessment tools that have been translated into
or adapted for other languages.
Culturally Appropriate Screening
Devices
The consensus panel does not recommend any
specific instruments for screening or assessing
mental or substance use disorders. Rather,
when selecting instruments, practitioners
should consider their cultural applicability to
the client being served (AACE 2012; Jome
and Moody 2002). For example, a screening
instrument that asks the respondent about his
or her guilt about drinking could be ineffective
for members of cultural, ethnic, or religious
groups that prohibit any consumption of
alcohol. Al-Ansari and Negrete’s (1990) re-
search supports this point. They found that
the Short Michigan Alcoholism Screening
Test was highly sensitive with people who use
alcohol in a traditional Arab Muslim society;
however, one question—“Do you ever feel
guilty about your drinking?”—failed to distin-
guish between people with alcohol dependency
disorders in treatment and people who drank
in the community. Questions designed to
measure conflict that results from the use of
alcohol can skew test results for participants
from cultures that expect complete abstinence
from alcohol and/or drugs. Appendix D sum-
marizes instruments tested on specific popula-
tions (e.g., availability of normative data for
the population being served).
Culturally Valid Clinical Scales
As the literature consistently demonstrates,
co-occurring mental disorders are common in
people who have substance use disorders.
Although an assessment of psychological
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 copy 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.
Reasons for
relocation or
migration
Legal and
socioeconomic
status
Time in
community
Language
spoken at home
and in
community
Family: List
each member
and circle the
client’s name
Health beliefs
and beliefs
about drug
and alcohol
use
Values about
structure,
power, myths,
and rules
Values about
education and
work
Religious and
cultural
institutions,
food, clothing,
and holidays
Oppression
and
discrimination
Impact of trauma,
substance abuse,
and other crisis
events
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.)
66
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 grandparents 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 genders 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
carefully. People who are abusing substances or
experiencing withdrawal from substances can
exhibit behaviors and thinking patterns con-
sistent with mental illness. After a period of
abstinence, symptoms that mimic mental
illness can disappear. Moreover, clinical in-
struments are imperfect measurements of
equally imperfect psychological constructs that
were created to organize and understand
clinical patterns and thus better treat them;
they do not provide absolute answers. As
research and science evolve, so does our under-
standing of mental illness (Benuto 2012).
Assessment tools are generally developed for
particular populations and can be inapplicable
67
Improving Cultural Competence
to diverse populations (Blume et al. 2005;
Suzuki and Ponterotto 2008). Appendix D
summarizes research on the clinical utility of
instruments for screening and assessing co-
occurring disorders in various cultural groups.
Diagnosis
Counselors should consider clients’ cultural
backgrounds when evaluating and assessing
mental and substance use disorders (Bhugra
and Gupta 2010). Concerns surrounding
diagnoses of mental and substance use disor-
ders (and the cross-cultural applicability of
those diagnoses) include the appropriateness
of specific test items or questions, diagnostic
criteria, and psychologically oriented concepts
(Alarcon 2009; Room 2006). Research into
specific techniques that address cultural differ-
ences in evaluative and diagnostic processes so
far remains limited and underrepresentative of
diverse populations (Guindon and Sobhany
2001; Martinez 2009).
Does the DSM-5 accurately diagnose mental
and substance use disorders among immi-
grants and other ethnic groups? Caetano and
Shafer (1996) found that diagnostic criteria
seemed to identify alcohol dependency con-
sistently across race and ethnicity, but their
sample was limited to African Americans,
Latinos, and Whites. Other research has
shown mixed results.
In 1972, the World Health Organization
(WHO) and the National Institutes of Health
(NIH) embarked on a joint study to test the
cross-cultural applicability of classification
systems for various diagnoses, including sub-
stance use disorders. WHO and NIH identi-
fied factors that appeared to be universal
aspects of mental and substance use disorders
and then developed instruments to measure
them. These instruments, the Composite
International Diagnostic Interview (CIDI)
and the Schedules for Clinical Assessment in
Neuropsychiatry (SCAN), include some DSM
and International Statistical Classification of
Diseases and Related Health Problems criteria.
Studies report that both the CIDI and SCAN
were generally accurate, but the investigators
urge caution in translation and interview pro-
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.
68
Chapter 3—Culturally Responsive Evaluation and Treatment Planning
Overall, psychological concepts that are ap-
propriate for and easily translated by some
groups are inappropriate for others. In some
Asian cultures, for example, feeling refers more
to a physical than an emotive state; questions
designed to infer emotional states are not
easily translated. In most cases, these issues
can be remedied by using culture-specific
resources, measurements, and references while
also adopting a cultural formulation in the
interviewing process (see Appendix E for the
APA’s cultural formulation outline). The
DSM-5 lists several cultural concepts of dis-
tress (see Appendix E), yet there is little em-
pirical literature providing data or treatment
guidance on using the APA’s cultural formula-
tion or addressing cultural concepts of distress
(Martinez 2009; Mezzich et al. 2009).
Step 7: Determine
Readiness and Motivation
for Change
Clients enter treatment programs at different
levels of readiness for change. Even clients
who present voluntarily could have been
pushed into it by external pressures to accept
treatment before reaching the action stage.
These different readiness levels require differ-
ent approaches. The strategies involved in
motivational interviewing can help counselors
prepare culturally diverse clients to change
their behavior and keep them engaged in
treatment. To understand motivational inter-
viewing, it is first necessary to examine the
process of change that is involved in recovery.
See TIP 35, Enhancing Motivation for Change
in Substance Abuse Treatment (Center for
Substance Abuse Treatment [CSAT] 1999b),
for more information on this technique.
Stages of Change
Prochaska and DiClemente’s (1984) classic
transtheoretical model of change is applicable
to culturally diverse populations. This model
divides the change process into several stages:
• Precontemplation. The individual does not
see a need to change. For example, a per-
son at this stage who abuses substances
does not see any need to alter use, denies
that there is a problem, or blames the
problem on other people or circumstances.
• Contemplation. The person becomes aware
of a problem but is ambivalent about the
course of action. For instance, a person
struggling with depression recognizes that
the depression has affected his or her life
and thinks about getting help but remains
ambivalent on how he/she may do this.
• Preparation. The individual has deter-
mined that the consequences of his or her
behavior are too great and that change is
necessary. Preparation includes small steps
toward making specific changes, such as
when a person who is overweight begins
reading about wellness and weight man-
agement. The client still engages in poor
health behaviors but may be altering some
behaviors or planning to follow a diet.
• Action. The individual has a specific plan
for change and begins to pursue it. In rela-
tion to substance abuse, the client may
make an appointment for a drug and alco-
hol assessment prior to becoming absti-
nent from alcohol and drugs.
• Maintenance. The person continues to
engage in behaviors that support his or her
decision. For example, an individual with
bipolar I disorder follows a daily relapse
prevention plan that helps him or her as-
sess warning signs of a manic episode and
reminds him or her of the importance of
engaging in help-seeking behaviors to
minimize the severity of an episode.
Progress through the stages is nonlinear, with
movement back and forth among the stages at
different rates. It is important to recognize
that change is not a one-time process, but
69
Improving Cultural Competence
rather, a series of trials and errors that eventu-
ally translates to successful change. For exam-
ple, people who are dependent on substances
often attempt to abstain several times before
they are able to acquire long-term abstinence.
Motivational Interviewing
Motivational interventions assess a person’s
stage of change and use techniques likely to
move the person forward in the sequence.
Miller and Rollnick (2002) developed a thera-
peutic style called motivational interviewing,
which is characterized by the strategic thera-
peutic activities of expressing empathy, devel-
oping discrepancy, avoiding argument, rolling
with resistance, and supporting self-efficacy.
The counselor’s major tool is reflective listen-
ing and soliciting change talk (CSAT 1999c).
This nonconfrontational, client-centered
approach to treatment differs significantly
from traditional treatments in several ways,
creating a more welcoming relationship. TIP
35 (CSAT 1999c) assesses Project MATCH
and other clinical trials, concluding that the
evidence strongly supports the use of motiva-
tional interviewing with a wide variety of
cultural and ethnic groups (Miller and
Rollnick 2013; Miller et al. 2008). TIP 35 is a
good motivational interviewing resource. For
specific application of motivational interview-
ing with Native Americans, see Venner and
colleagues (2006). For improvement of treat-
ment compliance among Latinos with depres-
sion through motivational interviewing, see
Interian and colleagues (2010).
Step 8: Provide Culturally
Responsive Case
Management
Clients from various racial, ethnic, and cultur-
al populations seeking behavioral health ser-
vices may face additional obstacles that can
interfere with or prevent access to treatment
and ancillary services, compromise appropriate
referrals, impede compliance with treatment
recommendations, and produce poorer treat-
ment outcomes. Obstacles may include immi-
gration status, lower SES, language barriers,
cultural differences, and lack of or poor cov-
erage with health insurance.
Case management provides a single profes-
sional contact through which clients gain
access to a range of services. The goal is to
help assess the need for and coordinate social,
health, and other essential services for each
client. Case management can be an immense
help during treatment and recovery for a
person with limited English literacy and
knowledge of the treatment system. Case
management focuses on the needs of individu-
al clients and their families and anticipates
how those needs will be affected as treatment
proceeds. The case manager advocates for the
client (CSAT 1998a; Summers 2012), easing
the way to effective treatment by assisting the
client with critical aspects of life (e.g., food,
childcare, employment, housing, legal prob-
lems). Like counselors, case managers should
possess self-knowledge and basic knowledge
of other cultures, traits conducive to working
well with diverse groups, and the ability to
apply cultural competence in practical ways.
Cultural competence begins with self-
knowledge; counselors and case managers
should be aware of and responsive to how
their culture shapes attitudes and beliefs.
This understanding will broaden as they
gain knowledge and direct experience with
the cultural groups of their client popula-
tion, enabling them to better frame client
issues and interact with clients in culturally
specific and appropriate ways. TIP 27,
Comprehensive Case Management for
Substance Abuse Treatment (CSAT
1998a), offers more information on effec-
tive case management.
70
Chapter 3—Culturally Responsive Evaluation and Treatment Planning
Exhibit 3-1 discusses the cultural matching of
counselors with clients. When counselors
cannot provide culturally or linguistically
competent services, they must know when and
how to bring in an interpreter or to seek other
assistance (CSAT 1998a). Case management
includes finding an interpreter who communi-
cates well in the client’s language and dialect
and who is familiar with the vocabulary re-
quired to communicate effectively about sensi-
tive subject matter. The case manager works
within the system to ensure that the interpret-
er, when needed, can be compensated. Case
managers should also have a list of appropriate
referrals to meet assorted needs. For example,
an immigrant who does not speak English
may need legal services in his or her language;
an undocumented worker may need to know
where to go for medical assistance. Culturally
competent case managers build and maintain
rich referral resources for their clients.
The Case Management Society of America’s
Standards of Practice for Case Management
(2010) state that case management is central
in meeting client needs throughout the course
of treatment. The standards stress understand-
ing relevant cultural information and com-
municating effectively by respecting and being
responsive to clients and their cultural contexts.
For standards that are also applicable to case
management, refer to the National Association
of Social Workers’ Standards on Cultural
Competence in Social Work Practice (2001).
Step 9: Incorporate
Cultural Factors Into
Treatment Planning
The cultural adaptation of treatment practices
is a burgeoning area of interest, yet research is
limited regarding the process and outcome of
culturally responsive treatment planning in
behavioral health treatment services for
Exhibit 3-1: Client–Counselor Matching
The literature is inconclusive about the value of
client–counselor matching based on race,
ethnicity, or culture (Imel et al. 2011; Larrison et
al. 2011; Suarez-Morales et al. 2010). Sue et al.
(1991) found that for people whose primary
language was not English, counselor–client
matching for ethnicity and language predicted
longer time in treatment (more sessions) with
better outcomes for all ethnic groups studied:
Asian Americans, African Americans, Mexican
Americans, and White Americans.
Ethnic matches may work better for Latinos in
treatment; gender congruence seems more
important than race or ethnicity in client–
counselor matching, particularly for female
clients (Sue and Sue 2013a). For Asian Americans
and Pacific Islanders, the many different ethnic
subgroups make a cultural match more difficult.
In multicultural communities, racial and ethnic
matching may help develop a working alliance
between the therapist and the consumer (Chao
et al. 2012). Other relevant variables of both the
client and therapist are age, marital status,
training, language, and parental status. The
extent to which a cultural match is necessary in
therapy depends on client preferences, charac-
teristics, presenting problems, and treatment
needs. For example, gender matching could be
more important than race/ethnicity matching to
female sexual abuse survivors, who may have
difficulty discussing their trauma with male
counselors.
Most clients want to know that their counselors
understands their worldviews, even if they do
not share them. Counselors’ understanding of
their clients’ cultures improves treatment out-
comes (Suarez-Morales et al. 2010). Fiorentine
and Hillhouse (1999) found that empathy,
regardless of race or ethnicity of counselor and
client, was the most important predictor of
favorable treatment outcomes. Sue et al. (1991)
found that clients using outpatient mental
health services more readily attended treatment
and stayed longer if services were culturally
responsive. In the treatment planning process,
matching clients with providers according to
cultural (and subcultural, when warranted)
backgrounds can help provide treatment that is
responsive to the personal, cultural, and clinical
needs of clients (Fontes 2008).
71
Improving Cultural Competence
diverse populations. How do counselors and
organizations respond culturally to the diverse
needs of clients in the treatment planning
process? How effective are culturally adaptive
treatment goals? (For a review, see Bernal and
Domenech Rodriguez 2012.) Typically, pro-
grams that provide culturally responsive ser-
vices approach treatment goals holistically,
including objectives to improve physical
health and spiritual strength (Howard 2003).
Newer approaches stress implementation of
strength-based strategies that fortify cultural
heritage, identity, and resiliency.
Treatment planning is a dynamic process that
evolves along with an understanding of the
clients’ histories and treatment needs. Fore-
most, counselors should be mindful of each
client’s linguistic requirements and the availa-
bility of interpreters (for more detail on inter-
preters, see Chapter 4). Counselors should be
flexible in designing treatment plans to meet
client needs and, when appropriate, should
draw upon the institutions and resources of
clients’ cultural communities. Culturally re-
sponsive treatment planning is achieved
through active listening and should consider
client values, beliefs, and expectations. Client
health beliefs and treatment preferences (e.g.,
purification ceremonies for Native American
clients) should be incorporated in addressing
specific presenting problems. Some people seek
help for psychological concerns and substance
abuse from alternative sources (e.g., clergy,
elders, social supports). Others prefer treatment
programs that use principles and approaches
specific to their cultures. Counselors can sug-
gest appropriate traditional treatment resources
to supplement clinical treatment activities.
In sum, clinicians need to incorporate culture-
based goals and objectives into treatment plans
and establish and support open client–
counselor dialog to get feedback on the pro-
posed plan’s relevance. Doing so can improve
client engagement in treatment services, com-
pliance with treatment planning and recom-
mendations, and treatment outcomes.
Group Clinical Supervision Case Study
Beverly is a 34-year-old White American who
feels responsible for the tension and dissension
in her family. Beverly works in the lab of an
obstetrics and gynecology practice. Since early
childhood, her younger brother has had prob-
lems that have been diagnosed differently by
various medical and mental health profession-
als. He takes several medications, including one
for attention deficit disorder. Beverly’s father
has been out of work for several months. He is
seeing a psychiatrist for depression and is on an
antidepressant medication. Beverly’s mother
feels burdened by family problems and ineffec-
tive in dealing with them. Beverly has always
helped her parents with their problems, but she
now feels bad that she cannot improve their
situation. She believes that if she were to work
harder and be more astute, she could lessen her
family’s distress. She has had trouble sleeping.
In the past, she secretly drank in the evenings to
relieve her tension and anxiety.
Most counselors agree that Beverly is too sub-
missive and think assertiveness training will help
her put her needs first and move out of the
family home. However, a female Asian American
counselor sees Beverly’s priorities differently,
saying that “a morally responsible daughter is
duty-bound to care for her parents.” She thinks
that the family needs Beverly’s help, so it would
be selfish to leave them.
Discuss:
• How does the counselor’s worldview affect
prioritizing the client’s presenting problems?
• How does the counselor’s individualistic or
collectivistic culture affect treatment plan-
ning?
• How might a counselor approach the initial
interview and evaluation to minimize the in-
fluence of his or her worldview in the evalu-
ation and treatment planning process?
Sources: The Office of Nursing Practice and
Professional Services, Centre for Addiction and
Mental Health & Faculty of Social Work, Univer-
sity of Toronto 2008; Zhang 1994.
72
Cavin, a 42-year-old African American man, arrived at a well-
known private substance abuse treatment center confused and
unable to provide his medical history at intake. Referred to the
center through his employee assistance program, he was accom-
panied by his spouse and 14-year-old son. Cavin’s wife provided
his medical history and recounted her husband’s 2-year decline
from a promising career as a journalist, researcher, and social
commentator to a bitter, often paranoid man who abused cocaine
and alcohol. Cavin, she explained, had become increasingly un-
predictable.
Upon admission, Cavin was initially cooperative and grateful to
his spouse for her efforts, but as withdrawal continued, he became
increasingly agitated, insisting that he could detoxify on his own.
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
IN THIS CHAPTER
• Cultural Competence at
the Organizational Level
• Organizational Values
• Governance
• Planning
• Evaluation and
Monitoring
• Language Services
• Workforce and Staff
Development
• Organizational
Infrastructure
4
Pursuing Organizational
Cultural Competence
73
Improving Cultural Competence
from commitment to culturally responsive
services, staffing, and treatment—if they make
no such commitment, their services may be
underused, unwelcome, and ineffective.
Multidimensional Model for Developing Cultural Competence: Organizational/
Administrative Level
74
Cultural Competence at
the Organizational Level
At the organizational level, cultural compe-
tence or responsiveness refers to a set of con-
gruent behaviors, attitudes, and policies that
enable a system, agency, or group of profes-
sionals to work effectively in multicultural
environments (Cross et al. 1989). Organiza-
tional cultural responsiveness is a dynamic,
ongoing process; it is not something that is
achieved once and is then complete. Organiza-
tional structures and components change. The
demographics and needs of communities
change. Employees and their job descriptions
change. Consequently, the commitment to
increase cultural competence must also involve
a commitment to maintain it through periodic
reassessments and adjustments. Based on the
Cross et al. (1989) definition of the culturally
competent organization, Goode (2001) identi-
fies three principal components (Exhibit 4-1)
that coincide with Sue’s (2001) multidimen-
sional model for developing cultural compe-
tence in behavioral health services.
Chapter 4—Pursuing Organizational Cultural Competence
This chapter provides a broad overview of
how behavioral health organizations can create
an institutional framework for culturally
responsive program delivery, staff develop-
ment, policies and procedures, and administra-
tive practices. Built on the U.S. Department of
Health and Human Services’ (HHS’s) Office
of Minority Health (OMH) Enhanced
National Standards for Culturally and
Linguistically Appropriate Services in Health
and Health Care (OMH 2013; for review, see
Appendix C), this chapter is organized around
the Health Resources and Services
Administration’s (HRSA’s) domains of organi-
zational cultural competence: organizational
values, governance, planning, evaluation and
monitoring, communication (language ser-
vices), workforce and staff development, and
organizational infrastructure (Linkins et al.
2002). (Another domain, services and inter-
ventions, is covered in Chapter 3.)
Within each domain, specific organizational
tasks are suggested to aid program and ad-
ministrative staff in developing a culturally
responsive clinical, work, and organizational
environment (Exhibit 4-2); these domains and
Exhibit 4-1: Requirements for
Organizational Cultural Competence
• The organization needs a defined set of
values and principles, along with demon-
strated behaviors, attitudes, policies, and
structures that enable effective work across
cultures.
• The organization must value diversity,
conduct self-assessment, manage the dy-
namics of difference, acquire and institu-
tionalize cultural knowledge, and adapt to
diversity and the cultural contexts of the
communities it serves.
• The organization must incorporate the
above in all aspects of policymaking, ad-
ministration, and service delivery and sys-
tematically involve consumers and families.
Source: Goode 2001.
Exhibit 4-2: Creating Culturally
Responsive Treatment Environments
Organizational values tasks:
• Commit to cultural competence.
• Review and update vision, mission, and
value statements.
• Address cultural competence in strategic
planning processes.
Governance tasks:
• Assign a senior manager to oversee the
organizational development of culturally re-
sponsive practices and services.
• Develop culturally competent governing and
advisory boards.
• Create a cultural competence committee.
Planning tasks:
• Engage clients, staff, and community in the
planning, development, and implementation
of culturally responsive services.
• Develop a cultural competence plan.
• Review and develop policies and procedures
to ensure culturally responsive organiza-
tional practices.
Evaluation and monitoring tasks:
• Create demographic profiles of the commu-
nity, clientele, staff, and board.
• Conduct an organizational self-assessment
of cultural competence.
Language services tasks:
• Plan for language services proactively.
• Establish practice and training guidelines for
the provision of language services.
Workforce and staff development tasks:
• Develop staff recruitment, retention, and
promotion strategies that reflect the popula-
tion(s) served.
• Create training plans and curricula that
address cultural competence.
• Give culturally congruent clinical supervision.
• Evaluate staff performance on culturally
congruent and complementary attitudes,
knowledge, and skills.
Organizational infrastructure:
• Invest in long-range fiscal planning to pro-
mote cultural competence.
• Create an environment that reflects the
populations served.
• Develop outreach strategies to improve
access to care.
Source: Linkins et al. 2002.
75
Improving Cultural Competence
tasks are adapted to behavioral health services.
Task overlap across domains may require work
on several tasks at once. HRSA’s organizational
cultural competence assessment profile is avail-
able online (http://www.hrsa.gov/cultural
competence/healthdlvr.pdf; Linkins et al.
2002).
Organizational Values
Journey Mental Health Center (JMHC), a
large outpatient mental health and substance
abuse treatment clinic in Wisconsin, is an
organization that is committed to providing
accessible, community-focused, culturally
responsive behavioral health services. JMHC
offers the following commentary on the im-
portance of clear, culturally responsive organi-
zational values ( JMHC 2013, paragraphs 1-3):
…cultural competence is fundamental to
providing quality services that promote indi-
vidual and family strengths, dignity, and self-
reliance. Cultural competence broadens and
enriches the delivery of mental health and
alcohol and other drug abuse (AODA) ser-
vices by providing a more holistic, relevant
view of the world and the helping process.
Cultural competence does not stand apart
from, but is intrinsic to good clinical practice.
Its threads are woven into the tapestry of ef-
fective assessment, treatment planning, inter-
vention, advocacy, and support. In addition,
cultural competence is intrinsic to effective
staff relationships and business practices.
Cultural competence promotes relationships
based upon understanding and knowledge of
how one’s own cultural beliefs and values in-
fluence the organization of information, per-
ceptions, feelings, experiences, and coping
strategies. It involves being able to identify,
learn from, and incorporate these into the
helping process. When cultural competence is
an integral part of personal competence, there
is the maximum opportunity to increase the
amount and quality of information and the
speed with which that information can be
shared and processed and to form healthy al-
liances.
Cultural competence demands an ongoing
commitment to openness and learning, taking
time and taking risks, sitting with uncertainty
and discomfort, and not having quick solu-
tions or easy answers. It involves building
trust, mentoring, and developing and nurtur-
ing a frame of reference that considers alli-
ances across culture as enriching rather than
threatening shared goals.
Task: Commit to Cultural
Competence
Counselors are typically a part of a larger
organization or system, but the focus on and
responsibility for developing culturally respon-
sive services has historically fallen on individ-
ual practitioners rather than on organizations.
Most literature on cultural competence ad-
dresses the cultural awareness, knowledge, and
skills of the practitioner, but until recently, it
has failed to apply these same concepts to
agencies. Cultural competence among coun-
selors is only as effective as their agencies’
commitment to and support of cultural com-
petence and ability to value diversity through
culturally congruent administrative practices,
including—but not limited to—policies and
procedures, programming, staffing, and com-
munity involvement.
Counselors are unlikely to affect organization-
al change to the same degree as the agency’s
overall administration can. Hence, culturally
responsive treatment cannot be sustained
without an agency’s commitment and support.
In fact, the organization itself can prevent
clients from receiving culturally responsive
services or treatment opportunities. Organiza-
tions that are unaware of cultural issues can
fail to recognize that diverse groups may have
difficulty accessing and engaging in treatment.
Also, counselors who attempt to use culturally
responsive practices—such as the involvement
of family members (as defined by the client)
and traditional healers—can encounter insur-
mountable hurdles if their agencies’ policies
76
Chapter 4—Pursuing Organizational Cultural Competence
and resources do not support these practices.
The system can actually impede efforts made
by counselors invested and trained in cultural
competence. Thus, the development of cultural
competence begins at the top level of the
organization, with an initial focus on systemic
changes.
Cultural competence does not occur by acci-
dent. To maximize its effectiveness in working
with diverse groups, the organization must
first view diversity as an asset. As importantly,
the organization must ensure that its process
of developing cultural competence has the
genuine, full, and lasting support of the organ-
ization’s leadership. The chief executive officer
(CEO), senior management, and board of
directors play critical roles. A strong mandate
from the board or CEO, coupled with a com-
mitment to provide resources, can be a good
motivator for staff and committees to under-
take major organizational change. Support of
cultural competence must be made clear
throughout the organization and community
in meaningful ways, in words and actions.
Leadership can make a difference in the im-
plementation of culturally responsive practices
by creating an organizational climate that
encourages and supports such practices. This
includes a willingness to discuss the im-
portance of cultural competence, try new
practices or approaches, tolerate the uncertain-
ty that accompanies transitional periods dur-
ing which practices and procedures are
evolving, respond to unforeseen barriers, and
revise innovations that are not working as
intended. It is important that leadership be
genuinely committed to the effort and that
their support be tangibly apparent in the
allocation of relevant resources. A strong
commitment to improving organizational
cultural competence should include the obli-
gation to monitor procedures after they have
been implemented, maintain and reevaluate
new practices, and provide resources and
opportunities for ongoing training and cultur-
ally competent supervision.
Task: Review and Update Vision,
Mission, and Value Statements
The organization’s mission, vision, and value
statements are vitally important in creating a
conceptual framework that promotes cultur-
ally responsive behavioral health services.
Agencies should examine how these state-
ments are developed. Are stakeholders in-
volved in the development process? In what
ways does the organization ensure that its
values and mission reflect the community and
populations that it serves? Does the organiza-
tion see this task as a singular event, or has it
planned for periodic review of its values and
mission to ensure continued organizational
responsiveness as needs, populations, or envi-
ronments change?
Initially, the planning committee should de-
termine how the culture of the organization as
well as the surrounding community can sup-
port achievement of the mission and vision
statements. Culturally responsive organiza-
tional statements cannot provide a tangible
framework unless supported by community,
referral, and client demographics; a needs
assessment; and an implementation plan.
Mission and vision statements need to be
operationalized through identified goals as
well as measurable indicators to track progress.
The Hands Across Cultures Corporation of
Organizations that fail to endorse and
make a commitment to cultural compe-
tence will more than likely displace the
responsibility of cultural competence onto
counselors or clients. If the responsibility is
on the clients, it is likely that the clients
will
have to “fit” or change to match the
treatment or program rather than treat-
ment services being adapted to fit the
needs of clients.
77
Improving Cultural Competence
northern New Mexico, which serves Native
peoples within pueblos (American Indians),
the City of Española, Pojoaque Valley, and
surrounding communities (predominantly
Latino), addresses the importance of the
cultural context of its work in its mission and
philosophy statements (Exhibit 4-3).
Task: Address Cultural
Competence in Strategic Planning
Processes
The strategic planning process provides an
opportunity to reevaluate an agency’s values,
mission, and vision regarding cultural compe-
tence. A comprehensive process involves eval-
uating the organization’s internal and external
environments prior to holding planning meet-
ings; this evaluation involves conducting staff,
client, and community assessments. From
assessing current needs to evaluating global
factors that influence the direction and deliv-
ery of services (e.g., funding sources, treat-
ment mandates, changes in health insurance),
organizations can begin to gain insight into
the demands and challenges of providing
culturally responsive services. Moreover, stra-
tegic planning is an opportunity to explore
and develop short- and long-term goals that
focus on incorporating culturally responsive
delivery systems while addressing issues of
sustainability (i.e., how to provide resources
and support the implementation of culturally
responsive policies and procedures over time).
A formal strategic planning meeting should be
held to determine specific goals, objectives,
and tasks that will ensure quality improvement
in culturally responsive services. The develop-
ment of timelines and methods to evaluate
progress, obstacles, and directions for each
goal are equally important. For organizations
that do not have a specific cultural competence
plan prior to the strategic planning meeting,
this process can provide the forum for devel-
oping the steps needed to create a formal plan.
Governance
Task: Assign a Senior Manager To
Oversee the Development of
Culturally Responsive Practices
and Services
From the outset, a senior staff member with
the authority to implement change should be
assigned to oversee the developmental process
of planning, evaluating, and implementing
culturally responsive administrative and clini-
cal services. Key responsibilities include the
ongoing development and facilitation of cul-
tural competence committees and advisory
boards, management of evaluative processes,
facilitation of the development of a cultural
competence plan and its implementation, and
oversight of policies and procedures to ensure
cultural competence within the organization
and among staff. Cultural competence cannot
come to fruition with only one voice being
heard, but assigning a key person to oversee
Exhibit 4-3: Hands Across Cultures
Mission Statement
Mission
To improve the health, education and well
being of the people of Northern New Mexico
through family-centered approaches deeply
rooted in the multicultural traditions of their
communities.
Philosophy
To believe in culture as the foundation of
human growth; spirituality as the strength of
the people; each person’s need to love and be
loved; family preservation; individual responsi-
bility; and the pursuit of human potential.
With a firm commitment to these beliefs,
Hands Across Cultures’ Board of Directors,
staff, and collaborators hold that:
Culture Is the Cure
La Cultura Cura
Source: Hands Across Cultures 2014.
78
Chapter 4—Pursuing Organizational Cultural Competence
the process will more likely keep top-priority
goals and objectives in view.
Task: Develop Culturally
Competent Governing and
Advisory Boards
Beyond having the foresight to plan for and
develop culturally responsive services, it is vital
that executive staff members on governing and
advisory boards and committees are educated
about and invested in the organization’s mis-
sion and plan. For example, the board’s hu-
man resources committee may be more
invested in developing and reinforcing cultur-
ally responsive recruitment and hiring policies
and practices if they are involved in the strate-
gic planning process and educated about the
organization’s mission, values, and vision. At
the same time, the organization should seek
outside direction. Given that sharing infor-
mation about the agency’s activities with
others outside the organization can create
some hesitancy or be a potential barrier, the
executive staff can frame the planning process
as an opportunity for positive development
and community involvement as a powerful
resource. The organization should establish a
community advisory board that includes
stakeholders, specialists, and/or experts in
multicultural behavioral health services along
with key administrators and staff. This adviso-
ry board should consist of local community
members from whom the organization can
solicit valuable advice, input, and potential
support for the development of culturally
responsive treatment (Minnesota Department
of Human Services 2004).
Representation should include clients, alumni,
family members, and community-based
organizations and institutions (e.g., commu-
nity centers, faith communities, social service
organizations). Developing an inclusive advi-
sory board of community members can en-
hance and extend use of and referral from
other community agencies. Moreover, this
board can help identify community leaders
and culturally appropriate resources for the
client population to supplement treatment
activities, such as traditional healing practices
(Castro et al. 1999a). The advice box on the
next page reviews strategies for engaging
communities in the development of culturally
responsive services.
Task: Establish a Cultural
Competence Committee
By creating a committee within the organiza-
tion to guide the process of becoming cultur-
ally competent and responsive, the
organization ensures that a core group will
provide oversight and direction. This commit-
tee should be inclusive not only in terms of
the racial and ethnic composition of the popu-
lation served, but also in terms of drawing
from all levels of the organization (Whaley
and Longoria 2008). Representatives of the
advisory board should also be included. Pro-
gram administrators should provide direction
to the cultural competence committee. The
person assigned to take the lead on cultural
competence should chair the committee, and
the CEO should be noticeably involved.
The cultural competence committee will
oversee the organization’s self-assessment
process while also creating the demographic
profile of the organization’s community, devel-
oping a cultural competence plan, and formu-
lating and monitoring procedures that evaluate
the implementation and effectiveness of the
organization’s plan in developing culturally
responsive services and practices. The commit-
tee should ensure that the organization’s plans
are continually updated. To succeed, this team
must be empowered to influence, formulate,
implement, and enforce initiatives on all levels
and throughout every department of the
organization (Constantine and Sue 2005;
Fung et al. 2012), including, for example,
79
Improving Cultural Competence
presenting data and subsequent recommenda-
tions to the administration and boards based
on employee feedback about their experiences
with newly adopted, culturally responsive
procedures in the organization. Exhibit 4-4
highlights key issues in behavioral health
treatment that must be addressed in providing
culturally responsive services.
Planning
Task: Engage Clients, Staff, and
the Community in the Planning,
Development, and
Implementation of Culturally
Responsive Services
Organizations can sometimes have the best
intentions of creating culturally responsive
services but miss the mark by operating in a
vacuum. Initially, the vacuum approach can
appear less time consuming, complex, and
expensive, but it can also represent paternalism
whereby organizations or administrators
assume that they inherently know what is best
for the program, clients, staff, and community.
Instead, organizations and the services that
Exhibit 4-4: Critical Treatment Issues
To Consider in Providing Culturally
Responsive Services
• Access: Degree to which services for clients
are quickly and readily available.
• Engagement: Having appropriate skills and
an environment that have a positive per-
sonal impact on the quality of clients’
commitment to treatment.
• Retention: The result of quality services
that help maintain clients in treatment with
continued commitment.
Source: The Connecticut Department of Chil-
dren and Families, Office of Multicultural
Affairs 2002.
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.
80
Chapter 4—Pursuing Organizational Cultural Competence
they provide need to be congruent with the
specific populations being served; clients and
the community should have an opportunity to
provide input on how services are delivered
and the types of services that are needed.
Otherwise, services may be poorly matched to
clients, underused by the community, and
detrimental to agency financial resources. For
example, an agency could decide that family
therapy is a culturally appropriate service and
proceed to create a multifamily program
(treating several families together in a group
format) without considering that, for some
cultural groups, family shame associated with
seeking help can deter the use of such services.
Staff members are likely to have specific
knowledge of client needs and to be able to
identify potential obstacles or challenges in
how an organization attempts to implement
culturally responsive policies and procedures.
A parallel process that can influence the po-
tential success of staff involvement and com-
mitment to the development of cultural
competence is the organizational culture.
Suppose, for example, that the staff perceives
the organization’s new commitment to cultural
competence as another expectation of more
work without training, adequate clinical
supervision, or ongoing support. Maybe staff
members have historically experienced fre-
quent announcements, mandates, or excite-
ment generated by the administration that
fade quickly. Perhaps the organization ar-
ranges committees and meetings, purporting
that they want staff input despite the fact
that decisions have already been made.
The organizational climate sets the stage for
staff responsiveness and motivation in devel-
oping cultural competence and in implement-
ing culturally responsive services. Without an
organizational history and culture of support-
ing change across time, staff members will
likely resent an increase in expectations with-
out some means of compensating for addi-
tional work, perceive themselves as powerless
over the proposed changes, or minimize the
need to make any immediate changes. For
example, staff members may view changes as
temporary or a phase and believe that the
organization will focus on other issues or new
directions once the pressure or attention on
this specific issue subsides.
Task: Develop a Cultural
Competence Plan
To ensure the delivery of culturally responsive
services, it is important to develop a cultural
competence plan (see the “Criteria for Devel-
oping an Organizational Cultural Compe-
tence Plan” advice box on the next page).
Using demographic data and an organizational
self-assessment (including community and
advisory board input), the organization’s cul-
tural competence committee can begin writing
an organizational plan for improving cultural
competence. The committee will need to
assign staff members to research and write
each component of the plan, which should
outline specific objectives, means of achieving
these objectives, and recommend timelines
and processes for evaluating progress. The
plan should contain at least the following
components:
• A narrative introduction that covers com-
munity demographics and history, organi-
zational self-assessment and other
evaluation tools, the rationale for provid-
ing culturally responsive services, and the
organization’s strengths and needs for im-
provement in providing services that are
responsive to client cultural groups; a brief
overview of current priorities, goals, and
tasks to help the organization develop and
improve culturally responsive clinical ser-
vices and administrative practices is also
advisable.
81
Improving Cultural Competence
• Strategies for recruiting, hiring, retaining,
and promoting qualified diverse staff.
• Resources and policies to support language
services and culturally responsive services.
• Methods to enhance professional devel-
opment (e.g., staff education and training,
peer consultation, clinical supervision) in
culturally responsive treatment services.
• Mechanisms for community involvement,
beginning with the development of a
community advisory board and cultural
competence committee and including
community participation in relevant
treatment activities or in support of treat-
ment services (e.g., spiritual direction).
• Approaches to amending facility design
and operations to present a culturally con-
gruent atmosphere.
• Identification of and recommendations for
culturally and linguistically appropriate
program materials.
• Programmatic strategies to incorporate
culturally congruent clinical and ancillary
treatment services.
• Fiscal planning for funding and human
resources needed for priority activities
(e.g., training, language services, program
development, organizational infrastructure).
• Guidelines for implementation that de-
scribe roles, responsibilities, timeframes,
and specific activities for each step.
The committee must determine how to over-
see the plan (e.g., by tracking accomplish-
ments, obstacles, and remediation strategies).
Who will develop and revise guidelines for
treatment planning, introduce new guidelines
to the staff and provide counselor training, and
coordinate revisions with the information
technology specialist or department?
Task: Develop and Review Policies
and Procedures To Ensure
Culturally Responsive
Organizational Practices
In essence, policies and procedures are the
backbone of an organization’s implementation
of culturally responsive services. By creating,
reviewing, and adapting clinical and adminis-
trative policies and procedures in response to
the ever-changing needs of client populations,
the agency is able to provide counselors and
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.
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Chapter 4—Pursuing Organizational Cultural Competence
other workers with support and the means to
respond in a consistent, yet flexible, manner.
Programs are likely to have the foresight to
develop relevant policies and procedures
through the planning and evaluative processes
outlined in this chapter, but it is unlikely that
they will anticipate every situation. Thus,
ongoing flexibility is paramount.
When putting together an organizational
cultural competence plan, providers should be
careful to follow the requirements set by state
licensing boards, accreditation agencies, and
professional organizations that oversee certifi-
cation and licensing of treatment profession-
als. Much of the push for cultural competence
throughout the healthcare field is in response
to the mandates of accrediting agencies, fun-
ders, and managed care organizations. These
entities have standards and guidelines that
state minimum expectations for client rights,
program structure, and staffing, along with
treatment content and conditions. Behavioral
health organizations, including substance
abuse treatment programs, must meet these
standards to be accredited by national organi-
zations and compensated by funders.
Although many accrediting bodies require a
cultural competence plan that is assessed as part
of the accreditation process, their requirements
can be minimal. Consequently, organizations
should go beyond such requirements in their
own thinking and planning to ensure that they
are responding adequately to the needs of the
communities they serve. Above all, are the
policies, procedures, and systems of care suited
to the served populations? Do policies reflect
the organization’s commitment to cultural
competence in administrative practices? For
example, are strategies for professional devel-
opment, personnel recruitment, and retention
of culturally competent staff members reflec-
tive of the populations and cultures that they
serve?
If an organization fails to develop culturally
responsive policies or procedures yet claims to
endorse or support culturally responsive ser-
vices, counselors and staff members will likely
carry the entire burden of implementing these
services and will face numerous obstacles that
could prevent the delivery of responsive ser-
vices. Take, for example, a counselor from a
county-funded program who was directed by
her supervisor to complement her counseling
approach with the client’s traditional healing
beliefs and practices. The agency did not
provide staff support, have policies or proce-
dures consistent with this request, or exhibit a
willingness to adapt current procedures to
meet the client’s needs. The counselor had
difficulty following this direction because of
barriers in finding an appropriate traditional
practitioner in the local area, coordinating
services, establishing and securing confidenti-
ality for the client and with the practitioner
(including educating the practitioner about
confidentiality), arranging transportation for
the client, obtaining a stipend for services, and
discerning how and when to incorporate the
traditional practice into the treatment milieu.
Counselors who feel that they have been left
to go it alone can view implementation of
culturally responsive practices as an insur-
mountable challenge when the agency pro-
vides limited support or fails to endorse
adaptive policies that are congruent with the
needs of the client population. Counselors
may have high motivation to incorporate
culturally responsive care but find themselves
without appropriate agency resources, permis-
sion, or infrastructure to implement it. By
developing and endorsing culturally responsive
policies and procedures, an organization can
provide carefully thought-out strategies and
processes to help staff members provide real-
time responsive services. Well-defined policies
and procedures reinforce commitment to and
expectations of cultural competence.
83
Improving Cultural Competence
Evaluation and Monitoring
To develop a viable cultural competence plan,
information must be gathered from all levels
of the organization, from clients and commu-
nity, and from other stakeholders. Beginning
with acquiring initial demographic data from
the populations that are or could be served by
the agency and extending to soliciting feed-
back from various stakeholders, gathering
information prior to plan development helps
the organization provide direction and deter-
mine priorities. Gathering information also
allows ongoing monitoring and feedback
regarding the plan’s effectiveness and areas in
need of improvement. Areas of evaluation and
monitoring can include a demographic profile
of the client, community, staff, and board
constellations; community needs assessment;
client, family, and referral feedback; adminis-
trative, clinical, medical, and nonclinical staff
assessments; and more (American Evaluation
Association 2011; LaVeist et al. 2008).
Task: Create a Demographic
Profile of the Community,
Clientele, Staff, and Board
Intake, admission, and discharge data provide
a good starting point for determining the
demographics of current populations being
served. Programs would likely benefit from
developing a demographic summary for each
population served, consisting of age, gender,
race, ethnic and cultural heritage, religion,
socioeconomic status, spoken and written
language preferences and capabilities, em-
ployment rates, treatment level, and health
status (HHS 2003b). With adequate resources,
the organization can generate reports dating
back 5 years to determine program trends.
Agencies should also gather demographic
information on groups in the agency’s local
community (Hernandez et al. 2009). This
information can be easily obtained through
census data and national centers (e.g., Bureau
of Labor Statistics) or through local sources,
including the library, city hall, or the county
commissioner’s office (Whealin and Ruzek
2008). Community demographics can provide
a quick benchmark on how well an agency
serves the local community and how the
community is represented at all levels of the
organization. A demographic profile should
also summarize information about clinical,
medical, and nonclinical staff members as well
as board members. Other information can also
be helpful for specific agencies, as can hiring a
consultant to gather demographic information
and conduct the organization’s self-assessment
of cultural competence to limit bias; however,
lack of funding can prohibit this possibility.
Task: Conduct Organizational Self-
Assessment of Cultural
Competence
An organization must have an awareness of
how it functions within the context of a multi-
cultural environment, evaluating operational
aspects of the agency as well as staff ability
and competence in providing culturally con-
gruent services to racially and ethnically di-
verse populations. Therefore, an agency should
assess how well it currently provides culturally
responsive treatment. An honest and thorough
organizational self-assessment can serve as a
blueprint for the cultural competence plan
and as a benchmark to evaluate progress
across time (National Center for Cultural
Competence 2013). To review a sample as-
sessment guide, refer to Appendix C.
The importance of organizational self-
assessment cannot be overstated. Thorough,
reliable, valid evaluations can gauge the effec-
tiveness of an agency’s services, structure, and
practices (e.g., clinical services, governing
practices, policy development, staff composi-
tion, and professional development) with
culturally and racially diverse clients, staff, and
84
Chapter 4—Pursuing Organizational Cultural Competence
communities. More and more, public and
private funding sources—as well as accrediting
bodies—use an organization’s self-assessment
as a means of measuring compliance, effec-
tiveness, or quality improvement practices.
A self-assessment can seem intensive in terms
of both labor and capital, but in the long run,
it can guide an organization’s quality im-
provement process more efficiently by helping
it provide the most relevant services at the
right time. Gathering feedback from many
internal and external sources gives agencies
considerable information needed to effectively
evolve as a culturally responsive organization,
including data on current performance, areas
needing improvement, and development
needs. In the initial self-assessment, an or-
ganization should obtain demographic in-
formation and seek feedback from key
stakeholders—including community mem-
bers, clients, families, and referral sources
(e.g., probation and parole offices, family and
child services, private practitioners)—and
from all levels of the organization, including
administrative, managerial, clinical, medical,
and support staff. The following steps are
recommended to help an agency gain the
information necessary to guide and support
the development of its cultural competence
plan.
Step 1:
With the advisory board and cultural
competence committee, identify key stake-
holders who can provide valuable feedback
about current strengths and areas in need of
improvement regarding the function of the
organization and the needs of its community.
Step 2:
Adopt a self-assessment guideline for
organizational cultural competence (see
Appendix C).
Step 3:
Determine the feasibility of using
consultants and/or external evaluators to
select, analyze, and manage assessment.
For many organizations, hiring outside con-
sultants is financially prohibitive. Nonetheless,
the cultural competence committee could
recommend hiring outside evaluators and
consultants to help them plan, conduct, and
assess the results of the organizational self-
evaluation. The committee should ensure that
consultants understand the population being
served by the treatment facility. This means
understanding the population’s cultural groups
across dimensions: language and communica-
tion, cultural beliefs and values, history, socio-
economic status, education, gender roles,
substance use patterns, spirituality, and other
distinctive aspects. Candidates should be able
to articulate a clear understanding of cultural
competence (American Evaluation Association
2011). If consultants will train staff, they
should have specific knowledge and profi-
ciency in training development and delivery.
If financially feasible, it can be useful for the
agency to consider using more than one con-
sultant and to invite each prospective consult-
ant to present their qualifications to the board
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).
85
Improving Cultural Competence
committee so that the best match can be
achieved between the agency’s needs and the
consultant based on his or her expertise, cost,
and consulting style. If a consultant is hired,
the organization should establish guidelines
for working closely with that person, including
reporting requirements to the cultural compe-
tence committee. The organization must
retain ownership of the process and provide
clear oversight and guidance.
Step 4:
Select assessment tools suitable for
each stakeholder group (e.g., clinical staff,
agency referrals, clients). Several self-
assessment tools are available, including
checklists and surveys, for use in evaluation or
as development guides. To date, most instru-
ments available have limited empirical support
(Delphin-Rittmon et al. 2012b; Shorkey et al.
2009).
More often than not, surveys and feedback
questionnaires will need to be individually
developed and tailored to the organization and
stakeholder group depending upon setting;
available resources; racial, ethnic, and cultural
backgrounds; language preferences; and com-
munity accessibility (e.g., rural versus urban).
Appendix C provides standards and lists the
items that should be included in evaluating an
agency and its services. Additional resources
for provider and organizational assessment of
cultural competence are available through the
National Center for Cultural Competence
(http://nccc.georgetown.edu/) and the Hogg
Foundation for Mental Health
(http://www.hogg.utexas.edu/index.php).
Step 5:
Determine distribution, administra-
tion, and data collection procedures (e.g.,
confidentiality, participant selection methods,
distribution time frames). Whatever methods
are used to gather data for the self-assessment
process, it is critical to explain the context of
the assessment to all participants. They need
to know why the assessment is being conduct-
ed and how the information they give will be
used. Confidentiality can be a major concern
for some respondents, especially staff members
and clients, and every effort should be made to
address this concern. Ideally, the evaluation
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 Iowa 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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Chapter 4—Pursuing Organizational Cultural Competence
instrument(s) should be administered by an
objective third party, such as a consultant or a
member of the cultural competence commit-
tee. Staff members should be asked about their
attitudes toward cultural issues with the un-
derstanding that their attitudes are not neces-
sarily indicative of the degree to which the
staff mirrors the cultural groups served. In
soliciting community feedback, the more
credibility the organization has in the com-
munity, the higher the return rate will likely
be. The lower the credibility, the more the
organization needs to reassure respondents
that it intends to listen to, and act on, what it
hears. If many survey forms are to be distrib-
uted, the organization could consider hiring
students or community members on a tempo-
rary basis to make follow-up or reminder calls.
Step 6:
Compile and analyze the data. The
process of reviewing and assessing data should
be overseen by the cultural competence com-
mittee. Basic data analysis procedures should
be used to ensure the accuracy of results and
credibility of reported information. For most
well-designed instruments, there are relatively
simple and appropriate ways to present data.
All available data should be assembled in a
report, along with interpretive comments and
recommended action steps. The report should
note areas of strength and needed improve-
ment and should offer possible explanations
for any shortcomings. For example, if the
community is 20 percent African American,
but only 2 percent of the agency’s clientele are
African American, what are some possible
explanations for this group’s apparent un-
deruse of services? It is also particularly im-
portant to share results with those who
participated in the assessment process. Find-
ings should be made available to staff, clients,
community members, boards, and managers.
This increases overall sense of ownership in
the assessment and cultural competence devel-
opment process and in implementing the
changes that will be made based on the find-
ings of and the priorities established through
this assessment.
Step 7:
Establish priorities for the organiza-
tion and incorporate these priorities into the
cultural competence plan. After obtaining the
results of the self-assessment process, the
organization—including boards, cultural
competence committee, community stake-
holders, and staff members—needs to estab-
lish realistic priorities based on the current
needs of clients and the community. Signifi-
cant consideration should be given to the level
of influence any given priority could have in
effecting organizational change that will
improve culturally responsive services. Some
priorities will require more planning to im-
plement and can involve more financial and
staff resources, whereas other priorities will be
easier to implement from the outset (e.g.,
hiring culturally competent counselors who
are bilingual versus translating intake and
program forms). Therefore, long- and short-
range priorities should be established at the
same time to maintain the momentum of
change in the organization.
Step 8:
Develop a system to provide ongoing
monitoring and performance improvement
strategies. Similar to the clinical assessment
process with clients, the organizational self-
assessment is only valuable if it provides guid-
ance, determines direction and priorities, and
facilitates action. Assessment is not a one-time
activity. It is important to continue monitoring
to identify barriers that may impede the full
implementation of the cultural competence
plan, to evaluate progress and performance,
and to identify new service needs. Establishing
a system to monitor an organization’s cultural
responsiveness equips it with the information
necessary to formulate strategies to meet new
demands and to continuously improve quality
of services.
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Improving Cultural Competence
Language Services
Task: Plan for Language Services
Proactively
An organization must anticipate the need for
language services and the resources required to
support these services, including funding, staff
composition, program materials, and transla-
tion services. Assessing the language needs of
the population to be served is essential. Upon
determination, the foremost task is letting
clients with limited English proficiency know
that language services are available as a basic
right for a client. Treatment providers need to
plan for the provision of linguistically appro-
priate services, beginning with actively recruit-
ing bicultural and bilingual clinical staff,
establishing translation services and contracts,
and developing treatment materials prior to
client contact. Although it is not realistic to
anticipate the language needs of all potential
clients, it is important to develop a list of
available resources and program procedures
that staff members can follow when a client’s
language needs fall outside the organization’s
usual client demographics (The Joint
Commission 2009).
Planning for language services is crucial, and
the need for these services must be assessed by
staff members who have initial contact with
clients, their family members, and/or other
individuals in their support systems (American
Psychological Association [APA] 1990, 2002).
If frontline administrative and clinical staff
members are bilingual, the initial screening
and assessment process can begin uninter-
rupted. If this is not the case, receptionists or
frontline clinical staff members should at least
be familiar with some rudimentary phrases in
the preferred languages of their client base.
The conversation can be scripted so that they
can convey their limited ability to speak the
client’s language, obtain contact information
and inquire about language service needs, and
inform the client that someone who can speak
the language more fluently will be made avail-
able to facilitate the initial screening process.
Most importantly, procedures should be in
place to provide pretreatment contact and
follow-up in the client’s language to bridge the
gap between initial contact and subsequent
arrangement of language services.
Written and illustrated materials or a video
about the program in the languages spoken by
the client population should be available to
answer frequently asked questions. All materi-
als given to clients, family members, and
community members should be available in
their primary languages. It is preferable to
develop the materials initially in those
languages rather than simply translating mate-
rials from one language to another. Along
with language, one should also consider the
level of literacy of the group in question. Some
clients may be functionally illiterate even in
their native languages. Materials should
graphically reflect the population served
through pictures or photographs, using ethnic
themes and traditional elements familiar to
the target audience. Also, materials should be
tested with the populations with whom they
How To Inform Clients About
Language Assistance Services
• Use language identification or “I speak…”
cards.
• Post signs in regularly encountered lan-
guages at all points of entry.
• Establish uniform procedures for timely,
effective telephone communication be-
tween staff members and persons with lim-
ited English proficiency.
• Include statements about the services
available and the right to free language as-
sistance services in appropriate non-English
languages in brochures, booklets, outreach
materials, and other materials that are rou-
tinely distributed to the public.
Source: OMH 2000.
88
Chapter 4—Pursuing Organizational Cultural Competence
will be used, perhaps through focus groups, to
ensure that they communicate effectively.
Task: Establish Practice and
Training Guidelines for the
Provision of Language Services
Key issues to consider in implementing and
overseeing language services within an organi-
zation include staff monitoring of language
proficiencies, selection of translators and
interpreters, confidentiality issues, and train-
ing needs. First, agencies need to assess lan-
guage proficiencies among staff members and
encourage them to learn a language relevant to
the population served. At a minimum, staff
members should acquire in the given language
some basic terminology and phrases that are
commonly used in the treatment setting.
In recruiting and hiring translators and inter-
preters, administrative staff members should
consider experience, motivation, skill level,
mastery of English, and fluency in the lan-
guage in need of interpretation (OMH 2000;
American Translators Association 2011). Be
aware, however, that there can be considerable
variation in dialects and levels of proficiency
within the language, and these must be de-
termined in the selection process. To supple-
ment hiring practices, administrative policies
should provide a means for determining the
credentials of any language services organiza-
tions (Appendix F lists American Translators
Association credentialing information).
Other important hiring issues revolve around
potential ethical dilemmas. In particular, care
should be taken in using interpreters from the
local community, which can create potential
challenges with confidentiality and dual rela-
tionships (e.g., the interpreter may also be
client’s cousin or neighbor). Policies should
place the burden on language service providers
to identify and disclose dual relationships to
supervisors immediately and on supervisors to
assess and determine the appropriateness of
using certain translator. Once a selection has
been made, a confidentiality agreement should
be signed. Organizations need to provide
information routinely to clients about their
confidentiality rights in using language ser-
vices. Implementing a procedure for handling
client grievances is also recommended.
In planning for the use of language services,
organizations should initially provide training
for staff on how to incorporate these services
and should familiarize translators and inter-
preters with the clinical setting, terminology,
behavioral expectations, and content related to
behavioral health (see the “Training Content
for Language Service Personnel” advice box
on the next page). The language of mental
health and substance abuse services requires an
additional degree of specialization. Experi-
enced translators and interpreters who are
unfamiliar with concepts of addiction, illness,
and recovery could convey information ade-
quately from a linguistic perspective but not
accurately convey the intent or meaning of
clinically oriented information or dialog.
Various training approaches can be used,
including role-plays mirroring intakes, evalua-
tions, and counseling sessions; indirect expo-
sure to client sessions through audio or video
recordings of sessions or viewing from an
observation room; direct observation by sitting
in on a session, if appropriate; and consulta-
tion with other experienced language service
providers and clinical staff. Using other expe-
rienced translators and interpreters for train-
ing and/or for consultations, as well as sharing
experiences in a peer support format, can be
very beneficial for new language service
providers.
89
Improving Cultural Competence
Organizations must also create opportunities
for translators and interpreters to inquire
about and clarify clinical content and mean-
ing. Language service providers often attempt
to convey terminology or concepts that do not
exactly match the words or meaning of the
client’s language or culture by becoming more
descriptive, taking longer to deliver the mes-
sage in an effort to match the intent of a
specific word or concept in English.
Workforce and Staff
Development
Task: Develop Staff Recruitment,
Retention, and Promotion
Strategies That Reflect the
Populations Served
To determine whether it adequately reflects
the population it serves, an organization has to
assess its personnel, including counselors,
administrators, and board of directors. Ac-
cording to a 10-year study that collected data
on treatment admissions, racial and ethnic
composition of treatment populations has not
significantly changed. Racially diverse groups
(excluding non-Latino Whites) represent
approximately 40 percent of treatment admis-
sions (Substance Abuse and Mental Health
Services Administration [SAMHSA] 2011c),
yet 80 percent of counselors are non-Latino
Whites (Duffy et al. 2004). In striving to
improve cultural responsiveness, staff compo-
sition should be a major strategic planning
consideration. As much as possible, the staff
should mirror the client population.
Nevertheless, providers should avoid hiring
“ethnic representatives,” which means hiring a
single person from an ethnic or cultural group
and expecting him or her to serve as the cul-
tural resource on that group for the entire
staff. This can be burdensome, if not offensive,
to that person. Belonging to a group does not
ensure cultural responsiveness toward,
knowledge of, or skill in working with mem-
bers of that group, nor does it guarantee that
the person culturally identifies with that cul-
tural group or its heritage. Hiring ethnic
Advice to Clinical Supervisors and
Administrators: Training Content for
Language Service Personnel
Translators and interpreters need additional
training to work in a clinical setting. Initial
training should include:
• General mental health and substance
abuse information.
• Introduction to behavioral health services.
• Familiarity with interviewing and assessment
questions, instruments, and formats.
• Legal and ethical issues, including confi-
dentiality and professional boundaries.
• Relevant programmatic policies and pro-
cedures.
• Review of program materials, forms, ques-
tionnaires, and other written clinical mate-
rials that clients receive during the course
of treatment.
• Knowledge of technical vocabulary relevant
to the behavioral health field.
• Emphasis on the importance of accurate
interpretation and translation without addi-
tions or omissions.
• Behavioral and professional guidelines on
how to manage potential client reactions in
and outside the session (e.g., outward dis-
plays of anger or hostility; grief reactions;
disclosing information to the translator with
a request to keep it a secret from clinical
staff; discomfort with translator’s biologi-
cal, social, and/or demographic character-
istics, such as gender orientation, age, or
socioeconomic status ).
• Importance of cultural sensitivity in dialog
between translator and client, including
how questions are asked.
• General guidelines on how to handle
personal issues that can be elicited by par-
ticipation in the intake, assessment, and
treatment processes, including identifica-
tion with similar clinical issues (e.g., sub-
stance use patterns, family dynamics,
traumatic events, emotional distress).
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Chapter 4—Pursuing Organizational Cultural Competence
representatives undermines the expansion of
diversity at all organizational levels and the
importance of developing opportunities for all
staff members to gain awareness and improve
their ability to effectively work with clients.
Some organizations struggle to find multicul-
tural staff members that represent the diversity
of their communities and clienteles. If re-
cruitment is perceived as an immediate short-
term goal, ongoing difficulties are likely in
hiring, promoting, and retaining a diverse staff.
Instead, recruitment strategies need to em-
brace a more comprehensive and long-term
approach that includes internships, marketing
to those interested in the field at an early age,
mentoring programs for clinical and adminis-
trative roles, support networks, educational
assistance, and training opportunities.
Task: Create Training Plans and
Curricula That Address Cultural
Competence
The primary purpose of training is to increase
cultural competence in the delivery of services,
beginning with outreach and extending to
continuing care services that support behav-
ioral health. Training should increase staff
self-awareness and cultural knowledge, review
culturally responsive policies and procedures,
and improve culturally responsive clinical skills
(Anderson et al. 2003; Brach and Fraser 2000;
Lie et al. 2011). The organization should be
prepared to offer relevant professional devel-
opment experiences consistent with counselors’
personal goals and assigned responsibilities as
well as the organization’s goals for culturally
responsive services. Board members, volun-
teers, and interpreters should all receive ap-
propriate training.
A professional development training plan
details the frequency, content, and schedule for
staff training and continuing education. Be-
cause becoming culturally competent is a
process, training and support for engaging in
culturally responsive services can be more
appropriate when delivered across a period of
time involving follow-up sessions rather than
through a single session. Outcome research
that evaluates the effectiveness of cultural
competence training materials, format, and
content in mental health services, including
treatment for substance use disorders (Bhui et
al. 2007; Lie et al. 2010), is limited. Nonethe-
less, numerous resources have suggested that
effective cultural training does feature certain
qualities (Exhibit 4-5).
Sometimes, staff members will express re-
sistance to participation in training activities
aimed at promoting cultural competence—
they may feel forced to learn about cultural
competence, or they may feel unable to take
the time away from their clients to attend the
“Improving the workforce to provide
competent services to diverse populations
goes far beyond merely increasing the
number of individuals from each of the
respective groups. While this is clearly an
important strategy, there is a need not
only to increase the numbers but also to
improve the quality of training for all
clinicians, regardless of their racial, ethnic,
cultural, or linguistic background. This also
includes the necessity to recruit, train, and
support interpreters.”
(Hoge et al. 2007, p. 192).
“The learning objectives of a professional
development program should include
awareness- and knowledge-based objec-
tives and skills-based objectives that
motivate students to explore personal
perspectives and multiple worldviews,
understand and embrace culturally com-
petent health promotion strategies, and
engage in self-directed competency
development.”
(Perez and Luquis 2008, p. 178).
91
Improving Cultural Competence
trainings. Others might object on the grounds
that they treat everyone equally, thus ignoring
their own cultural blindness.
The organization’s leadership needs to address
staff reluctance and concerns regarding train-
ing through initial education on the rationale
for cultural competence. Assume that staff
members are invested in creating the best
opportunities for their clients to achieve suc-
cess, and use this premise to introduce the
need for training centered on culturally re-
sponsive care. Some staff members may re-
spond to incentives or predetermined
objectives and criteria reflected in employee
performance evaluations. Others may be more
motivated by opportunities that arise from the
organization’s commitment to culturally re-
sponsive services or by other factors, such as
specialized training and supervision, the
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.
92
Chapter 4—Pursuing Organizational Cultural Competence
desire to be perceived by other staff members
as team players, or their roles as agents of
change with other staff members.
Opportunities for cultural competence train-
ing abound. National organizations, agencies
dedicated to multicultural learning, academic
institutions, government agencies, and infor-
mation clearinghouses offer training or have
information about training opportunities and
curricula on cultural competence on their Web
sites. In addition to OMH guidelines on staff
education and training (Exhibit 4-6), guide-
lines are available from psychological and
counseling associations (APA 2002). To re-
view sample training modules, see Cultural
Competence for Health Administration and
Public Health (Rose 2011).
Task: Provide Culturally
Congruent Clinical Supervision
Little research is available that measures cul-
tural competence among clinical supervisors or
evaluates the effects of supervision on cultural
competence among counselors (Colistra and
Brown-Rice 2011; Constantine and Sue 2005).
Not much is known about the effectiveness of
clinical supervision in enhancing culturally
competent behavior among counselors,
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.
“It takes time and energy to work through
significant changes, whether in the work-
place or in our personal lives. Many times,
resistance to change is a natural reaction
of people trying to understand what is
expected of them and how the change will
impact their lives.”
(Addiction Technology Transfer Center
2004, p. 28)
93
Improving Cultural Competence
although some research with a multicultural
focus has measured counselor self-efficacy
after receiving supervision and has examined
the dynamics of supervisee–supervisor rela-
tionships. Even though educational institu-
tions have developed curricula and standards
to reinforce the need for a multicultural per-
spective in training, many clinical supervisors
lack sufficient training in this area (e.g., avoid
cultural topics in supervision, have difficulty
giving culturally appropriate consultations or
direction, fail to guide/reinforce timely im-
plementation of policies or procedures that
support culturally responsive services with
their supervisees). This can significantly im-
pede organizations attempting to introduce or
improve culturally responsive clinical services.
It is essential for organizations to provide
counselors with clinical supervisors who are
culturally aware, have engaged in multicultural
training, and model culturally competent
behaviors in clinical supervision sessions (e.g.,
allowing or engaging in discussions centered
on race, ethnicity, and cultural groups in the
session). Clinical supervision is the glue 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).
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.
94
Chapter 4—Pursuing Organizational Cultural Competence
reinforces culturally competent behavior, and
it is often the only avenue of ongoing clinical
training and follow-up after specific workshops
or trainings are offered by the organization.
Clinical supervisors should adopt a multicul-
tural framework to guide the supervision
process (e.g., Sue’s [2001] multidimensional
model for developing cultural competence).
Endorsement of a model for developing and
enhancing cultural competence helps both
supervisors and supervisees understand how to
address cultural issues in supervision and
pursue personal and professional development
that supports culturally responsive clinical
services. (For a specific example, see Field and
colleagues’ [2010] Latina–Latino multicultural
developmental supervisory model.) The model
guides supervision and reinforces the premise
that cultural variables influence each aspect of
supervision: the relationship between supervi-
sors and supervisees, the supervisors’ and
supervisees’ perceptions and assessments of
clients’ presenting issues, the interactions
between supervisees and their clients, and the
treatment recommendations and directions
that evolve from supervision.
Task: Evaluate Staff Performance
on Culturally Congruent and
Complementary Attitudes,
Knowledge, and Skills
Organizations committed to endorsing and
implementing culturally responsive services
need policies and procedures that reflect this
commitment in job descriptions and staff
evaluations across all levels of the organiza-
tion. By incorporating specific goals,
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.
95
Improving Cultural Competence
expectations, and tasks into performance
evaluations, staff members will receive an
important and consistent message from the
organization that culturally competent behav-
ior and responsive services are valued and
rewarded.
Organizational
Infrastructure
Task: Plan Long-Range Fiscal
Support of Cultural Competence
An organization’s commitment to providing
culturally responsive treatment services will
only succeed if resources are consistently
dedicated to supporting the plan. Realistical-
ly, treatment program funds may be insuffi-
cient to initially meet the goals outlined in
the organization’s self-assessment. More
often than not, the committee, executive staff,
and board will have to prioritize the specific
changes that are financially feasible. However,
this necessity does not preclude the organiza-
tion from soliciting help from the communi-
ty, finding creative and inexpensive ways to
make organizational changes, and using
strategic and financial planning to build
resources designated for culturally responsive
services.
Task: Create an Environment That
Reflects the Populations Served
The self-assessment process should include
an environmental review of the organization’s
physical facilities in which barriers to access
are examined. The plan should address iden-
tified deficits. For example, signage should be
written in all primary languages spoken by
the clients served; it should be written at an
appropriate level of literacy in those lan-
guages. When possible, signs should use
pictures and graphics to replace written in-
structions. The design of the facility, includ-
ing use of space and décor, should be inviting,
comfortable, and culturally sensitive. The
plan should establish how to make facilities
more accessible and culturally appropriate. In
addition, the organization should create an
environment that reflects the culture(s) of its
clients not only within the facility, but
through business practices, such as using local
and community vendors.
Task: Develop Outreach
Strategies To Improve Access to
Care
The best-laid plans for providing culturally
competent treatment are futile if clients
cannot access treatment. Providers should
develop outreach plans for diverse ethnic and
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.
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Chapter 4—Pursuing Organizational Cultural Competence
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 community health 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.)
97
Improving Cultural Competence
racial communities, particularly those whose
members may find it difficult to seek services
on their own. For example, see Community-
Defined Solutions for Latino Mental Health
Care Disparities (Aguilar-Gaxiola et al. 2012).
From the outset, effective outreach and im-
proved access to care should include formal
and informal contacts with community organ-
izations, spiritual leaders, and media. Providers
can learn from these contacts about the behav-
ioral health concerns in the community, spe-
cial considerations for working with members
of the community, cultural impediments to
treatment, and cultural resources to aid treat-
ment and recovery.
Unfortunately, many providers lack sufficient
funding to offer the level of outreach services
needed by the communities they serve. Be-
cause they are overwhelmed already, the issue
of outreach to underserved populations is
often seen as a low priority, which can cause
these providers to send people in need of
treatment away, disappointed and disheart-
ened. However, thoughtful and strategic use of
community resources can result in more mem-
bers of underserved populations receiving the
treatment they need and deserve. At mini-
mum, outreach enables providers to offer
accurate information and referral to appropri-
ate mutual-help or community groups.
Regarding fiscal planning and funding op-
portunities, some HHS initiatives support
outreach through integrated care. For exam-
ple, the Health Resources and Services
Administration (HRSA) Center for Integrated
Health Solutions (CIHS) promotes the devel-
opment of integrated primary and behavioral
health services to better address the needs of
individuals with mental health and substance
use concerns. Resources are available to help
physicians screen for behavioral health prob-
lems and refer individuals to appropriate
treatment. SAMHSA’s Center for Substance
Abuse Treatment has a Targeted Capacity
Expansion Program that offers grants in
support of outreach to specific populations.
The challenges outlined in this chapter are
burdensome but can be overcome. Many
organizations have been able to develop cul-
tural competence over time (for a historical
perspective of one organization’s journey, see
Exhibit 4-7). A well-defined and organized
plan, coupled with a consistent organizational
commitment, will enable organizations to
initiate and accomplish the tasks necessary to
promote culturally responsive services.
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 Indian people have expe-
rienced success in publishing a monthly newsletter that is sent to individual American Indians and
agencies serving the Native American community.
98
Chapter 4—Pursuing Organizational Cultural Competence
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.
99
John, 27, is an American Indian from a Northern Plains Tribe. He
recently entered an outpatient treatment program in a midsized
Midwestern city to get help with his drinking and subsequent low
mood. John moved to the city 2 years ago and has mixed feelings
about living there, but he does not want to return to the reserva-
tion because of its lack of job opportunities. Both John and his
counselor are concerned that (with the exception of his girlfriend,
Sandy, and a few neighbors) most of his current friends and
coworkers are “drinking buddies.” John says his friends and family
on the reservation would support his recovery—including an uncle
and a best friend from school who are both in recovery—but his
contact with them is infrequent.
John says he entered treatment mostly because his drinking was
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
5
Behavioral Health
Treatment for Major
Racial and Ethnic Groups
IN THIS CHAPTER
• Introduction
• Counseling for African
and Black Americans
• Counseling for Asian
Americans, Native
Hawaiians, and Other
Pacific Islanders
• Counseling for Hispanics
and Latinos
• Counseling for Native
Americans
• Counseling for White
Americans
101
Improving Cultural Competence
home who have been through treatment and
still drink or use drugs. Even though he
doesn’t consider himself particularly tradition-
al, he is especially concerned that there is
nothing “Indian” about the program; he dis-
likes that his treatment plan focuses more on
changing his thinking than addressing his
spiritual needs or the fact that drinking has
been a poison for his whole community.
John’s counselor recognizes the importance of
connecting John to his community and, if
possible, to a source of traditional healing.
After much research, his counselor is able to
locate and contact an Indian service organiza-
tion in a larger city nearby. The agency puts
him in touch with an older woman from
John’s Tribe who resides in that city. She, in
turn, puts the counselor in touch with another
member of the Tribe who is in recovery and
had been staying at her house. This man
agrees to be John’s sponsor at local 12-Step
meetings. With John’s permission, the counse-
lor arranges an initial family therapy session
that includes his new sponsor, the woman who
serves as a local “clan mother,” John’s girl-
friend, and, via telephone, John’s uncle in
recovery, mother, and brother. With John’s
permission and the assistance of his new
sponsor, the counselor arranges for John and
some other members of his treatment group to
attend a sweat lodge, which proves valuable in
helping John find some inner peace as well as
giving his fellow group members some insight
into John and his culture.
To provide culturally responsive treatment,
counselors and organizations must be commit-
ted to gaining cultural knowledge and clinical
skills that are appropriate for the specific racial
and ethnic groups they serve. Treatment pro-
viders need to learn how a client’s identifica-
tion with one or more cultural groups
influences the client’s identity, patterns of
substance use, beliefs surrounding health and
healing, help-seeking behavior, and treatment
expectations and preferences. Adopting Sue’s
(2001) multidimensional model in developing
cultural competence, this chapter identifies
cultural knowledge and its relationship to
treatment as a domain that requires proficien-
cy in clinical skills, programmatic develop-
ment, and administrative practices. This
chapter focuses on patterns of substance use
and co-occurring disorders (CODs), beliefs
about and traditions involving substance use,
beliefs and attitudes about behavioral health
treatment, assessment and treatment consider-
ations, and theoretical approaches and treat-
ment interventions across the major racial and
ethnic groups in the United States.
Introduction
Culture is a primary force in the creation of a
person’s identity. Counselors who are culturally
competent are better able to understand and
respect their clients’ identities and related
cultural ways of life. This chapter proposes
strategies to engage clients of diverse racial
and ethnic groups (who can have very differ-
ent life experiences, values, and traditions) in
treatment. The major racial and ethnic groups
in the United States covered in this chapter
are African Americans, Asian Americans
(including Native Hawaiians and other Pacific
Islanders), Latinos, Native Americans (i.e.,
Alaska Natives and American Indians), and
White Americans. In addition to providing
epidemiological data on each group, the chap-
ter discusses salient aspects of treatment for
these racial/ethnic groups, drawing on clinical
and research literature. This information is
only a starting point in gaining cultural
knowledge as it relates to behavioral health.
Understanding the diversity within a specific
culture, race, or ethnicity is essential; not all
information presented in this chapter will
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
are not static factors to consider in providing
services for clients, families, or communities.
Although these broad racial/ethnic categories
are often used to describe diverse cultural
groups, the differences between two members
of the same racial/ethnic group can be greater
than the differences between two people from
different racial/ethnic groups (Lamont and
Small 2008; Zuckerman 1998). It is not possi-
ble to capture every aspect of diversity within
each cultural group. Behavioral health workers
should acknowledge that there will be many
individual variations in how people interact
with their environments, as well as in how
environmental context affects behavioral
health. However, to provide a framework for
understanding many diverse cultural groups,
some generalizations are necessary; thus, broad
categories are used to organize information in
this chapter. Counselors are encouraged to
learn as much as possible about the specific
populations they serve. Sources listed in
Appendix F provide additional information.
Counseling for African and
Black Americans
According to the 2010 U.S. Census definition,
African Americans or Blacks are people whose
103
Improving Cultural Competence
origins are “in any of the black racial groups of
Africa” (Humes et al. 2011, p. 3). The term
includes descendants of African slaves brought
to this country against their will and more
recent immigrants from Africa, the Caribbean,
and South or Central America (many individ-
uals from these latter regions, if they come
from Spanish-speaking cultural groups, iden-
tify or are identified primarily as Latino). The
term “Black” is often used interchangeably
with African American, although sometimes
the term “African American” is used specifi-
cally to describe people whose families have
been in this country since at least the 19
th
century and thus have developed distinct
African American cultural groups. “Black” can
be a more inclusive term describing African
Americans as well as more recent immigrants
with distinct cultural backgrounds.
Beliefs About and Traditions
Involving Substance Use
In most African American communities,
significant alcohol or drug use may be socially
unacceptable or seen as a sign of weakness
(Wright 2001), even in communities with
limited resources, where the sale of such sub-
stances may be more acceptable. Overall,
African Americans are more likely to believe
that drinking and drug use are activities for
which one is personally responsible; thus, they
may have difficulty accepting alcohol
abuse/dependence as a disease (Durant 2005).
Substance Use and Substance Use
Disorders
To date, there has not been much research
analyzing differences in patterns of substance
use and abuse among different groups of
Blacks, but there are indications that some
gender differences exist. For example, alcohol
consumption among African American wom-
en increases as they grow older, but Caribbean
Black women report consistently low alcohol
consumption as they grow older (Center for
Substance Abuse Treatment [CSAT] 1999a;
Galvan and Caetano 2003). Rates of overall
substance use among African Americans vary
significantly by age. Several researchers have
observed that despite Black youth being less
likely than White American youth to use
substances, as African Americans get older,
they tend to use at rates comparable with
those of White Americans (Watt 2008). This
increase in substance use with age among
Blacks is often referred to as a crossover effect.
However, Watt (2008), in her analysis of 4
years of National Survey on Drug Use and
Health (NSDUH) data (1999–2002), found
that when controlling for factors such as drug
exposure, marriage, employment, education,
income, and family/social support, the cross-
over effect disappeared for Blacks ages 35 and
older; patterns for drug and heavy alcohol use
among Black and White American adults
remained the same as for Black and White
American adolescents (i.e., White Americans
were significantly more likely to use substanc-
es). Watt concludes that systemic issues, such
as lower incomes and education levels, and
other factors, such as lower marriage rates,
contribute to substance use among Black
adults. Additional research also suggests that
exposure to discrimination increases willing-
ness to use substances in African American
youth and their parents (Gibbons et al. 2010).
When comparing African Americans with
other racial and ethnic groups, NSDUH data
from 2012 suggest that they are somewhat
more likely than White Americans to use illicit
drugs and less likely than White Americans to
use alcohol. They also appear to have an inci-
dence of alcohol and drug use disorders simi-
lar to that seen in White Americans
(Substance Abuse and Mental Health Services
Administration [SAMHSA] 2013d). Crack
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
rates of abuse of methamphetamine, inhalants,
most hallucinogens, and prescription drugs are
lower (SAMHSA 2011a). Phencyclidine use
also appears to be a more serious problem,
albeit affecting a relatively small group, among
African Americans than among members of
other racial/ethnic groups.
There appear to be some other differences in
how African Americans use substances com-
pared with members of other racial/ethnic
groups. For example, Bourgois and Schonberg
(2007) observed that among people who inject-
ed heroin in San Francisco, White Americans
tended to administer the drug quickly whether
or not they could find a vein, which led them
to inject into fat or muscle tissue and resulted
in a higher rate of abscesses. However, African
Americans who injected heroin were more
methodical and took the time to find a vein,
even if it took multiple attempts. This, in turn,
often resulted in using syringes that were
already bloodied and increased their chances
of contracting HIV/AIDS and other blood-
borne diseases. African Americans who inject-
ed heroin were significantly more likely to also
use crack cocaine than were White Americans
who injected heroin (Bourgois et al. 2006).
African American patterns of substance use
have changed over time and will likely contin-
ue to do so. Based on treatment admission
data, admissions of African Americans who
injected heroin declined by 44 percent during
a 12-year period, whereas admissions declined
by only 14 percent among White Americans
(Broz and Ouellet 2008). Additionally, during
this period, the peak age for African Americans
who injected heroin increased by 10 years, yet
it decreased by 10 years for White Americans.
This suggests that the decrease in injectable
heroin use among African Americans was
largely due to decreased use among younger
individuals.
Some preliminary evidence suggests that
African Americans are less likely to develop
drug use disorders following initiation of use
(Falck et al. 2008), yet more research is needed
to identify variables that influence the devel-
opment of drug use disorders. Even though
African Americans seem less likely than
White Americans to develop alcohol use
disorders, a number of older studies have
found that they more frequently experience
liver cirrhosis and other alcohol-related health
problems (Caetano 2003; Polednak 2008). In
tracking 25 years of data, Polednak (2008)
found that the magnitude of difference has
decreased over time; nonetheless, health dispar-
ities continue to exist for African Americans in
terms of access to and quality of care, which
can affect a number of health problems
(Agency for Healthcare Research and Quality
2009; Smedley et al. 2003).
Mental and Co-Occurring
Disorders
A number of studies have found biases that
result in African Americans being overdiag-
nosed for some disorders and underdiagnosed
for others. African Americans are less likely
than White Americans to receive treatment
for anxiety and mood disorders, but they are
more likely to receive treatment for drug use
disorders (Hatzenbuehler et al. 2008). In one
study evaluating posttraumatic stress disorder
(PTSD) among African Americans in an
outpatient mental health clinic, only 11 per-
cent of clients had documentation referring to
PTSD, even though 43 percent of the clients
showed symptoms of PTSD (Schwartz et al.
2005). Black immigrants are less likely to be
diagnosed with mental disorders than are
Blacks born in the United States (Burgess et
al. 2008; Miranda et al. 2005b).
African Americans are more likely to be
diagnosed with schizophrenia and less likely
to be diagnosed with affective disorders than
105
Improving Cultural Competence
White Americans, even though multiple
studies have found that rates of both disorders
among these populations are comparable
(Baker and Bell 1999; Bresnahan et al. 2000;
Griffith and Baker 1993; Stockdale et al. 2008;
Strakowski et al. 2003). African Americans are
about twice as likely to be diagnosed with a
psychotic disorder as White Americans and
more than three times as likely to be hospital-
ized for such disorders. These differences in
diagnosis are likely the result of clinician bias
in evaluating symptoms (Bao et al. 2008;
Trierweiler et al. 2000; Trierweiler et al.
2006). Clinicians should be aware of bias in
assessment with African Americans and with
other racial/ethnic groups and should consid-
er ways to increase diagnostic accuracy by
reducing biases. For an overview of mental
health across populations, refer to Mental
Health United States, 2010 (SAMHSA
2012a).
In some African American communities,
incidence and prevalence of trauma exposure
and PTSD are high, and substance use ap-
pears to increase trauma exposure even further
(Alim et al. 2006; Breslau et al. 1995; Curtis-
Boles and Jenkins-Monroe 2000; Rich and
Grey 2005). Black women who abuse sub-
stances report high rates of sexual abuse
(Ross-Durow and Boyd 2000). Trauma histo-
ries can also have a greater effect on relapse for
African American clients than for clients from
other ethnic/racial groups (Farley et al. 2004).
There are few integrated approaches to trau-
ma and substance abuse that have been evalu-
ated with African American clients, and
although some have been found effective at
reducing trauma symptoms and substance
use, the extent of that effectiveness is not
necessarily as great as it is for White
Americans (Amaro et al. 2007; Hien et al.
2004; SAMHSA 2006).
African Americans are less likely than White
Americans to report lifetime CODs (Mericle
et al. 2012). However, limited research indi-
cates that, as with other racial groups, there are
differences across African American groups in
the screening and symptomatology of CODs.
Seventy-four percent of African Americans
who had a past-year major depressive episode
were identified as also having both alcohol and
marijuana use disorders (Pacek et al. 2012).
Miranda et al. (2005b) found that American-
born Black women were more than twice as
likely to be screened as possibly having depres-
sion than African- or Caribbean-born Black
women, but this could reflect, in part, differ-
ences in acculturation (see Chapter 1). How-
ever, research findings strongly suggest that
cultural responses to some disorders, and
possibly the rates of those disorders, do vary
among different groups of Blacks. Differences
do not appear to be simply reflections of
differences in acculturation (Joe et al. 2006).
For a review of African American health, see
Hampton et al. (2010).
Treatment Patterns
African Americans may be less likely to re-
ceive mental health services than White
Americans. In the Baltimore Epidemiologic
Catchment Services Area study conducted
during the 1980s, African Americans were less
likely than White Americans to receive mental
health services. However, at follow-up in the
early 1990s, African American respondents
were as likely as White Americans to receive
such services, but they were much more likely
to receive those services from general practi-
tioners than from mental health specialists
(Cooper-Patrick et al. 1999). Stockdale et al.
(2008) analyzed 10 years of data from the
National Ambulatory Medical Care Survey;
they found significant improvements in diag-
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
that disparities persisted in the diagnosis and
treatment of mental disorders in primary care
settings. Fortuna et al. (2010) suggest that
persistent problems exist in the delivery of
behavioral health services, as evidenced by
lower retention rates for treating depression.
Even among people who enter substance
abuse treatment, African Americans are less
likely to receive services for CODs. A study of
administrative records from substance abuse
and mental health treatment providers in New
Jersey found that African Americans were
significantly more likely than White Americans
to have an undetected co-occurring mental
disorder, and, if detected, they were signifi-
cantly less likely than White Americans or
Latinos to receive treatment for that disorder
(Hu et al. 2006). Among persons with sub-
stance use disorders and co-occurring mood or
anxiety disorders, African Americans are
significantly less likely than White Americans
to receive services (Hatzenbuehler et al. 2008).
African Americans who do receive services for
CODs are more likely to obtain them through
substance abuse treatment programs than
mental health programs (Alvidrez and
Havassy 2005).
According to the Treatment Episode Data
Sets (TEDS) from 2001 to 2011, African
American clients entering substance abuse
treatment most often reported alcohol as their
primary substance of abuse, followed by mari-
juana. However, gender differences are evident,
indicating that women report a broader range
of substances as their primary substance of
abuse than men do (SAMHSA, Center for
Behavioral Health Statistics and Quality
[CBHSQ], 2013). Most recent research sug-
gests that African Americans are about as
likely to seek and eventually receive substance
abuse treatment as are White Americans
(Hatzenbuehler et al. 2008; Perron et al. 2009;
SAMHSA, CBHSQ 2011; Schmidt et al.
2006). Data analyzed by Perron et al. (2009)
indicate that among African Americans with
lifetime diagnoses of drug use disorders, 20.8
percent had received some type of treatment,
as defined broadly to include resources such as
pastoral counseling and mutual-help group
attendance. This made them more likely to
have received treatment than White Ameri-
cans (15.5 percent of whom received treat-
ment) or Latinos (17.3 percent of whom
received treatment). Although data indicate
that African Americans were less likely to
receive services from private providers, they
also indicate that African Americans were
more likely to use more informal services (e.g.,
pastoral counseling, mutual help).
Although most major studies have found that
race is not a significant factor in receiving
treatment, African Americans report lengthier
waiting periods, less initiation of treatment,
more barriers to treatment participation (e.g.,
lack of childcare, lack of insurance, lack of
knowledge about available services), and
shorter lengths of stay in treatment than do
White Americans (Acevedo et al. 2012;
Brower and Carey 2003; Feidler et al. 2001;
Grant 1997; Hatzenbuehler et al. 2008; Marsh
et al. 2009; SAMHSA 2011c; Schmidt et al.
2006). In SAMHSA’s 2010 NSDUH, 33.5
percent of African Americans who had a need
for substance abuse treatment but did not
receive it in the prior year reported that they
lacked money or the insurance coverage to pay
for it (SAMHSA, CBHSQ 2011). Economic
disadvantage does leave many Africans Amer-
icans uninsured; approximately 16.1 percent of
non-Latino Blacks had no coverage in 2004
(Schiller et al. 2005).
Likewise, some researchers have found that
African Americans are less likely than White
Americans to receive needed services or an
appropriate level of service (Alegria et al.
107
Improving Cultural Competence
2011; Bluthenthal et al. 2007; Marsh et al.
2009). For example, African Americans and
Latinos are less likely than White Americans
to receive residential treatment and are more
likely to receive outpatient treatment, even
when they present with more serious substance
use problems (Bluthenthal et al. 2007). Other
studies have found that African Americans
with severe substance use or CODs were less
likely to enter or receive treatment than White
Americans with equally severe disorders
(Schmidt et al. 2006, 2007).
African Americans are overrepresented among
people who are incarcerated in prisons and
jails (for review, see Fellner 2009), and a sub-
stantial number of those who are incarcerated
(64.1 percent of jail inmates in 2002) have
substance use disorders (Karberg and James
2005) and mental health problems (SAMHSA
2012a). However, according to Karberg and
(James 2005), African Americans with sub-
stance dependence disorders who were in jail
in 2002 were less likely than White Americans
or Latinos to participate in substance abuse
treatment while under correctional supervision
(32 percent of African Americans participated
compared with 37 percent of Latinos and 45
percent of White Americans). In the 2010
TEDS survey, African Americans entering
treatment were also less likely than Asian
Americans, White Americans, Latinos, Native
Hawaiians/Pacific Islanders, or American
Indians in the same situation to be referred to
treatment through the criminal justice system
(SAMHSA, CBHSQ 2012). Notwithstand-
ing, African Americans are more likely to be
referred to treatment from criminal justice
settings rather than self-referred or referred by
other sources (Delphin-Rittmon et al. 2012)
Beyond issues related to diagnosis and care
that can prevent African Americans from
accessing mental health services, research
suggests that a lack of familiarity with the
value and use of specialized behavioral health
services among some African Americans may
limit service use. Hines-Martin et al. (2004)
found a positive relationship between famili-
arity and use of mental health services among
African Americans. Additionally, factors such
as social and familial prejudices (Ayalon and
Alvidrez 2007; Mishra et al. 2009; Nadeem et
al. 2007) and fears relating to past abuses of
African Americans within the mental health
system (Jackson 2003) can contribute to the
lack of acceptance and subsequent use of these
services. An essential step in decreasing dis-
parity in behavioral health services among
African Americans involves conducting cul-
turally appropriate mental health screenings
and using culturally sensitive instruments and
evaluation tools (Baker and Bell 1999).
Beliefs and Attitudes About
Treatment
According to 2011 NSDUH data, African
Americans were, next to Asian Americans,
the least likely of all major ethnic and racial
groups to state a need for specialized sub-
stance abuse treatment (SAMHSA, CBHSQ
2013a). Still, logistical barriers may pose a
greater challenge for African Americans than
for members of other major racial and ethnic
groups. For example, 2010 NSDUH data
regarding individuals who expressed a need
for substance abuse treatment but did not
receive it in the prior year indicate that
African Americans were more likely than
members of other major ethnic/racial groups
to state that they lacked transportation to the
program or that their insurance did not cover
the cost of such treatment (SAMHSA
2011a). African Americans experience several
challenges in accessing behavioral health
treatment, including fears about the therapist
or therapeutic process and concerns about
discrimination and costs (Holden et al. 2012;
108
Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups
Holden and Xanthos 2009; Williams et al.
2012).
Longstanding suspicions regarding established
healthcare institutions can also affect African
Americans’ participation in, attitudes toward,
and outcomes after treatment (for review, see
Pieterse et al. 2012). Historically, the mental
health system has shown bias against African
Americans, having been used in times past to
control and punish them (Boyd-Franklin and
Karger 2012; Jackson 2003). After controlling
for socioeconomic factors, African Americans
are significantly more likely to perceive the
healthcare system as poor or fair and signifi-
cantly more likely to believe that they have
been discriminated against in healthcare
settings (Blendon et al. 2007). Attitudes to-
ward psychological services appear to become
more negative as psychological distress in-
creases (Obasi and Leong 2009). In many
African American communities, there is a
persistent belief that social and treatment
services try to impose White American values,
adding to their distrust of the treatment sys-
tem (Larkin 2003; Solomon 1990).
African Americans, even when receiving the
same amount of services as White Americans,
are less likely to be satisfied with those services
(Tonigan 2003). However, recent evidence
suggests that, once engaged, African American
clients are at least as likely to continue partici-
pation as members of other ethnic/racial
groups (Harris et al. 2006). Because distrust of
the healthcare system can make it more diffi-
cult to engage African American clients ini-
tially in treatment, Longshore and Grills
(2000) recommend culturally congruent moti-
vational enhancement strategies to address
African American clients’ ambivalence about
treatment services. Providers also need to craft
culturally responsive health-related messages
for African Americans to improve treatment
engagement and effectiveness (Larkin 2003).
Most importantly, providers need to demon-
strate multicultural experience. In a study
comparing outcomes among Black and White
clients at community mental health centers,
the only clinician factor that predicted more
favorable outcomes was clinicians’ general
experiences and relationships with people
from racial/ethnic and cultural groups other
than their own (Larrison et al. 2011).
Treatment Issues and
Considerations
African American clients generally respond
better to an egalitarian and authentic relation-
ship with counselors (Sue 2001). Paniagua
(1998) suggests that in the initial sessions with
African American clients, counselors should
develop a collaborative client–counselor rela-
tionship. Counselors should request personal
information gradually rather than attempting
to gain information as quickly as possible,
avoid information-gathering methods that
clients could perceive as an interrogation, pace
the session, and not force a data-gathering
agenda (Paniagua 1998; Wright 2001). Coun-
selors must also establish credibility with
clients (Boyd-Franklin 2003).
Next, counselors should establish trust. Self-
disclosure can be very difficult for some clients
because of their histories of experiencing
racism and discrimination. These issues can be
exacerbated in African American men whose
experience of racism has been more severe or
who have had fewer positive relationships with
White Americans (Reid 2000; Sue 2001).
Counselors, therefore, need to be willing to
address the issue of race and to validate African
American clients’ experiences of racism and its
reality in their lives, even if it differs from
their own experiences (Boyd-Franklin 2003;
Kelly and Parsons 2008). Moreover, racism
and discrimination can lead to feelings of
anger, anxiety, or depression. Often, these
feelings are not specific to any given event;
109
Improving Cultural Competence
Exhibit 5-1: Core Culturally
Responsive Principles in Counseling
African Americans
According to Schiele (2000), culturally respon-
sive counseling for African American clients
involves adherence to six core principles:
1. Discussion of clients’ substance use should
be framed in a context that recognizes the
totality of life experiences faced by clients
as African Americans.
2. Equality is sought in the therapeutic coun-
selor–client relationship, and counselors
are less distant and more disclosing.
3. Emphasis is placed on the importance of
changing one’s environment—not only for
the good of clients themselves, but also for
the greater good of their communities.
4. Focus is placed on alternatives to sub-
stance use that underscore personal rituals,
cultural traditions, and spiritual well-being.
5. Recovery is a process that involves gaining
power in the forms of knowledge, spiritual
insight, and community health.
6. Recovery is framed within a broader con-
text of how recovery contributes to the
overall healing and advancement of the
African American community.
rather, they are pervasive (Boyd-Franklin et al.
2008). Counselors should explore with clients
the psychological effects of racism and develop
approaches to challenge internal negative
messages that have been received or generated
through discrimination and prejudice (Good-
ing 2002).
Additional methods that may enhance en-
gagement and promote participation include
peer-supported interventions and strategies
that promote empowerment by emphasizing
strengths rather than deficits (Paniagua 1998;
Tondora et al. 2010; Wright 2001). It is
important to explore with clients the
strengths that have brought them this far.
What personal, community, or family
strengths have helped them through difficult
times? What strengths will support their
recovery efforts? Exhibit 5-1 gives an
overview of core guiding principles in work-
ing with African American clients.
Theoretical Approaches and
Treatment Interventions
Research suggests that culturally congruent
interventions are effective in treating African
Americans (Longshore and Grills 2000;
Longshore et al. 1998a; Longshore et al.
1998b; 1999). Although there are conflicting
results on the effectiveness of motivational
interviewing among African American clients
(Montgomery et al. 2011), some motivational
interventions have been found to reduce sub-
stance use among African Americans
(Bernstein et al. 2005; Longshore and Grills
2000). Longshore and Grills (2000) describe a
culturally specific motivational intervention
for African Americans involving both peer
and professional counseling that makes use of
the core African American value of commu-
nalism by addressing the ways in which the
individual’s substance abuse affects his or her
whole community. The motivational program
affirms “the heritage, rights, and responsibili-
ties of African Americans…using interaction
styles, symbols and values shared by members
of the group” (Longshore et al. 1998b, p. 319).
So too, African American music, artwork, and
food can help programs create a welcoming
and familiar atmosphere, as is the case for
other racial and ethnic groups when familiar
cultural symbols appear in the clinical setting.
Many of the interventions developed for
substance abuse treatment services in general
have been evaluated with populations that
were at least partly composed of African
Americans; many of these interventions are as
effective for African Americans as they are for
White Americans (Milligan et al. 2004; To-
nigan 2003). One intervention that appears to
work better for African American (and Latino)
clients than for White American clients—
perhaps because it focuses on improving
110
Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups
client–counselor communication—is node-
link mapping (visual representation using
information diagrams, fill-in-the-blank graph-
ic tools, and client-generated diagrams or
visual maps). This approach was associated
with lower rates of substance use, better treat-
ment attendance, and better counselor ratings
of motivation and confidence among African
Americans than among White Americans
(Dansereau et al. 1996; Dansereau and
Simpson 2009).
In addition, cognitive–behavioral therapy
(CBT) has certain distinct advantages for
African American clients; it fosters a collabo-
rative relationship and recognizes that clients
are experts on their own problems (Kelly and
Parsons 2008). Maude-Griffin et al. (1998)
compared CBT and 12-Step facilitation for a
group of mostly African American (80 per-
cent) men who were homeless and found that
CBT achieved significantly better abstinence
outcomes, except among those who considered
themselves very religious (these individuals
had better outcomes with 12-Step facilitation).
Other interventions that use CBT principles
have also been effective with African American
populations. For example, a number of studies
have evaluated contingency management
approaches with predominantly African
American client populations, finding that this
model was effective at reducing cocaine and
illicit opioid use, improving employment
outcomes for clients in methadone mainte-
nance (Silverman et al. 2002; Silverman et al.
2007), reducing substance use during and after
treatment, and improving self-reported quality
of life (Petry et al. 2004; Petry et al. 2005; Petry
et al. 2007). The Living in the Balance inter-
vention, which uses psychoeducation and CBT
techniques, has also been evaluated with a
mostly African American sample and has been
shown to improve treatment retention and
reduce substance use (Hoffman et al. 1996).
Another therapy that has been evaluated with
African American clients and found effective
is supportive–expressive psychotherapy, which
reduces substance use and improves psycho-
logical functioning for individuals in metha-
done maintenance (Woody et al. 1987; Woody
et al. 1995). Medications for substance abuse
can also work well with African American
clients. In one large study, African Americans
were more likely than Latinos or White
Americans to indicate that they found metha-
done helpful (Gerstein et al. 1997), and in
another study, they reported greater perceived
quality of life as a result of participation in a
methadone program (Geisz 2007). Schroeder et
al. (2005) also reported that African Americans
in a methadone program had significantly
fewer adverse medical events (e.g., infections,
gastrointestinal complaints) than did White
American participants. African Americans
who were being treated for cocaine depend-
ence remained in treatment significantly
longer than did other African Americans if
they received disulfiram (Milligan et al. 2004).
A review of cultural adaptations of evidence-
based practices is given by Bernal and
Domenech Rodriguez (2012). For an over-
view of gender-specific treatment considera-
tions for mental and substance use disorders
among African American men and women,
see Shorter-Gooden (2009).
Family therapy
African American clients appear more likely
to stay connected with their families through-
out the course of their addiction. For instance,
Bourgois et al. (2006) reported that in compar-
ing African American and White American
individuals who injected heroin, African
Americans appeared to be more likely to
maintain contact with their extended families.
Some research also suggests that African
Americans with substance use disorders are
more likely to have family members with
111
Improving Cultural Competence
Advice to Counselors: Strengths of
African American Families
African American kinship bonds have historically
been sources of strength. Although substance
abuse lessens the strength of the family and
can erode relationships, counselors can use the
inherent strengths of the family to benefit
clients and their families (Boyd-Franklin and
Karger 2012; Larkin 2003; Reid 2000). Bell-
Tolliver et al. (2009) and Hill (1972) suggest that
strengths of African American family life include:
• Strong bonds and extensive kinship.
• Adaptability of family roles.
• A strong family hierarchy.
• A strong work orientation.
• A high achievement orientation.
• A strong religious orientation.
histories of substance abuse, suggesting an
even greater need to address substance abuse
within the family (Brower and Carey 2003).
Strong family bonds are important in African
American cultural groups. African American
families are embedded in a complex kinship
network of biologically related and unrelated
persons. Hence, counselors should be willing
to expand the definition of family to a more
extended kinship system (Boyd-Franklin
2003; Hines and Boyd-Franklin 2005). Clients
need to be asked how they define family,
whom they would identify as family or “like
family,” who resides with them in their homes,
and whom they rely on for help. Hines and
Boyd-Franklin (2005) discuss the importance
of both blood and nonblood kinship networks
for African American families. To build a
support network for African American clients,
counselors should start by asking clients to
identify people (whether biological kin or not)
who would be willing and able to support
their recovery and then ask clients for permis-
sion to contact those people and include them
in the treatment process.
Family therapy is often a productive approach
to treatment with African Americans (Boyd-
Franklin 2003; Hines and Boyd-Franklin
2005; Larkin 2003). However, the extended
family can be large and have many ties with
other families in a community; therefore, the
family therapist sometimes needs to take on
other roles to assist with case management or
other activities, including involvement in
community-wide interventions (Sue 2001). In
reviewing specific family therapy approaches
for African Americans, Boyd-Franklin (2003)
discusses the use of a multisystem family
therapy approach, which incorporates an
extended network of relationships that play a
part in clients’ lives. Using this model, social
service and other community agencies can be
considered a significant part of the family
system. Network therapy, which involves
clients’ extended social networks, has also been
found to improve substance use outcomes for
African American clients when added to
standard treatment (Keller and Galanter
1999). Likewise, the family team conference
model can be a useful approach, given that it
also engages both families and communities in
the helping process by attempting to stimulate
extensive mobilization of activity in the formal
and informal relationships in and around cli-
ents’ families (State of New Jersey Department
of Human Services 2004).
Brief structural family therapy and strategic
family therapy reduce substance use as well,
but research has primarily focused on African
American youth (Santisteban et al. 1997;
Santisteban et al. 2003; Szapocznik and
Williams 2000). Multidimensional family
therapy has increased abstinence from sub-
stance use among African American adoles-
cents and produced more lasting effects than
CBT, but it also has not been evaluated with
adult clients (Liddle et al. 2008). In reviewing
specific family programs, Larkin (2003) reports
promising preliminary data on a family therapy
intervention among African Americans in
public housing that addresses substance abuse.
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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups
The program initially engages families via
psychoeducation on substance abuse and its
effects on the family, followed by a strength-
based family therapy intervention. Despite the
small sample size, all 10 families admitted to
the program completed treatment, and 7 of 10
family members with substance abuse prob-
lems entered recovery and continuing care.
Participant surveys indicated that 60 percent
of families preferred multiple-family therapy
over single-family therapy, and 80 percent
preferred services delivered in the housing
project community center to other venues.
Engaging Moms is another family-oriented
program and intervention developed specifi-
cally for African American mothers that has
been shown to significantly improve treatment
engagement (Dakof et al. 2003). The interven-
tion is designed for women who have children
and have been identified as cocaine users. The
program focuses on mobilizing family members
who would be likely to motivate the mothers to
enroll and remain in substance abuse treatment.
Research has shown no long-term impact, yet
women who received the intervention were
significantly more likely to enter treatment (88
percent of women involved in the program
versus 46 percent of the control group) and
remain for at least 2 weeks.
Group therapy
Because of the communal, cooperative values
held by many African Americans, group ther-
apy can be a particularly valuable component
of the treatment process (Sue and Sue 2013b).
A strong oral tradition is one of many forms
of continuity with African tradition main-
tained in the African American experience;
therefore, speaking in groups is generally
acceptable to African American clients. How-
ever, Bibb and Casimer (2000) note that Black
Caribbean Americans can be less comfortable
with the group process, particularly the re-
quirement that they self-disclose personal
problems to people who are relative strangers.
African Americans seem less likely to self-
disclose about the past in group settings that
include non-Hispanic Whites (Johnson et al.
2011; Richardson and Williams 1990). Con-
sequently, groups composed only of African
Americans can be more beneficial. Homoge-
nous African American groups can also be
good venues for clients to deal with systemic
problems, such as racism and lack of economic
opportunities in the African American com-
munity (Jones et al. 2000).
Mutual-help groups
A variety of mutual-help groups are available
for African Americans entering recovery from
substance use and mental disorders. However,
most of the literature focuses on 12-Step
groups, including Alcoholics Anonymous
(AA) and Narcotics Anonymous. Some find
that the 12-Step approach warrants careful
consideration with African Americans, who
can find the concept of powerlessness over
substances of abuse to be too similar to experi-
ences of powerlessness via discrimination.
Additionally, the disease concept of addiction
presented in 12-Step meetings can be difficult
for many African Americans (Durant 2005).
In some instances, the Black community has
changed the mutual-help model for substance
use and mental health to make it more em-
powering and relevant to African American
participants. For additional information on the
12 Steps for African Americans, visit Alcohol-
ics Anonymous World Services (AAWS), AA
for the Black and African American Alcoholic,
available online (http://www.aa.org/
pdf/products/p-51_CanAAHelpMeToo.pdf).
Despite their emphasis on the concept of
powerlessness, 12-Step programs are significant
support systems for many African Americans.
In AA’s 2011 membership survey, 4 percent of
members identified their race as Black
(AAWS 2012). Analysis of 2006–2007
113
Improving Cultural Competence
NSDUH data showed that African Americans
were less likely to use mutual-help groups in
the past year for substance use (about 11
percent did) than White Americans (about 67
percent did) or Latinos (about 16 percent did;
SAMHSA 2013d). However, the National
Epidemiologic Survey on Alcohol and Related
Conditions (NESARC) survey did find that
African Americans who had a lifetime drug
use disorder diagnosis and had sought help
were more than three times as likely to have
attended mutual-help meetings as were White
Americans or Latinos (Perron et al. 2009).
Several other surveys suggest that African
Americans with alcohol-related problems are
at least as likely to participate in AA as White
Americans and that greater problem severity is
associated with increased likelihood of partici-
pation (Kingree and Sullivan 2002). Of the
participants who attended mutual-help group
sessions for mental health in the past year,
approximately 10 percent were Black or Afri-
can American, 75 percent were White Ameri-
can, and 11.4 percent were Latino (SAMHSA
2010).
Durant (2005) observes that African American
12-Step participants tend to participate differ-
ently in meetings where participants are most-
ly White Americans than in meetings where
most participants are African American. In
some areas, there are 12-Step meetings that
are largely or entirely composed of African
American members, and some African
American clients feel more comfortable par-
ticipating in these meetings. Mutual-help
groups can be particularly helpful for African
Americans who consider themselves religious.
Maude-Griffin et al. (1998) found that indi-
viduals who identified as highly religious did
significantly better when receiving 12-Step
facilitation than when receiving CBT, but that
pattern was reversed for those who did not
consider themselves highly religious. Other
studies have found that African Americans
express a greater degree of comfort with shar-
ing in meetings, and they are more likely to
engage in AA services and state that they had
a spiritual awakening as a result of AA partic-
ipation (Bibb and Casimer 2000; Kaskutas et
al. 1999; Kingree 1997).
Research suggests that African Americans
who attend 12-Step programs have higher
levels of affiliation than White Americans in
the same programs (Kingree and Sullivan
2002). However, they are less likely to have a
sponsor or to read program materials (Kaskutas
et al. 1999), and their abstinence appears to be
less affected by meeting attendance (Timko et
al. 2006). Other research has found that
African Americans who participate in 12-Step
groups report an increase in the number of
people within their social networks who sup-
port their recovery efforts (Flynn et al. 2006).
Other mutual-help groups for African
Americans are available, particularly faith-
based programs to support recovery from
mental illness and substance use disorders and
to aid individuals in the process of transition-
ing from correctional institutions. For exam-
ple, the Nation of Islam has been involved in
successful substance abuse recovery efforts,
especially for incarcerated persons (Sanders
2002; White and Sanders 2004).
Traditional healing and
complementary methods
In general, African Americans are less likely to
make use of popular alternative or comple-
mentary healing methods than White Ameri-
cans or Latinos (Graham et al. 2005).
However, the African American culture and
history is steeped in healing traditions passed
down through generations, including herbal
remedies, root medicines, and so forth (Lynch
and Hanson 2011). The acceptance of tradi-
tional practices by African American clients
and their families does not necessarily indicate
that they oppose or reject the use of modern
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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups
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).
therapeutic approaches or other alternative
approaches. They can accept and use all forms
of treatment selectively, depending on the
perceived nature of their health problems.
That said, psychological and substance abuse
problems can be seen as having spiritual causes
that need to be addressed by traditional heal-
ers or religious practices (Boyd-Franklin
2003). Moreover, African Americans are much
more likely to use religion or spirituality as a
response to physical or psychological problems
(Cooper et al. 2003; Dessio et al. 2004;
Graham et al. 2005; Nadeem et al. 2008).
African American cultural and religious insti-
tutions (see advice box below) play an im-
portant role in treatment and recovery, and
African Americans who use spirituality or
religion to cope with health problems are nearly
twice as likely as other African Americans to
also make use of complementary or alterna-
tive medicine (Dessio et al. 2004). Likewise,
African American churches and mosques play
a central role in education, politics, recreation,
and social welfare in African American com-
munities. To date, African Americans report
the highest percentage (87 percent) of reli-
gious affiliation of any major racial/ethnic
group (Kosmin and Keysar 2009; Pew Forum
on Religion and Public Life 2008). Even
though most are committed to various
Christian denominations (with the Baptist and
African Methodist Episcopal churches ac-
counting for the largest percentages), a growing
number of African Americans are converts to
Islam, and many recent immigrants from
Africa to the United States are also Muslims
(Boyd-Franklin 2003; Pew Forum on Religion
and Public Life 2008).
Relapse prevention and recovery
African Americans appear to be responsive to
continuing care participation and recovery
activities associated with substance use and
mental disorders, yet research is very limited.
According to NESARC data (Dawson et al.
115
Improving Cultural Competence
2005), African Americans in recovery from
alcohol dependence were more than twice as
likely as White Americans to maintain absti-
nence rather than just limiting alcohol con-
sumption or changing drinking patterns. In
another study analyzing the use of continuing
care following residential treatment in the U.S.
Department of Veterans Affairs care system,
African American men were significantly
more likely than White Americans to partici-
pate in continuing care (Harris et al. 2006).
Other research evaluating continuing care for
African American men who had been man-
dated to outpatient treatment by a parole or
probation office found that participants as-
signed to a continuing care intervention were
almost three times as likely to be abstinent and
five times less likely to be using any drugs on a
weekly basis during the 6-month follow-up
period compared with those who did not
receive continuing care (Brown et al. 2004).
In evaluating appropriate relapse prevention
strategies for African American clients,
Walton et al. (2001) found that African
American clients leaving substance abuse
treatment reported fewer cravings, greater use
of coping strategies, and a greater belief in
their self-efficacy. However, they also expected
to be involved in fewer sober leisure activities,
to be exposed to greater amounts of substance
use, and to have a greater need for continuing
care services (e.g., housing, medical care,
assistance with employment). Walton notes
that these findings could reflect a tendency of
African American clients to underestimate the
difficulties they will face after treatment; they
report a greater need for resources and greater
exposure to substance use, but they still have a
greater belief in their ability to remain free of
substances. Although an individual’s belief in
coping can have a positive effect on initially
managing high-risk situations, it also can lead
to a failure to recognize the level of risk in a
given situation, anticipate the consequences,
secure resources and appropriate support when
needed, or engage in coping behaviors condu-
cive to maintaining recovery. Counselors can
help clients practice coping skills by role-
playing, even if clients are confident that they
can manage difficult or high-risk situations.
Counseling for Asian
Americans, Native
Hawaiians, and Other
Pacific Islanders
Asian Americans, per the U.S. Census Bureau
definition, are people whose origins are in the
Far East, Southeast Asia, or the Indian sub-
continent (Humes et al. 2011). The term in-
cludes East Asians (e.g., Chinese, Japanese, and
Korean Americans), Southeast Asians (e.g.,
Cambodian, Laotian, and Vietnamese
Americans), Filipinos, Asian Indians, and
Central Asians (e.g., Mongolian and Uzbek
Americans). In the 2010 Census, people who
identified solely as Asian American made up
4.8 percent of the population, and those who
identified as Asian American along with one
or more other races made up an additional 0.9
percent. Census data includes specific infor-
mation on people who identify as Asian Indian,
Chinese, Filipino, Japanese, Korean,
Vietnamese, and “other Asians.” The largest
Asian populations in the United States are
Chinese Americans, Filipino Americans,
Asian Indian Americans, Korean Americans,
and Vietnamese Americans. Asian Americans
overwhelmingly live in urban areas, and more
than half (51 percent) live in just three states
(NY, CA, and HI; Hoeffel et al. 2012).
Not all people with origins in Asia belong to
what is commonly conceived of as the Asian
race. Some Asian Indians, for example, self-
identify as White American. For this reason,
among others, counselors should be careful to
learn from their Asian American clients how
116
Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups
they identify themselves and which national
heritages they claim. Counselors should rec-
ognize that clients who appear to be Asian
may not necessarily think of themselves pri-
marily as persons of Asian ancestry or have a
deep awareness of the traditions and values of
their countries of origin. For example, Asian
orphans who have been adopted in the United
States and raised as Americans in White
American families may have very little con-
nection with the cultural groups of their bio-
logical parents (St. Martin 2005). Counselors
should not make generalizations across Asian
cultures; each culture is quite distinct.
Little literature on substance use and mental
disorders, rates of co-occurrence, and treatment
among Asian Americans focuses on behavioral
health treatment for Native Hawaiians and
Pacific Islanders; thus, a text box at the end
of this section summarizes available
information.
Beliefs About and Traditions
Involving Substance Use
Within many Asian societies, the use of intox-
icants is tolerated within specific contexts. For
example, in some Asian cultural groups, alco-
hol is believed to have curative, ceremonial, or
beneficial value. Among pregnant Cambodian
women, small amounts of herbal medicines
with an alcohol base are sometimes used to
ensure an easier delivery. Following childbirth,
similar medicines are generally used to in-
crease blood circulation (Amodeo et al. 1997).
Some Chinese people believe that alcohol
restores the flow of qi (i.e., the life force). The
written Chinese character for “doctor” con-
tains the character for alcohol, which implies
the use of alcohol for medicinal purposes.
Some Asian American cultural groups make
allowances for the use of other substances.
Marijuana, for instance, has been used medici-
nally in parts of Southeast Asia for many years
(Iversen 2000; Martin 1975). However, some
Asian Americans tend to view illicit substance
use and abuse as a serious breach of acceptable
behavior that cannot readily be discussed.
Nonetheless, there are broad differences in
Asian cultures’ perspectives on substance use,
thus requiring counselors to obtain more
specific information during intake and subse-
quent encounters.
Acknowledging a substance abuse problem
often leads to shame for Asian American
clients and their families. Families may deny
the problem and inadvertently, or even inten-
tionally, isolate members who abuse substances
(Chang 2000). For example, some Cambodian
and Korean Americans perceive alcohol abuse
and dependence as the result of moral weak-
ness, which brings shame to the family
(Amodeo et al. 2004; Kwon-Ahn 2001).
Substance Use and Substance Use
Disorders
According to the 2012 NSDUH, Asian
Americans use alcohol, cigarettes, and illicit
substances less frequently and less heavily than
members of any other major racial/ethnic
group (SAMHSA 2013d). However, large
surveys may undercount Asian American
substance use and abuse, as they are typically
conducted in English and Spanish only
(Wong et al. 2007b). Despite the limitations of
research, data suggest that although Asian
Americans use illicit substances and alcohol
less frequently than other Americans, sub-
stance abuse problems have been increasing
among Asian Americans. The longer Asian
Americans reside in the United States, the
more their substance use resembles that of
other Americans. Excessive alcohol use, intox-
ication, and substance use disorders are more
prevalent among Asians born in the United
States than among foreign-born Asians living
in the United States (Szaflarski et al. 2011).
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Improving Cultural Competence
Among Asian Americans who entered sub-
stance abuse treatment between 2000 and
2010, methamphetamine and marijuana were
the most commonly reported illicit drugs
(SAMHSA, CBHSQ 2012). Methampheta-
mine abuse among Asian Americans is partic-
ularly high in Hawaii and on the West Coast
(OAS 2005a). As with other racial and ethnic
groups, numerous factors—such as age, birth
country, immigration history, acculturation,
employment, geographic location, and in-
come—add complexity to any conclusions
about prevalence among specific Asian cultur-
al groups. Asian Americans who are recent
immigrants, highly acculturated, unemployed,
or living in Western states are generally more
likely than other Asian Americans to abuse
drugs or alcohol (Makimoto 1998). For exam-
ple, according to the National Latino and
Asian American Study (NLAAS), Asians who
are more acculturated are at greater risk for
prescription drug abuse (Watkins and Ford
2011).
There are variations among particular groups
of Asians; some Asian cultural groups have
different attitudes toward substance use than
others, and these differences tend to be ob-
scured in large-scale surveys. Researchers have
found that Korean American college students
drank more frequently and drank greater
quantities than did Chinese American stu-
dents at the same schools and were more likely
to consider drinking socially acceptable
(Chang et al. 2008). Another study in the
District of Columbia and surrounding metro-
politan area compared substance use among
different groups of Southeast Asians (i.e.,
Cambodian, Laotian, and Vietnamese
Americans); Vietnamese Americans had the
highest rates of alcohol use, but Cambodian
Americans had the highest rates of illicit drug
use (Wong et al. 2007b). Research in San
Francisco found Chinese Americans to be less
likely than Vietnamese or Filipino Americans
to use illicit drugs, whereas Filipino Americans
had the highest rate of illicit drug use
(Nemoto et al. 1999). In that same study,
Filipino American immigrants were also
significantly more likely to have begun using
substances prior to immigrating than were
Chinese or Vietnamese immigrants. Other
studies have found that Filipino Americans are
more likely to use illicit drugs and to inject
drugs than other Asian American populations
(see review in Nemoto et al. 2002).
To date, the largest national study to assess
substance use and mental disorders across
Asian American groups is the NLAAS
(Takeuchi et al. 2007). This study found that
Filipino American men were 2.38 times more
likely to have a lifetime substance use disorder
than were Chinese American men, whereas
the differences among women of diverse Asian
ethnicities were much smaller. Other research
suggests that Korean Americans are more
likely to have family histories of alcohol de-
pendence than are Chinese Americans
(Ebberhart et al. 2003).
Besides the variations across different cultures,
substance use and abuse among Asian Ameri-
cans is also influenced by age. Substance abuse
appears higher for young Asian Americans
than for those who are older (possibly reflect-
ing differences in acculturation). A study
conducted in New York City showed that
Asian American junior and senior high school
students had the lowest percentage of heavy
drinkers of any ethnic group, but those who
were heavy drinkers drank twice as much daily
as those who did not drink heavily (Makimoto
1998). Asian American youth, especially im-
migrants, tend to start using substances at a
later age than members of other ethnic groups,
which could be a factor in the lower levels of
abuse seen among Asian Americans.
Despite rates of substance use disorders
among Asian Americans having increased over
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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups
time, research has regularly found that, of all
major racial/ethnic groups in United States,
Asian Americans have the lowest rates of
alcohol use disorders (Grant et al. 2004;
SAMHSA 2012b). This phenomenon has
typically been explained in part by the fact
that some Asians lack the enzyme aldehyde
dehydrogenase, which chemically breaks down
alcohol (McKim 2003). Thus, high levels of
acetaldehyde, a byproduct of alcohol metabo-
lism, accumulate and cause an unpleasant
flushing response (Yang 2002). The alcohol
flushing response primarily manifests as flush-
ing of the neck and face but can also include
nausea, headaches, dizziness, and other
symptoms.
Additional factors that could play a part in
increasing the likelihood of substance use
disorders among Asian Americans include
experiences of racism and the absence of
ethnic identification. Compared with Asian
Americans who do not have alcohol use disor-
ders, Asian Americans who have alcohol use
disorders are more than five times as likely to
report unfair treatment because of their race
and are more than twice as likely to deny
strong ethnic identification (Chae et al. 2008).
Compared with other racial and ethnic
groups, Asian Americans who drink heavily
are more likely to have friends or peers who
also drink heavily (Chi et al. 1989).
Mental and Co-Occurring
Disorders
Overall, health and mental health are not
seen as two distinct entities by Asian Ameri-
can cultural groups. Most Asian American
views focus on the importance of virtue,
maturity, and self-control and find full emo-
tional expression indicative of a lack of ma-
turity and self-discipline (Cheung 2009).
Given the potential shame they often associate
with mental disorders and their typically
holistic worldview of health and illness, Asian
Americans are more likely to present with
somatic complaints and less likely to present
with symptoms of psychological distress and
impairment (Hsu and Folstein 1997; Kim et
al. 2004; Room et al. 2001; U.S. Department
of Health and Human Services [HHS] 2001;
Zhang et al. 1998), even though mental illness
appears to be nearly as common among Asian
Americans as it is in other ethnic/racial
groups. In 2009, approximately 15.5 percent of
Asians reported a mental illness in the past
year, but only 2 percent reported past-year
occurrence of serious mental illness (SAMHSA
2012a). Asian Americans have a lower inci-
dence of CODs than other racial/ethnic groups
because the prevalence of substance use disor-
ders in this population is lower. In the 2012
NSDUH, 0.3 percent of Asian Americans
indicated co-occurring serious psychological
distress and substance use disorders, and 1.1
percent had some symptoms of mental distress
along with a substance use disorder—the low-
est rates of any major racial/ethnic group in the
survey (SAMHSA 2013c).
Considerable variation in the types of mental
disorders diagnosed among diverse Asian
American communities is evident, although it
is unclear to what extent this reflects diagnostic
and/or self-selection biases. For example,
Barreto and Segal (2005) found that Southeast
Asians were more likely to be treated for
major depression than other Asians or mem-
bers of other ethnic/racial groups; East Asians
were the most likely of all Asian American
groups to be treated for schizophrenia (nearly
twice as likely as White Americans). Traumat-
ic experiences and PTSD can be particularly
difficult to uncover in some Asian American
clients. Although Asian Americans are as
likely to experience traumatic events (e.g.,
wars experienced by first-generation immi-
grants from countries such as Vietnam and
Cambodia) in their lives, their cultural respons-
es to trauma can conceal its psychological
119
Improving Cultural Competence
effects. For instance, some Asian cultural
groups believe that stoic acceptance is the
most appropriate response to adversity (Lee
and Mock 2005a,b).
Treatment Patterns
Treatment-seeking rates for mental illness are
low among most Asian populations, with rates
varying by specific ethnic/cultural heritage
and, possibly, level of acculturation (Abe-Kim
et al. 2007; Barreto and Segal 2005; Lee and
Mock 2005a,b). Asian Americans who seek
help for psychological problems will most
likely consult family members, clergy, or tradi-
tional healers before mental health profession-
als, in part because of a lack of culturally and
linguistically appropriate mental health ser-
vices available to them (HHS 2001; Spencer
and Chen 2004). However, among those Asian
Americans who seek behavioral health treat-
ment, the amount of services used is relatively
high (Barreto and Segal 2005).
Asian Americans tend to enter treatment with
less severe substance abuse problems than
members of other ethnic/racial groups and
have more stable living situations and fewer
criminal justice problems upon leaving treat-
ment (Niv et al. 2007). However, for Asian
Americans involved in the criminal justice
system, there is a more pronounced relation-
ship between crime and drug abuse than for
other ethnic and racial groups. In the early
1990s, an estimated 95 percent of Asian
Americans in California prisons were there
because of drug-related crimes (Kuramoto
1994). According to SAMHSA’s 2010 TEDS
data, 48.5 percent of Asian Americans in
treatment were referred by the criminal justice
system in that year, compared with 36.4 per-
cent of African Americans and 36.6 percent of
White Americans (SAMHSA, CBHSQ
2012). According to 2010 NSDUH data
regarding individuals who reported a need for
treatment but did not receive it in the prior
year, Asian Americans were also the most
likely of all major racial/ethnic groups to
report that they could not afford or had no
insurance coverage for substance abuse treat-
ment (SAMHSA, CBHSQ 2011).
Beliefs and Attitudes About
Treatment
Compared with the general population, Asian
Americans are less likely to have confidence in
their medical practitioners, feel respected by
their doctors, or believe that they are involved
in healthcare decisions. Many also believe that
their doctors do not have a sufficient under-
standing of their backgrounds and values; this
is particularly true for Korean Americans
(Hughes 2002). Even so, Asian Americans,
especially more recent immigrants, seem more
likely to seek help for mental and substance
use disorders from general medical providers
than from specialized treatment providers
(Abe-Kim et al. 2007). Many Asian American
immigrants underuse healthcare services due to
confusion about eligibility and fears of jeopard-
izing their residency status (HHS 2001).
As with other groups, discrimination, accul-
turation stress, and immigration and genera-
tional status, along with language needs, have
a large influence on behavioral health and
treatment-seeking for Asian Americans (Meyer
et al. 2012; Miller et al. 2011). The NLAAS
found that although rates of behavioral health
service use were lower for Asian Americans
who immigrated recently than for the general
population, those rates increased significantly
for U.S.-born Asian Americans; third-
generation U.S.-born individuals’ rates of ser-
vice use also were relatively high (Abe-Kim et
al. 2007). Of those Asian Americans who had
any mental disorder diagnosis in the prior year,
62.6 percent of third-generation Americans
sought help for it in the prior year compared
with 30.4 percent of first-generation
Americans.
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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups
Overall, Asian Americans place less value on
substance abuse treatment than other popula-
tion groups and are less likely to use such
services (Yu and Warner 2012). Niv et al.
(2007) found that Asian and Pacific Islanders
entering substance abuse treatment programs
in California expressed significantly more
negative attitudes toward treatment and rated
it as significantly less important than did
others entering treatment. Seeking help for
substance abuse can be seen, in some Asian
American cultural groups, as an admission of
weakness that is shameful in itself or as an
interference with family obligations (Masson
et al. 2013). Among 2010 NSDUH respond-
ents who stated a need for substance abuse
treatment in the prior year but did not receive
it, Asian Americans were more likely than
members of all other major racial/ethnic
groups to say that they could handle the prob-
lem without treatment or that they did not
believe treatment would help (SAMHSA
2011c). Combining NSDUH data from 2003
to 2011 NSDUH, Asian Americans who
needed but did not receive treatment in the
past year were the least likely of all major
ethnic/racial groups to express a need for such
treatment (SAMHSA, CBHSQ 2013c).
Treatment Issues and
Considerations
It is important for counselors to approach
presenting problems through clients’ culturally
based explanations of their own issues rather
than imposing views that could alter their
acceptance of treatment. In Asian cultural
groups, the physical and emotional aspects of
an individual’s life are undifferentiated (e.g.,
the physical rather than emotional or psycho-
logical aspect of a problem can be the focus
for many Asian Americans); thus, problems as
well as remedies are typically handled holisti-
cally. Some Asian Americans with traditional
backgrounds do not readily accept Western
biopsychosocial explanations for substance use
and mental disorders. Counselors should
promote discussions focused on clients’ under-
standing of their presenting problems as well
as any approaches the clients have used to
address them. Subsequently, presenting prob-
lems need to be reconceptualized in language
that embraces the clients’ perspectives (e.g., an
imbalance in yin and yang, a disruption in chi;
Lee and Mock 2005a,b). It is advisable to
educate Asian American clients on the role of
the counselor/therapist, the purpose of thera-
peutic interventions, and how particular aspects
of the treatment process (e.g., assessment) can
help clients with their presenting problems
(Lee and Mock 2005a,b; Sue 2001). Asian
American clients who receive such education
participate in treatment longer and express
greater satisfaction with it (Wong et al. 2007a).
As with other racial/ethnic groups, Asian
American clients are responsive to a warm and
empathic approach. Counselors should realize,
though, that building a strong, trusting rela-
tionship takes time. Among Asian American
clients, humiliation and shame can permeate
the treatment process and derail engagement
with services. Thus, it is essential to assess and
discuss client beliefs about shame (see the
“Assessing Shame in Asian American Clients”
advice box on the next page). In some cases,
self-disclosure can be helpful, but the counse-
lor should be careful not to self-disclose in a
way that will threaten his or her position of
respect with Asian American clients.
Asian American clients may look to counse-
lors for expertise and authority. Counselors
should attempt to build client confidence in
the first session by introducing themselves by
title, displaying diplomas, and mentioning his
or her experience with other clients who have
similar problems (Kim 1985; Lee and Mock
2005a,b). Asian American clients may expect
and be most comfortable with formalism on
121
Improving Cultural Competence
the part of counselors, especially at the begin-
ning of treatment and prior to assessment of
clients’ needs (Paniagua 1998). Many Asian
American clients expect counselors to be
directive (Leong and Lee 2008). Passivity on
the part of the counselor can be misinterpret-
ed as a lack of concern or confidence.
Counselors who are unaccustomed to working
with Asian populations will likely encounter
conflict between their theoretical worldview of
counseling and the deference to authority and
avoidance of confrontation that is common
among more traditional Asian American
clients. Some clients can be hesitant to con-
tradict the counselor or even to voice their
own opinions. Confrontation can be seen as
something to avoid whenever possible. Fur-
thermore, many Asian cultural groups have
high-context styles of communication, mean-
ing that members often place greater im-
portance on nonverbal cues and the context of
verbal messages than on the explicit content of
messages (Hall 1976). Asian Americans often
use indirect communication, relying on subtle
gestures, expressions, or word choices to con-
vey meaning without being openly confronta-
tional. Counselors must not only be observant
of nuances in meaning, but also learn about
verbal and nonverbal communication styles
specific to Asian cultural groups (for a review
of guidelines to use when working with Asian
Americans, see Gallardo et al. 2012).
Asian American clients appear to respond
more favorably to treatment in programs that
provide services to other Asian clients.
Takeuchi et al. (1995) found that Asian
Americans were much more likely to return to
mental health clinics where most clients were
Asian American than to programs where that
was not the case (98 percent and 64 percent
returned, respectively). When demographic
differences were controlled for, those who
attended programs that had predominantly
Asian clients were 15 times more likely to
return after the initial visit. Asian Americans
were also more likely to stay in treatment
when matched with an Asian American coun-
selor regardless of the type of program they
attended. Sue et al. (1991) also found that
Asian American clients attended significantly
more treatment sessions if matched with an
Asian American counselor.
Among Asian American women, crucial
strategies include reducing the shame of sub-
stance abuse and focusing on the promotion of
overall health rather than just addressing
substance abuse. Such strategies reduce the
chance of a woman and her family seeing
substance abuse as an individual flaw. Home
visits, when agreed in advance with the client,
can be appropriate in some cases as a way to
gain the trust of, and show respect for, Asian
American women. Asian American women
may not be as successful in mixed-gender
Advice to Counselors: Assessing
Shame in Asian American Clients
Shame and humiliation can be significant barri-
ers to treatment engagement for Asian Ameri-
cans. Gaw (1993) suggests that the presence of
the following factors may indicate that a client
has shame about seeking treatment:
• The client or a family member is extremely
concerned about the qualifications of the
counselor.
• The client is hesitant to involve others in
the treatment process.
• The client is excessively worried about
confidentiality.
• The client refuses to cover expenses with
private insurance.
• The client frequently misses or arrives late
for treatment.
• Family members refuse to support treat-
ment.
• The client insists on having a White Ameri-
can counselor to avoid opening up to an-
other Asian.
• The client refuses treatment even when
severe problems are evident.
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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups
groups if strict gender roles exist whereby
communication is constricted within and out-
side the family; women will likely remain silent
or defer to the men in the group (Chang 2000).
For more information on treating women, see
Treatment Improvement Protocol (TIP) 51,
Substance Abuse Treatment: Addressing the
Specific Needs of Women (CSAT 2009c).
Theoretical Approaches and
Treatment Interventions
Some Asian cultural groups emphasize cogni-
tions. For instance, Asian cultural groups that
have a Buddhist tradition, such as the Chinese,
view behavior as controlled by thought. Thus,
they accept that addressing cognitive patterns
will affect behaviors (Chen 1995). Some Asian
cultural groups encourage a stoic attitude
toward problems, teaching emotional suppres-
sion as a coping response to strong feelings
(Amodeo et al. 2004; Castro et al. 1999b; Lee
and Mock 2005a,b; Sue 2001). Treatment can
be more effective if providers avoid approaches
that target emotional responses and instead
use strategies that are more indirect in discuss-
ing feelings (e.g., saying “that might make
some people feel angry” rather than asking
directly what the client is feeling; Sue 2001).
Asian Americans often prefer a solution-
focused approach to treatment that provides
them with concrete strategies for addressing
specific problems (Sue 2001). Even though
little research is available in evaluating specific
interventions with Asian Americans, clinicians
tend to recommend cognitive–behavioral,
solution-focused, family, and acceptance
commitment therapies (Chang 2000; Hall et
al. 2011; Iwamasa et al. 2006; Rastogi and
Wadhwa 2006; Sue 2001). Asian American
clients are likely to expect that their counselors
take an active role in structuring the therapy
session and provide clear guidelines about
what they expect from clients. CBT has the
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.
123
Improving Cultural Competence
advantages of being problem focused and time
limited, which will likely increase its appeal for
many Asian Americans who might see other
types of therapy as failing to achieve real goals
(Iwamasa et al. 2006). Although specific data
on the effectiveness of CBT among Asian
Americans is not available, there is some
research indicating that CBT is effective for
treating depressive symptoms in Asians (Dai
et al. 1999; Fujisawa et al. 2010). In China, a
Chinese Taoist version of CBT has been
developed to treat anxiety disorders and was
found to be effective, especially in conjunction
with medication (Zhang et al. 2002).
Family therapy
Some Asian Americans, particularly those
who are less acculturated, prefer individual
therapy to group or family interventions be-
cause it better enables them to save face and
keep their privacy (Kuramoto 1994). Some
clients may wish to enter treatment secretly so
that they can keep their families and friends
from knowing about their problems. Once
treatment is initiated, counselors should
strongly reinforce the wisdom of seeking help
through statements such as “you show concern
for your husband by seeking help” or “you are
obviously a caring father to seek this help.”
The norm in Asian families is that “all prob-
lems (including physical and mental problems)
must be shared only among family members”;
sharing with others can cause shame and guilt,
exacerbating problems (Paniagua 1998, pp.
59–60). Counselors should expect to take
more time than usual to learn about clients’
situations, anticipate client needs for reassur-
ance in divulging sensitive information, and
frame discussions in a culturally competent
way. For example, counselors can assure cli-
ents that discussing problems is a step toward
resuming their full share of responsibility in
their families and removing some of the stress
their families have been feeling.
For most Asian Americans, particularly those
who are less acculturated, successful treatment
involves the client’s family (Chang 2000; Kim
et al. 2004; Rastogi and Wadhwa 2006). Even
in individual treatment, it is important to
understand the client’s family and his or her
relationship with its members, the dynamics
and style of the family, and the family’s role in
the client’s substance abuse (Meyer et al.
2012). Particularly among Asian American
women, family involvement can be essential
due to the client’s concern about being re-
sponsive to her family’s needs. Nonetheless,
involving the family can be quite difficult, as
both male and female clients may wish to
conceal their substance abuse from their fami-
lies because of the shame that it brings.
Advice to Counselors: Culturally
Responsive Family Therapy
Guidelines for Asian Families
Kim et al. (2004) reviewed references that
provide guidelines for family therapy with
Korean Americans. They established 11 essen-
tial ingredients applicable to Korean and other
Asian American groups and families. To pro-
vide culturally responsive therapy to Asian
Americans, counselors should:
• Assess support from community and ex-
tended family systems.
• Assess immigration history, if appropriate.
• Establish credibility as a professional in the
initial meeting with the family.
• Explain the key principles and expectations
of family therapy and the family roles (es-
pecially elders/decisionmakers) in the pro-
cess.
• Enable clients, particularly male elders or
decisionmakers, to save face.
• Validate and address somatic complaints.
• Be both problem focused and present
focused.
• Be directive in guiding therapy.
• Respect the family’s hierarchy.
• Avoid being confrontational and facilitate
interactions that are nonconfrontational.
• Reframe problems in positive terms.
Source: Kim et al. 2004.
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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups
To engage family members in the client’s
treatment, the counselor first needs to be
familiar with the way the family functions.
Different acculturation levels among individu-
al family members and across generations can
affect how the family functions, producing
significant stress and internal conflict. Also,
the counselor must be aware of how gender
roles and generational status influence the
communication patterns and rules within each
family (e.g., expectations of how a child ad-
dresses a parent, the potential relegation of
authority among female family members).
Even more than for other clients, it is critical
for Asian Americans to “avoid embarrassing
the family members in front of each other.
The counselor should always protect the
dignity and self-respect of the client and his or
her family” (Paniagua 1998, p. 71).
Group therapy
Group therapy may not be a good choice for
Asian Americans, as many prefer individual
therapy (Lai 2001; Sandhu and Malik 2001).
Paniagua (1998, p. 73) suggests that “group
therapy…would be appropriate in those cases
in which the client’s support system (relatives
and close friends) is not available and an
alternative support system is quickly needed.”
Some Asian Americans participating in group
therapy will find it difficult to be assertive in a
group setting, preferring to let others talk.
They can also abide by more traditional roles
in this context; men might not want to divulge
their problems in front of women, women can
feel uncomfortable speaking in front of men,
and both men and women might avoid con-
tradicting another person in group (especially
an older person). It may not make sense to
Asian American clients to hear about the
problems of strangers who are not part of their
community.
Asian Americans are likely to be motivated to
work for the good of the group; presenting
group goals in this framework can garner
active participation. Still, in group settings and
in other instances, Asian American clients
may expect a fair amount of direction from the
group leader. Chen (1995) described leader-
ship of a culturally specific therapy group for
Chinese Americans, noting that clients expect
a group leader to act with authority and give
more credence to his or her expertise than to
other group members. If members of the
group belong to the same Asian American
community, the issue of confidentiality will
loom large, because the community is often
small. Asian cultural groups generally appreci-
ate education in more formal settings, so
psychoeducation groups can work well for
Asian Americans. It is possible for a psy-
choeducational group with Asian American
participants to evolve comfortably into group
therapy.
Mutual-help groups
According to 2012 NSDUH data, Asian
Americans were less likely than other racial
and ethnic groups to report the use of mutual-
help groups in the past year (SAMHSA
2013d). Mutual-help groups can be challeng-
ing for Asian Americans who find it difficult
and shaming to self-disclose publicly. The
degree of emotion and candor within these
groups can further alienate traditional Asian
American clients. Furthermore, linguistically
appropriate mutual-help groups are not always
available for people who do not speak English.
Highly acculturated Asian Americans may
perceive participation in mutual-help groups
as less of a problem, but nevertheless, Asian
Americans can benefit from culture-specific
mutual-help groups where norms of interper-
sonal interaction are shared. Asian American
12-Step groups are available in some locales.
It is important for counselors to assess client
attitudes toward mutual-help participation
and find alternative strategies and resources,
125
Improving Cultural Competence
including encouragement to attend without
sharing (Sandhu and Malik 2001).
Although they are not mutual-help groups in
the traditional sense, mutual aid societies and
associations are important in some Asian
American communities. Some mutual aid
societies have long histories and have provided
assistance ranging from financial loans to help
with childcare and funerals. The Chinese have
family associations for people with the same
last name who share celebrations and offer
each other help. Japanese, Chinese, and South
Asians have specific associations for people
from the same province or village. For some
Asian American groups, such as Koreans,
churches are the primary organizational vehi-
cles for assistance. These social support groups
can be important resources for Asian American
clients, their families, and the behavioral
health agencies that provide services to them.
Traditional healing and
complementary methods
Asian Americans are twice as likely as other
Americans to report making use of acupunc-
ture and traditional healers. Even though there
is considerable variation in their use of com-
plementary and traditional medicine (Hughes
2002), many Asian Americans highly regard
traditional healers, herbal preparations, and
other culturally specific interventions as a
means of restoring harmony and balance.
However, Asian American clients do not
always readily disclose the use of traditional
medicine to Western treatment providers. Ahn
et al. (2006) found that about two-thirds of
Chinese and Vietnamese Americans who
spoke no or limited English had used tradi-
tional medicine, but only 7.6 percent had
discussed the use of these therapies with their
Western medical providers.
Traditional treatment to restore physical and
emotional balance for Asian Americans occurs
through a variety of culture-specific interven-
tions. For example, some Southeast Asian
cultural groups practice cao gio—massaging
the skin with ointment and hot coins (Chan
and Chen 2011). The Chinese have developed
enormously complex systems of medical
treatment over centuries of pragmatic experi-
mentation. Traditional herbal medicine com-
bines plant substances according to precise
formulas to have the desired influence on the
affected organs of the body. Acupuncture
techniques involve regulating the flow of
energy (qi) through the body by inserting
needles at precise locations called acupuncture
points. In traditional Chinese medicine, which
has influenced traditional medical practices in
other Asian cultural groups, illness is seen as
an imbalance of yin and yang; a return to
physical wellness can require introducing
elements such as herbs to increase yin or yang
as needed (Torsch and Ma 2000).
Among less acculturated Asian Americans,
Western medicine, including Western behav-
ioral health services, can be insufficient to deal
with a problem such as substance abuse and its
effects on clients and their families. For exam-
ple, all health problems for the Hmong
(whether physical or psychological) are con-
sidered spiritual in nature; if providers ignore
the clients’ understanding of their problems as
spiritual maladies, they are unlikely to effect
positive change (Fadiman 1997). Even for
more acculturated Asian Americans, the use of
traditional healing methods and spirituality
can be a very important aspect of treatment
(see Chan and Chen 2011 for an overview of
health beliefs and practices). Such use can
provide a spiritual connection that helps man-
age feelings that are especially difficult to
express to others. Many practices associated
with meditation, yoga, and Eastern religious
traditions can help disperse the stress and
anxiety experienced during treatment and
recovery. In the United States, there are few
126
Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups
Behavioral Health Counseling for Native Hawaiians and Other Pacific Islanders
The ancestors of Native Hawaiians and other Pacific Islanders were the original inhabitants of Hawaii,
Guam, 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, Samoans, 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, cannabis, 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.
127
Improving Cultural Competence
examples of culturally specific treatment pro-
grams that focus on Asian religious or spiritual
treatment; however, there are programs over-
seas, such as the Thai Buddhist treatment
center described by Barrett (1997).
Asian Americans are much more likely than
members of other racial/ethnic groups to label
themselves as secular, agnostic, or atheist
(Kosmin and Keysar 2009; Pew Forum on
Religion and Public Life 2008). That said, a
substantial number of Asian Americans still
have religious affiliations. About 45 percent
are Protestant; 17 percent, Catholic; 14 per-
cent, Hindu; 9 percent, Buddhist; and 4 per-
cent, Muslim (Pew Forum on Religion and
Public Life 2008). More acculturated Asian
Americans are likely to enter treatment
through medical settings and to be comforta-
ble with a medical model for treatment, but
those who are less acculturated or are foreign-
born can prefer the use of traditional healing
and/or religious traditions and beliefs as part
of their treatment (Ja and Yuen 1997). Reli-
gious institutions can play an important part
in the treatment of some groups of Asian
Americans. For example, Kwon-Ahn (2001)
notes that many Korean Americans, particu-
larly more recent immigrants, turn to Chris-
tian clergy or church groups for assistance
with family and personal problems, such as
substance abuse, before seeking professional
help. Amodeo et al. (2004) suggest that, in
working with Cambodian immigrants, provid-
ers integrate Buddhist philosophy and practic-
es into treatment, and, if possible, partner with
Buddhist temples to facilitate treatment entry
or to provide services for clients who choose
to reside in Buddhist temples.
Relapse prevention and recovery
Little research has evaluated relapse preven-
tion and recovery promotion strategies specifi-
cally for Asian Americans. However, issues
involving shame can make the adjustment to
abstinence difficult for Asian clients. Counse-
lors should take this into account and address
difficulties that can arise for clients with fami-
lies who have shame about mental illness or
substance use disorders. To date, there are no
indications that standard approaches are un-
suitable for Asian American clients. For more
information on these approaches, see the
planned TIP, Relapse Prevention and Recovery
Promotion in Behavioral Health Services
(SAMHSA planned e).
Counseling for Hispanics
and Latinos
The terms “Hispanic” and “Latino” refer to
people whose cultural origins are in Spain and
Portugal or the countries of the Western
Hemisphere whose culture is significantly
influenced by Spanish or Portuguese coloniza-
tion. Technically, a distinction can be drawn
between Hispanic (literally meaning people
from Spain or its former colonies) and Latino
(which refers to persons from countries ranging
from Mexico to Central and South America
and the Caribbean that were colonized by
Spain, and also including Portugal and its
former colonies); this TIP uses the more
inclusive term (Latino), except when research
specifically indicates the other. The term
“Latina” refers to a woman of Latino descent.
Latinos are an ethnic rather than a racial
group; Latinos can be of any race. According
to 2010 Census data, Latinos made up 16
percent of the total United States population;
they are its fastest growing ethnic group (Ennis
et al. 2011). Latinos include more than 30
national and cultural subgroups that vary by
national origin, race, generational status in the
United States, and socioeconomic status
(Padilla and Salgado de Snyder 1992;
Rodriguez-Andrew 1998). According to Ennis
et al. (2011), of Latinos currently living in the
United States (excluding Puerto Rico and
128
Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups
other territories), Mexican Americans are the
largest group (63 percent), followed by Central
and South Americans (13.4 percent), Puerto
Ricans (9.2 percent), and Cubans (3.5 percent).
Beliefs About and Traditions
Involving Substance Use
Attitudes toward substance use vary among
Latino cultural groups, but Latinos are more
likely to see substance use in negative terms
than are White Americans. Marin (1998)
found that Mexican Americans were signifi-
cantly more likely to expect negative conse-
quences and less likely to expect positive
outcomes as a result of drinking than were
White Americans. Similarly, Hadjicostandi
and Cheurprakobkit (2002) note that most
Latinos believe that prescription drug abuse
could have dangerous effects (85.7 percent),
that individuals who abuse substances cause
their whole families to suffer (81.4 percent),
and that people who use illicit drugs will
participate in violent crime (74.9 percent) and
act violently toward family members (78.9
percent). Driving under the influence of alco-
hol is one of the most serious substance use
problems in the Latino community.
Other research suggests that some Latinos
hold different alcohol expectancies. When
comparing drinking patterns and alcohol
expectancies among college students, Velez-
Blasini (1997) found that Puerto Rican partic-
ipants were more likely than other students to
see increased sociability as a positive expectan-
cy related to drinking and sexual impairment
as a negative expectancy. Puerto Rican partici-
pants were also significantly more likely to
report abstinence from alcohol. In another
study comparing Puerto Ricans and Irish
Americans, Puerto Rican participants who
expected a loss of control when drinking had
fewer alcohol-related problems, whereas Irish
Americans who expected a loss of control had
a greater number of such problems (Johnson
and Glassman 1999). The authors concluded
that “losing control” has a different cultural
meaning for these two groups, which in turn
affects how they use alcohol.
For many Latino men, drinking alcohol is a
part of social occasions and celebrations. By
contrast, solitary drinking is discouraged and
seen as deviant. Social norms for Latinas are
often quite different, and those who have
substance abuse problems are judged much
more harshly than men. Women can be per-
ceived as promiscuous or delinquent in meet-
ing their family duties because of their
substance use (Hernandez 2000). Amaro and
Aguiar (1995) note that the heavy emphasis
on the idealization of motherhood contributes
to the level of denial about the prevalence of
substance use among Latinas. Women who
use injection drugs feel the need to maintain
their roles as daughters, mothers, partners, and
community members by separating their drug
use from the rest of their lives (Andrade and
Estrada 2003), yet research suggests that
substance abuse among women does not go
unrecognized within the Latino community
(Hadjicostandi and Cheurprakobkit 2002).
Among families, Latino adults generally show
strong disapproval of alcohol use in adoles-
cents of either gender (Flores-Ortiz 1994).
Adults of both genders generally disapprove of
the initiation of alcohol use for youth 16 years
of age and under (Rodriguez-Andrew 1998).
Long (1990) also found that even among
Latino families in which there has been multi-
generational drug abuse, young people were
rarely initiated into drug abuse by family
members. However, evidence regarding paren-
tal substance use and its influence on youth
has been mixed; most studies show some
correlation between parental attitudes toward
alcohol use and youth drinking (Rodriguez-
Andrew 1998). For instance, research with
college students found that family influences
129
Improving Cultural Competence
had a significant effect on drinking in Latinos
but not White Americans; the magnitude of
this effect was greater for Latinas than for
Latino men (Corbin et al. 2008).
Substance Use and Substance Use
Disorders
According to 2012 NSDUH data, rates of
past-month illicit substance use, heavy drink-
ing, and binge drinking among Latinos were
lower than for White Americans, Blacks, and
Native Americans, but not significantly so
(SAMHSA 2013d). The same data showed
that 8.3 percent of Latinos reported past-
month illicit drug use compared with 9.2
percent of White Americans and 11.3 percent
of African Americans.
Although data are available from a number of
studies regarding Latino drinking and drug
use patterns, more targeted research efforts are
needed to unravel the complexities of sub-
stance use and the many factors that affect use,
abuse, and dependence among subgroups of
Latino origin (Rodriguez-Andrew 1998). For
example, some studies show that Latino men
are more likely to have an alcohol use disorder
than are White American men (Caetano
2003), whereas others have found the reverse
to be true (Schmidt et al. 2007). Disparities
in survey results may reflect varying efforts to
develop culturally responsive criteria (Carle
2009; Hasin et al. 2007). The table in Exhibit
5-2 shows lifetime prevalence of substance
use disorders among Latinos based on
Exhibit 5-2: Lifetime Prevalence of Substance Use Disorders According to Ethnic
Subgroup and Immigration Status
Ethnic
Subgroup
Any
Substance Use
Disorder, %
Alcohol
Abuse, %
Alcohol
Dependence,
%
Drug
Abuse, %
Drug
Dependence,
%
Puerto Ricans
(born in the U.S.
mainland)
15.9 7.7 5.6 4.6 4.3
Puerto Ricans
(born in
Puerto Rico)
11.1 4.6
5.3
4.3 3.6
Cuban
Americans (born in
the U.S.)
20.9 6.5 8.2 3.6 5.7
Cuban
Americans
(foreign-born)
6.4 3.4 2.2 2.2 1.9
Mexican Ameri-
cans (born in the
U.S.)
21.4 9.4 7.7 5.8 5.3
Mexican Ameri-
cans (foreign-born)
7 3.5 2.8 2.0 1.7
Other Latino (born
in the U.S.)
20.4 10.4 5.3 8.4 5.2
Other Latino
(foreign-born)
5.7 3.2 2.2 2.1 1.0
Source: Alegria et al. 2008a.
130
Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups
immigration status and ethnic subgroup
(Alegria et al. 2008a).
Among diverse Latino cultural groups, differ-
ent patterns of alcohol use exist. For example,
some older research suggests that Mexican
American men are more likely to engage in
binge drinking (having five or more drinks at
one time; drinking less frequently, but in
higher quantities) than other Latinos but use
alcohol less frequently (Caetano and Clark
1998). There are also differences regarding the
abuse of other substances. Among Latinos
entering substance abuse treatment in 2006,
heroin and methamphetamine use were espe-
cially high among Puerto Ricans and Mexican
Americans, respectively. Other research has
found that Puerto Ricans are more likely to
inject drugs and tend to inject more often
during the course of a day than do other
Latinos (Singer 1999).
Patterns of substance use are also linked to
gender, age, socioeconomic status, and accul-
turation in complex ways (Castro et al. 1999a;
Wahl and Eitle 2010). For instance, increased
frequency of drinking is associated with great-
er acculturation for Latino men and women,
yet the drinking patterns of Latinas are affect-
ed significantly more than those of Latino
men (Markides et al. 2012; Zemore 2005).
Age appears to influence Latino drinking
patterns somewhat differently than it does for
other racial/ethnic groups. Research indicates
that White Americans often “age out” of
heavy drinking after frequent and heavy alco-
hol use in their 20s, but for many Latinos,
drinking peaks between the ages 30 and 39.
Latinos in this age range have the lowest
abstention rates and the highest proportions
of frequent and heavy drinkers of any age
group (Caetano and Clark 1998). In the same
study, Latino men between 40 and 60 years of
age had higher rates of substance use disorders
than men in the same age group across other
racial/ethnic populations.
Latino youth appear to start using illicit drugs
at an earlier age than do members of other
major ethnic/racial groups. Cumulative data
from 28 years of the Monitoring the Future
Study show Latino eighth graders as having
higher rates of heavy drinking, marijuana use,
cocaine use, and heroin use than African or
White Americans in the same grade. Among
youth in grade 12, the rates of use among
Latino and White American students are
more similar, but Latinos still had the highest
rates of crack cocaine and injected heroin use
(Johnston et al. 2003).
Patterns of substance use and abuse vary based
on Latinos’ specific cultural backgrounds.
Among Latinos, rates of past-year alcohol
dependence were higher among Puerto Rican
and Mexican American men (15.3 percent and
15.1 percent, respectively) than among
South/Central American or Cuban American
men (9 percent and 5.3 percent, respectively).
Among Latinas, past-year alcohol dependence
rates were significantly higher for Puerto
Rican women (6.4 percent) than for Mexican
American (2.1 percent), Cuban American (1.6
percent), or South/Central American (0.8
percent) women (Caetano et al. 2008).
Mental and Co-Occurring
Disorders
As with other populations, it is important to
address CODs in Latino clients, as CODs
have been associated with higher rates of
treatment dropout (Amodeo et al. 2008).
There are also reports of diagnostic bias, sug-
gesting that some disorders are underreported
and others are overreported. Minsky et al.
(2003) found that, at one large mental health
treatment site in New Jersey, major depression
was overdiagnosed among Latinos, especially
Latinas, whereas psychotic symptoms were
131
Improving Cultural Competence
sometimes ignored. Among Latinos with
CODs, other mental disorders preceded the
development of a substance use disorder 70
percent of the time (Vega et al. 2009).
Overall, research indicates fewer mental disor-
ders and CODs among Latinos than among
White Americans (Alegria et al. 2008a; Vega
et al. 2009). However, data from the 2012
NSDUH indicate that the magnitude of the
difference may be decreasing; 1.2 percent of
Latinos had both serious mental illness and
substance use disorders in the prior year, as did
White Americans, similar to the rate seen
among African Americans (0.9 percent;
SAMHSA 2013c). When any mental disorder
symptoms co-occurring with a substance use
disorder diagnosis were evaluated, Latinos had
a slightly higher rate of co-occurrence (3.4
percent) than did African Americans (3.3
percent; SAMHSA 2013c). Rates of mental
disorders and CODs also vary by Latino
subgroup (Alegria et al. 2008a), and accultura-
tion can play a confounding, but inconsistent,
role in the identification and development of
CODs in Latino populations (Alegria et al.
2008a; Vega et al. 2009).
Treatment Patterns
Barriers to treatment entry for Latinos in-
clude, but are not limited to, lack of Spanish-
speaking service providers, limited English
proficiency, financial constraints, lack of cul-
turally responsive services, fears about immi-
gration status and losing custody of children
while in treatment, negative attitudes toward
providers, and discrimination (Alegria et al.
2012; Mora 2002). Among all ethnic/racial
groups included in the 2010 NSDUH, Lati-
nos were the most likely to report that they
had a need for treatment but did not receive it
because they could not find a program with
the appropriate type of treatment or because
there were no openings in programs that they
wished to attend, which may reflect a lack of
linguistically and/or culturally appropriate
services (SAMHSA 2011c). They were about
twice as likely to state the former and four
times as likely to state the latter as members of
the group that was the next most likely to
make such statements.
A significant problem prohibiting participa-
tion in substance abuse treatment among
Latinos is the lack of insurance coverage to
pay for treatment. In SAMHSA’s 2010
NSDUH, 32 percent of Latinos who needed
but did not receive substance abuse treatment
in the past year reported that they lacked mon-
ey or insurance coverage to pay for it compared
with 29.5 percent of White Americans and
33.5 percent of African Americans
(SAMHSA 2011c). Other national surveys
also found that Latinos with self-identified
drinking problems were significantly more
likely than either White Americans or African
Americans to indicate that they did not seek
treatment because of logistical barriers, such as
a lack of funds or being unable to obtain
childcare (Schmidt et al. 2007).
Latinos with substance use disorders are about
as likely to enter substance abuse treatment
programs as White Americans (Hser et al.
1998; Perron et al. 2009; Schmidt et al. 2006).
Latinos tend to enter treatment at a younger
age than either African Americans or White
Americans (Marsh et al. 2009). There are also
significant differences in treatment-seeking
patterns among Latino cultural groups. For
example, Puerto Ricans who inject heroin are
much more likely to participate in methadone
main-tenance and less likely to enter other
less-effective detoxification programs than
are Dominicans, Central Americans, and
other Latinos (Reynoso-Vallejo et al. 2008).
The researchers note, however, that this could
be due partially to the fact that Puerto Ricans,
compared with other Latinos, have a greater
awareness of treatment options.
132
Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups
Beliefs and Attitudes About
Treatment
In general, Latino attitudes toward health care
are shaped by a lack of access to regular quality
care, including inability to afford it (see review
of health beliefs and help-seeking behaviors
among Mexican Americans and Mexicans
dwelling in the United States in Rogers 2010).
DeNavas-Walt et al. (2006) found that Lati-
nos are less likely to have health insurance
(32.7 percent were uninsured in 2005) than
either non-Latino White Americans (11.3
percent were uninsured) or African Americans
(19.6 percent were uninsured). They are also
less likely to have had a regular place to go for
conventional medical care (Schiller et al.
2005). Lack of knowledge about available
services can be a major obstacle to seeking
services (Vega et al. 2001). In their review,
Murguia et al. (2000) identified several factors
that influence the use of medical services,
including cultural health beliefs, demographic
barriers, level of acculturation, English profi-
ciency, accessibility of service providers, and
flexibility of intake procedures; they found
that many Latinos only seek medical care for
serious illnesses.
Research on substance abuse indicates that
Latinos who use illicit drugs appear to have
relatively unfavorable attitudes toward treat-
ment and perceive less need for treatment than
do illicit drug users among every other major
ethnic and racial group but Native Americans
(Brower and Carey 2003). However, in the
2011 NSDUH, Latinos were more likely than
White Americans, African Americans, or
Asian Americans to indicate that they had a
need for substance abuse treatment in the
prior year but did not receive it (SAMHSA
2012b). Other studies have found that Latinos
with substance use disorders are about as likely
to enter substance abuse treatment programs
as other racial and ethnic groups (Hser et al.
1998; Perron et al. 2009; Schmidt et al. 2006).
Latinos who receive substance abuse treatment
also report less satisfaction with the services
they receive than White or African Americans
(Wells et al. 2001). Even when receiving a
level of substance abuse treatment services
comparable to those received by White and
African Americans, Latinos are more likely to
be dissatisfied with treatment (Tonigan 2003).
Treatment Issues and
Considerations
Latino clients’ responsiveness to therapy is
influenced not only by counselor and program
characteristics, but also by individual charac-
teristics, including worldview, degree of accul-
turation, gender orientation, religious beliefs,
and personality traits. As with other cultural
groups, efforts to establish clear communica-
tion and a strong therapeutic alliance are
essential to positive treatment outcomes
among Latino clients. Foremost, counselors
should recognize the importance of—and
integrate into their counseling style and ap-
proach—expressions of concern, interest in
clients’ families, and personal warmth (person-
alismo; Ishikawa et al. 2010).
Counselors and clinical supervisors need to be
educated about culturally specific attributes
that can influence participation and clinical
interpretation of client behavior in treatment.
For instance, some Latino cultural groups view
time as more flexible and less structured; thus,
rather than negatively interpreting the client’s
behavior regarding the keeping of strict
schedules or appointment times, counselors
should adopt scheduling strategies that pro-
vide more flexibility (Alvarez and Ruiz 2001;
Sue 2001). However, counselors should also
advise Latino clients of the need to take rele-
vant actions with the aim of arriving on time
for each appointment or group session. Coun-
selors should try to avoid framing noncompli-
ance in Latino clients as resistance or anger. It
133
Improving Cultural Competence
is often, instead, a pelea nonga (relaxed fight)
showing both a sense of being misunderstood
and respeto (respect that also encompasses a
sense of duty) for the counselor’s authority
(Barón 2000; Medina 2001).
Unfortunately, many providers who work with
Latino cultural groups continue to have mis-
perceptions and can even see culture as a
hindrance to effective treatment rather than as
a source of potential strength (Quintero et al.
2007). For instance, in treating the alcohol
problems of Latinas, many counselors believe
that they should not incorporate endorsement
of traditional and possibly harmful cultural
patterns into the services they provide (Mora
2002). However, other counselors note that
the transformative value of the most positive
aspects of Latino cultural groups can be em-
phasized: strength, perseverance, flexibility,
and an ability to survive (Gloria and Peregoy
1996). Respecting women’s choices can mean
supporting empowerment to pursue new roles
and make new choices free of alcohol, guilt,
and discrimination (Mora 2002). For others, it
can mean reinvigorating the positivity of
Latina culture to promote abstinence while
respecting and maintaining traditional family
roles for women (Gloria and Peregoy 1996).
Because some research has found that Latinos
have higher rates of treatment dropout than
other populations (Amaro et al. 2006), pro-
grams working with this population should
consider ways to improve retention and out-
comes. Treatment retention issues for Latinos
can be similar to those found for other popu-
lations (Amodeo et al. 2008), but culturally
specific treatment has been associated with
better retention for Latinos (Hohman and
Galt 2001). Research evaluating ethnic match-
ing with brief motivational interventions also
found more favorable substance abuse treat-
ment outcomes at 12-month follow-up when
clients and providers were ethnically matched
(Field and Caetano 2010). Available literature
and research highlight four main themes sur-
rounding general counseling issues and pro-
grammatic strategies for Latinos, as follows.
Socializing the client to treatment:
Latino
clients are likely to benefit from orientation
sessions that review treatment and counseling
processes, treatment goals and expectations,
and other components of services (Organista
2006).
Reassurance of confidentiality:
Regardless of
the particular mode of therapy, counselors
should explain confidentiality. Many Latinos,
especially undocumented workers or recent
immigrants, are fearful of being discovered by
authorities like the United States Citizenship
and Immigration Services and subsequently
deported back to their countries of origin
(Ramos-Sanchez 2009).
Client–counselor matching based on gen-
der:
To date, research does not provide con-
sistent findings on client–counselor matching
based on similarity of Latino ethnicity. How-
ever, client–counselor matching based on
gender alone appears to have a greater effect
on improving engagement and abstinence
among Latinos than it does for clients of other
ethnicities (Fiorentine and Hillhouse 1999).
Client
–
program matching:
Matching clients
to ethnicity-specific programs appears to
improve outcomes for Latinos. Takeuchi et al.
(1995) found that only 68 percent of Mexican
American clients in programs that had a
majority of White American clients returned
after the first session compared with 97 per-
cent in those programs where the majority of
clients were Mexican American.
Theoretical Approaches and
Treatment Interventions
Overall, research evaluating cultural adoption
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
(Carvajal and Young 2009). For instance,
empirical literature evaluating CBT specifical-
ly for substance abuse and substance use dis-
orders in Latinos is quite limited. Still, a
number of authors recommend CBT for
Latinos in mental health and substance abuse
treatment settings because it is action oriented,
problem focused, and didactic (Alvarez and
Ruiz 2001; Organista 2006; Organista and
Muñoz 1998). CBT’s didactic component can
educate Latinos about disorders and frame
therapy as an educational (and hence less
shameful) experience. However, Organista’s
(2006) review of available research on CBT
for mental disorders among Latinos suggests
that this approach is not always as effective
with Latinos as it is with other populations.
Other effective interventions include contin-
gency management and motivational inter-
viewing; see the review by Amaro et al. (2006)
for more on these interventions. Methadone
maintenance, too, has been associated with
long-term reductions in the use of alcohol as
well as heroin and other illicit drugs among
Mexican Americans with opioid use disorders,
although 33 percent of the original cohort
died before the 22-year longitudinal study
concluded (Goldstein and Herrera 1995).
Another therapeutic intervention that can
improve outcomes for Latino clients is node-
link mapping (visual representation using
information diagrams, fill-in-the blank graph-
ic tools, and client-generated diagrams or
visual maps), which has been associated with
lower levels of opioid and cocaine use, better
treatment attendance, and higher counselor
ratings of motivation and confidence for
Latinos in methadone maintenance treatment
(Dansereau et al. 1996; Dansereau and Simp-
son 2009). For a review of Latino outcome
studies in health, substance abuse, and mental
health in social work, refer to Jani and col-
leagues (2009).
Family therapy
Family therapy is often recommended for
treating Latinos with substance use disorders
(Amaro et al. 2006; Barón 2000; Hernandez
2000). Although there is little research evalu-
ating the effectiveness of family therapy for
adults, both multidimensional family therapy
(Liddle 2010) and brief strategic family thera-
py (Santisteban et al. 1997; Santisteban et al.
2003; Szapocznik and Williams 2000) have
been found to reduce substance use and im-
prove psychological functioning among Latino
youth. The term familismo
refers to the cen-
trality of the family in Latino culture and can
include valuing and protecting children, re-
specting the elderly, preserving the family
name, and consulting with one another before
making important decisions. As highlighted in
the case study of a Puerto Rican client on the
next page, counselors must consider the poten-
tially pivotal roles families can play in support-
ing treatment and recovery. Latino families are
likely to have a strong sense of obligation and
commitment to helping their members, in-
cluding those who have substance use disor-
ders. Even so, the level of family support for
people who have substance use or mental
disorders varies among Latinos depending on
country of origin, level of acculturation, degree
of family cohesion, socioeconomic status, and
factors related to substance use (Alegria et al.
2012). For example, Reynoso-Vallejo et al.
(2008) concluded that significantly higher
rates of homelessness found among people
from Central American countries who inject-
ed heroin compared with other Latinos could
stem from lower levels of tolerance for injec-
tion drug use among their families.
For counselors who lack cultural understand-
ing, it can be easy to simply label and judge
families’ behavior as enabling or codependent.
Instead, counselors should move away from
labeling the behavior and focus more on help-
ing families recognize how their behavior can
135
Improving Cultural Competence
affect one member’s substance abuse and how
best to handle it. The advice box on the next
page provides general therapeutic guidelines
for working with Latino families.
Group therapy
Little information is available concerning
Latinos’ preferences in behavioral health
services, but a study evaluating mental health
treatment preferences for women in the Unit-
ed States found that Latinas were significantly
more likely to prefer group treatment
(Nadeem et al. 2008). According to Paniagua
(1998), the use of group therapy with Latino
clients should emphasize a problem-focused
approach. Group leaders should allow mem-
bers to learn from each other and resist func-
tioning as a content expert or a representative
of the rules of the system. Otherwise, mem-
bers could see group therapy as oppressive.
Facilitators in groups consisting mostly of
Latino clients must establish trust, responsibil-
ity, and loyalty among members. In addition,
acculturation levels and language preferences
should be assessed when forming groups so
that culturally specific or Spanish-speaking
groups can be made available if needed.
Mutual-help groups
Findings on the usefulness of 12-Step groups
for Latino clients are inconsistent. Member-
ship surveys of AA indicate that Latinos
comprise about 5 percent of AA membership
(AAWS 2012). Latinos who received inpatient
treatment were less likely to attend AA than
White Americans (Arroyo et al. 1998). Rates
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.
136
Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups
Advice to Counselors: Family Therapy
Guidelines for Latino Families
• Provide bilingual services.
• Use family therapy as a primary method of
treatment.
• Assess cultural identity and acculturation
level for each family member.
• Determine the family’s level of belief in
traditional and complementary healing
practices; integrate these as appropriate.
• Discuss the family’s beliefs, history, and
experiences with standard American be-
havioral health services.
• Explore migration and immigration experi-
ences, if appropriate.
• Provide additional respect to the father or
father figure in the family.
• Interview family members or groups of
family members (e.g., children) separately
to allow them to voice concerns.
• Generate solutions with the family. Do not
force changes in family relationships.
• Provide specific, concrete suggestions for
change that can be quickly implemented.
• Focus on engaging the family in the first
session using warmth and personalismo.
Sources: Bean et al. 2001; Hernandez 2005;
Lynch and Hanson 2011.
of mutual-help participation among people
with drug use disorders are also lower for
Latinos (Perron et al. 2009). Language can
present a barrier to mutual-help group partici-
pation for Spanish-speaking Latinos; however,
Spanish-language meetings are held in some
locations. Counselors should consider the
appropriateness of 12-Step participation on a
case-by-case basis (Alvarez and Ruiz 2001).
For example, Mexican American men who
identify with attitudes of machismo can feel
uncomfortable with the 12-Step approach.
Concern about divulging family issues in public
can cause hesitation to address substance-
related problems in public meetings.
For Latinos who do participate in 12-Step
programs, findings suggest higher rates of
abstinence, degree of commitment, and level
of engagement than for White American
participants (Hoffman 1994; Tonigan et al.
1998). For some Latinos, 12-Step groups can
appeal to religious and spiritual beliefs. Her-
nandez (2000) suggests that mutual-help
groups composed solely of Latinos make it
easier for participants to address the cultural
context of substance abuse. Some Latino 12-
Step groups do not hold that substance abuse
is a biopsychosocial problem, instead concep-
tualizing the disorder as a weakness of charac-
ter that must be corrected. Hoffman (1994)
studied Latino 12-Step groups in Los Angeles
and observed that, in addition to a more
traditional form of AA, there were groups that
practiced terapia dura (i.e., rough therapy),
which often uses a confrontational approach
and endorses family values related to machismo
(e.g., by reinforcing that overcoming substance
abuse rather than drinking is manly). Howev-
er, these groups were not overly welcoming of
female members and gay men. In such cases,
gay Latino men and Latinas can benefit from
attending 12-Step groups that are not cultur-
ally specific or that do not use terapia dura.
Traditional healing and
complementary methods
In a study of the use of alternative and com-
plementary medical therapies, Latinos were
less likely to use medical alternatives than
were White Americans (Graham et al. 2005).
However, those who did use such approaches
were more likely to do so because they could
not afford standard medical care (Alegria et al.
2012). As in other areas, the use of comple-
mentary and traditional medicine likely varies
according to acculturation level and country of
origin. For instance, the use of faith and reli-
gious practices to cope with mental and emo-
tional problems is significantly more common
among foreign-born Latinos than among
those born in the United States (Nadeem et al.
2008; Vega et al. 2001).
137
Improving Cultural Competence
Many Latinos place great importance on the
practice of Roman Catholicism. Yamamoto
and Acosta (1982) describe the central tenets
of Latino Catholicism as sacrifice, charity, and
forgiveness. These beliefs can hinder assertive-
ness in some Latinos, but they can also be a
source of strength and recovery. Traditionally,
Latinos have been Catholic, although several
Protestant and evangelical groups have con-
verted millions of Latinos to their religions
since the 1970s. Some Latinos also believe in
syncretistic religions (e.g., Santería or
Curanderismo) or practices derived from them
and make use of a variety of traditional heal-
ing practices and rituals to heal mental and
spiritual ailments (Lefley et al. 1998; Sandoval
1979). Among Puerto Ricans, espiritismo
(spiritualism) is a popular traditional healing
system successfully used to address mental
health issues (Lynch and Hanson 2011; Moli-
na 2001). Some Mexican Americans rely on
curanderos, folk healers who address problems
that might be framed as psychological (Falicov
2005, 2012). For a review of culturally respon-
sive interventions with Latinos, refer to
Gallardo and Curry (2009).
Relapse prevention and recovery
There are no substantial studies evaluating the
use of relapse prevention and recovery promo-
tion with Latinos, yet literature suggests that
they would be appropriate and effective for
this population (Blume et al. 2005; Castro et
al. 2007). Overall, Latinos can face somewhat
different triggers for relapse relating to accul-
turative stress or the need to uphold particular
cultural values (e.g., personalismo, machismo;
Castro et al. 2007), which can lead to higher
rates of relapse among some Latino clients.
For example, in a study of relapse patterns
among White American and Latino individu-
als who used methamphetamine, Brecht et al.
(2000) found that Latino participants relapsed
more quickly than White American
participants.
Data are lacking on long-term recovery for
Latinos. Given the many obstacles that block
accessibility to treatment for Latinos, continu-
ing care planning can benefit from greater use
of informal or peer supports. For example,
White and Sanders (2004) recommend the
use of a recovery management approach with
Latinos. They point to an early example of the
East Harlem Protestant Parish’s work, which
helped Puerto Rican individuals recovering
from heroin dependence connect to social
clubs and religious communities that sup-
ported recovery. Latinos use community and
family support in addition to spirituality to
address mental disorders (Lynch and Hanson
2011; Molina 2001). Castro et al. (2007) also
note that family support systems can be espe-
cially important for Latinos in recovery.
Counseling for Native
Americans
There are 566 federally recognized American
Indian Tribes, and their members speak more
than 150 languages (U.S. Department of the
Interior, Indian Affairs 2013a); there are
numerous other Tribes recognized only by
states and others that still go unrecognized by
government agencies of any sort. According to
the 2010 U.S. Census (Norris et al. 2012), the
majority (78 percent) of people who identified
as American Indian or Alaska Native, either
alone or in combination with one or more
other races, lived outside of American Indian
and Alaska Native areas.
Approximately 60
percent of the 5.2 million people who identi-
fied as American Indian or Alaska Native,
alone or in combination with one or more
other races, reside in urban areas (Norris et al.
2012). The category of Alaska Natives in-
cludes four recognized Tribal groups—
Alaskan Athabascan, Aleut, Eskimo, and
Tingit-Haida—along with many other inde-
pendent communities (Ogunwole 2006).
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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups
Native Americans who belong to federally
recognized Tribes and communities are mem-
bers of sovereign Indian nations that exist
within the United States. On lands belonging
to these Tribes and communities, Native
Americans are able to govern themselves to a
large extent and are not subject to most state
laws—only to federal legislation that is specif-
ically designated as applying to them (Henson
2008). Although health care (including sub-
stance abuse treatment) is provided to many
Native Americans by Indian Health Services
(IHS), Tribal governments do have the option
of taking over those services. Counselors
working with these populations should re-
member that Native Americans, by virtue of
their membership in sovereign Tribal entities,
have rights that are different from those of
other Americans; this distinguishes them from
members of other ethnic/racial groups.
American Indians live in all 50 states; the
states with the largest populations of Ameri-
can Indians are Oklahoma, California, and
Arizona. The 2000 Census allowed people to
identify, for the first time, as a member of
more than one race. Of persons who checked
two or more races, nearly one in five indicated
that they were part American Indian or Alaska
Native (U.S. Census Bureau 2001a,b).
Behavioral health service providers should
recognize that Native American Tribes repre-
sent a wide variety of cultural groups that
differ from one another in many ways (Duran
et al. 2007). Alaska Natives who live in coastal
areas have very different customs from those
inhabiting interior areas (Attneave 1982). The
diversity of Native American Tribes notwith-
standing, they also share a common bond of
respect for their cultural heritages, histories,
and spiritual beliefs, which are different from
those of mainstream American culture. For
more information on the treatment and pre-
vention of substance abuse and mental illness
among Native Americans, see the planned TIP,
Behavioral Health Services for American Indians
and Alaska Natives (SAMHSA planned a).
Beliefs About and Traditions
Involving Substance Use
Few American Indian Tribes and no Alaska
Natives consumed alcoholic beverages prior to
contact with non-Native people, and those
who did used alcohol primarily for special
occasions and ceremonies. Most Tribes first
encountered the use of alcohol when they
encountered European settlers and traders.
Because of this lack of experience with alco-
hol, few Native Americans had a context for
drinking besides what they learned from these
non-Natives, who at the time drank in large
quantities and often engaged in binge drink-
ing. Although patterns of alcohol consump-
tion in the mainstream population of the
United States changed over time, they re-
mained relatively the same in the more isolat-
ed Native American communities. According
to an NSDUH report on American Indian
and Alaska Native adults, binge drinking
continues to be a significant problem for these
populations. Both binge drinking and illicit
drug use is higher among Native Americans
than the national average (30.2 percent versus
23 percent and 12.7 percent versus 9.2 percent,
respectively; SAMHSA 2013d).
American Indian drinking patterns vary a
great deal by Tribe. Tribal attitudes toward
alcohol influence consumption in complicated
ways. For example, in Navajo communities,
excessive drinking was acceptable if done in a
group or during a social activity. However,
solitary drinking (even in lesser amounts) was
considered to be deviant (Kunitz et al. 1994).
Kunitz et al. (1994) observed that during the
1960s, binge drinking was acceptable among
the Navajo during public celebrations, whereas
any drinking was considered unacceptable
among the neighboring Hopi population,
139
Improving Cultural Competence
wherein regular drinkers were shunned or, in
some cases, expelled from the community.
Hopi individuals who did drink tended to do
so alone or moved off the reservation to bor-
der towns where heavy alcohol use was com-
mon. The ostracism of Hopi drinkers seemed
to lead to even greater levels of abuse, given
that there were much higher death rates from
alcoholic cirrhosis among the Hopi than
among the Navajo.
Native American recovery movements have
often viewed substance abuse as a result of
cultural conflict between Native and Western
cultures, seeing substances of abuse as weapons
that have caused further loss of traditions
(Coyhis and White 2006). To best treat this
population, substance abuse treatment provid-
ers need to expand their perspectives regarding
substance abuse and dependence and must
embrace a broader view that explores the
spiritual, cultural, and social ramifications of
substance abuse (Brady 1995; Duran 2006;
Jilek 1994).
Substance Use and Substance Use
Disorders
According to 2012 NSDUH data, American
Indian and Alaska Native peoples have the
highest rates of substance use disorders and
binge drinking (SAMHSA 2013d). Although
rates of substance abuse are high among
Native Americans, so too are rates of absti-
nence. American Indians and Alaska Natives
are more likely to report no alcohol use in the
past year than are members of all other major
racial and ethnic groups (OAS 2007). The
American Indian Services Utilization and
Psychiatric Epidemiology Risk and Protective
Factors Project (AI-SUPER PFP) also found
that rates of lifetime abstinence from alcohol
for American Indians in the study were signif-
icantly higher than lifetime abstinence rates
among the general population (Beals et al.
2003). Data on alcohol consumption also
show that Alaska Natives are significantly
more likely to abstain than are other Alaskans
(Wells 2004).
The most common pattern of abusive drink-
ing among American Indians appears to be
binge drinking followed by long periods of
abstinence (French 2000; May and Gossage
2001). A similar pattern is seen among Alaska
Natives (Seale et al. 2006; Wells 2004). As an
example, the Urban Indian Health Institute
(2008) found that binge drinking was signifi-
cantly more common among the Native
American population (with 21.3 percent
engaging in binge drinking in the prior 30
days compared with 15.8 percent of non-
Native Americans) and that, among those who
drank, 40.7 percent of Native American par-
ticipants engaged in binge drinking compared
with 26.9 percent of non-Natives.
There are a number of historical reasons for
the development of binge drinking among
Native Americans. The existence of dry reser-
vations (which can limit the times when indi-
viduals are able to get alcohol), high levels of
poverty, lack of availability (e.g., in remote
Alaska Native villages), a history of trauma,
and the loss of cultural traditions can all con-
tribute to the development and continuation
of this pattern of drinking. Native Americans
are also more likely than members of other
major racial/ethnic groups to have had their
first drink before the age of 21 or before the
age of 16, which also may shape drinking
patterns (SAMHSA 2011c).
However, data on heavy and binge drinking do
not reflect the same pattern of alcohol con-
sumption for all Native American Tribes. One
analysis of alcohol dependence among mem-
bers of seven different Tribes found rates of
dependence varying from 56 percent of men
and 30 percent of women in one Tribe to 1
percent of men and 2 percent of women in
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
among diverse Native American communities
(O’Connell et al. 2005; Whitesell et al. 2006).
In addition to alcohol, methamphetamine and
inhalant abuse are major concerns for a num-
ber of Native American communities. None-
theless, there are considerable regional
differences in patterns and prevalence of drug
use (Miller et al. 2012). According to the
National Congress of American Indians
(2006), 74 percent of Tribal police forces
ranked methamphetamine as the drug causing
the most problems in their communities.
Methamphetamine abuse can be even more
serious for Native Americans living in rural
areas than for those in urban areas, but it is
also a serious problem for growing numbers of
American Indians, especially women, entering
treatment in urban areas (Spear et al. 2007).
American Indians and Alaska Natives are
more likely to report having used inhalants at
some time during their lives, but use tends to
peak in 8th grade and then decrease (Miller et
al. 2012). In some Native American communi-
ties (e.g., on the Kickapoo reservation in Tex-
as), inhalants have been a major drug of abuse
for adults as well as youth. During the early
1990s, about 46 percent of the adult popula-
tion on that reservation were thought to abuse
inhalants (Fredlund 1994). Although more
recent data are not available, reports from the
area suggest that inhalant abuse remains a
significant problem (Morning Star 2005).
Rates of substance use disorders appear to be
higher in individuals who consider themselves
exclusively Native American than for those
who identify as more than one race/ethnicity,
but even when surveys ask whether people are
of mixed race, those who report themselves to
be partially Native American still have high
rates of substance use disorders (OAS 2007).
Native Americans are about 1.4 times more
likely than White Americans to have a lifetime
diagnosis of an alcohol use disorder (Gilman
et al. 2008). Illicit drug use is also more com-
mon for Native Americans than for members
of other major racial/ethnic groups.
Among Native Americans entering treatment
in 2010, alcohol use disorders alone or in
conjunction with drug use disorders were the
most pressing substance-related problem, with
cannabis and opioids other than heroin being
the next most common primary substances of
abuse. One of the largest studies on American
Indian substance use and abuse to date, the
AI-SUPER PFP, found that 31.2 percent of
American Indians met criteria for a lifetime
diagnosis of a substance use disorder, and 13.4
percent met criteria for a past-year diagnosis
(Beals et al. 2003). The study found that rates
of alcohol use disorders were high among men
from the three Tribes represented but varied
to a greater degree among women across
Tribes (Mitchell et al. 2003).
American Indians have high rates of certain
diseases and conditions. In particular, the
incidence of diabetes is increasing among
Native Americans, and approximately 38
percent of elder Native Americans have diabe-
tes (Moulton et al 2005). Diabetes is also
associated with both substance use disorders
and depression in this population (Tann et al.
2007). Other health problems associated with
alcohol use include fetal alcohol syndrome,
cirrhosis, and depression.
Mental and Co-Occurring
Disorders
According to the 2012 NSDUH, 28.3 percent
of American Indians and Alaska Natives
report having a mental illness, with approxi-
mately 8.5 percent indicating serious mental
illness in the past year (SAMHSA 2013c).
Native Americans were nearly twice as likely
to have serious thoughts of suicide as members
of other racial/ethnic populations, and more
141
Improving Cultural Competence
than 10 percent reported a major depressive
episode in the past year. Common disorders
include depression, anxiety, and substance use.
As with other groups, substance use disorders
among Native Americans have been associated
with increased rates of a variety of different
mental disorders (Beals et al. 2002; Tann et al.
2007; Westermeyer 2001). The 2012 NSDUH
revealed that 14 percent of Native Americans
reported both past-year substance use disor-
ders and mental illness. Among those who
reported mental illness, nearly 5 percent re-
ported several mental illnesses co-occurring
with substance use disorders (SAMHSA
2013c).
Native American communities have experi-
enced severe historical trauma and discrimina-
tion (Brave Heart and DeBruyn 1998; Burgess
et al. 2008). Studies suggest that many Native
Americans suffer from elevated exposure to
specific traumas (Beals et al. 2005; Ehlers et al.
2006; Manson 1996; Manson et al. 2005), and
they may be more likely to develop PTSD as a
result of this exposure than members of other
ethnic/racial groups. PTSD comparison rates
taken from the AI-SUPER PFP study and
the National Comorbidity Study show that
12.8 percent of the Southwest Tribe sample
and 11.5 percent of the Northern Plains Tribe
sample met criteria for a lifetime diagnosis of
PTSD compared with 4.3 percent of the
general population (Beals et al. 2005). Trauma
histories and PTSD are so prevalent among
Native Americans in substance abuse treat-
ment that Edwards (2003) recommends that
assessment and treatment of trauma should be
a standard procedure for behavioral health
programs serving this population. For exam-
ple, Native American veterans with substance
use disorders are significantly more likely to
have co-occurring PTSD than the general
population of veterans with substance use
disorders (Friedman et al. 1997).
Treatment Patterns
Despite a number of potential barriers to
treatment (Venner et al. 2012), Native Ameri-
cans are about as likely as members of other
racial/ethnic groups to enter behavioral health
programs. According to data from the 2003
and 2011 NSDUH (SAMHSA, CBHSQ
2012), Native Americans were more likely to
have received substance use treatment in the
past year than persons from other racial/ethnic
groups (15.0 percent versus 10.2 percent).
Other studies indicate that about one-third of
Native Americans with a current substance use
disorder had received treatment in the prior
year (Beals et al. 2006; Herman-Stahl and
Chong 2002). The 2012 NSDUH reported
that approximately 15 percent of Native
Americans received mental health treatment
(SAMHSA 2013c).
Native Americans were least likely of all major
ethnic/racial groups to state that they could not
find the type of program they needed and were
the next least likely after Native Hawaiians and
other Pacific Islanders to state that they did not
know where to go or that their insurance did
not cover needed treatment. Among Native
Americans who identified a need for treat-
ment in the prior year but did not enter treat-
ment, the most commonly cited reasons for
not attending were lack of transportation, lack
of time, and concerns about what one’s neigh-
bors might think (SAMHSA 2011c).
Many Native Americans, especially those
residing on reservations or other Tribal lands,
seek mental health and substance abuse treat-
ment through Tribal service providers or IHS
(Jones-Saumty 2002; McFarland et al. 2006).
However, an analysis using multiple sources
found that 67 percent of Native Americans
entering substance abuse treatment over the
course of a year did so in urban areas, and the
majority of those urban-based programs were
not operated by IHS (McFarland et al. 2006).
142
Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups
The same research also found that Native
Americans were somewhat more likely than
the general treatment-seeking population to
enter residential programs.
Native Americans were more likely to enter
treatment as a result of criminal justice refer-
rals than were White Americans or African
Americans: 47.9 percent of American Indians
and Alaska Natives entering public treatment
programs in 2010 were court-ordered to
treatment compared with 36.6 percent of
White Americans and 36.4 percent of African
Americans (SAMHSA, CBHSQ 2012). The
lack of recognition of special needs and
knowledge of Native American cultures within
behavioral health programs may be the main
reasons for low treatment retention and un-
deruse of help-seeking behaviors among
Native Americans (LaFromboise 1993; Sue
and Sue 2013e).
Beliefs and Attitudes About
Treatment
Duran et al. (2005) evaluated obstacles to
treatment entry among American Indians on
three different reservations; most frequently
mentioned were the perception that good-
quality or suitable services were unavailable
and the perceived need for individuals to be
self-reliant. They also found social relation-
ships to be extremely important in overcoming
these barriers. Jumper-Thurman and Plested
(1998) reported that focus groups of American
Indian women listed mistrust as one of the
primary barriers for seeking treatment. This is
due, in part, to the women’s belief that they
would encounter people they knew among
treatment agency staff; they also doubted the
confidentiality of the treatment program.
Treatment Issues and
Considerations
Each Tribe and community will likely have
different customs, healing traditions, and
beliefs about treatment providers that can
influence not only willingness to participate in
treatment services, but also the level of trust
clients have for providers. Counselors and
other behavioral health workers must develop
ongoing relationships within local Native
American communities to gain knowledge of
the unique attributes of each community, to
show investment in the community, and to
learn about community resources (Exhibit 5-
3). Identifying and developing resources with-
in Native communities can help promote
culturally congruent relationships.
Exhibit 5-3: Native Americans and
Community
Many Native Americans believe that recovery
cannot happen for individuals alone and that
their entire community has become sick.
Coyhis calls this the “healing forest” model:
one cannot take a sick tree from a sick forest,
heal it, and put it back in the same environ-
ment expecting that it will thrive. Instead, the
community must embrace recovery.
Today, community development models are
being implemented in American Indian and
Alaska Native communities to address preven-
tion and treatment issues for mental and sub-
stance use disorders as well as related issues,
such as suicide prevention (Edwards and
Egbert-Edwards 1998; HHS 2010; May et al.
2005). Using these models, communities move
toward greater commitment to social problem-
solving and the development of effective,
culturally congruent strategies relevant to their
Tribes or villages. According to Edwards et al.
(1995), community approaches often lead to:
• A reduction of substance use.
• Breaking intergenerational cycles of alco-
hol abuse.
• Increased community support.
• The strengthening of individual and group
cultural identity.
• Leadership development.
• Increased interpersonal and inter-Tribal
problem-solving skills and solidarity.
For an example, see Jumper-Thurman et al.
(2001).
143
Improving Cultural Competence
To provide culturally responsive treatment,
providers need to understand the Native
American client’s Tribe; its history, traditions,
worldview, and beliefs; the dimensions of its
substance abuse problem and other communi-
ty problems; the incidence of trauma and
abuse among its members; its traditional
healing practices; and its intrinsic strengths.
Providers who work with Native Americans
but do not have an understanding of their
cultural identity and acculturation patterns are
at a distinct disadvantage (Ponterotto et al.
2000). Before beginning any treatment, pro-
viders should routinely seek consultation with
knowledgeable professionals who are experi-
enced in working with the specific Tribal
group in question (Duran 2006; Edwards and
Egbert-Edwards 1998; Straits et al. 2012) and
should conduct thorough client assessments
that evaluate cultural identity (see Appendix F
and Chapter 2 for resources). Some Native
American persons have a strong connection to
their cultures and others do not; some identify
with a blend of American Indian cultural
groups called pan-Indianism or inter-Tribal
identity. Still others are comfortable with a
dual identity that embraces both Native and
non-Native cultural groups.
Native Americans often approach the begin-
ning of a relationship in a calm, unhurried
manner, and they may need more time to
develop trust with providers. Concerns about
confidentiality can be an important issue to
address with Native American clients, espe-
cially for those in small, tightly-knit commu-
nities. For providers, it is very important to
make clear to clients that what they say to the
counselor will be held in confidence, except
when there is an ethical duty to report.
Native American cultural groups generally
believe that health is nurtured through balance
and living in harmony with nature and the
community (Duran 2006; Garrett et al. 2012).
They also, for the most part, have a holistic
view of health that incorporates physical,
emotional, and spiritual elements (Calabrese
2008), individual and community healing
(Duran 2006; McDonald and Gonzalez 2006),
and prevention and treatment activities
(Johnston 2002). For many, culture is the path
to prevention and treatment.
However, not all Native Americans have a
need to develop stronger connections to their
communities and cultural groups. As Brady
(1995) cautions, culture is complex and chang-
ing, and a return to the values of a traditional
culture is not always desired. An initial inquiry
into each client’s connection with his or her
culture, cultural identity, and desire to incor-
porate cultural beliefs and practices into
treatment is an essential step in culturally
competent practice. When appropriate, pro-
viders can help facilitate the client’s reconnec-
tion with his or her community and cultural
values as an integral part of the treatment
plan. In addition, treatment providers need to
adapt services to be culturally responsive. In
doing so, outcomes are likely to improve not
only for Native American clients, but for all
clients within the program. Fisher et al. (1996)
modified a therapeutic community in Alaska
to incorporate Alaska Native spiritual and
cultural practices and found that retention
rates improved for White and African Ameri-
can clients as well as Alaska Native clients
participating in the program.
In working with Native American clients,
providers should be prepared to address spirit-
uality and to help clients access traditional
healing practices. Culturally responsive treat-
ment should involve community events, group
activities, and the ability to participate in
ceremonies to help clients achieve balance and
find new insight (Calabrese 2008). Stronger
attachment to Native American cultural
groups protects against substance use and
144
Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups
abuse; therefore, strengthening this connection
is important in substance abuse treatment
(Duran 2006; Moss et al. 2003; Spicer 2001;
Stone et al. 2006).
Theoretical Approaches and
Treatment Interventions
Some clinicians caution that a model of coun-
seling that requires self-disclosure to relative
strangers can be counterproductive with Native
American clients. Other authors recommend
CBT and social learning approaches for
Native American clients, as such approaches
typically have less cultural bias, focus on prob-
lem-solving and skill development, emphasize
client strengths and empowerment, recognize
the need to accept personal responsibility for
change, and make use of learning styles that
many Native Americans find culturally ap-
propriate (Heilbron and Guttman 2000;
McDonald and Gonzalez 2006). Motivational
interviewing is also recommended for Native
American clients. In a small study, Villanueva
et al. (2007) found that all treatment modali-
ties resulted in improvements at 15-month
follow-up, but clients who received motiva-
tional enhancement therapy reported signifi-
cantly fewer drinks per drinking day during
the 10- to 15-month posttreatment follow-up
period. Venner et al. (2006) wrote a manual for
motivational interviewing with Native
American clients.
Family therapy
Family involvement in treatment leads to
better outcomes for Native Americans at the
time of discharge from treatment (Chong and
Lopez 2005). Research also suggests that
family and community support can have a
significant effect on recovery from substance
use disorders for this population ( Jones-
Saumty 2002; Paniagua 1998). Family therapy
can be quite helpful and perhaps even essential
for American Indian clients (Coyhis 2000),
especially when other social supports are
lacking (Jones-Saumty 2002)
.
American Indians place high value on family
and extended family networks; restoring or
healing family bonds can be therapeutic for
clients with substance use disorders. Moreo-
ver, Native American clients are sometimes
less motivated to engage in “talk therapy” and
more willing to participate in therapeutic
activities that involve social and family rela-
tionships (Joe and Malach 2011). Treatment
approaches should remain flexible and in-
clude clients’ families when appropriate.
Counselors should be able to recognize what
constitutes family, family constellations, and
Advice to Counselors: Counseling
Native Americans
When working with Native American clients,
providers should:
• Use active listening and reflective re-
sponses.
• Avoid interrupting the client.
• Refrain from asking about family or per-
sonal matters unrelated to substance abuse
without first asking the client’s permission
to inquire about these areas.
• Avoid extensive note-taking or excessive
questioning.
• Pay attention to the client’s stories, experi-
ences, dreams, and rituals and their rele-
vance to the client.
• Recognize the importance of listening and
focus on this skill during sessions.
• Accept extended periods of silence during
sessions.
• Allow time during sessions for the client to
process information.
• Greet the client with a gentle (rather than
firm) handshake and show hospitality (e.g.,
by offering food and/or beverages).
• Give the client ample time to adjust to the
setting at the beginning of each session.
• Keep promises.
• Offer suggestions instead of directions
(preferably more than one to allow for cli-
ent choice).
Sources: Aragon 2006; Trimble et al. 2012.
145
Improving Cultural Competence
family characteristics. The Native American
concept of family can include elders, others
from the same clan, or individuals who are not
biologically related. In many Tribes, all mem-
bers are considered relatives. Families can be
matrilineal (i.e., kinship is traced through the
female line) and/or matrilocal (i.e., married
couples live with wife’s parents).
When families do enter treatment, they may
initially prefer to focus on a concrete problem,
but not necessarily on the most significant
family issue. Discussion of a clearly defined
presenting problem enables families to assess
the therapeutic process and better understand
what is expected of them in treatment. Provid-
ers should be aware that the entire clan and/or
Tribe could know about a given client’s treat-
ment and progress. Family therapy models
such as network therapy, which makes use of
support structures outside the immediate
family and which were originally developed
for Native American families living in urban
communities, can be particularly effective with
Native clients, especially when they have been
cut off from their home communities because
of substance abuse or other issues. For more
information on network therapy and similar
approaches, see TIP 39, Substance Abuse
Treatment and Family Therapy (CSAT 2004b).
Group therapy
Although researchers and providers once
viewed group therapy as ineffective for Ameri-
can Indian clients (Paniagua 1998), opinion
has shifted to recognize that, when appropri-
ately structured, group therapy can be a pow-
erful treatment component (Garrett 2004;
Garrett et al. 2001; Trimble and Jumper-
Thurman 2002). Garrett (2004) notes that
many Native American Tribes have traditional
healing practices that involve groups; for many
of these cultural groups, healing needs to occur
within the context of the group or community
(e.g., in talking circles). Thus, if properly
adapted, group therapy can be very beneficial
and culturally congruent. It is important,
however, to determine Native American clients’
level of acculturation before recommending
Western models of group therapy, as less
acculturated Native clients are likely to be less
comfortable with group talk therapy (Mail and
Shelton 2002). Group therapy for Alaska
Natives should also be nonconfrontational and
focus on clients’ strengths.
Group therapy can incorporate Native
American traditions and rituals to make it
more culturally suitable. For example, the
talking circle is a Native tradition easily
adapted for behavioral health treatment. In
this tradition, the members of the group sit in
a circle. An eagle feather, stone, or other sym-
bolic item is passed around, and each person
speaks when he or she is handed the item.
Based on a review of the literature, Paniagua
(1998) recommends that providers using
group therapy with Native American clients:
• Earn support or permission from Tribal
authorities before organizing group therapy.
• Consult with Native professionals.
• If group members consent, invite respected
Tribal members (e.g., traditional healers or
elders) to participate in sessions.
Mutual-help groups
Native American peoples have a long history
of involvement in mutual-help activities that
predates the 12-Step movement (Coyhis and
White 2006). Depending on acculturation,
availability of a community support network,
and the nature of their presenting problems,
Native American clients may be more likely to
solicit help from significant others, extended
family members, and community members.
Contemporary manifestations of Native
American mutual-help efforts include adapta-
tions of the 12 Steps (Exhibit 5-4) and of 12-
Step meeting rituals and practices (Coyhis and
White 2006). Another modified element of
146
Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups
the 12 Steps is use of a circular, rather than a
linear, path to healing. The circle is important
to American Indian philosophy, which sees the
great forces of life and nature as circular
(Coyhis 2000). In addition, staff members of
the White Bison program have also rewritten
the AA “Big Book” from a Native American
perspective (Coyhis and Simonelli 2005). The
principles of the 12 Steps, which involve using
the group or community to provide support
and motivation while emphasizing spiritual
reconnection, appeal to many Native Ameri-
cans who see treatment as social in nature and
who view addiction as a spiritual problem.
The Native American Wellbriety movement is
a modern, indigenous mutual-help program
that has its roots in 12-Step groups but incor-
porates Native American spiritual beliefs and
cultural practices (Coyhis and Simonelli 2005;
Coyhis and White 2006; White Bison, Inc.
2002; also see http://www.whitebison.org).
Although the Wellbriety movement is popular
with many Native Americans in recovery, a
considerable number also continue to partici-
pate in traditional 12-Step groups. In the AI-
SUPER-PFP, 47 percent of Northern Plains
Tribe respondents and 28.8 percent of South-
west Tribe respondents with a past-year sub-
stance use disorder reported 12-Step group
attendance in the prior year (Beals et al. 2006).
Mohatt et al. (2008b) found that more Alaska
Natives in recovery reported participation in
12-Step groups than in substance abuse treat-
ment. In Venner and Feldstein’s (2006) re-
search with American Indians in recovery, 84
percent of respondents had attended some
mutual-help meetings.
Traditional healing and
complementary methods
Native American peoples have a range of be-
liefs about health care—from traditional beliefs
to strong support for modern science—and
may use a number of strategies when address-
ing health problems. Traditional healing prac-
tices are often used in conjunction with modern
medicine. For example, American Indians
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 Great Spirit 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 brothers and sisters 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.
147
Improving Cultural Competence
There are a number of potential pitfalls
that can occur when trying to integrate
Native spiritual and cultural practices into
treatment. Cultural groups are complex
systems; removing pieces of them for
implementation as part of a treatment
program can be a disservice to the culture
as well as the clients (Kunitz et al. 1994;
Moss et al. 2003); a breach of customs
and traditions; and a sign of disrespect for
the community and Tribe, Tribal lead-
ership, and Native American practices. It
is important to take the time to build
relationships and seek consultation with
Tribal elders, and other Tribal leaders to
ensure that the best and most appropriate
steps are taken in creating a culturally
relevant and responsive treatment
model and program.
traditionally view all things as deeply inter-
connected. Disruption of the physical, mental,
spiritual, or emotional sides of a person can
result in illness. A Native American client may
consult a medical doctor to address part of the
problem and a traditional healer to help regain
balance and harmony.
The use of traditional healing for substance
abuse and mental health problems is fairly
common among Native Americans (Herman-
Stahl and Chong 2002; Herman-Stahl et al.
2003). For example, among Native American
individuals who reported a substance use
disorder in the past year, 57.4 percent of those
from a Southwest Tribe and 31.7 percent from
a Northern Plains Tribe used traditional heal-
ers or healing practices (Beals et al. 2006). In a
survey of American Indians from three differ-
ent Arizona Tribes, 27.4 percent stated that
they had used traditional healers and/or heal-
ing practices to help with mental health prob-
lems (Herman-Stahl and Chong 2002).
Overall, many Native Americans believe that
culture is the primary avenue of healing and
that connecting with one’s culture is not only a
means of prevention, but also a healing treat-
ment (Bassett et al. 2012)
Each Native American culture has its own
specific healing practices, and not all of those
practices are necessarily appropriate to adapt
to behavioral health treatment settings. How-
ever, many traditional healing activities and
ceremonies have been made accessible during
treatment or effectively integrated into treat-
ment settings (Castro et al. 1999b; Coyhis
2000; Coyhis and White 2006; Mail and
Shelton 2002; Sue 2001; White 2000). These
practices include sacred dances (such as the
Plains Indians’ sun dance and the Kiowa’s
gourd dance), the four circles (a model for
conceptualizing a harmonious life), the talking
circle, sweat lodges, and other purification
practices (Cohen 2003; Mail and Shelton
2002; White 2000). The sweat lodge, in par-
ticular, is frequently used in substance abuse
treatment settings (Bezdek and Spicer 2006;
Schiff and Moore 2006).
Alaskan behavioral health programs have
developed recovery camps to provide a treat-
ment setting that incorporates Native beliefs
and seasonal practices (e.g., Old Minto Family
Recovery Camp:
http://www.tananachiefs.org/ health-
services/old-minto-family-recovery-camp-
new/). Recovery camps are based on the mod-
el of traditional Native Alaskan fishing camps
and provide a context in which clients can
learn about traditional practices, such as suste-
nance activities. Another program, the Village
Sobriety Project, incorporates traditional
Yup’ik and Cup’ik Eskimo traditions of hunt-
ing, chopping wood, berry picking, and taking
tundra walks (Mills 2003). See Niven (2010)
for a review of client-centered, culturally
responsive behavioral health techniques for
use with Alaska Natives.
It is difficult to measure the effectiveness of
Native American healing practices using
148
Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups
Western standards and practices. Limited or
inconsistent funding, migration patterns,
culturally incompetent or incongruent evalua-
tion practices, and abuses incurred during or
after data collection are major confounding
variables that have limited knowledge on the
effectiveness of incorporating traditional
practices into Western approaches to the
treatment of substance abuse and mental
illness. Nonetheless, Mail and Shelton (2002)
reviewed earlier literature on the use of “indig-
enous therapeutic interventions” for alcohol
abuse and dependence and suggest that a
number of these interventions have been of
value to Native Americans with substance use
disorders. Other authors have concurred
(Coyhis and White 2006; Sabin et al. 2004).
Regardless of whether a program adapts spe-
cific Native American healing practices, pro-
viders working with this population should
recognize that spirituality is central to its
values and is perceived as an integral part of
life itself. It is through spiritual experiences
that Native Americans believe they will find
meaning in life. Some Native languages have
words that refer to spirituality as “walking
around” or “living the path.” In many cases, the
spiritual traditions of Native Americans are
not (and have never been) conceived of as a
religion, but rather as a set of beliefs and
practices that pervades every aspect of daily
life (Deloria 1973).
Despite religion and spirituality often playing
important roles in recovery from mental and
substance use disorders for Native Americans,
providers should not assume that only indige-
nous spirituality is relevant. The majority of
Native Americans do not practice their tradi-
tional spirituality exclusively, and Christian
religious institutions like the Native American
Church and Pentecostal churches have been
instrumental in helping many Native Ameri-
cans overcome substance use disorders
(Garrity 2000). In 2001, roughly 20 percent of
American Indians identified as Baptist, 17
percent as Catholic, 17 percent as having no
religious preference, and 3 percent as following
a Tribal religion (Kosmin et al. 2001).
The relative importance of religion can also
vary among diverse Native American commu-
nities. Before pursuing traditional methods,
assessment of clients’ spiritual orientation is
important. Spirituality is a personal issue that
treatment providers must respect; clients
should choose which spiritual and cultural
methods to incorporate into treatment. Pro-
viders should also be wary of an obsession
with their clients’ cultural activities, which may
be considered intrusive (LaFromboise et al.
1993). Checking with community resources
on the subject and asking the client “What
feels right for you?” are appropriate steps to
take in identifying whether traditional healing
practices will have therapeutic value. Providers
should consult with Native healers or Tribal
leaders about the appropriateness of using a
particular practice as part of behavioral health
services. Rather than using traditional healing
methods themselves, counselors may wish to
refer clients to a Native American healer in
the community or in the treatment program.
Relapse prevention and recovery
Despite limited data on long-term recovery
for Native Americans who have substance use
disorders, a few studies have found high rates
of relapse following substance abuse treatment
(see review in Chong and Herman-Stahl
2003). White and Sanders (2004) recommend
that long-term recovery plans for Native
Americans make use of a recovery manage-
ment rather than a traditional continuing care
approach. Such an approach emphasizes the
use of informal recovery communities and
traditional healing approaches to provide
extended monitoring and support for Native
Americans leaving treatment.
149
Improving Cultural Competence
Researchers have conducted interviews with
both American Indians (Bezdek and Spicer
2006) and Alaska Natives (Hazel and Mohatt
2001; Mohatt et al. 2008; People Awakening
Project 2004) who have achieved extended
periods of recovery. Bezdek and Spicer (2006)
identified two key tasks for American Indians
entering recovery. First, they need to learn how
to respond to family and friends who drank
with them and to those who supported their
recovery. Next, they have to find new ways to
deal with boredom and negative feelings. By
accomplishing these tasks, Native clients can
build new social support systems, develop
effective coping strategies for negative feelings,
and achieve long-term recovery. The People
Awakening Project found that, among Alaska
Natives who had a substantial period of recov-
ery, the development of active, culturally ap-
propriate coping strategies was essential (e.g.,
distancing themselves from friends or family
who drank heavily, getting involved in church,
doing community service, praying; Hazel and
Mohatt 2001; Mohatt et al. 2008; People
Awakening Project 2004).
Counseling for White
Americans
According to the 2010 U.S. Census definition,
White Americans are people whose ancestors
are among those ethnic groups believed to be
the original peoples of Europe, the Middle
East, or North Africa (Humes et al. 2011).
The racial category of White Americans
includes people of various ethnicities, such as
Arab Americans, Italian Americans, Polish
Americans, and Anglo Americans (i.e., people
with origins in England), among others. Many
Latinos will also identify racially (if not ethni-
cally) as White American. Non-Latino White
Americans constitute the largest racial group
in the United States (making up 63.7 percent
of the population in the 2010 Census; Mather
et al. 2011).
White Americans, like other large ethnic and
cultural groups, are extremely heterogeneous
in historical, social, economic, and personal
features, with many (often subtle) distinctions
among subgroups. Perhaps because White
Americans have been the majority in the
United States, it is sometimes forgotten how
historically important certain distinctions
between diverse White American ethnic
heritages have been (and continue to be, for
some). Conversely, many White American
people prefer not to see themselves as such
and instead identify according to their specific
ethnic background (e.g., as Irish American).
For similar reasons, certain cross-cutting
cultural issues (see Chapter 1) like geographic
location, sexual orientation, and religious
affiliation are important in defining the cul-
tural orientations of many White Americans.
Beliefs About and Traditions
Involving Substance Use
Historically, use of alcohol was accepted
among White/European cultural groups
because it provided an easy way to preserve
fruit and grains and did not contain bacteria
that might be found in water. Over time, the
production and consumption of alcohol be-
came an often-integral part of cultural activi-
ties, which can be seen in the way some White
cultural groups take particular pride in nation-
al brands of alcoholic beverages (e.g., Scotch
whisky, French wine; Abbott 2001; Hudak
2000). A number of European cultural groups
(e.g., French, Italian) traditionally believed
that daily alcohol use was healthy for both
mind and body (Abbott 2001; Marinangeli
2001), and for others (e.g., English, Irish), the
bar or pub was the traditional center of com-
munity life (O’Dwyer 2001). Despite some
variations in cultural attitudes toward appro-
priate drinking practices, alcohol has been and
150
Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups
remains the primary recreational substance for
Whites in the United States. Predominant
attitudes toward drinking in the United States
more closely reflect those of Northern Europe;
alcohol use is generally accepted during cele-
brations and recreational events, and, at such
times, excessive consumption is more likely to
be acceptable.
Typically, White European cultural groups
accept alcohol use as long as it does not inter-
fere with responsibilities, such as work or
family, or result in public drunkenness (Hamid
1998). However, among certain groups of
White Americans (usually defined by religious
beliefs), the use of alcohol or any other intoxi-
cant is considered immoral (van Wormer
2001). These religious beliefs, combined with
concerns about the effects of problematic
drinking patterns (especially among men in
the frontier; White 1998), became the impetus
for the early 19th-century creation of the
Temperance Movement and culminated in the
passing of the 18th Amendment to the United
States Constitution, which enacted Prohibition.
Although the Temperance Movement is no
longer a major political force, belief in the
moral and social value of abstinence continues
to be strong among some segments of the
White American population.
Illicit drug use, on the other hand, has histori-
cally been demonized by White American
cultural groups and seen as an activity engaged
in by people of color or undesirable subcul-
tures (Bonnie and Whitebread 1970; Hamid
1998; Whitebread 1995). For example, White
Americans typically link drug use to per-
ceived threat of crime—particularly crimes
perpetrated by people of color (Hamid 1998;
Whitebread 1995). Attitudes have changed
over time, but White American cultural
groups continue to enforce strong cultural
prohibitions against most types of illicit drug
use. At the same time, White Americans are
often more accepting of prescription medica-
tion abuse and less likely to perceive prescrip-
tion medications as potentially harmful
(Hadjicostandi and Cheurprakobkit 2002).
Despite illicit drug use now being as common
among White Americans as people of color,
White Americans still tend to perceive drug
use as an activity that occurs outside their
families and communities. In a 2001 survey,
only 54 percent of White Americans ex-
pressed concern that someone in their family
might develop a drug abuse problem compared
with 81 percent of African Americans (Pew
Research Center for the People and the Press
2001). In the same survey, White Americans
expressed less concern about drug abuse in
their neighborhoods than did other racial and
ethnic groups. However, in terms of seeing
drugs as a national problem, White Americans
and other racial and ethnic groups are in closer
agreement. Perhaps as a result of this misper-
ception about the prevalence of drug use in
their homes and communities, White
American parents are less likely to convey
disapproval of drug use to their children than
African American parents (National Center
on Addiction and Substance Abuse 2005) and
much more likely than Latino or African
American parents to think that their children
have enough information about drugs (Pew
Research Center for the People and the Press
2001).
There are also differences in how White Amer-
icans, Latinos, and African Americans perceive
drug and alcohol addictions. White Americans
are less likely than African Americans, but
more likely than Latinos, to state that they
believe a person can recover fully from addic-
tion (Office of Communications 2008). How-
ever, White Americans are more likely than
African Americans to indicate that substance
use disorders should be treated as diseases
(Durant 2005).
151
Improving Cultural Competence
Substance Use and Substance Use
Disorders
According to 2012 NSDUH data, rates of
past-year substance use disorders were higher
for White Americans than for Native
Hawaiians, other Pacific Islanders, and Asian
Americans; rates of current alcohol use were
higher than for every other major ethnic/racial
group (SAMHSA 2013d). Alcohol has tradi-
tionally been the drug of choice among White
Americans of European descent; however, not
all European cultural groups have the same
drinking patterns. Researchers typically con-
trast a Northern/Eastern European pattern, in
which alcohol is consumed mostly on week-
ends or during celebrations, with that of
Southern Europe, in which alcohol is con-
sumed daily or almost daily but in smaller
quantities and almost always with food. The
Southern European pattern involves more
regular use of alcohol, but it is also associated
with less alcohol-related harm overall (after
controlling for total consumption; Room et al.
2003). The pattern of White Americans typi-
cally follows that of Northern and Eastern
Europe, but individuals from some ethnic
groups maintain the Southern European
pattern.
White Americans, on average, begin drinking
and develop alcohol use disorders at a younger
age than African Americans and Latinos
(Reardon and Buka 2002). White Americans
are more likely to have their first drink before
the age of 21 and to have their first drink
before the age of 16 than members of any
other major racial/ethnic group except Native
Americans (SAMHSA 2011c). Some data
suggest that White Americans begin using
illicit drugs at an earlier age than African
Americans (Watt 2008) and that the mean age
for White Americans who inject heroin has
decreased (Broz and Ouellet 2008).
White Americans who use heroin are less likely
than people who use heroin from all other
major racial/ethnic groups except African
Americans to have injected the drug
(SAMHSA 2011c). White Americans are also
more likely than members of other major
racial/ethnic groups, except Native Hawaiians
and other Pacific Islanders (for whom esti-
mates may not be accurate), to have tried
ecstasy. Except for Native Americans (some of
whom may use the hallucinogen peyote for
religious purposes), they are also more likely
than other racial/ethnic groups to have tried
hallucinogens (SAMHSA 2011c). Research
confirms that prescription drug misuse is
more common among White Americans than
African Americans or Latinos (Ford and
Arrastia 2008; SAMHSA 2011c), and they are
more likely to have used prescription opioids
in the past year and to use them on a regular
basis.
Comparative studies indicate that White
Americans are more likely than all other major
racial/ethnic groups except Native Americans
to have an alcohol use disorder (Hasin et al.
2007; Perron et al. 2009; Schmidt et al. 2007).
White Americans are at a greater risk of having
severe alcohol withdrawal symptoms (such as
delirium tremens) than are African Americans
or Latinos with alcohol use disorders (Chan et
al. 2009). So too, White Americans are more
likely than African Americans or Latinos to
meet diagnostic criteria for a drug use disorder
at some point during their lives (Perron et al.
2009). Overall, substance use disorders vary
considerably across and within non-European
White American cultural groups. For example,
rates of substance abuse treatment admissions
in Michigan from 2005 suggest that substance
use disorders may be considerably lower for
Arab Americans than other White Americans
(Arfken et al. 2007).
152
Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups
Mental and Co-Occurring
Disorders
About 20 percent of White Americans report-
ed some form of mental illness in the past year,
and they were more likely to have past-year
serious psychological distress than other popu-
lation groups excluding Native Americans
(SAMHSA 2012a).
White Americans appear to be more likely
than Latinos or Asian Americans to have
CODs (Alegria et al. 2008a; Vega et al. 2009)
and more likely to have concurrent serious
psychological distress and substance use disor-
ders (SAMHSA 2011c). White Americans
with CODs are also more likely to receive
treatment for both their substance use and
mental disorders than are African Americans
with CODs (Alvidrez and Havassy 2005;
Hatzenbuehler et al. 2008), but they are per-
haps less likely to receive treatment for their
substance use disorder alone (Alvidrez and
Havassy 2005). White Americans are more
likely to receive family counseling and mental
health services while in substance abuse treat-
ment and less likely to have unmet treatment
needs (Marsh et al. 2009; Wells et al. 2001). In
addition, White Americans are significantly
less likely than Latinos or African Americans
to believe that antidepressants are addictive
(Cooper et al. 2003).
The most common mental disorders among
White Americans are mood disorders (par-
ticularly major depression and bipolar I disor-
der) and anxiety disorders (specifically
phobias, including social phobia, and general-
ized anxiety disorder; Grant et al. 2004b).
Among White Americans, these disorders are
more prevalent than in any other ethnic/racial
groups save Native Americans (Grant et al.
2005; Hasin et al. 2005). For example, rates of a
lifetime diagnosis of generalized anxiety disor-
der are about 40 percent lower for African
Americans and Latinos than for White
Americans and about 60 percent lower for
Asian Americans (Grant et al. 2005). A simi-
lar pattern exists for major depressive disorder
(Hasin et al. 2005).
Treatment Patterns
White Americans are more likely to receive
mental health treatment or counseling than
other racial/ethnic groups (SAMHSA 2012b).
White Americans are more likely than African
Americans to receive substance abuse treat-
ment services from a private physician or
other behavioral health or primary care profes-
sional (Perron et al. 2009). Among White
American clients entering substance abuse
treatment programs in 2010, alcohol (alone or
in conjunction with illicit drugs) was most
often the primary substance of abuse, followed
by heroin and cannabis. However, findings are
inconsistent concerning the relative frequency
with which White Americans enter substance
abuse treatment. Some studies have found that
White Americans are more likely to receive
needed behavioral health services than both
African Americans and Latinos (Marsh et al.
2009; Wells et al. 2001). In contrast, other
studies have found that African Americans
with an identified need are somewhat more
likely to enter treatment for drug use disorders
and about as likely to receive treatment for
alcohol use disorders when compared with
White Americans (Hatzenbuehler et al. 2008;
Perron et al. 2009; SAMHSA, CBHSQ 2012;
Schmidt et al. 2006).
Beliefs and Attitudes About
Treatment
White Americans appear to be generally
accepting of behavioral health services. They
have better access to health care and are more
likely to use services than people of color, but
this varies widely based on socioeconomic
status and cultural affiliation. Most treatment
services have historically been developed for
153
Improving Cultural Competence
White American populations, so it is not
surprising that White Americans are more
likely than other racial/ethnic groups to be
satisfied with treatment services (Tonigan
2003).
Still, attitudes differ among certain cultural
subgroups of White Americans. For example,
Russian immigrants from the former Soviet
Union have a longstanding distrust of mental
health systems and hence may avoid substance
abuse treatment (Kagan and Shafer 2001).
Other groups who have a strong family orien-
tation, such as Italian Americans or Scotch-
Irish Americans, might avoid treatment that
asks them to reveal family secrets (Giordano
and McGoldrick 2005; Hudak 2000).
According to 2010 NSDUH data regarding
people who recognized a need for substance
abuse treatment in the prior year but did not
receive it, White Americans were more likely
than members of other major racial/ethnic
groups to state that it was because they had no
time for treatment, that they were concerned
what their neighbors might think, that they
did not want others to know, and/or that they
were concerned about how it might affect
their jobs (SAMHSA 2011c). Other research
confirms that White Americans are significant-
ly more likely to avoid treatment due to fear of
what others might think or because they are in
denial (Grant 1997). White Americans may
also have different attitudes toward recovery, at
least regarding alcohol use disorders, than do
members of other ethnic/racial groups. Ac-
cording to NESARC data on people who
met criteria for a diagnosis of alcohol de-
pendence at some point during their lives,
White Americans were more likely than
African Americans, Latinos, or other non-
Latinos to have achieved remission from that
disorder but were also less likely than African
Americans or other non-Latinos (but not
Latinos) to currently abstain from drinking, as
opposed to being in partial remission or drink-
ing without symptoms of alcohol dependence
(Dawson et al. 2005).
Treatment Issues and
Considerations
Most major treatment interventions have been
evaluated with a population that is largely or
entirely White American, although the role of
White American cultural groups is rarely
considered in evaluating those interventions.
For example, as Straussner (2001) notes, “the
paradox of writing about substance abusers of
European background is that they are a group
that is believed to be the group for whom the
traditional alcohol and other drug treatment
models have been developed, and yet they are
a group whose unique treatment needs and
treatment approaches have rarely been ex-
plored” (p. 165). Very few evaluations of
treatment strategies and interventions (wheth-
er based on research or clinical observation)
have taken into account ethnic and cultural
differences among White American clients,
and therefore it is generally not possible to
make culturally responsive recommendations
for specific subgroups of White Americans.
Culturally responsive treatment for many
White Americans will involve helping them
rediscover their cultural backgrounds, which
sometimes have been lost through acculturation
and can be an important part of their long-
term recovery. Giordano and McGoldrick
(2005) note that ethnic identity and culture
can be more important for some White
Americans “in times of stress or personal
crisis,” when they may want to “return to
familiar sources of comfort and help, which
may differ from the dominant society’s norms”
(p. 503). Appendix B provides information on
instruments for assessing cultural identifica-
tion. For an overview of challenges in main-
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,
see Downey and D’Andrea (2012).
Theoretical Approaches and
Treatment Interventions
Overall, the optimum treatment approach
with White Americans is a comprehensive
one; the more tools in the toolkit, the greater
the chance of success (McCaul et al. 2001).
Within-group differences arise regarding
education level, socioeconomic status, gender,
and other factors, which must be considered.
Providers can, however, assume that most
well-accepted treatment approaches and inter-
ventions (e.g., CBT, motivational interviewing,
12-Step facilitation, contingency management,
pharmacotherapies) have been tested and
evaluated with White American clients.
Still, treatment is not uniformly appropriate
even for White Americans. Approaches may
need modification to suit class, ethnic, reli-
gious, and other client traits. Providers should
establish not only the client’s ethnic back-
ground, but also how strongly the person
identifies with that background. Few clinicians
have made observations on best therapeutic
approaches for members of particular White
American cultural/ethnic subgroups.
Family therapy
In White American families, individuals are
generally expected to be independent and self-
reliant; as a result, families in therapy can have
trouble adjusting to work that focuses more on
communication processes than specific prob-
lems or content (McGill and Pearce 2005).
Van Wormer (2001) notes that many White
Americans need help addressing communica-
tion issues. In family therapy, useful approach-
es include those that encourage open, direct,
and nonthreatening communication.
There is no singular description that fits
White American families within or across
ethnic heritages, and there is no approach that
is effective for all White Americans in family
therapy (Hanson 2011). Hierarchical families,
such as German American families, may
expect the counselor to be authoritative, at
least in the initial sessions (Winawer and
Wetzel 2005), although a more egalitarian
German American family might not respond
well to such imperatives. In the same vein, one
client of French background could readily
accept direct and clear therapeutic assign-
ments that contain measurable goals (Abbot
2001), whereas another French American
client may value counseling that is more pro-
cess oriented. Thus, it is imperative to assess
the cultural identification of clients and their
families, along with the treatment needs that
best match their cultural worldviews.
In some White American families, there is a
longstanding culture of drinking. Attempts at
abstinence can be perceived by family mem-
bers as culturally inappropriate. In other fami-
lies, there is deep denial about alcohol abuse or
dependence, especially when talking about
substance use to those outside the family. For
example, some Polish American families can
be resistant to the idea that drinking is the
cause of family problems (Folwarski and
Smolinski 2005) and sometimes believe that
to admit an alcohol problem, especially to
someone outside the family, signals weakness.
Group therapy
Standard group therapies developed for men-
tal health and substance abuse treatment
programs have generally been used and evalu-
ated with White American populations. For
details on group therapy in substance abuse
treatment, see TIP 41, Substance Abuse Treat-
ment: Group Therapy (CSAT 2005c).
Mutual-help groups
Mutual-help groups, of which AA is the most
prevalent, have a largely White American
155
Improving Cultural Competence
membership (AAWS 2008; Atkins and
Hawdon 2007). In a 2011 survey, 87 percent
of AA members indicated their race as White
(AAWS 2012). In research with largely White
populations, AA participation has been found
to be an effective strategy for promoting
recovery from alcohol use disorders (Dawson
et al. 2006; McCrady et al. 2004; Moos and
Moos 2006; Ritsher et al. 2002; Weisner et al.
2003). Other mutual-help groups, such as
Self-Management and Recovery Training,
Secular Organizations for Sobriety/Save Our
Selves, and Women for Sobriety, also have
predominately White American membership
and are based on Western ideas drawn from
psychology (Atkins and Hawdon 2007; White
1998).
The appeal of mutual-help groups among
White Americans rests on the historical ori-
gins of this model. The 12-Step model was
originally developed by White Americans
based on European ideas of spirituality, faith,
and group interaction. Although the model
has been adopted worldwide by different
cultural groups (White 1998), the 12-Step
model works especially well for White ethnic
groups, including Irish Americans, Polish
Americans, French Americans, and Scotch-
Irish Americans, because it incorporates
Western cultural traditions involving spiritual
practice, public confession, and the use of
anonymity to protect against humiliation
(Abbott 2001; Gilbert and Langrod 2001;
Hudak 2000; McGoldrick et al. 2005; Taggart
2005).
In addition to mutual-help groups for sub-
stance abuse, numerous recovery support
groups, Internet resources, Web-based com-
munities, and peer support programs are
available to promote mental health recovery.
Many resources are available through the
National Alliance on Mental Illness
(http://www.nami.org).
Traditional healing and
complementary methods
Only 12 percent of White Americans consider
themselves atheist, agnostic, or secular without
a religious affiliation, meaning that, as a group,
White Americans are more religious than
Asian Americans but less so than Latinos or
African Americans (Pew Forum on Religion
and Public Life 2008). As with other groups,
White Americans belong to many different
religions, although the vast majority belong to
various Christian denominations, with approx-
imately 57 percent identifying as Protestant
and 25.9 percent as Catholic (National Center
on Addiction and Substance Abuse, 2001).
White Americans also make up 91 percent of
practitioners of Judaism in the United States,
14 percent of followers of Islam, and 32 per-
cent of the American Buddhist population
(Kosmin et al. 2001). For more religious
White Americans, pastoral counseling or
prayer can be useful aids in the treatment of
substance use disorders. However, White
Americans are significantly less likely to use
prayer as a method of coping (Graham et al.
2005). White Americans are more likely than
members of other major racial/ethnic groups
to use complementary or alternative medical
therapies, such as herbal medicine, acupunc-
ture, chiropractors, massage therapy, yoga, and
special diets (Graham et al. 2005).
Relapse prevention and recovery
Factors that promote recovery for White
Americans include the learning and use of
coping skills (Litt et al. 2003; Litt et al. 2005;
Maisto et al. 2006). Even though some research
suggests that White Americans are less likely
to use coping skills than African Americans
(Walton 2001) and have lower levels of self-
efficacy upon leaving treatment (Warren et al.
2007), the development of these skills and of
self-efficacy is important in managing relapse
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
coping strategies, specific skills to manage
stressful situations or environments, and op-
portunities to practice these skills during
treatment. Some coping skills or strategies
may be more important than others in manag-
ing high-risk situations, but research suggests
that greater use of a variety of coping strate-
gies is more important than the use of any one
specific skill (Gossop et al. 2002).
Social and family supports are also important
in maintaining recovery and preventing re-
lapse among White Americans (Laudet et al.
2002; McIntosh and McKeganey 2000;
Rumpf et al. 2002). Other important factors
include continuing care, the development of
substitute behaviors (i.e., reliance on healthy
or positive activities in lieu of substance use),
the creation of new caring relationships that
do not involve substance use, and increased
spirituality (Valliant 1983). Valliant (1983)
and others (e.g., Laudet et al. 2002; McCrady
et al. 2004; Moos and Moos 2006) conclude,
based on research with mostly White partici-
pants, that mutual-help groups often play an
important role in maintaining recovery.
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
6
Drug Cultures and the
Culture of Recovery
IN THIS CHAPTER
• What Are Drug Cultures?
• The Role of Drug Cultures
in Substance Abuse
Treatment
159
Lisa is a 19-year-old White college student living in San Diego,
CA, who was sent to treatment by her parents after failing her
college classes and being placed on academic probation. While
home on break earlier that year, her parents found pills in her room
but let her return to school after she promised to stop using. The
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 sister 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 electronic dance music 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
Improving Cultural Competence
or music.” Lisa points out that, unlike most of
her classmates, she doesn’t drink and has
stopped doing addictive drugs like ecstasy and
methamphetamine, which were responsible for
her weight loss. She is convinced that she can
continue to smoke pot and Salvia divinorum,
which she notes “isn’t even illegal,” and take
other botanical hallucinogens. She is adamant
about keeping her friends, who she says have
been supportive of her and are not materialis-
tic “sellouts” like her parents.
Her counselor places a priority on connecting
Lisa with other people her age who are in
recovery. She asks a client who graduated from
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-
ages Lisa’s friendships with other young peo-
ple in the program. When Lisa complains
about her parents’ materialism and the materi-
alism of mainstream culture, her counselor
brings up the spiritual elements of mutual-
help recovery groups and how they provide an
Multidimensional Model for Developing Cultural Competence: Drug Cultures
This Treatment Improvement Protocol
(TIP) emphasizes the concept that many
subcultures exist within and across diverse
ethnic and racial populations and cultures.
Drug cultures are a formidable example—
these are cultures that can influence the
presentation of mental, substance use,
and co-occurring disorders as well as
prevention and treatment strategies
and outcomes.
160
Chapter 6—Drug Cultures and the Culture of Recovery
alternative model for interacting with others.
The counselor begins to help Lisa explore how
her drug use may be an attempt to fill her
unmet emotional and social needs and may
hinder the development of her own interests,
identity, and goals.
Treatment providers should consider how
cultural aspects of substance use reinforce
substance use, substance use disorders, and
relapses. Factors to note include clients’ possi-
ble self-medication of psychological distress or
mental disorders. Beyond specific biopsycho-
social issues that contribute to the risk of
substance-related disorders and the initiation
and progression of use, counselors and treat-
ment organizations must continually acquire
knowledge about the ever-changing, diverse
drug cultures in which client populations may
participate and which reinforce the use of
drugs and alcohol. Moreover, behavioral health
service providers and program administrators
need to translate this knowledge into clinical
and administrative practices that address and
counter the influence of these cultures within
the treatment environment (e.g., by instituting
policies that ban styles of dress that indicate
affiliation with a particular drug culture).
Adopting Sue’s multidimensional model (2001)
for developing cultural competence, this chap-
ter identifies drug cultures as a domain that
requires proficiency in clinical skills, program-
matic development, and administrative practic-
es. It explores the concept of drug cultures, the
relationship between drug cultures and main-
stream culture, the values and rituals of drug
cultures, and how and why people value their
participation in drug cultures. This chapter
describes how counselors can determine a
client’s level of involvement in a drug culture,
how they can help clients identify and develop
alternatives to the drug cultures in which they
participate, and the importance of assisting
clients in developing a culture of recovery.
What Are Drug Cultures?
Up to this point, this TIP has focused on
cultures based on ethnicity, race, language, and
national origin. The TIP looks primarily at
those cultural groups because they are the
major cultural forces that shape an individual’s
life and worldview. However, there are other
types of cultural groups (sometimes referred to
as subcultures) that are also organized around
shared values, beliefs, customs, and traditions;
these cultural groups can have, as their core
organizing theme, such factors as sexuality,
musical styles, political ideologies, and so on.
For most clients in treatment for substance use
disorders (including those who have a co-
occurring mental disorder), the drug subcul-
ture will likely have affected their substance
use and can affect their recovery; that is the
primary rationale for the development of this
unique chapter. Research literature in this
topic area is considerably limited.
Some people question whether a given drug
culture is in fact a subculture, but many seem
to have all the elements ascribed to a culture
(see Chapter 1). A drug culture has its own
history (pertaining to drug use) that is usually
orally transmitted. It has certain shared values,
beliefs, customs, and traditions, and it has its
own rituals and behaviors that evolve over
time. Members of a drug culture often share
similar ways of dressing, socialization patterns,
language, and style of communication. Some
even develop a social hierarchy that gives
different status to different members of the
culture based on their roles within that culture
(Jenkot 2008). As with other cultures, drug
cultures are localized to some extent. For exam-
ple, people who use methamphetamines in
Hawaii and Missouri could share certain atti-
tudes, but they will also exhibit regional differ-
ences. The text boxes in this chapter offer
examples of the distinct values, languages,
161
Improving Cultural Competence
rituals, and types of artistic expression associ-
ated with particular drug cultures.
Many subcultures exist outside mainstream
society and thus are prone to fragmentation. A
single subculture can split into three or four
related subcultures over time. This is especially
true of drug cultures, in which people use
different substances, are from different locales,
or have different socioeconomic statuses; they
may also have very different cultural attitudes
related to the use of substances. Bourgois and
Schonberg (2007) described how ethnic and
racial differences can affect the drug cultures
of users of the same drugs to the point that
even such things as injection practices can
differ between Black and White heroin users
in the same city. Exhibit 6-1 lists of some of
the ways in which drug cultures can differ
from one another.
Differences in the physiological and psycho-
logical effects of drugs account for some dif-
ferences among drug cultures. For example,
the drug culture of people who use heroin is
typically less frenetic than the drug culture
involving methamphetamine use. However,
other differences seem to be more clearly
related to the historical development of the
culture itself or to the effects of larger social
forces. Cultural and socioeconomic compo-
nents contributed to the rise in methamphet-
amine use among gay men on the West Coast
(Reback 1997) and among Whites of lower
socioeconomic status in rural Missouri
(Topolski and Anderson-Harper 2004). How-
ever, in these two cases, the details of those
change factors are quite different. In Missouri,
the low cost and easy production of the drug
influenced development of a methampheta-
mine drug culture. Missouri leads the nation
in the number of methamphetamine labs seized
by police; a disproportionately large number of
seizures occur in rural areas (Carbone-Lopez et
al. 2012; Topolski and Anderson-Harper
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.)
Exhibit 6-1: How Drug Cultures Differ
• There is overlap among members, but drug
cultures differ based on substance used—
even among people from similar ethnic and
socioeconomic backgrounds. The drug cul-
ture of heroin use (McCoy et al. 2005;
Pierce 1999; Spunt 2003) differs from the
drug culture of ecstasy use (Reynolds 1998).
• Drug cultures differ according to geo-
graphic area; people who use heroin in the
Northeast United States are more likely to
inhale than inject the drug, whereas the
opposite is true among people in the
Western United States who use heroin
(Office of Applied Studies [OAS] 2004).
• Drug cultures can differ according to other
social factors, such as socioeconomic status.
The drug culture of young, affluent people
who use heroin can occasionally mirror the
drug culture of the street user, but it will al-
so have notable differences (McCoy et al.
2005; Pierce 1999; Spunt 2003).
• Drug cultures (even involving the same
drugs and the same locales) change over
time; older people from New York who use
heroin and who entered the drug culture in
the 1950s or 1960s feel marginalized within
the current drug scene, which they see as
promoting a different set of values
(Anderson and Levy 2003).
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
Credibility
How do you go about
establishing credibility?
Socialization
How were you introduced to the
culture?
Values
What values are upheld or
devalued in the group?
Status
In what ways can you obtain
status or be seen as a success?
Rules
Are there spoken and unspoken
rules or norms?
Gender Roles and
Relationships
What gender expectations
exist surrounding drug use?
Concepts of Sanction,
Punishment, and Conflict
Mediation
How does the group deal with
in-group conflicts?
Symbols and Images
Are there symbols that represent
a particular association with a
group or substance?
Dress
Are there specific ways to
dress that show allegiance
to a specific substance or
group?
View of Past, Present,
and Future
Are there specific beliefs about
the past, present, and/or future?
Language & Communication
Are there special verbal or
nonverbal ways to communicate
about substance-
related activities?
Attitudes
What are common attitudes
toward others (nonusers,
police, etc.)?
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Improving Cultural Competence
Whites could be linked to the historical de-
velopment of the methamphetamine trade by
White motorcycle gangs (Morgan and Beck
1997). On the other hand, most gay men who
use the drug report having first used it at
parties with the expectation of involvement in
sexual activity (Hunt et al. 2006). In studies of
gay men who used methamphetamine, the
main reason for use was to heighten sexual
experience (Halkitis et al. 2005; Kurtz 2005;
Reback 1997). Morgan and Beck (1997)
found that increased sexual activity was one
reason why certain women and heterosexual
men used methamphetamine, but it was not as
important a reason as it was for gay men.
This chapter aims to explain that people who
use drugs participate in a drug culture, and
further, that they value this participation.
However, not all people who abuse substances
are part of a drug culture. White (1996) draws
attention to a set of individuals whom he calls
“acultural addicts.” These people initiate and
sustain their substance use in relative isolation
from other people who use drugs. Examples of
acultural addicts include the medical profes-
sional who does not have to use illegal drug
networks to abuse prescription medication, or
the older, middle-class individual who “pill
shops” from multiple doctors and procures
drugs for misuse from pharmacies. Although
drug cultures typically play a greater role in
the lives of people who use illicit drugs, people
who use legal substances—such as alcohol—
are also likely to participate in such a culture
(Gordon et al. 2012). Drinking cultures can
develop among heavy drinkers at a bar or a
college fraternity or sorority house that works
to encourage new people to use, supports high
levels of continued or binge use, reinforces
denial, and develops rituals and customary
behaviors surrounding drinking. In this chap-
ter, drug culture refers to cultures that evolve
from drug and alcohol use.
The Relationship Between Drug
Cultures and Mainstream Culture
To some extent, subcultures define themselves
in opposition to the mainstream culture. Sub-
cultures may reject some, if not all, of the values
and beliefs of the mainstream culture in favor
of their own, and they will often adapt some
elements of that culture in ways quite different
from those originally intended (Hebdige 1991;
Issitt 2009; Exhibit 6-2). Individuals often
identify with subcultures—such as drug cul-
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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Chapter 6—Drug Cultures and the Culture of Recovery
unable to participate in mainstream society.
The subculture provides an alternative source
of social support and cultural activities, but
those activities can run counter to the best
interests of the individual. Many subcultures
are neither harmful nor antisocial, but their
focus is on the substance(s) of abuse, not on
the people who participate in the culture or
their well-being.
Mainstream culture in the United States has
historically frowned on most substance use
and certainly substance abuse (Corrigan et al.
2009; White 1979, 1998). This can extend to
legal substances such as alcohol or tobacco
(including, in recent years, the increased pro-
hibition against cigarette smoking in public
spaces and its growing social unacceptability
in private spaces). As a result, mainstream
culture does not—for the most part—have an
accepted role for most types of substance use,
unlike many older cultures, which may accept
use, for example, as part of specific religious
rituals. Thus, people who experiment with
drugs in the United States usually do so in
highly marginalized social settings, which can
contribute to the development of substance
use disorders (Wilcox 1998). Individuals who
are curious about substance use, particularly
young people, are therefore more likely to
become involved in a drug culture that en-
courages excessive use and experimentation
with other, often stronger, substances (for a
review of intervention strategies to reduce
discrimination related to substance use disor-
ders, see Livingston et al. 2012).
When people who abuse substances are mar-
ginalized, they tend not to seek access to
mainstream institutions that typically provide
sociocultural support (Myers et al. 2009). This
can result in even stronger bonding with the
drug culture. A marginalized person’s behavior
is seen as abnormal even if he or she attempts
to act differently, thus further reducing the
chances of any attempt to change behavior
(Cohen 1992). The drug culture enables its
members to view substance use disorders as
normal or even as status symbols. The disorder
becomes a source of pride, and people may
celebrate their drug-related identity with other
members of the culture (Pearson and Bourgois
1995; White 1996). Social stigma also aids in
the formation of oppositional values and
beliefs that can promote unity among mem-
bers of the drug culture (Exhibit 6-3).
When people with substance use disorders
experience discrimination, they are likely to
delay entering treatment and can have less
positive treatment outcomes (Fortney et al.
2004; Link et al. 1997; Semple et al. 2005).
Discrimination can also increase denial and
step up the individual’s attempts to hide sub-
stance use (Mateu-Gelabert et al. 2005). The
immorality that mainstream society attaches
to substance use and abuse can unintentionally
serve to strengthen individuals’ ties with the
drug culture and decrease the likelihood that
they will seek treatment.
The relationship between the drug and main-
stream cultures is not unidirectional. Since the
beginning of a definable drug culture, that
culture has had an effect on mainstream cul-
tural institutions, particularly through music
(Exhibit 6-4), art, and literature. These con-
nections can add significantly to the attraction
a drug culture holds for some individuals
(especially the young and those who pride
themselves on being nonconformists) and
create a greater risk for substance use escalat-
ing to abuse and relapse.
Understanding Why People Are
Attracted to Drug Cultures
To understand what an individual gains from
participating in a drug culture, it is important
first to examine some of the factors involved
165
Improving Cultural Competence
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 emotional intimacy 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 jazz 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 youth culture, 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 rave 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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Chapter 6—Drug Cultures and the Culture of Recovery
in substance use and the development of
substance use disorders. Despite having differ-
ing theories about the root causes of substance
use disorders, most researchers would agree
that substance abuse is, to some extent, a
learned behavior. Beginning with Becker’s
(1953) seminal work, research has shown that
many commonly abused substances are not
automatically experienced as pleasurable by
people who use them for the first time
(Fekjaer 1994). For instance, many people find
the taste of alcoholic beverages disagreeable
during their first experience with them, and
they only learn to experience these effects as
pleasurable over time. Expectations can also be
important among people who use drugs; those
who have greater expectancies of pleasure
typically have a more intense and pleasurable
experience. These expectancies may play a part
in the development of substance use disorders
(Fekjaer 1994; Leventhal and Schmitz 2006).
Additionally, drug-seeking and other behav-
iors associated with substance use have a
reinforcing effect beyond that of the actual
drugs. Activities such as rituals of use (Exhibit
6-5), which make up part of the drug culture,
provide a focus for those who use drugs when
the drugs themselves are unavailable and help
them shift attention away from problems they
might otherwise need to face (Lende 2005).
Drug cultures serve as an initiating force as
well as a sustaining force for substance use and
abuse (White 1996). As an initiating force, the
culture provides a way for people new to drug
use to learn what to expect and how to appre-
ciate the experience of getting high. As White
(1996) notes, the drug culture teaches the new
user “how to recognize and enjoy drug effects”
(p. 46). There are also practical matters involved
in using substances (e.g., how much to take,
how to ingest the substance for strongest effect)
that people new to drug use may not know
when they first begin to experiment with drugs.
The skills needed to use some drugs can be
quite complicated, as shown in Exhibit 6-6.
The drug culture has an appeal all its own that
promotes initiation into drug use. Stephens
(1991) uses examples from a number of ethno-
graphic studies to show how people can be as
taken by the excitement of the drug culture as
they are by the drug itself. Media portrayals,
along with singer or music group autobiog-
raphies, that glamorize the drug lifestyle may
increase its lure (Manning 2007; Oksanen
2012). In buying (and perhaps selling) drugs,
individuals can find excitement that is missing
in their lives. They can likewise find a sense of
purpose they otherwise lack in the daily need to
seek out and acquire drugs. In successfully
navigating the difficulties of living as a person
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 hip hop (Esan 2007; Schensul et al. 2000) or narcocorridos (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.
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Improving Cultural Competence
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
Netherlands, 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 methylphenidate with alcohol to intensify euphoric effects (for review of central nervous system
stimulant 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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Chapter 6—Drug Cultures and the Culture of Recovery
who uses drugs, they can gain approval from
peers who use drugs and a feeling that they are
successful at something.
In some communities, participation in the
drug trade—an aspect of a drug culture—is
simply one of the few economic opportunities
available and is a means of gaining the admi-
ration and respect of peers (Bourgois 2003;
Simon and Burns 1997). However, drug deal-
ing as a source of status is not limited to eco-
nomically deprived communities. In studying
drug dealing among relatively affluent college
students at a private college, Mohamed and
Fritsvold (2006) found that the most im-
portant motives for dealing were ego gratifica-
tion, status, and the desire to assume an outlaw
image.
Marginalized adolescents and young adults
find drug cultures particularly appealing.
Many individual, family, and social risk factors
associated with adolescent substance abuse are
also risk factors for youth involvement with a
drug culture. Individual factors—such as
feelings of alienation from society and a strong
rejection of authority—can cause youth to
look outside the traditional cultural institu-
tions available to them (family, church, school,
etc.) and instead seek acceptance in a subcul-
ture, such as a drug culture (Hebdige 1991;
Moshier et al. 2012). Individual traits like
sensation-seeking and poor impulse control,
which can interfere with functioning in main-
stream society, are often tolerated or can be
freely expressed in a drug culture. Family
involvement with drugs is a significant risk
factor due to additional exposure to the drug
lifestyle, as well as early learning of the values
and behaviors (e.g., lying to cover for parents’
illicit activities) associated with it (Haight et
al. 2005). Social risk factors (e.g., rejection by
peers, poverty, failure in school) can also in-
crease young people’s alienation from tradi-
tional cultural institutions. The need for social
acceptance is a major reason many young
people begin to use drugs, as social acceptance
can be found with less effort within the drug
culture.
In addition to helping initiate drug use, drug
cultures serve as sustaining forces. They sup-
port continued use and reinforce denial that a
problem with alcohol or drugs exists. The
importance of the drug culture to the person
using drugs often increases with time as the
person’s association with it deepens (Moshier
et al. 2012). White (1996) notes that as a
person progresses from experimentation to
abuse and/or dependence, he or she develops a
more intense need to “seek for supports to
sustain the drug relationship” (p. 9). In addi-
tion to gaining social sanction for their sub-
stance use, participants in the drug culture
learn many skills that can help them avoid the
pitfalls of the substance-abusing lifestyle and
thus continue their use. They learn how to
avoid arrest, how to get money to support
their habit, and how to find a new supplier
when necessary.
The more an individual’s needs are met within
a drug culture, the harder it will be to leave
that culture behind. White (1996) gives an
example of a person who was initially attracted
in youth to a drug culture because of a desire
for social acceptance and then grew up within
that culture. Through involvement in the drug
culture, he was able to gain a measure of self-
esteem, change his family dynamic, explore his
sexuality, develop lasting friendships, and find
a career path (albeit a criminal one). For this
individual, who had so much of his life invest-
ed in the drug culture, it was as difficult to
conceive of leaving that culture as it was to
conceive of stopping his substance use.
Online Drug Cultures
One major change that has occurred in drug
cultures in recent years is the development of
169
Improving Cultural Competence
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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Chapter 6—Drug Cultures and the Culture of Recovery
Internet communities organized around drug
use (Gatson 2007a; Murguia et al. 2007) and
drug use facilitation, including information on
use, production, and sales (Bowker 2011; U.S.
Department of Justice 2002). Such communi-
ties develop around Web sites or discussion
boards where individuals can describe their
drug-related experiences, find information on
acquiring and using drugs, and discuss related
issues ranging from musical interests to legal
problems. Many of the Web sites where these
online communities develop are originally
created to lessen the negative consequences of
substance use by informing people about vari-
ous related legal and medical issues (Gatson
2007b; Murguia et al. 2007). As in other drug
cultures, users of these Web sites and discus-
sion boards develop their own language and
values relating to drug use. Club drugs and
hallucinogenics are the most often-discussed
types of drugs, but online communities involve
the discussion of all types of licit and illicit
substances, including stimulants and opioids
(Gatson 2007a; Murguia et al. 2007; Tackett-
Gibson 2007).
Murguia et al. (2007) reported on a survey of
adult (ages 18 and older) participants in one
online community. The self-selected survey
sample included 1,038 respondents, 80 percent
of whom were from the United States. Re-
spondents were likely to be young (90 percent
were under 30), male (76 percent), White (92
percent), relatively affluent (58 percent had
household incomes of $45,000 or more),
employed (41 percent were employed full
time; another 28 percent, part time), and/or in
school (57 percent were attending school full
or part time). According to the 2011 National
Survey on Drug Use and Health, approxi-
mately 0.3 percent of individuals 12 years of
age or older purchase prescription drugs
through the Internet (SAMHSA, 2012b).
The Role of Drug Cultures
in Substance Abuse
Treatment
Most people seek some kind of social affilia-
tion; it is one aspect of life that gives meaning
to day-to-day existence. Behavioral health
service providers can better understand and
help their clients if they have an understand-
ing of the culture(s) with which they identify.
This understanding can be even more im-
portant when addressing the role of drug
culture in a client’s life because, of all cultural
affiliations, it is likely to be the one most
intimately connected with his or her substance
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
171
Improving Cultural Competence
abuse. The drug culture is likely to have had a
considerable influence on the client’s behav-
iors related to substance use.
Drug Cultures in Assessment and
Engagement
The first step in understanding the role a drug
culture plays in a client’s life is to assess which
drug culture(s) the client has been involved
with and his or her level of involvement. There
are no textbooks that can inform providers
about the drug cultures in their areas, but
counselors probably know quite a bit about
them already, as they learn much about drug
cultures through talking with their clients.
Counselors who are themselves in recovery
may be familiar with some clients’ substance-
using lifestyles and social environments or will
have insight into how to explore the issue with
clients. They can also educate their colleagues.
Providers who have never personally abused
substances can learn from recovered counse-
lors as well as from their clients. However,
asking a client point-blank about his or her
involvement in a drug culture is likely to be
answered with a blank stare. Instead, talking to
clients about their relationships, daily activities
and habits relating to substance use, values,
and views of other people and the world can
allow providers to develop a good sense of the
meanings drug cultures hold for clients.
To engage a client in treatment, understanding
his or her relationship with a drug culture may
be as important as understanding elements of
that client’s racial or ethnic identity. Clients
are unlikely to self-identify as members of the
drug culture in the same way that they would
identify as an African American or Asian
American, for example, but they can still be
offended or distrustful if they think the provid-
er or program does not understand how their
lifestyle relates to their substance use. Affilia-
tion with a drug culture is a source of client
identity; the client’s place in the drug culture
can be important to his or her self-esteem.
After the assessment and engagement stage,
the provider’s attitude toward the client’s
participation in a drug culture will be signifi-
cantly different from his or her attitude to-
ward the client’s other cultural affiliations. As
most providers already know (even if they do
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.
172
Chapter 6—Drug Cultures and the Culture of Recovery
continues to be closely affiliated with the
drug-using life, then he or she is more likely to
relapse. The people, places, things, thoughts,
and attitudes related to drug and/or alcohol
use act as triggers to resume use of substances.
Behavioral health service providers need to
help their clients weaken and eventually elim-
inate their connections to the drug culture.
White (1996) identifies an important issue to
address during transition from engagement to
treatment—in the process of engaging clients,
providers help them identify how their con-
nections to the drug culture prevent them
from reaching their goals and how the loss of
these connections would affect them if they
chose to cut ties with the drug culture.
Finding Alternatives to Drug
Cultures
A client can meet the psychosocial needs previ-
ously satisfied by the drug culture in a number
of ways. Strengthening cultural identity can be
a positive action for the client; in some cases,
the client’s family or cultural peers can serve as
a replacement for involvement in the drug
culture. This option is particularly helpful when
the client’s connection to a drug culture is
relatively weak and his or her traditional culture
is relatively strong. However, when this option
is unavailable or insufficient, clinicians must
focus on replacing the client’s ties with the drug
culture (or the culture of addiction) with new
ties to a culture of recovery.
To help clients break ties with drug cultures,
programs need to challenge clients’ continued
involvement with elements of those cultures
(e.g., style of dress, music, language, or com-
munication patterns). This can occur through
two basic processes: replacing the element
with something new that is positively associat-
ed with a culture of recovery (e.g., replacing a
marijuana leaf keychain with an NA key-
chain), and reframing something so that it is
no longer associated with drug use or the drug
culture (e.g., listening to music that was asso-
ciated with the drug culture at a sober dance
with others in recovery; White 1996). The
process will depend on the nature of the cul-
tural element.
Developing a Culture of Recovery
Just as people who are actively using or abus-
ing substances bond over that common experi-
ence to create a drug culture that supports
their continued substance use, people in recov-
ery can participate in activities with others
who are having similar experiences to build a
culture of recovery. There is no single drug
culture; likewise, there is no single culture of
recovery. However, large international mutual-
help organizations like Alcoholics Anonymous
(AA) do represent the culture of recovery for
many individuals (Exhibit 6-7). Even within
such organizations, though, there is some
cultural diversity; regional differences exist, for
example, in meeting-related rituals or attitudes
toward certain issues (e.g., use of prescribed
psychotropic medication, approaches to
spirituality).
The planned TIP, Relapse Prevention and
Recovery Promotion in Behavioral Health
Services (SAMHSA planned e), provides more
information on using mutual-help groups in
“The culture of recovery is an informal
social network in which group norms (pre-
scribed patterns of perceiving, thinking,
feeling, and behaving) reinforce sobriety
and long-term recovery from addiction.”
(White 1996, p. 222)
Recovery from mental and substance use
disorders is a process of change through
which people improve their health and
wellness, live in a self-directed manner, and
work toward achieving their full potential.
(SAMHSA 2011b)
173
Improving Cultural Competence
treatment settings and in long-term recovery.
It contains detailed information about poten-
tial recovery supports that behavioral health
programs can use to foster cultures of recovery
among clients and program graduates.
Most treatment programs try to foster a culture
of recovery for their clients. Some modalities,
with therapeutic communities being the lead
example, focus on this issue as a primary treat-
ment strategy. Even one-on-one outpatient
treatment programs typically encourage attend-
ance at mutual-help groups, such as AA, to
meet sociocultural recovery needs. Most pro-
viders also recognize that clients need to
replace the activities, beliefs, people, places, and
things associated with substance abuse with
new recovery-related associations—the central
purpose of creating a culture of recovery.
Even programs that already recognize the
need to create a culture of recovery for their
clients can make doing so more of a focus in
treatment. White (1996) explores ways to do
this, including:
• Teaching clients about the existence of
drug cultures and their potential influence
in clients’ lives.
• Teaching clients about cultures of recovery
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 ritual 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
culture of recovery.
• Establishing clear boundaries for appro-
priate behavior (e.g., behavior that does
not reflect drug cultures) in the program
and consistently correcting behaviors that
violate boundaries (e.g., wearing shirts de-
picting pot leaves; displaying gang-
affiliated symbols, gestures, and tattoos).
• Working to shape a peer culture within the
program so that longer-term clients and
staff members can socialize new clients to
a culture of recovery.
• Having regular assessments of clients and
the entire program in which staff members
and clients determine areas where work is
needed to minimize cultural attitudes that
can undermine treatment.
• Involving clients’ families (when appropri-
ate) in the treatment process so they can
support clients’ recovery as well as partici-
pate in their own healing process.
White (1996) suggests that programs build
linkages with mutual-help groups; include
mutual-help meetings in their programs or
provide access to community mutual-help
meetings; and include mutual-help rituals,
symbols, language, and values in treatment
processes.
Other activities that can improve integration
into a recovery culture include SAMHSA’s
Recovery Community Services Program
(http://www.samhsa.gov/grants/2011/ti_11_0
04.aspx), which was developed to provide and
evaluate peer-based recovery support services,
and Recovery Community Centers, which
provide space for recovering people to social-
ize, organize, and develop a recovery culture
(White and Kurtz 2006). Developing a culture
of recovery involves connecting individuals
back to the larger community and to their
cultures of origin (Davidson et al. 2008). This
can require efforts to educate the community
about recovery as well (e.g., by promoting a
recovery month in the community, hosting
recovery walks or similar events, or offering
outreach to community groups, such as
churches or fraternal/benevolent societies).
Programs that do not have a plan for creating
a culture of recovery among clients risk their
clients returning to the drug culture or hold-
ing on to elements of that culture because it
meets their basic and social needs. In the worst
case scenario, clients will recreate a drug cul-
ture among themselves within the program. In
the best case, staff members will have a plan
for creating a culture of recovery within their
treatment population.
SAMHSA’s Guiding Principles of
Recovery
• Recovery emerges from hope.
• Recovery is person driven.
• Recovery occurs via many pathways.
• Recovery is holistic.
• Recovery is supported by peers and allies.
• Recovery is supported through relationship
and social networks.
• Recovery is culturally based and influenced.
• Recovery is supported by addressing
trauma.
• Recovery involves individual, family, and
community strengths and responsibility.
• Recovery is based on respect.
More information on the Guiding Principles of
Recovery is available at the SAMHSA Store
(http://store.samhsa.gov/shin/content//PEP12-
RECDEF/PEP12-RECDEF.
pdf).
Source: SAMHSA 2012c.
175
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252
Appendix B—Instruments To
Measure Identity and Acculturation
Some researchers have tested the usefulness of
acculturation and identity models with people
who abuse substances. For example, Peña and
colleagues’ racial identity attitude scale was
found, in a study of African American men in
treatment for cocaine dependence, to help
counselors better understand the roles that
ethnic and cultural identity play in clients’
substance abuse issues (Peña et al. 2000). In
1980, Cuellar and colleagues published their
acculturation rating scale for Mexican
Americans, which conceptualized accultura-
tion as progressing across a 5-point continu-
um ranging from Mexican or low acculturated
(level 1) to American or high acculturated
(level 5). The mid-level designation of bicul-
tural (level 3) was set as the midpoint between
the two extremes, although various investiga-
tors have questioned this assumption
(Oetting and Beauvais 1990; Sayegh and
Lasry 1993). Since then, scholars have devel-
oped new ways to conceptualize identity and
acculturation, ranging from simple scales to
complex multidimensional models (Skinner
2001). The table that begins on the next page
summarizes the instruments available to
measure acculturation and ethnic identity.
(See also the Center of Excellence for
Cultural Competence for additional resources
at http://nyculturalcompetence.org).
Other scales have been developed to examine
specific culture-related variables, including
machismo (Cuellar et al. 1995; Fragoso and
Kashubeck 2000), simpatía (Griffith et al.
1998), familismo (Sabogal et al. 1987), tradi-
tionalism–modernism (Ramirez 1999), and
family traditionalism and rural preferences
(Castro and Gutierres 1997).
Counselors can
use acculturation scales to help match patients
to providers, to make treatment plans, and to
identify the role of identity in substance abuse.
Although these instruments can be helpful,
the counselor must not rely solely on them to
determine the client’s identity or level of
acculturation.
253
Improving Cultural Competence
Acculturation and Ethnic Identity Measures
Instrument Description Cultural Group
African American Accul-
turation Scale-Revised
(Klonoff and Landrine
2000)
This scale measures eight dimensions of African
American culture: (1) traditional beliefs and prac-
tices, (2) traditional family structure and practices,
(3) traditional socialization, (4) preparation and
consumption of traditional foods, (5) preference
for African American things, (6) interracial atti-
tudes, (7) superstitions, and (8) traditional health
beliefs and practices.
African Americans
Black Racial Identity
Attitude Scale—Form B
(Helms 1990)
This scale measures beliefs or attitudes of Blacks
toward both Blacks and Whites using 5-point
scales. It is available in short and long forms.
African Americans
Cross Racial Identity
Scale (Worrell et al.
2001)
This scale measures six identity clusters associated
with four stages of racial identity development.
African Americans
Multidimensional Inven-
tory of Black Identity
(MIBI; Sellers et al. 1997)
The MIBI measures centrality of Black identity,
ideology, and regard for a Black identity. It is
available online at
http://sitemaker.umich.edu/aaril/files/mibiscaleand
scoring.pdf.
African Americans
Scale To Assess African
American Acculturation
(Snowden and Hines
1999)
This is a 10-item scale that assesses media prefer-
ences, racial bias in relationships, race-related
attitudes, and comfort in interacting with other
races.
African Americans
African Self-
Consciousness Scale
(Baldwin and Bell 1985)
This scale measures within-group variability in the
level of acculturation/cultural identity continuum
(Baldwin and Bell 1985) based on degree of
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.
African
Americans/African
Immigrants
Native American Accul-
turation Scale (Garrett
and Pichette 2000)
The Native American Acculturation scale asks 20
questions to ascertain a client’s level of involve-
ment with Native American culture.
Native Americans
Rosebud Personal
Opinion Survey
(Hoffmann et al. 1985)
This assessment evaluates components of accul-
turation, including language use, values, social
behaviors, social networks, religious affiliation and
practice, home community, education, ancestry,
and cultural identification.
Native Americans
Asian American Multi-
dimensional Accultura-
tion Scale (AAMAS; Gim
Chung et al. 2004)
The AAMAS was developed to be easy to use with
a variety of Asian American ethnic groups. It
includes questions relating to cultural identity,
language use, cultural knowledge, and food
preferences.
Asian Americans
(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
Difficulties Checklist
(CADC; Sodowsky and
Lai 1997)
The CADC helps avoid potential problems relating
to acculturation by asking about language use,
social customs, family interactions, perceptions of
prejudice, friendship networks, and cultural ad-
justment.
Asian Americans
(East Asians)
East Asian Acculturation
Measure (Barry 2001)
This instrument includes 29 items that assess
assimilation, level of separation from other Asians,
integration, and marginalization.
Asian Americans
(East Asians)
General Ethnicity Ques-
tionnaire (GEQ; Tsai et
al. 2000)
The GEQ is an instrument designed to be used
with minor modifications for assessing cultural
orientation with different cultural groups. There
are original and abridged versions. The original
includes 75 items asking about language use,
social affiliations, cultural practices, and cultural
identification.
Asian Americans
(although
designed to be
multicultural in
orientation)
Suinn-Lew Asian Self-
Identity Acculturation
Scale (Suinn et al. 1992)
This instrument was modeled after the Accultura-
tion Rating Scale for Mexican Americans, and
research indicates it has high reliability.
Asian Americans
Ethnocultural Identity
Behavioral Index (Yama-
da et al. 1998)
This is a 19-item self-report assessment with high
validity.
Asian Americans
and Pacific
Islanders
Internal-External Ethnic
Identity Measure (Kwan
1997)
The instrument evaluates ethnic friendships and
affiliation, ethnocommunal expression, ethnic food
orientation, and family collectivism, in order to
differentiate three Chinese American identity
groups: (1) internal, (2) external, and (3) internal-
external undifferentiated.
Chinese
Americans
Marín and Marín Accul-
turation Scale (Marín et
al. 1987)
This scale is a 12-item instrument that assesses
three domains: (1) language use, (2) media prefer-
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
Chinese
Americans
Behavioral Acculturation
Scale and Value Accul-
turation Scale (Szapocz-
nik et al. 1978)
These two scales, used in conjunction with one
another, ask individuals about behaviors and
values in order to determine acculturation. If used
singly, the behavioral scale is the superior measure
for acculturation.
Cuban Americans
Na Mea Hawai’i
(Hawaiian Ways), A
Hawaiian Acculturation
Scale (Rezentes 1993)
This is a 34-item scale. An adolescent version is
available (Hishinuma et al. 2000).
Native Hawaiians
(Continued on the next page.)
255
Improving Cultural Competence
Acculturation and Ethnic Identity Measures (continued)
Instrument Description Cultural Group
Abbreviated Multi-
dimensional Accul-
turation Scale
(AMAS-ZABB; Zea et
al. 2003)
The AMAS-ZABB is a multidimensional, bilinear, 42-
item scale that evaluates identity, language compe-
tence, and cultural competence.
Latinos
Acculturation Scale
(Marin et al. 1987)
This 12-item acculturation scale, available in English
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
Latinos
Bicultural Involve-
ment Questionnaire
(BIQ; Szapocznik et
al. 1980)
The BIQ assesses language use and involvement in
both Latino and mainstream American activities. It
relates two sets of scores to derive a measure of
bicultural involvement, with individuals who are highly
involved in both cultures scoring highest on the scale.
Latinos
The Bidimensional
Acculturation Scale
for Hispanics (Marin
and Gamba 1996)
This 24-item scale asks questions about language use,
language proficiency, and media preferences.
Latinos
Brief Acculturation
Scale for Hispanics
(Norris et al. 1996)
This scale has only four items, but scores on the scale
have been correlated highly with generation, nativity,
length of time in the United States, language prefer-
ences, and subjective perceptions of acculturation.
Latinos
Multidimensional
Measure of Cultural
Identity for Latinos
(Felix-Ortiz et al.
1994)
This measure places adolescents in one of four cate-
gories based on language, behavior/familiarity, and
values/attitudes: (1) bicultural, (2) Latino-identified, (3)
American-identified, and (4) low-level bicultural.
Latinos
Acculturation Rating
Scale for Mexican
Americans-I
(ARSMA-I; Cuellar et
al. 1980)
The ARSMA-I differentiates between 5 levels of accul-
turation: (1) Very Mexican, (2) Mexican-Oriented
Bicultural, (3) True Bicultural, (4) Anglo-Oriented
Bicultural, and (5) Very Anglicized. Established validity.
Mexican
Americans
Acculturation Rating
Scale for Mexican
Americans-II (Cuellar
et al. 1995)
This scale is like the ARSMA-I, except that it includes
separate subscales to measure multidimensional
aspects of cultural orientation toward Mexican and
Anglo cultures independently.
Mexican
Americans
Cultural Life Style
Inventory (Mendoza
1989)
This self-report instrument, available in Spanish and
English, evaluates five dimensions of acculturation:
intrafamily language use, extrafamily language use,
social activities and affiliations, cultural knowledge
and activities, and cultural identification and pride.
Mexican
Americans
(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
Inventory (Mendoza
1989)
This self-report instrument, available in Spanish and
English, evaluates acculturation on five dimensions:
intrafamily language use, extrafamily language use,
social activities and affiliations, cultural knowledge and
activities, and cultural identification and pride.
Mexican
Americans
Mexican American
Acculturation Scale
(Montgomery 1992)
This 28-item scale evaluates cultural orientation and
comfort with ethnic identity. Items ask about language
use, media preferences, cultural activities/traditions,
and self-perceived ethnic identity.
Mexican
Americans
Padilla’s
Acculturation Scale
(Padilla 1980)
Padilla’s Acculturation Scale is a 155-item question-
naire that assesses cultural knowledge and ethnic
loyalties.
Mexican
Americans
Bidimensional
Acculturation Scale
for Hispanics (Marín
and Gamba 1996)
This scale measures evaluates two major dimensions
of acculturation (Hispanic and non-Hispanic) using 12
items measuring 3 language-related areas. It has been
found to have high consistency and validity.
Mexican
Americans and
Central
Americans
Stephenson
Multigroup
Acculturation Scale
(Stephenson 2000)
This is a 32-item instrument that evaluates immersion
in both culture of origin and the dominant culture of
the society.
Multicultural
Vancouver Index of
Acculturation (Ryder
et al. 2000)
This instrument includes 20 questions that assess
interest/participation in one’s “heritage culture” and
“typical American culture” (available online at
http://www2.psych.ubc.ca/~dpaulhus/Paulhus_measur
es/VIA.American.doc).
Multicultural
Bicultural Accultura-
tion Scale (Cortés
and Rogler 1994)
Developed for use with first- and second-generation
Puerto Rican adults, this scale measures involvement
in American culture and Puerto Rican culture, but it
has limited evidence of validity and reliability.
Puerto Rican
Americans
Psychological
Acculturation Scale
(Tropp et al. 1999)
The items on this scale pertain to the client’s sense of
psychological attachment to and belonging within
Anglo American and Hispanic/Latino cultures.
Puerto Ricans on
the U.S. main-
land
Acculturation Scale
for Southeast Asians
(Anderson et al.
1993)
This 13-item scale evaluates languages proficiency and
preferences regarding social interactions, cultural
activities, and food. It includes two subscales for
proficiency in languages, as well as language, social,
and food preferences.
Cambodian,
Laotian, and
Vietnamese
Americans
White Racial Identity
Attitude Scale (Helms
and Carter 1990)
This 50-item instrument rates items on a 5-point scale
to measure attitudes associated with Helms’s stages of
racial identity development for Caucasians.
White Americans
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
Precontact
Problem Identification
Problem Specification
Mutual Goal Formulation
Problem Solving
Termination
Items
A _______ G _______ M _______ S _______
B _______ H _______ N _______ T _______
C _______ I _______ O _______ U _______
D _______ J _______ P _______ V _______
E _______ K _______ Q _______ W _______
F _______ L _______ R _______ X _______
Source: Ho 1991. Reproduced with permission.
263
Improving Cultural Competence
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.
265
Improving Cultural Competence
8. Provide easy-to-understand print 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.
(Continued on the next page.)
266
Appendix C—Tools for Assessing Cultural Competence
Sample of Process Measures by Domain (continued)
Domain Topic Areas Measures/Indicators
Communication Linguistically
competent
organization
Number of trained translators and interpreters available
Number of staff proficient in languages of the community
Communication Language
ability,
written and
oral, of the
consumer
Consumer reading and writing levels of primary languages and
dialects is recorded.
Policies and
procedures
Choice of
health plan
network
Contract continuation and renewal with health plan is contingent
upon successful achievement of performance targets that demon-
strate effective service, equitable access, and comparability of
benefits for populations of racial/ethnic groups.
Policies and
procedures
Staff hiring,
recruitment
Number of multilingual/multicultural staff
Ratio by culture of staff to clients
Family and
community
participation
Community
and
consumer
participation
Degree to which families participate in key decisionmaking activities:
• Family participation on advisory committees or task forces
• Hiring of family members to serve as consultants to provid-
ers/programs
• Inclusion of family members in planning, implementation, and
evaluation of activities
Communication
Translated
materials
Allocated resources for interpretation and translation services for
medical encounters and health education/promotion material.
Communication
Linguistic
capacity of
the provider
Ability to conduct audit of the provider network, which includes the
following components:
• 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
information,
education
• Organization has the capacity to disseminate information on
health care plan benefits in languages of community.
• Organization has the capacity to disseminate information and
explanation of rights to enrollees.
Policies and
procedures
Grievance
and conflict
resolution
Organization has structures in place to address cross-cultural ethi-
cal and legal conflicts in health care delivery and complaints or
grievances by patients and staff about unfair, culturally insensitive,
or discriminatory treatment, or difficulty in accessing services or
denial of services.
Policies and
procedures
Grievance
and conflict
resolution
Organization has feedback mechanisms in place to track number of
grievances and complaints and number of incidents.
Policies and
procedures
Planning
and govern-
ance
Composition of the governing board, advisory committee, other
policymaking and influencing groups, and consumers served re-
flects service area demographics.
267
Improving Cultural Competence
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?
Sample of Capacity/Structure Measures by Domain
Domain Topic Areas Measures/Indicators
Facility charac-
teristics, capaci-
ty, and
infrastructure
Available and
accessible
services
• Transportation is available from residential areas to culturally
competent providers.
• Organization has the flexibility to conduct home visits and
community outreach.
• Culturally responsive services are available evenings and
weekends.
Facility charac-
teristics, capaci-
ty, and
infrastructure
Information
systems
Capacity for tracking of access and utilization rates for popula-
tion of different racial/ethnic groups in comparison to the
overall service population.
Monitoring,
evaluation, and
research
Organizational
assessment
Ability to conduct ongoing organizational self-assessments of
cultural and linguistic competence and integration of measures
of access, satisfaction, quality, and outcomes into other organi-
zational internal audits and performance improvement pro-
grams.
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
STATEMENT
Strongly
Disagree Disagree
Neither Agree
Nor Disagree Agree
Strongly
Agree
1. The staff here understands some of
the ideas that I, my family, and others
from my cultural, racial, or ethnic
group may have.
1 2 3 4 5
2. Staff here understands the im-
portance of my cultural beliefs in my
treatment process.
1 2 3 4 5
3. The staff here listens to me and my
family when we talk to them.
1 2 3 4 5
4. If I want, the staff will help me get
services from clergy or spiritual leaders.
1 2 3 4 5
5. The services I get here really help
me work toward things like getting a
job, taking care of my family, going to
school, and being active with my
friends, family, and community.
1 2 3 4 5
(Continued on the next page.)
273
Improving Cultural Competence
Iowa Cultural Understanding Assessment–Client Form (continued)
RESPONSE
STATEMENT
Strongly
Disagree Disagree
Neither Agree
Nor Disagree Agree
Strongly
Agree
6. The staff here seems to under-
stand the experiences and problems I
have in my past life.
1 2 3 4 5
7. The waiting room and/or facility
has pictures or reading material that
show people from my racial or ethnic
group.
1 2 3 4 5
8. The staff here knows how to use
their knowledge of my culture to
help me address my current day-to-
day needs.
1 2 3 4 5
9. The staff here understands that I
might want to talk to a person from
my own racial or ethnic group about
getting the help I want.
1 2 3 4 5
10. The staff here respects my reli-
gious or spiritual beliefs.
1 2 3 4 5
11. Staff from this program comes to
my community to let people like me
and others know about the services
they offer and how to get them.
1 2 3 4 5
12. The staff here asks me, my family,
or others close to me to fill out forms
that tell them what we think of the
place and services.
1 2 3 4 5
13. Staff here understands that
people of my racial or ethnic group
are not all alike.
1 2 3 4 5
14. It was easy to get information I
needed about housing, food, cloth-
ing, child care, and other social
services from this place.
1 2 3 4 5
15. The staff here talks to me about
the treatment they will give me to
help me.
1 2 3 4 5
16. The staff here treats me with
respect.
1 2 3 4 5
17. The staff seems to understand
that I might feel more comfortable
working with someone who is the
same sex as me.
1 2 3 4 5
(Continued on the next page.)
274
Appendix C—Tools for Assessing Cultural Competence
Iowa Cultural Understanding Assessment–Client Form (continued)
RESPONSE
STATEMENT
Strongly
Disagree
Disagree
Neither Agree
Nor Disagree
Agree
Strongly
Agree
18. Most of the time, I feel I can trust
the staff here who work with me.
1 2 3 4 5
19. The waiting room has brochures
or handouts that I can easily under-
stand that tell me about services I
can get here.
1 2 3 4 5
20. If I want, my family or friends are
included in discussions about the
help I need.
1 2 3 4 5
21. The services I get here deal with
the problems that affect my day-to-
day life such as family, work, money,
relationships, etc.
1 2 3 4 5
22. Some of the staff here under-
stand the difference between their
culture and mine.
1 2 3 4 5
23. Some of the counselors are from
my racial or ethnic group.
1 2 3 4 5
24. Staff members are willing to be
flexible and provide alternative
approaches or services to meet my
cultural/ethnic treatment needs.
1 2 3 4 5
25. If I need it, there are translators
or interpreters easily available to
assist me and/or my family.
1 2 3 4 5
Source: White et al. 2009. Reproduced with permission.
275
Appendix D—Screening and
Assessment Instruments
Important Note: The following tables pro-
vide an overview of selected instruments that
screen and assess for substance use disorders
and mental disorders and symptoms. These
tables only represent a sample of instruments.
In reviewing the tables, do not assume that the
instruments have normative data across race
and ethnicities. The citations and information
listed in this appendix serve only as a starting
point for investigating the appropriateness of
available instruments within specific popula-
tions. Citations reflect information about the
effectiveness of the testing measurements as
well as research that suggests modifications or
reports testing discrepancies among racial and
ethnic populations.
Screening and Assessment Instruments for Substance Use Disorders
Instrument Description Clinical Utility
Alcohol, Smoking, and
Substance Involvement
Screening Test (ASSIST;
Humeniuk et al. 2010)
The ASSIST (version
3.1) has eight items
to screen for use of
tobacco products,
alcohol, and drugs
ASSIST was developed by the World Health
Organization (WHO) as a culturally neutral tool for
use in primary and general medical care settings.
This paper-pencil instrument takes 5 to 10 minutes
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
Identification Test
(AUDIT; Babor et al. 1992;
Saunders et al. 1993)
This 10-item screen-
ing questionnaire
was developed to
identify people
whose alcohol
consumption is
hazardous or harm-
ful to their health.
The AUDIT was developed by WHO for use in
multinational settings—the original sample includ-
ed subjects from Australia, Bulgaria, Kenya, Mexico,
Norway, and the United States (Allen et al. 1997;
Saunders et al. 1993).
Populations researched: Latinos (Cherpitel 1999;
Cherpitel and Bazargan 2003; Cherpitel and Borges
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); Brazilians (Lima et al.
2005), and Nigerians (Adewuya 2005).
(Continued on the next page.)
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
(McLellan et al. 1980).
Available online at
http://www.tresearch.org/
index.php/tools/download-
asi-instruments-manuals/
Currently in its 5th
edition, this instru-
ment assesses the
severity of substance
use disorders. It has
200 items distributed
over seven subscales.
Populations researched: African Americans (Drake
et al. 1995; Leonhard et al. 2000; McLellan et al.
1985), and Northern Plains American Indians (Carise
and McLellan 1999).
Languages available in: Numerous languages,
including Spanish (Sandí Esquivel and Avila Corrales
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
Associated Disabilities
Interview Schedule
(AUDADIS; Grant and
Hasin 1990). Available
online at
http://pubs.niaaa.nih.gov/
publications/audadis.pdf
This structured inter-
view is administered
by nonprofessional
interviewers to diag-
nose substance use
disorders and assess
some co-occurring
mental disorders. It
evaluates acculturation
and racial/ethnic
orientation. Currently
in its 4th edition
(AUDADIS-IV).
The AUDADIS has been found reliable in large
general-population studies (Grant et al. 1995; Ruan
et al. 2008).
Populations researched: African Americans,
Latinos, Asians, and Native Americans (Canino et al.
1999; Chatterji et al. 1997; Grant et al. 1995; Ruan
et al. 2008).
Languages available in: Chinese and Spanish
(Canino et al. 1999; Horton et al. 2000; Leung and
Arthur 2000).
CAGE (Ewing 1984; May-
field et al. 1974)
This is a set of four
questions used to
detect possible
alcohol use disorder.
Populations researched: African Americans
(Cherpitel 1997; Frank et al. 2008); Latino (Saitz et
al. 1999).
Languages available in: Numerous languages,
including Spanish, Creole, Chinese, and Japanese.
Composite International
Diagnostic Interview-
Substance Abuse Module
(CIDI-SAM; Cottler 2000)
This structured,
detailed interview
diagnoses substance
abuse and depend-
ence; it is an expand-
ed version of the
substance use section
of the CIDI.
The instrument has been well evaluated with inter-
national populations from a variety of different
nations and found to have good reliability for most
substances of abuse (Ustün et al. 1997).
Populations researched: African Americans (Horton
et al. 2000) and Brazilians (Quintana et al. 2004; 2007).
Languages available in: Numerous languages,
including Portuguese, Spanish, Arabic, Japanese,
Vietnamese, and Malay.
(Continued on the next page.)
278
Appendix D—Screening and Assessment Instruments
Screening and Assessment Instruments for Substance Use Disorders (continued)
Instrument Description Clinical Utility
Drug Abuse Screening
Test (DAST; Skinner
1982)
This self-report
instrument (10- and
20-item versions)
identifies people who
are abusing psycho-
active drugs and
measures degree of
related problems.
No significant differences in DAST reliability
across race or cultural background were found
(Yudko et al. 2007).
Languages available in: Numerous, including
Spanish for the 10-item DAST (DAST-10; Bedregal
et al. 2006), Portuguese, Hebrew, Arabic, and
Thai.
Rapid Alcohol Prob-
lems Screen (RAPS;
Cherpitel 1995, 2000)
The RAPS is a five-
question test (also
available in a newer
four-item version,
the RAPS-4) that
combines optimal
questions from other
instruments.
The RAPS has high sensitivity across both ethnicity
and gender (Cherpitel 1997; 2002). It has also
been found to work significantly better than the
AUDIT for screening African American and Latino
men and to be on par with the AUDIT for women
(Cherpitel and Bazargan 2003).
Populations researched: Mexican Americans
(Borges and Cherpitel 2001); residents of various
countries (Argentina, Belarus, Brazil, Canada,
China, Czech Republic, India, Mexico,
Mozambique, Poland, South Africa, and Sweden;
Cherpitel et al. 2005).
Languages available in: Numerous, including
Spanish, Chinese, and Portuguese.
Short Michigan Alcohol
Screening Test (S-
MAST; Selzer et al.
1975)
The S-MAST screens
for alcohol use
disorder.
Populations researched: African Americans, Arab
Muslims, American Indians, Asian Indians, and
Thai (Al-Ansari and Negrete 1990; Pal et al. 2004;
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
screening instrument
originally created to
screen for risky
drinking during
pregnancy (but has
been validated for a
range of male and
female populations).
Populations researched: Mexican Americans
(Borges and Cherpitel 2001) and African
Americans (Cherpitel 1997).
Languages available in: Spanish (Cremonte and
Cherpitel 2008).
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-
tory (BAI; Beck and
Steer 1990)
The BAI is a 21-item
scale that distinguishes
anxiety from depres-
sion.
Populations researched: African Americans
(Chapman et al. 2009).
Languages available in: Numerous languages,
including Spanish (Novy et al. 2001), Arabic,
Chinese, Farsi, Korean, and Turkish.
Beck Depression
Inventory (BDI) and
Beck Depression
Inventory, 2nd Edi-
tion (BDI-II; Beck et al.
1996)
The BDI is a 21-item
instrument used to
assess the intensity of
depression.
Several versions of the BDI are available with cultur-
al specificity.
Populations researched: African Americans (Dutton
et al. 2004; Grothe et al. 2005; Joe et al. 2008),
Asian Americans (Carmody 2005; Crocker et al.
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-
logical Studies-
Depression Scale
(CES-D; Radloff 1977)
The CES-D is a 20-item
self-report scale de-
signed to measure
depressive symptoms.
May underestimate symptoms in African Americans
(Bardwell and Dimsdale 2001; Cole et al. 2000).
Populations researched: Latinos (Batistoni et al.
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
Scale (Sheikh and
Yesavage 1986)
Available in 30- and 15-
item forms, this instru-
ment screens for de-
pression in older adults.
Populations researched: Latinos (Reuland et al.
2009) and Asians (Broekman et al. 2008; Nyunt et
al. 2009).
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-
axial Inventory-III
(Millon et al. 2009)
Assesses 13 personality
disorders (DSM-III-R
Axis II disorders) and 9
clinical syndromes
(DSM-III-R Axis I disor-
ders); includes scales to
assess substance relat-
ed problems.
Populations researched: African Americans (Calsyn
et al.1991; Craig and Olson 1998) and Latinos
(Fernández-Montalvo et al. 2006).
Languages available in: Multiple languages, includ-
ing Spanish, Korean, Cantonese, and Portuguese.
(Continued on the next page.)
280
Appendix D—Screening and Assessment Instruments
Instruments To Screen and Assess Mental Disorders and Symptoms (continued)
Minnesota Multiphasic
Personality Inventory,
2nd Edition (MMPI-2)
(Butcher et al. 1989)
The MMPI-2
measures personali-
ty traits and symp-
tom patterns.
Normed for Asian Americans, African Americans,
Latinos, and American Indians (Hathaway et al.1989).
Populations researched: African Americans (Castro
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
Neuropsychiatric Inter-
view (M.I.N.I.; Sheehan
et al. 1998)
This is a short,
structured, diagnos-
tic interview that
assesses the most
common mental
disorders (including
substance use
disorders).
Populations researched: African Americans (Black
et al. 2004).
The Major Depressive Episode and Posttraumatic
Stress Disorder (PTSD) sections of the M.I.N.I.
have been adapted for use in screening for PTSD
in refugees, and found effective across cultures in
a multinational sample (Eytan et al. 2007).
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
Assessment in Neuro-
psychiatry, 2nd Version
(SCAN-2; Wing et al.
1998)
The SCAN-2 is a set
of instruments that
measure psycho-
pathology and
behavior associated
with major mental
disorders.
Populations researched: The SCAN-2 was devel-
oped by WHO with an international sample that
included participants from Turkey, Greece, India,
the United States, Nigeria, Romania, Mexico,
Spain, and South Korea and is intended to be
cross-culturally appropriate (Room et al. 1996).
Languages available in: Chinese (Cheng et al.
2001), Danish, Dutch, English, French, German,
Greek, Italian, Kannada, Portuguese, Spanish,
Thai, Turkish, and Yoruba.
Symptom Checklist-90-
R (SCL-90R; Derogatis
1992)
This 90-item check-
list evaluates psy-
chiatric symptoms
and their intensity in
nine different cate-
gories and screens
for a broad range of
mental disorders.
The SCL-90R has been normed for adult inpatient
and outpatient psychiatric patients and adult and
adolescent nonpatients across a number of ethnic
groups (Derogatis 1992).
Populations researched: Latinos (Martinez et al.
2005) and African Americans (Ayalon and Young
2009).
Languages available in: Spanish, French,
Armenian, and Persian.
281
Appendix E—Cultural Formulation
in Diagnosis and Cultural Concepts
of Distress
Cultural Formulation in
Diagnosis
Clinicians need to consider the effects of cul-
ture when diagnosing clients. The following
cultural formulation adopted by the American
Psychiatric Association (APA) in the Diagnostic
and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5; 2013, pp. 749–759) provides
a systematic outline for incorporating culturally
relevant information when conducting a multi-
axial diagnostic assessment. Whether or not
they are credentialed to diagnose disorders,
counselors and other clinical staff can use the
main content areas listed below to guide the
interview, initial intake, and treatment planning
processes. (For review, see Mezzich and Caracci
2008; for Native American application, specifi-
cally Lakota, refer to Brave Heart 2001.)
1. Cultural identity of the person
. Note the
person’s ethnic or cultural reference groups. For
immigrants and ethnic minorities, also note
degree of involvement with culture of origin
and host culture (where applicable). Also note
language ability, use, and preference (including
multilingualism).
2. Cultural explanations of the person’s
illness
. Identify the following: the predomi-
nant idioms of distress through which symp-
toms or the need for social support are com-
municated (e.g., “nerves,” possessing spirits,
somatic complaints, inexplicable misfortune),
the meaning and perceived severity of the
individual’s symptoms in relation to norms of
the cultural reference group, any local illness
category used by the individual’s family and
community to identify a condition (see the
“Cultural Concepts of Distress” section of this
appendix), the perceived causes or explanatory
models that the individual and the reference
group use to explain the illness, and current
preferences for and past experiences with
professional and popular sources of care.
3. Cultural factors related to psychosocial
environment and level of functioning
. Note
culturally relevant interpretations of social
stressors, available social supports, and levels of
functioning and disability, including stresses in
the local social environment and the role of
religion and kin networks in providing emo-
tional, instrumental, and informational support.
4. Cultural elements of the relationship
between client and clinician
. Indicate differ-
ences in culture and social status between
client and clinician, as well as any problems
these differences may cause in diagnosis and
283
Improving Cultural Competence
treatment (e.g., difficulty communicating in
the client’s first language, eliciting symptoms
or understanding their cultural significance,
negotiating an appropriate relationship or level
of intimacy, determining whether a behavior is
normative or pathological).
5. Overall cultural assessment for diagnosis
and care. Conclude cultural formulation by
discussing how cultural considerations specifi-
cally influence comprehensive diagnosis and
care.
Cultural Concepts of
Distress
Just as standard screening instruments can
sometimes be of limited use with culturally
diverse populations, so too are standard diag-
noses. Expressions of psychological problems
are, in part, culturally specific, and behavior
that is aberrant in one culture can be standard
in another. For example, seemingly paranoid
thoughts are to be expected in clients who
have migrated from countries with oppressive
governments. Culture plays a large role in
understanding phenomena that might be
construed as mental illnesses in Western
medicine. These cultural concepts of distress
may or may not be linked to particular DSM-
5 diagnostic criteria (APA 2013). The table
that follows lists DSM-5 cultural concepts of
distress; other concepts exist that are not
recognized in DSM-5.
DSM-5 Cultural Concepts of Distress
Syndrome Description Populations
Ataque de
nervios
Commonly reported symptoms include uncontrollable shouting,
attacks of crying, trembling, heat in the chest rising into the head,
and verbal or physical aggression. Dissociative experiences, sei-
zurelike or fainting episodes, and suicidal gestures are prominent in
some attacks but absent in others. A general feature of an ataque
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 panic
disorder. 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.
Caribbean,
Latin
American,
Latin
Mediterranean
Dhat (jiryan
in India, skra
prameha in
Sri Lanka,
shen-k’uei in
China)
A folk diagnosis for severe anxiety and hypochondriacal concerns
associated with the discharge of semen, whitish discoloration of
the urine, weakness, and exhaustion.
Asian Indian
(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
syndrome evoked by difficult life circumstances. Nervios includes a
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, sleep
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.
Latin
American
Shenjing
shuairuo
A condition characterized by physical and mental fatigue, head-
aches, difficulty concentrating, dizziness, sleep disturbance, and
memory loss. Other symptoms include gastrointestinal problems,
sexual dysfunction, irritability, excitability, and autonomic nervous
system disturbances.
Chinese
Susto
(espanto,
pasmo, tripa
ida, perdida
del alma, or
chibih)
An illness attributed to a frightening event that causes the soul to
leave the body and results in unhappiness and sickness. Individuals
with susto also experience significant strains in key social roles.
Symptoms can appear days or years after the fright is experi-
enced. In extreme cases, susto can result in death. Typical symp-
toms include appetite disturbances, inadequate or excessive
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.
Latino
American,
Mexican,
Central and
South
American
Taijin
kyofusho
This syndrome refers to an individual’s intense fear that his or her
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.
Japanese
Source: APA 2013. Used with permission.
285
Appendix F—Cultural Resources
General Resources
Addiction Technology Transfer
Centers
http://www.nattc.org
The Addiction Technology Transfer Centers
Network identifies and advances opportunities
for improving substance abuse treatment. The
Network comprises 14 regional centers as well
as a national office serving the United States
and its territories. Regional centers cater to
unique needs in their areas while supporting
national initiatives. Improving cultural compe-
tence is a major focus for the Network, which
seeks to improve substance abuse treatment by
identifying standards of culturally competent
treatment and generating ways to foster their
adoption in the field.
Agency for Healthcare Research
and Quality–Minority Health
http://www.ahrq.gov/research/findings/factsh
eets/minority/index.html
This site provides research findings, papers, and
press releases related to minority health.
American Translators Association
http://www.atanet.org
The American Translators Association (ATA)
offers a certification program that evaluates
the competence of translators according to
guidelines that reflect current professional
practice. The ATA also has online directories
available. The Directory of Translation and
Interpreting Services is an online directory of
individual translators and interpreters. The
Directory of Language Services Companies is
a directory of companies that offer translating
or interpreting services.
Center for Research on Ethnicity,
Culture, and Health
http://www.crech.org
Established in 1998 in the University of
Michigan’s School of Public Health, the Center
provides a forum for basic and applied public
health research on relationships among eth-
nicity, culture, socioeconomic status, and
health. It develop new interdisciplinary
frameworks for understanding these relation-
ships while promoting effective collaboration
among public health academicians, healthcare
providers, and communities to reduce racial
and ethnic disparities in health care.
Community Toolbox: Cultural
Competence in a Multicultural
World
http://ctb.ku.edu/en/table-of-
contents/culture/cultural-competence
The cultural competence section of this Web
site provides information (including examples
and links) on a number of relevant topics, such
287
Improving Cultural Competence
as how to build relationships with people from
different cultures, reduce prejudice and racism,
build organizations and communities that are
responsive to people from diverse cultures, and
heal the effects of internalized oppression.
The Cross Cultural Health Care
Program
http://www.xculture.org
Since 1992, the Cross Cultural Health Care
Program (CCHCP) has been addressing
broad cultural issues that affect the health of
individuals and families in ethnic minority
communities in Seattle and nationwide.
Through a combination of cultural competen-
cy trainings, interpreter trainings, research
projects, community coalition building, and
other services, CCHCP serves as a bridge
between communities and healthcare institu-
tions to ensure full access to quality health care
that is culturally and linguistically appropriate.
Cultural Competence Standards in
Managed Care Mental Health
Services
Western Interstate Commission for Higher
Education. Cultural Competence Standards in
Managed Mental Health Care for Four Under-
served/Underrepresented Racial/Ethnic Groups.
Boulder, CO: Western Interstate Commission
for Higher Education, 1998.
The Center for Mental Health Services
(CMHS) presents cultural competence stand-
ards for managed care mental health services to
improve the availability of high-quality services
for four underserved and/or underrepresented
racial and ethnic groups—African Americans,
Latinos, Native Americans, and Asian/Pacific
Islander Americans. With help from the
Western Interstate Commission for Higher
Education Mental Health Program, CMHS
convened national panels representing each
major racial/ethnic group. Mental health
professionals, families, and consumers on the
panels prepared the document.
http://www.diversityrx.org
This Web site offers resources relating to
cross-cultural communication issues in
healthcare settings and information on inter-
preter practice, legal issues relating to language
barriers and access to linguistically appropriate
services, and the ways language and culture
can affect the use of healthcare services.
Health Resources and Services
Administration Culture, Language
and Health Literacy Page
http://www.hrsa.gov/culturalcompetence/
The Health Resources and Services
Administration Culture, Language and Health
Literacy Web site provides links to various
online resources relating to cultural compe-
tence in general and to providing culturally
competent health care to a number of specific
cultural/ethnic groups.
Instruments for Measuring
Acculturation, University of
Calgary
http://www.ucalgary.ca/~taras/_private/Accult
uration_Survey_Catalogue.pdf
This document gives information on accul-
turation and cultural identity measures, pre-
senting many in full. It does not always include
scoring information but typically provides
questions from each instrument.
Minority Health Project
http://www.minority.unc.edu/
The Minority Health Project (MHP) of the
University of North Carolina’s Gillings School
of Global Public Health seeks to improve the
288
Appendix F—General Resources
quality of racial and ethnic population data, to
expand the capacity for conducting statistical
research and developing research proposals on
minority health, and to foster a network of
researchers in minority health. MHP collabo-
rates with the Center for Health Statistics
Research, the University of North Carolina, the
National Center for Health Statistics, and the
Association of Schools of Public Health to
conduct educational programs and provide
information on minority health research and
data sources.
National Center for Cultural
Competence
http://nccc.georgetown.edu
The National Center for Cultural Compe-
tence’s (NCCC) mission is to increase the
capacity of health and mental health programs
to design, implement, and evaluate culturally
and linguistically responsive service delivery
systems. NCCC conducts training, technical
assistance, and consultation; participates in
networking, linkages, and information ex-
change; and engages in knowledge and prod-
uct development and dissemination.
The National Center on Minority
Health and Health Disparities
http://www.ncmhd.nih.gov
The Center’s mission is to promote minority
health and reduce health disparities. It is
particularly useful as a resource for infor-
mation about health disparities and the best
methods to address them.
International MultiCultural
Institute
http://www.imciglobal.org/
The International MultiCultural Institute
(iMCI) works with individuals, organizations,
and communities to create a society that is
strengthened and empowered by its diversity.
iMCI’s initiatives aim to increase communica-
tion, understanding, and respect among people
of diverse backgrounds and address systemic
cultural issues facing our society. The Institute
accomplishes this through its conferences,
individualized organizational training and
consulting interventions, publications, and
leading-edge projects.
Office of Civil Rights
http://www.hhs.gov/ocr/civilrights/resources/s
pecialtopics/lep/
The Office of Civil Rights of the U.S.
Department of Health and Human Services
investigates complaints, enforces rights, devel-
ops policies, and promulgates regulations to
ensure compliance with nondiscrimination
and health information privacy laws. The
agency offers technical assistance and public
education to ensure understanding of and
compliance with these laws, including the
provision of resources and tools to improve
services for individuals with limited English
proficiency.
Office of Minority Health
Resource Center
http://minorityhealth.hhs.gov/
The Office of Minority Health (OMH) was
established by the U.S. Department of Health
and Human Services in 1985 to advise the
Secretary and the Office of Public Health and
Science on public health policies and programs
affecting Native Americans, African Ameri-
cans, Asian Americans, Latinos, and Native
Hawaiians and other Pacific Islanders. The
mission of OMH is to improve and protect the
health of racial and ethnic minority populations
through the development of policies and pro-
grams that will eliminate health disparities.
The OMH Resource Center (OMHRC) is a
national resource and referral service for
289
Improving Cultural Competence
minority health issues. It collects and distrib-
utes information on various health topics,
including substance abuse, cancer, heart dis-
ease, violence, diabetes, HIV/AIDS, and
infant mortality. OMHRC also facilitates
information exchange on minority health
issues, and offers customized database search-
es, publications, mailing lists, referrals, and
the like regarding Native American, African
American, Asian American, Pacific Islander,
and Latino populations.
Substance Abuse and Mental
Health Services Administration
http://store.samhsa.gov/
The Substance Abuse and Mental Health
Services Administration (SAMHSA) is the
Nation’s one-stop resource for information
about substance abuse and mental illness
prevention and behavioral health treatment.
The SAMHSA Store Web site provides in-
formation on behavioral health topics such as
cultural competence, healthcare-related laws,
and mental health and substance abuse.
Surgeon General’s Report on
Mental Health: Culture, Race, and
Ethnicity
U.S. Department of Health and Human
Services. Mental Health: Culture, Race, and
Ethnicity. A Supplement to Mental Health: A
Report of the Surgeon General. HHS Pub. No.
SMA 01-3613. Rockville, MD: U.S.
Department of Health and Human Services,
Substance Abuse and Mental Health Services
Administration, Center for Mental Health
Services, 2001.
This report highlights the roles that culture
and society play in mental health, mental
illness, and the types of mental health services
people seek. The report finds that, although
effective, well-documented treatments for
mental illnesses are available, minorities are
less likely to receive quality care than the gen-
eral population. It articulates the foundation for
understanding relationships among culture,
society, mental health, mental illness, and
services, and also describes how these issues
affect different racial and ethnic groups.
Stanford University Curriculum in
Ethnogeriatrics
http://www.stanford.edu/group/ethnoger/
This online curriculum explores healthcare
issues for older adults from a variety of cultur-
al groups (with modules on African
Americans, Latinos, Native Americans, and
several Asian American populations).
African and Black
American Resources
Congressional Black Caucus
Foundation Health
http://www.cbcfinc.org/what-we-
do/researchandpolicy.html
Congressional Black Caucus Foundation
Health’s mission is to empower people of
African descent to make better decisions
about their health and that of their communi-
ties. The Web site provides information about
public health issues, key legislation on public
policy issues, health initiatives, and local
events directly and indirectly relating to the
health of people of African descent world-
wide. It includes a section on substance abuse.
National Black Alcoholism and
Addictions Council, Inc.
http://www.nbacinc.org
The National Black Alcoholism and Addictions
Council, Inc. (NBAC) is a nonprofit, tax-
exempt organization of Black individuals
concerned about alcoholism and drug abuse.
290
Appendix F—General Resources
NBAC educates the public about the preven-
tion of alcohol and drug abuse and alcoholism
and is committed to increasing services for
persons who are dependent upon alcohol and
their families, providing quality care and treat-
ment, and developing research models designed
for Blacks. NBAC helps Blacks concerned with
or involved in the field of alcoholism and drug-
related issues to exchange ideas, offer services,
and facilitate substance abuse treatment pro-
grams for Black Americans.
National Medical Association
http://www.nmanet.org
A professional and scientific organization
representing the interests of more than 25,000
physicians and their patients, the National
Medical Association (NMA) is the collective
voice of African American physicians and a
leading force for parity and justice in medicine
and health. Established in 1895, NMA aims
to prevent diseases, disabilities, and adverse
health conditions that disproportionately or
differentially affect African American and
underserved populations; improve quality and
availability of health care for poor and under-
served populations; and increase representa-
tion and contributions of African Americans
in medicine. NMA provides educational
programs and opportunities for scholarly
exchange, conducts outreach to promote im-
proved public health, and establishes national
health policy agendas in support of African
American physicians and their patients.
Asian American, Native
Hawaiian, and Other
Pacific Islander Resources
Asian and Pacific Islander
American Health Forum
http://www.apiahf.org
The Asian and Pacific Islander American
Health Forum (APIAHF) is a national advo-
cacy organization that promotes policy, pro-
gram, and research efforts to improve the
health of Asian and Pacific Islander Americans.
APIAHF established the Asian and Pacific
Islander Health Information Network
(APIHIN) in 1995. APIHIN was developed
as an integrated telecommunications infra-
structure that gives Asians and Pacific Is-
landers access to health information and
resources through local community access
points and key provider intermediaries. The
organization supports two mailing lists: API-
HealthInfo, which concentrates on Asian and
Pacific Islander American health, and API-
SAMH, which deals with issues related to
behavioral health of special interest to the
Asian and Pacific Islander community.
National Asian American Pacific
Islander Mental Health
Association
http://www.naapimha.org
The National Asian American Pacific Islander
Mental Health Association (NAAPIMHA)
evolved from an Asian American Pacific
Islander Mental Health Summit sponsored by
SAMHSA. NAAPIMHA focuses on five
interrelated areas: enhancing collection of
appropriate and accurate data; identifying
current best practices and service models;
capacity building, including provision of tech-
nical assistance and training of service
providers, both professional and paraprofes-
sional; conducting research and evaluation; and
working to engage consumers and families.
National Asian Pacific American
Families Against Substance Abuse
http://www.napafasa.org
The National Asian Pacific American Families
Against Substance Abuse is a nonprofit
291
Improving Cultural Competence
membership organization that addresses the
alcohol, tobacco, and drug issues of Asian
American and Pacific Islander populations; it
involves providers, families, and youth in
reaching Asian American and Pacific Islander
communities to promote health and social
justice and reduce substance abuse and related
problems.
Psychosocial Measures for Asian
American Populations: Tools for
Direct Practice and Research
http://www.columbia.edu/cu/ssw/projects/pmap
This Web site presents information on psy-
chosocial measures (including some related to
substance abuse) found to be reliable and valid
with Asian Americans (in general group or for
a specific subgroup).
The Vietnamese Community
Health Promotion Project
http://www.suckhoelavang.org/main.html
This project’s mission is to improve the health
of Vietnamese Americans. A part of the Uni-
versity of California–San Francisco School of
Medicine, the Web site provides information
in Vietnamese and English, along with links
to Vietnamese Web sites related to health
issues.
Hispanic and Latino
Resources
Hispanic/Latino Portal to Drug
Abuse Prevention
http://www.latino.prev.info
The Indiana University Prevention Resource
Center created this trilingual Web site to serve
the growing Latino population and those who
work with Latinos. Many Latinos face a lan-
guage barrier, as do many prevention profes-
sionals trying to address their needs. This Web
site helps bridge the communication barrier by
offering information about and links to re-
sources for substance abuse prevention, general
health information, building cultural pride, and
research tools, such as databases and bibliog-
raphies.
National Alliance for Hispanic
Health
http://www.hispanichealth.org
The National Alliance for Hispanic Health is
the nation’s oldest and largest network of
Hispanic health and human service providers.
Alliance members deliver quality services to
more than 12 million persons annually. As the
nation’s action forum for Hispanic health and
well-being, the programs of the Alliance
inform and mobilize consumers, support
providers in the delivery of quality care, pro-
mote appropriate use of technology, improve
the science base for accurate decisionmaking,
and promote philanthropy.
National Council of La Raza
Institute for Hispanic Health
http://www.nclr.org/index.php/issues_and_pr
ograms/health_and_nutrition/hispanic_health
The Institute for Hispanic Health (IHH)
works closely with National Council of La
Raza affiliates, government partners, private
funders, and Latino-serving organizations to
deliver quality health interventions and im-
prove access to and use of quality health pro-
motion and disease prevention programs.
IHH provides culturally responsive and lin-
guistically appropriate technical assistance and
science-based approaches that emphasize
public health, rather than disease-specific,
themes. Themes include behavior change
communication, healthy lifestyle promotion,
improving access to quality services, and
292
Appendix F—General Resources
increasing the number and level of Latinos in
health fields.
National Hispanic Medical
Association
http://www.nhmamd.org
Established in 1994, the National Hispanic
Medical Association (NHMA) is a nonprofit
association representing 36,000 licensed His-
panic physicians in the United States. Its
mission is to improve the health of Latinos
and other underserved populations. NHMA
provides policymakers and healthcare provid-
ers with expert information and support in
strengthening health service delivery to Latino
communities across the Nation. Its agenda
includes expanding access to quality health
care; increasing medical education, cultural
competence, and research opportunities for
Latinos; and developing policy and education
to eliminate health disparities for Latinos.
Native American
Resources
Centers for American Indian and
Alaska Native Health
http://www.ucdenver.edu/academics/colleges/
PublicHealth/research/centers/
CAIANH/Pages/caianh.aspx
The Centers for American Indian and Alaska
Native Health (CAIANH) at the University
of Colorado, Denver promote the health and
well-being of American Indians and Alaska
Natives by pursuing research, training, contin-
uing education, technical assistance, and in-
formation dissemination in a biopsychosocial
framework that recognizes the unique cultural
contexts of this special population. The site
provides online access to the group’s journal,
American Indian and Alaska Native Mental
Health Research, as well as information about
ongoing research projects.
Indian Health Service
http://www.ihs.gov
The Indian Health Service (IHS) is the prin-
cipal federal healthcare provider and advocate
for Native Americans; it ensures that compre-
hensive, culturally acceptable personal and
public health services are available and acces-
sible to Native peoples. Its Web site provides a
tour of the IHS and its service areas, adminis-
trative reports, legislative news, IHS job op-
portunities, and healthcare resources targeted
to this group.
National Indian Child Welfare
Association
http://www.nicwa.org
The National Indian Child Welfare Associa-
tion (NICWA), a comprehensive source of
information on American Indian child welfare,
works on behalf of Indian children and fami-
lies to provide public policy, research, and
advocacy; information and training on Indian
child welfare; and community development
services to Tribal governments and programs,
State child welfare agencies, and other organi-
zations, agencies, and professionals interested
in Indian child welfare. NICWA addresses
child abuse and neglect through training,
research, public policy, and grassroots commu-
nity development. NICWA also supports
compliance with the Indian Child Welfare Act
of 1978, which seeks to keep American Indian
children with American Indian families.
One Sky Center
http://www.oneskycenter.org
One Sky Center aims to improve prevention
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
treatment services and practices for applica-
tion across diverse Tribal communities. It also
provides training, technical assistance, and
products to expand the capacity and quality of
substance abuse prevention and treatment
services for this population. SAMHSA creat-
ed, designed, and funds One Sky Center to
work with all federal and state agencies
providing services to Native Americans.
SAMHSA’s Tribal Training and
Technical Assistance Center
http://beta.samhsa.gov/tribal-ttac
The Tribal Training and Technical Assistance
(TTA) Center uses a culturally relevant, evi-
dence-based, holistic approach to support
Native communities in their self-
determination efforts through infrastructure
development and capacity building, as well as
program planning and implementation. The
Center provides TTA on mental and sub-
stance use disorders, bullying and violence,
suicide prevention, and the promotion of
mental health. It offers TTA to federally
recognized tribes, other American Indian and
Alaska Native communities, SAMHSA Tribal
grantees, and organizations serving Indian
Country. The Web site provides resources
across behavioral health topics relevant to
Native peoples.
White Bison
http://www.whitebison.org/
This Web site offers resources related to the
Wellbriety self-help movement for Native
Americans, including a discussion board and
access to the Wellbriety online magazine.
294
Appendix G—Glossary
Acculturation
typically refers to the socializa-
tion process through which people from one
culture adopt certain elements from the domi-
nant culture in a society.
American Indian and Alaska Native
people
include those “having origins in any of the
original peoples of North and South America
(including Central America), and who main-
tain tribal affiliation or community attach-
ment” (Grieco and Cassidy 2001, p. 2).
Asians
are defined in the United States (U.S.)
Census as “people having origins in any of the
original peoples of the Far East, Southeast
Asia, or the Indian subcontinent,” including,
for example, Cambodia, China, India, Japan,
Korea, Malaysia, Pakistan, the Philippine
Islands, Thailand, and Vietnam (Grieco and
Cassidy 2001, p. 2).
Biculturalism
is “a well-developed capacity to
function effectively within two distinct cul-
tures based on the acquisition of the norms,
values, and behavioral routines of the domi-
nant culture” and one’s own culture (Castro
and Garfinkle 2003, p. 1385).
Biracial
individuals have two distinct racial
heritages, either one from each parent or as a
result of racial blending in an earlier genera-
tion (Root 1992).
Blacks/African Americans
are, according to
the U.S. Census Bureau (2000) definition,
people whose origins are “in any of the black
racial groups of Africa” (p. A-3). The term
includes descendants of African slaves brought
to this country against their will and more
recent immigrants from Africa, the Caribbean,
and South or Central America (many individ-
uals from these latter regions, if they come
from Spanish-speaking cultural groups, iden-
tify or are identified primarily as Latino). The
term Black is often used interchangeably with
African American, although for some, the
term African American is used specifically to
describe those individuals whose families have
been in this country since at least the 19th
century and thus have developed distinctly
African American cultural groups. Black can
be a more inclusive term describing African
Americans as well as for more recent immi-
grants with distinct cultural backgrounds.
Confianza
means trust or confidence in the
benevolence of the other person.
Conformity
in Helms’s model of racial iden-
tity development refers to the tendency of
members of a racial group to behave in con-
gruence with the values, beliefs, and attitudes
of their own culture to which they have been
exclusively exposed.
Cultural competence
is “a set of congruent
behaviors, attitudes, and policies that . . . ena-
ble a system, agency, or group of professionals
to work effectively in cross-cultural situations”
295
Improving Cultural Competence
(Cross et al. 1989, p. 13). It refers to the
ability to honor and respect the beliefs, lan-
guages, interpersonal styles, and behaviors of
individuals and families receiving services, as
well as staff members who are providing such
services. “Cultural competence is a dynamic,
ongoing developmental process that requires a
long-term commitment and is achieved over
time” (U.S. Department of Health and
Human Services [HHS] 2003a, p. 12).
Cultural competence plans
are strategic
plans that outline a systematic organizational
approach to providing culturally responsive
services to individuals and to increasing cul-
tural competence among staff at each level of
the organization.
Cultural diffusion
is the process of cultural
intermingling.
Cultural humility
“incorporates a lifelong
commitment to self-evaluation and critique”
(Tervalon and Murray-García 1998, p. 123) to
redress the power imbalances in counselor–
client relationships.
Cultural norms
are the spoken or unspoken
rules or standards for a cultural group that
indicate whether a certain social event or
behavior is considered appropriate or inappro-
priate.
Cultural proficiency
involves a deep and rich
knowledge of a culture—an insider’s view—
that allows the counselor to accurately inter-
pret the subtle meanings of cultural behavior
(Kim et al. 1992).
Culture
is the conceptual system that struc-
tures the way people view the world—it is the
particular set of beliefs, norms, and values that
influence ideas about the nature of relation-
ships, the way people live their lives, and the
way people organize their world.
Ethnicity
refers to the social identity and
mutual belongingness that defines a group of
people on the basis of common origins, shared
beliefs, and shared standards of behavior
(culture).
Ethnocentrism
is “the tendency to view one’s
own culture as best and to judge the behavior
and beliefs of culturally different people by
one’s own standards” (Kottak 1991, p. 47).
Health disparity
is a particular type of health
difference that is closely linked with social,
economic, and/or environmental disadvantage.
Health disparities adversely affect groups of
people who have systematically experienced
greater obstacles to health based on their racial
or ethnic group; religion; socioeconomic
status; gender; age; mental health; cognitive,
sensory, or physical disability; sexual orienta-
tion or gender identity; geographic location; or
other characteristics historically linked to
discrimination or exclusion (HHS 2011a).
Hembrismo
refers to female strength, endur-
ance, courage, perseverance, and bravery
(Falicov 1998).
Latinos
are those who identify themselves in
one of the specific Hispanic or Latino Census
categories—Mexican, Puerto Rican, or
Cuban—as well as those who indicate that
they are “other Spanish, Hispanic, or Latino.”
Origin can be viewed as the heritage, nation-
ality, group, lineage, or country of birth of the
person or the person’s parents or ancestors
before their arrival in the United States.
Immersion–emersion
is a stage in the identi-
ty development models of both Cross and
Helms during which a transition takes place
from satisfaction with the old self to commit-
ment to personal change: from immersion in
one’s old identity to emerging with a more
mature view of one’s identity (Cross 1995b).
Indigenous peoples
are those people native
to a particular country or region. In the case
of the United States and its territories, this
296
Appendix G—Glossary
includes Native Hawaiians, Alaska Natives,
Pacific Islanders, and American Indians.
Institutional racism
generally “refers to the
policies, practices, and norms that incidentally
but inevitably perpetuate inequality,” resulting
in “significant economic, legal, political and
social restrictions” (Thompson and Neville
1999, p. 167).
Language
is a culture’s communication sys-
tem and the vehicle through which aspects of
race, ethnicity, and culture are communicated.
Machismo
is the traditional sense of responsi-
bility Latino men feel for the welfare and
protection of their families.
Marianismo
is the traditional belief that
Latinas should be self-sacrificing, endure
suffering for the sake of their families, and
defer to their husbands in all matters. The
Virgin Mary is held up as the model to which
all women should aspire.
Motivational interviewing
is a counseling
style
characterized by the strategic therapeutic
activities of expressing empathy, developing
discrepancy, avoiding argument, rolling with
resistance, and supporting self-efficacy. In
motivational interviewing, the counselor’s
major tool is reflective listening.
Multiracial
individuals are any racially mixed
people and include biracial people, as well as
those with more than two distinct racial herit-
ages (Root 1992).
Native Hawaiians and other Pacific Is-
landers
include those with “origins in any of
the original peoples of Hawaii, Guam, Samoa,
or other Pacific Islands” (Grieco and Cassidy
2001, p. 2). Other Pacific Islanders include
Tahitians; Northern Mariana Islanders;
Palauans; Fijians; and cultural groups like
Melanesians, Micronesians, or Polynesians.
Nguzo saba
are the seven African American
principles celebrated during Kwanzaa:
• Umoja is unity with family, community,
nation, and race.
• Kujichagulia means self-determination to
define collective selves, create for collective
selves, and speak for collective selves.
• Ujima refers to collective responsibility to
build and maintain community and solve
problems together.
• Ujamaa refers to cooperative economics to
build and maintain businesses and to prof-
it from them together.
• Nia is a sense of purpose to collectively
build and develop community to restore
people to their traditional greatness.
• Kuumba is creativity to always do as much
as possible to leave the community more
beautiful and beneficial than it was.
• Imani refers to belief in the community’s
parents, teachers, and leaders and in the
righteousness and victory of the struggle.
Organizational cultural competence and
responsiveness
refers to a set of congruent
behaviors, attitudes, and policies that enable a
system, agency, or group of professionals to
work effectively in cross-cultural situations
(Cross et al. 1989). It is a dynamic, ongoing
process.
Orgullo
means pride and dignity.
Personalismo
is the use of positive personal
qualities to accomplish a task.
Race
is a social construct that describes people
with shared physical characteristics.
Racism
is an attitude or belief that people
with certain shared physical characteristics are
better than others.
Reculturation
occurs when individuals return
to their countries of origin after a prolonged
period in other countries and readapt to the
dominant culture.
297
Improving Cultural Competence
Respeto
can be translated as respect but also
includes elements of both emotional depend-
ence and dutifulness (Barón 2000).
Selective perception
is, in Helms’s model of
racial identity development, the tendency of
people early in the process to observe their
environment in ways that generally confirm
their pre-existing beliefs.
Simpatía
is an approach to social interaction
that avoids conflict and confrontation. One
who is simpático is agreeable and strives to
maintain harmony within the group.
Syncretism
is the result of combining differ-
ing systems, such as traditional and introduced
cultural traits.
Transculturation
is the acceptance of a part
or a trait of one culture into another culture.
White privilege
is a form of ethnocentrism
and refers to a position of entitlement based
on a presumed culturally superior status.
Whites/Caucasians
are people “having ori-
gins in any of the original peoples of Europe,
the Middle East, or North Africa.” This
category includes people who indicate their
race as White or report entries “such as Irish,
German, Italian, Lebanese, Near Easterner,
Arab, or Polish” (Grieco and Cassidy 2001,
p. 2).
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
Senior Advisor
Special Populations Office
National Institute on Drug Abuse
National Institutes of Health
Bethesda, MD
Candace Baker, Ph.D.
Clinical Affairs Manager
Lesbian, Gay, Bisexual, and Transgender
Special Interest Group
National Association of Alcoholism and Drug
Abuse Counselors
Alexandria, VA
Carole Chrvala, Ph.D.
Senior Program Officer
Board on Neuroscience & Behavioral Health
Institute of Medicine
Washington, DC
Christine Cichetti
Drug Policy Advisor
United States Department of Health and
Human Services
Washington, DC
Cathi Coridan, M.A.
Senior Director for Substance Abuse
Programs
National Mental Health Association
Alexandria, VA
Edwin M. Craft, Dr.P.H.
Program Analyst
Practice Improvement Branch
Division of Services Improvement
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services
Administration
Rockville, MD
Christina Currier
Public Health Analyst
Practice Improvement Branch
Division of Services Improvement
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services
Administration
Rockville, MD
Dorynne Czechowicz, M.D.
Medical Officer
Treatment Development Branch
Division of Treatment Research and Development
National Institute on Drug Abuse
National Institutes of Health
Bethesda, MD
Janie B. Dargan
Senior Policy Analyst
Office of National Drug Control Policy
Executive Office of the President
Washington, DC
299
Improving Cultural Competence
James (Gil) Hill, Ph.D.
Director
Office of Rural Health and Substance Abuse
American Psychological Association
Washington, DC
Hendree E. Jones, M.A., Ph.D.
Assistant Professor
CAP Research Director
Department of Psychiatry and Behavioral
Sciences
Johns Hopkins University Center
Baltimore, MD
Guadelupe Pacheco, M.P.A.
Special Assistant to the Deputy Assistant
Secretary
Office of Minority Health
Department of Health and Human Services
Rockville, MD
Cecilia Rivera-Casale, Ph.D.
Senior Project Officer
Center for Mental Health Services
Substance Abuse and Mental Health Services
Administration
Rockville, MD
Deidra Roach, M.D.
Health Science Administrator
National Institute on Alcohol Abuse and
Alcoholism
Bethesda, MD
Kevin Shipman, M.H.S., LPC
Deputy Chief
Grants and Program Management Division
Special Population Services
Washington, DC
Richard T. Suchinsky, M.D.
Associate Chief for Addictive Disorders and
Psychiatric Rehabilitation
Mental Health and Behavioral Sciences
Services
Department of Veterans Affairs
Washington, DC
Jan Towers, Ph.D.
Director
Health Policy
American Academy of Nurse Practitioners
Washington, DC
Jose Luis Velasco
Project Director
National Hispanic Council on Aging
Washington, DC
Karl D. White, Ed.D.
Public Health Analyst
Practice Improvement Branch
Division of Services Improvement
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services
Administration
Rockville, MD
Jeanean Willis, D.P.M., CDR, USPHS
Public Health Analyst
Office of Minority Health
Health Resources and Services
Administration
Rockville, MD
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
President/CEO
SuMoe Partners
Germantown, MD
African American Workgroup Member
Deion Cash
Executive Director
Community Treatment and Correction
Center, Inc.
Canton, OH
African American Workgroup Member
Magdalen Chang, Ph.D.
Center Manager
Haight Ashbury Free Clinics, Inc.
San Francisco, CA
Asian/Pacific Islander Workgroup Member
Diana Yazzie Devine, M.B.A.
Executive Director
Native American Connections, Inc.
Phoenix, AZ
Native American Workgroup Member
Terry S. Gock, Ph.D.
Director
Pacific Clinics Asian Pacific Family Center
Rosemead, CA
Asian/Pacific Islander Workgroup and Lesbian/
Gay/Bisexual/Transgender Workgroup Member
Renata J. Henry, M.Ed.
Director
Delaware Health and Social Services
New Castle, DE
African American Workgroup Member
Adelaida F. Hernandez, M.A., LCDC
Youth OSR Services Program Director
S.C.A.N., Inc.
Laredo, TX
Hispanic/Latino Workgroup Member
Ford H. Kuramoto, D.S.W.
President
National Asian Pacific American Families
Against Substance Abuse
Los Angeles, CA
Asian/Pacific Islander Workgroup Member
301
Improving Cultural Competence
Victor Leo, M.S.W., LCSW
Board Chair
Asian/Pacific American Consortium on Sub-
stance Abuse
Portland, OR
Aging Workgroup Member and Asian/Pacific
Islander Workgroup Member
Harry Montoya, M.A.
President/CEO
Hands Across Cultures
Espanola, NM
Hispanic/Latino Workgroup Member
Michael E. Neely, Ph.D., MFCC
Administrator
Integrated Care System
Los Angeles, CA
African American Workgroup Member
Tam Khac Nguyen, M.D., CCJS, LMSW
President
Vietnamese Mutual Association, Inc.
Polk City, IA
Asian/Pacific Islander Workgroup Member
Rick Rodriguez
Manager/Counselor
Services United
Santa Paula, CA
Hispanic/Latino Workgroup Member
Mariela C. Shirley, Ph.D.
Assistant Professor
University of North Carolina at Wilmington
Wilmington, NC
Hispanic/Latino 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.
Director
Student Health Services
University of North Dakota
Grand Forks, ND
Deborah Altschul, Ph.D.
Assistant Professor/Psychologist
Mental Health Services Research and
Evaluation Unit
Adult Mental Health Division
Hawaii Department of Health
University of Hawaii
Honolulu, HI
Diana S. Amodia, M.D.
Medical Director
Substance Abuse Treatment Services
Haight Ashbury Free Clinics, Inc.
San Francisco, CA
Ronald G. Black
Director, Residential Group
Drug Abuse Foundation
Del Ray Beach, FL
Patricia T. Bowman
Probation Counselor
Fairfax Alcohol Safety Action Program
Fairfax, VA
Rodolfo T. Briseno, M.D., M.P.H.
Facilitator
Worker’s Assistance Program–Youth
Advocacy
Austin, TX
Stephanie Brooks, M.S.W.
Interim Director & Assistant Professor
Programs in Couple & Family Therapy
College of Nursing and Health Professions
Drexel University
Philadelphia, PA
Jutta H. Butler, B.S.N., M.S.
Public Health Advisor
Practice Improvement Branch
Division of Services Improvement
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services
Administration
Rockville, MD
Flanders Byford, M.S.W., LCSW
Licensed Clinical Social Worker
Oklahoma City County Health Department
Oklahoma City, OK
Maria J. Carrasco, M .P. A
Director
Multicultural Action Center
Arlington, VA
303
Improving Cultural Competence
Gerhard E. Carrier, Ph.D.
Chair, Mental Health & Addiction Studies
Department of Mental Health
Alvin Community College
Alvin, TX
Carol J. Colleran, CAP, ICADC
National Director of Older Adult Services
Center of Recovery for Older Adults
Hazelden Foundation/Hanley-Hazelden
West Palm Beach, FL
Cynthia C. Crone, APN, MNSC
Executive Director
Center for Addictions Research, Education,
and Services
College of Medicine, Department of
Psychiatry and Behavior Health
University of Arkansas for Medical Sciences
Little Rock, AR
John P. de Miranda, Ed.M.
Executive Director
National Association on Alcohol, Drugs, and
Disability, Inc.
San Mateo, CA
Efrain R. Diaz, Ph.D., LCSW
Program Supervisor
Connecticut Department of Mental Health
and Addiction Services
Hartford, CT
Dedric L. Doolin, M.P.A.
Deputy Director
Area Substance Abuse Council, Inc.
Cedar Rapids, IA
Donna Doolin, LCSW
Director
Division of Health Care Policy, Addiction &
Prevention Services
Kansas Department of Social and
Rehabilitation Services
Topeka, KS
Lynn Dorman, Ph.D., J.D.
President
Creating Solutions
Portland, OR
Gayle R. Edmunds
Director
Indian Alcoholism Treatment Services
Wichita, KS
Michele J. Eliason, Ed.S., Ph.D.
Associate Professor
The University of Iowa
Iowa City, IA
Jill Shepard Erickson, M.S.W., ACSW
Public Health Advisor
Child and Family Branch
Center for Mental Health Services
Substance Abuse and Mental Health Services
Administration
Rockville, MD
Elena Flores, M.A., Ph.D.
Associate Professor
School of Education
Counseling and Psychology Department
University of California, San Francisco
San Francisco, CA
Jo Ann Ford, M.R.C.
Assistant Director
Substance Abuse Resources and Disability
Issues
School of Medicine
Wright State University
Dayton, OH
Maria del Mar Garcia, M.S.W., M.H.S.
Continuing Education Coordinator
Caribbean Basin and Hispanic Addiction
Centro de Estudios en Adicción
Universidad Central del Caribe
Bayamon, PR
304
Appendix J—Field Reviewers
Virgil A. Gooding, Sr., M.A., M.S.W.,
LISC
Clinical Director
Foundation II, Inc.
Cedar Rapids, IA
Maya D. Hennessey, CRADC
Women’s Specialist
Supervisor, Quality Assurance, Technical
Assistance & Training
Office of Special Programs
Division of Substance Abuse
Illinois Department of Human Services and
Substance Abuse
Chicago, IL
Michael W. Herring, LCSW
Wayne Psychiatric Associates, P.A.
Goldsboro, NC
Deborah J. Hollis, M.A.
Administrator
Office of Drug Control Policy
Division of Substance Abuse and Gambling
Services
Michigan Department of Community Health
Lansing, MI
Ruth Hurtado, M.H.A.
Public Health Advisor
Center for Substance Abuse Treatment
Division of Pharmacologic Therapies
Substance Abuse and Mental Health Services
Administration
Rockville, MD
Ting-Fun May Lai, M.S.W., CASAC
Director
Chinatown Alcoholism Center
Hamilton-Madison House
New York, NY
Tom Laws
Talihina, OK
Susan F. LeLacheur, M.P.H., PA-C
Assistant Professor of Health Care Sciences
The George Washington University
Washington, DC
Jeanne Mahoney
Director
Provider’s Partnership-Women’s Health Issues
American College of Obstetricians and
Gynecologists
Washington, DC
Michael Mobley, Ph.D., M.Ed.
Assistant Professor in Counseling Psychology
Department of Educational, School and
Counseling Psychology
University of Missouri–Columbia
Columbia, MO
Valerie Naquin, M.A.
Vice President
Planning and Development
Cook Inlet
Anchorage, AK
Paul C. Purnell, M.S.
President
Social Solutions, LLC
Potomac, MD
Laura Quiros, M.S.W.
Program Associate
Program Planning & Development Department
Palladia, Inc.
New York, NY
Melissa V. Rael, USPHS
Senior Program Management Officer
Co-Occurring and Homeless Branch
Division of State and Community Assistance
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services
Administration
Rockville, MD
305
Improving Cultural Competence
Susanne R. Rohrer, R.N.
Nurse Consultant
Practice Improvement Branch
Division of Services Improvement
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services
Administration
Rockville, MD
Laurie J. Rokutani, Ed.S., NCC, CPP,
MAC
Training Coordinator
Virginia Commonwealth University
Mid-America Addiction Technology Transfer
Center
Richmond, VA
LaVerne R. Saunders, B.S.N., R.N., M.S.
Training Specialist and Consultant
Dorrington & Saunders and Associates
Framingham, MA
Gary Q. Tester, MAC, CCDC III-E, OCPS
II
Director
Ohio Department of Alcohol and Drug
Addiction Services
Columbus, OH
Ralph Varela, M.S.W.
Chief Executive Officer
Pinal Hispanic Council
Eloy, AZ
Ming Wang, L.C.S.W.
Program Manager
Division of Substance Abuse and Mental
Health
Utah Department of Human Services
Salt Lake City, UT
Mike Watanabe, M.S.W.
President and CEO
Asian American Drug Abuse Program, Inc.
Los Angeles, CA
Debbie A. Webster
Community Program Coordinator
Best Practice Team
Division of Mental Health, Developmental
Disabilities, and Substance Abuse Services
North Carolina Department of Health and
Human Services
Raleigh, NC
Melvin H. Wilson, M.B.A., LCSW-C
High Intensity Drug Trafficking Area
Coordinator
Maryland Division of Parole and Probation
Baltimore, MD
Ann S. Yabusaki, M.Ed., M.A., Ph.D.
Director
Coalition for a Drug-Free Hawaii
Honolulu, HI
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. Max 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
AA (Alcoholics Anonymous), 113, 114, 136,
137, 147, 155–156, 173, 174
ACA (American Counseling Association)
Counselor Competencies, 46, 47, 56
acceptance, culturally competent counselors
showing, 49
access to care. See also health insurance cover-
age
by African Americans, 106–108
by Asians and Asian Americans, 120
as critical treatment issue, 80
by Hispanics and Latinos, 132
by Native Americans, 142–143
outreach strategies, 96–98, 97–98
for White Americans, 153
acculturation, 24–27
asking clients about, 62
defined, 24, 295
five-level model for, 25
generational gap in, 23
tools for identifying and measuring, 27,
253, 254–257, 288
acupuncture, 126
adapting intervention strategies to clients’
cultural needs, 50, 55, 56, 71–72
Addiction Technology Transfer Centers, 287
Addressing the Specific Behavioral Health Needs
of Men (TIP 56), 20
advisory and governing boards, 79
affective/mood disorders, 105–106, 153
Affordable Care Act, 7
African Americans, 14, 103–116
Afrocentricity of, 62
CODs of, 105–106, 107, 108
cultural identification by, 27
cultural resources for, 290–291
defined, 14, 103–104, 295
evaluation and treatment planning, 109–
116, 110, 112, 115
families, concepts of and attitudes about,
19
gender issues, 19, 104, 107, 111
health disparities, 20
health, illness, and healing, attitudes to-
ward, 108–109
as high-context cultural group, 17
historical trauma of, 28, 108, 109–110
incarceration rates, 108
Kwanzaa, seven principles of, 297
mental disorders suffered by, 105–106
organizational cultural competence and,
73
power and trust issues, 109–110
recovery and relapse prevention, 115–116
religion and spirituality, 114, 115
substance use and abuse and drug cul-
tures, 27, 104–105
traditional/alternative healing practices
and, 114–115
treatment patterns, 106–108
Agency Cultural Competence Checklist, 264–
265
Agency for Healthcare Research and Quality
(AHRQ), 20, 85, 287
AI-SUPER PFP (American Indian Services
Utilization and Psychiatric Epidemiology
309
Improving Cultural Competence
Risk and Protective Factors Project), 140,
141, 142, 147
Alaskan Natives. See Native Americans
Alcoholics Anonymous (AA), 113, 114, 136,
137, 147, 155–156, 173, 174
alcohol abuse. See drug cultures; substance
abuse
alcohol flushing response, 119
alternative healing practices. See tradition-
al/alternative healing practices
American Counseling Association (ACA)
Counselor Competencies, 46, 47, 56
American Indian Services Utilization and
Psychiatric Epidemiology Risk and Protec-
tive Factors Project (AI-SUPER PFP), 140,
141, 142, 147
American Indians. See Native Americans
American Psychiatric Association (APA), 69,
283
American Religious Identification Survey, 30
American Translators Association, 287
anxiety disorders, 61, 72, 105, 107, 109, 124,
126, 142, 153
APA (American Psychiatric Association), 69,
283
APIs (Asians and Pacific Islanders), 14. See
also Asians and Asian Americans; Pacific
Islanders
appreciation, as stage in racial and cultural
identity development, 40
Arab Americans, 32, 65, 150, 152
Asian Indians, 14, 116. See also Asians and
Asian Americans
Asians and Asian Americans, 14, 116–128. See
also immigrants
adopted into White families, 117
client–counselor matching, 71
CODs, 119–120
community fairs, 98
complex cultural problems, counselors al-
lowing for, 51
in criminal justice system, 120
cultural resources for, 291–292
defined, 295
educational factors, 22
emotional expression and, 69, 119, 123
evaluation and treatment planning for,
121, 121–128, 123
families, role of, 1, 19, 61, 72, 124
gender issues, 122–123
geographic factors, 18
health, illness, and healing, attitudes to-
ward, 119, 120–121
language and communication issues, 17,
54
mental disorders, 57, 119–120
recovery and relapse prevention among,
128
religion and spirituality, 126–128
shame and guilt, 1, 117, 119, 121, 122
structured approach to counseling often
preferred by, 55
substance use and abuse and drug cul-
tures, 1, 57, 117–119
traditional/alternative healing practices
used by, 126–128
trauma, personal or historical, 119–120
treatment patterns, 120
assessment. See evaluation and planning;
measurement; self-assessment
assimilation, 24
Association for Multicultural Counseling, 37,
45
ataque de nervios, 284
attitudes and behaviors of culturally compe-
tent counselors, 49–50
avoidance of certain counselor behaviors, 51
B
Baltimore Epidemiologic Catchment Services
Area study (1980s), 106
behavioral health
critical treatment issues for culturally re-
sponsive services, 80
cultural knowledge about, as core compe-
tency, 48, 48–49
defined, 3
Behavioral Health Services for American Indians
and Alaska Natives (planned TIP), 139
310
Index
behavioral health service providers and coun-
selors. See also core competencies; self-
assessment; self-knowledge, as core compe-
tency
behaviors to avoid, 51
on continuum of cultural competence,
10–11
diversity of, 4–5, 8
evaluation and monitoring of staff per-
formance, 95–96, 96
importance of cultural competence for, 2
matching clients with, 71
organizational staff development, 75, 90–
96, 92–96
professional development tool for super-
visor-supervisee discussions, 95
in Sue’s multidimensional model for de-
veloping cultural competence, 6, 6–7
behaviors and attitudes of culturally compe-
tent counselors, 49–50
biculturalism and mixed cultural identity, 5,
24, 57–58, 62, 116–117, 295
bipolar disorders, 41, 69, 153
biracial or multiracial people, 5, 13, 14, 62,
295, 297
Blacks. See African Americans
boards, governing and advisory, 79
Brief Interventions and Brief Therapies for
Substance Abuse (TIP 34), 157
Buddhists and Buddhism, 32–33, 123, 128,
156
C
cabellerismo, 19
Cambodians, 117, 118, 119, 123, 128. See also
Asians and Asian Americans
cao gio, 126
Caribbeans, 104, 106, 113, 128, 284. See also
African Americans; Hispanics and Latinos
case management, culturally responsive, 70,
70–71, 71
Case Management Society of America, 71
case studies
core competencies (Gil), 35
drug cultures (Lisa), 159–161
evaluation and treatment planning
(Zhang Min), 57–58, 62
group clinical supervision case study
(Beverly), 72
Hispanics and Latinos (Anna), 136
importance of cultural competence
(Hoshi), 1
Native Americans (John), 101–102
organizational cultural competence
(Cavin), 73–74
racial and cultural identity, 41
Caucasians. See White Americans
CBT. See cognitive–behavioral therapy
CCHCP (Cross Cultural Health Care Pro-
gram), 288
Census Bureau, U.S., racial and ethnic groups,
xvi, 13
Center for Integrated Health Solutions
(CIHS), 98
Center for Mental Health Services (CMHS),
288
Center for Research on Ethnicity, Culture,
and Health, 287
Center for Substance Abuse Treatment
(CSAT)
Targeted Capacity Expansion Program,
98
TIPs. See Treatment Improvement Proto-
cols
Central and South Americans, 32, 129, 131,
135, 285. See also Hispanics and Latinos
change, determining readiness and motivation
for, 69–70
chibih, 285
Chinese, 14, 32, 51, 57, 98, 117, 118, 123, 124,
125, 126, 285. See also Asians and Asian
Americans
Christians and Christianity, 31, 101, 115, 128,
138, 149, 156
CIDI (Composite International Diagnostic
Interview), 68
CIHS (Center for Integrated Health Solu-
tions), 98
circles, in Native American philosophy, 147,
148
311
Improving Cultural Competence
cirrhosis, 105, 140, 141
Civil Rights Movement, 38
clinical issues, culturally framing, 49
clinical/program attributes. See evaluation and
treatment planning
clinical scales and CODs, 65–68
clinical supervisors and clinical supervision.
See also core competencies
diversity of, 4–5, 8
evaluation and monitoring of staff per-
formance, 95–96, 96
group clinical supervision case study
(Beverly), 72
importance of cultural competence for, 2,
93–95, 94
mapping racial and cultural identity de-
velopment and, 42
professional development tool for super-
visor-supervisee discussions, 95
training content for language services per-
sonnel, 90
clinical worldview, 43
CMHS (Center for Mental Health Services),
288
co-occurring disorders (CODs)
of African Americans, 105–106, 107, 108
of Asians and Asian Americans, 119–120
clinical scales, culturally valid, 65–68
counselor knowledge of cultural distribu-
tion of, 48–49
of Hispanics and Latinos, 131–132
immigrants and, 26
of Native Americans, 141–142
Substance Abuse Treatment for Persons With
Co-Occurring Disorders (TIP 42), 20,
157
of White Americans, 153
cognitive–behavioral therapy (CBT)
for African Americans, 111
for Asians and Asian Americans, 123–124
for Hispanics and Latinos, 135
for Native Americans, 145
for White Americans, 155
collaborative approach, 60–61, 109, 111
collateral information of cultural relevance, 64,
64–65, 66–67
committees, organizational, for cultural com-
petence, 79–80
communication. See language and communi-
cation
Community-Defined Solutions for Latino Men-
tal Health Care Disparities (Aguilar-Gaxiola
et al., 2012), 98
community involvement and awareness
demographic profiles, 84
environmental appropriateness for popu-
lations served, 96
feedback, gathering, 86
as key culturally responsive practice, 8
Native American treatment planning and,
101–102, 143, 144
outreach programs, 96–98, 97–98
strategies for engaging, 80, 80–81
Community Toolbox, 287
complementary healing practices. See tradi-
tional/alternative healing practices
complex cultural problems, counselors allow-
ing for, 51
Composite International Diagnostic Interview
(CIDI), 68
confianza, 295
confidentiality issues, 134, 144
conformity, as stage in racial and cultural
identity development, 40, 295
Consumer Assessment of Healthcare Provid-
ers and Systems Cultural Competence Item
Set, 85
contingency management approaches, 111,
135
continuum of cultural competence, 9–11, 10–
11
core assumptions of cultural competence, xvii,
4–5
core competencies, xvii–xviii, 3, 36–56. See also
self-knowledge, as core competency
adapting intervention strategies to clients’
cultural needs, 50, 55, 56
attitudes and behaviors of culturally com-
petent counselors, 49–50
312
Index
behavioral health, cultural knowledge
about, 48, 48–49
behaviors to avoid, 51
case studies, 35, 41
clinical issues, framing in culturally rele-
vant ways, 49
complex cultural problems, allowing for,
51
cross-cutting factors affecting, 46–47
knowledge of other cultural groups, 44–
47, 45, 47
personal space issues, dealing with, 51–52
power and trust issues, 44, 52
self-assessment tools, 55, 259–63
skill development, 49–50, 49–55, 51, 53–
54
in Sue’s multidimensional model for de-
veloping cultural competence, 6, 36, 37
touch, awareness of culturally specific
meanings of, 52
counselors. See behavioral health service pro-
viders and counselors
criminal justice system
African Americans in, 108
Asians and Asian Americans in, 120
Native Americans in, 143
Substance Abuse Treatment for Adults in the
Criminal Justice System (TIP 44), 157
cross-cultural applicability of diagnostic sys-
tems, 68–69
cross-cultural communication, 59
Cross Cultural Health Care Program
(CCHCP), 288
cross-cutting factors, xvii, 16–33, 46–47, 62–
63, 150
CSAT. See Center for Substance Abuse
Treatment
Cubans and Cuban Americans, 129, 130, 131.
See also Hispanics and Latinos
culturagrams, 65, 66–67
cultural awareness, 38
cultural blindness, 10–11
cultural competence, xv–xxi, 1–33
core assumptions of, xvii, 4–5
core competencies for counselors and
clinical staff, xvii–xviii, 3, 35–56. See
also core competencies
cross-cutting factors, xvii, 16–33, 46–47,
62, 63, 150
defined, xv, 5–7, 11, 295–296
development of, xvi, 9–11, 10–11
diversity aiding, 4–5, 8
drug cultures, xxi, 3, 159–175. See also
drug cultures; substance abuse
in evaluation and treatment planning,
xviii–xix, 3, 57–72. See also evaluation
and treatment planning
importance to behavioral health field, xv–
xvi, 1–2, 7–9
at multiple levels of operation, 4
in organizations, xix–xx, 73–99. See also
organizational cultural competence
public advocacy of, 5
purpose and objectives of pursuing, 2
for specific racial and ethnic groups, xx–
xxi, 3, 101–57. See also racial and ethnic
groups; specific groups
Sue’s multidimensional model for devel-
oping, xv, 5–7, 6, 36, 37, 58, 74, 102,
103, 160, 161
terminology used in discussing, 3
Cultural Competence for Health Administra-
tion and Public Health, 93
cultural competence plans, 81–82, 82, 84, 87,
296
cultural concepts of distress, 30, 69, 284–285
cultural destructiveness, 10
cultural diffusion, 296
cultural formulation, 69, 283–284
cultural humility, 50, 296
cultural identity, 24–27
asking clients about, 62
case study, 41
defined, xvii, 16
diagnosis, cultural formulation in, 283
drug culture, as alternative to, 173
mapping, 41, 42
mixed, 57–58, 62, 116–117
models of, 39, 40
313
Improving Cultural Competence
for Native Americans, 26–27, 144–145
self-knowledge of counselors regarding,
38, 38–41, 40, 41
subcultures, 62–63
terminology of, 24
tools for measuring and identifying, 253,
254–257, 288
for White Americans, 39, 154
cultural incapacity, 10
cultural norms, xvi, 12, 45, 48, 52, 60, 296
Cultural Orientation Resource Center, 23
cultural precompetence, 11
cultural proficiency, 296
culture, defined, xvi, 11–13, 12, 296
Culture Matters: The Peace Corps Cross-Cultural
Workbook (2012), 52
culture of recovery, xxi, 173, 173–175, 174, 175
Cup’ik Eskimo, 148
curanderismo, 138
D
daily routines and rituals of substance abusers,
assessing, 172
dances, sacred, 148
demographic profiles, developing, 84
Departments, U.S. See entries at U.S.
depression, 21, 49, 51, 57, 69, 72, 107, 109,
119, 124, 131, 141, 142, 153
development of cultural competence, xvi, 9–11,
10–11
dhat, 284
diabetes, 49, 141, 290
diagnosis, 68–69, 283–285
Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5), 30, 68,
283, 284–285
dissonance, as stage in racial and cultural
identity development, 40
distress, cultural concepts of, 30, 69, 284–285
diversity
at developmental and organizational lev-
els, 4–5, 8, 90–91
within racial and ethnic groups, 17–18,
103
Diversity Rx, 288
drug cultures, xxi, 3, 159–175. See also sub-
stance abuse
of African Americans, 104–105
of Asians and Asian Americans, 117–119
attraction of, 165–169
case study (Lisa), 159–161
cultural identity as alternative to, 173
culture of recovery replacing, xxi, 173,
173–175, 174, 175
daily routines and rituals, assessing, 172
defined, 161–164
differences between, 161, 162
evaluation and treatment planning ad-
dressing, 171–175, 172
exercise on benefits, losses, and the fu-
ture, 170–171
families and, 169
geographical variations, 161, 162
of Hispanics and Latinos, 129–131, 130
identifying key characteristics of, 162–163
as initiating and sustaining force for sub-
stance abuse, 167, 169
language and terminology of, 164
mainstream culture, relationship to, 164–
165
music and, 165, 166–167
of Native Americans, 139–141
online, 169–171
rituals of, 167, 168
SES and, 162, 169
skills required for certain drug use,
transmitting, 167, 168
as subcultural phenomenon, 160, 161–162
Sue’s multidimensional model for devel-
oping cultural competence and, 160,
161
of White Americans, 150–152
worldviews, values, and traditions of, 165,
166
DSM-5 (Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition), 30, 68,
283, 284–285
314
Index
E
East Harlem Protestant Parish, 138
EBP. See evidence-based practices
educational factors, 21–22, 22, 67
emotional expression, 54–55, 69, 119, 123
enculturation, 24
engaging clients, 59, 59–60
Engaging Moms, 113
Enhanced National Standards for Culturally and
Linguistically Appropriate Services in Health
and Health Care (OMH, 2013), 8, 75, 265–
266
Enhancing Motivation for Change in Substance
Abuse Treatment (TIP 35), 69, 70, 157
environmental appropriateness for populations
served, 96
epicanthic eye fold, 13
equality, commitment to, 40, 50
ESI (Ethnic-Sensitive Inventory), 262–263
espanto, 285
espiritismo, 138
ethnic groups. See racial and ethnic groups
Ethnic-Sensitive Inventory (ESI), 262–263
ethnocentrism, 9, 40, 296, 298
ethnogeriatrics, 290
evaluation and monitoring
of organizational cultural competence, 74,
75, 84–87, 85, 86, 264–273
of staff performance, 95–96, 96
evaluation and treatment planning, xviii–xix, 3,
57–72
adapting intervention strategies to clients’
cultural needs, 50, 55, 56, 71–72
for African Americans, 109–116, 110,
112, 115
benefits of cultural competency for, 4
case management, 70, 70–71, 71
case studies, 57–58, 62, 72
change, determining readiness and moti-
vation for, 69–70
collaborative approach to, 60–61
collateral information of cultural rele-
vance, 64, 64–65, 66–67
cross-cutting factors affecting, 62, 63
culturagram, 65, 66–67
cultural identity and acculturation, de-
termining, 62
diagnosis, 68–69, 283–285
distress, cultural concepts of, 30, 69, 284–
285
diversity of population developing, 4–5
drug cultures, addressing, 171–175, 172
eliciting client views on their problems,
63
engaging clients at initial meeting, 59,
59–60
familiarization of client with process, 59–
60
families, inclusion of, 1, 59–60, 61, 64–65
health, illness, and healing, different cul-
tural attitudes toward, 60, 61, 63, 64
for Hispanics and Latinos, 133–138
immigration history, taking, 23, 61, 66
integration of culturally relevant issues,
61–63, 61–64
matching clients and counselors, 71, 134
motivational interviewing, 70
multicultural intake checklist, 64
for Native Americans, 143, 143–150, 145
one-size-fits-all approach, importance of
avoiding, 58
for Pacific Islanders, 127
screening and assessment tools, 65–69,
68, 277, 277–81
strength-based interviews, 61
subcultures, 62–63
in Sue’s multidimensional model for de-
veloping cultural competence, 6, 6–7,
58
traumatic experiences, 63
for White Americans, 154–156
evidence-based practices (EBPs)
counselors’ cultural sensitivity and, 37
health disparities, reducing, 20
for Hispanics and Latinos, 134
F
families
in Asian culture, 1, 19, 61, 72, 124
315
Improving Cultural Competence
counselor’s worldview of, 72
culturagrams, 66
cultural variations regarding, 19
drug cultures and, 169
gathering culturally relevant collateral in-
formation from, 64–65
health, illness, and healing, cultural atti-
tudes toward, 30, 60, 61
in Hispanic and Latino culture, 129–130,
135
immigration and migration issues, 22, 23
inclusion in evaluation and treatment
process, 1, 59–60, 61, 64–65
in Native American culture, 145–146
family therapy, 19, 49
for African Americans, 111–113, 113
for Asians and Asian Americans, 124,
124–125
for Hispanics and Latinos, 135–136, 136,
137
for Native Americans, 145–146
Substance Abuse Treatment and Family
Therapy (TIP 39), 19, 146, 157
for White Americans, 155
feedback, gathering, 85, 85–87, 86, 273–275
fetal alcohol syndrome, 141
Filipinos, 14, 118. See also Asians and Asian
Americans
fiscal support of organizational cultural com-
petence, 96
flexibility, culturally competent counselors
showing, 50, 55
four circles, 158
G
gender, 19–20
acculturation and, 26
Addressing the Specific Behavioral Health
Needs of Men (TIP 56), 20
African Americans and, 19, 104, 107, 111
for Asians and Asian Americans, 122–
123
client–counselor matching for, 71, 134
in Hispanic and Latino culture, 19–20,
129, 134
mental disorders and substance abuse is-
sues, 20
Substance Abuse Treatment: Addressing the
Specific Needs of Women (TIP 51), 20,
123, 157
White Americans and, 19
genetics and race, 13
geographical factors in cultural competence,
17–18, 62–63, 161, 162
governance, of organizations, 75, 78–80, 80
governing and advisory boards, 79
group clinical supervision case study (Beverly),
72
group therapy
for African Americans, 113
for Asians and Asian Americans, 125
exercise on benefits, losses, and the fu-
ture, 170–171
for Hispanics and Latinos, 136
Ho’oponopono (used by Native Hawai-
ians), 127
for Native Americans, 146
Substance Abuse Treatment: Group Therapy
(TIP 41), 155, 157
for White Americans, 155
H
Hands Across Cultures Corporation, New
Mexico, 77–78, 78
Hawaiians. See Pacific Islanders
health disparities
causes of, 20
cultural competence reducing, 7
defined, 7, 296
National Center on Minority Health and
Health Disparities, 289
SES and, 21
health, illness, and healing
African American attitudes toward, 108–
109
Asian and Asian American attitudes to-
ward, 119, 120–121
core competency, cultural knowledge of
behavioral health as, 48, 48–49
316
Index
culturagrams, 67
different cultural attitudes toward, 29–30,
60, 61, 63, 64
Hispanic and Latino attitudes toward,
133
Native American attitudes toward, 143,
147–148
Pacific Islanders’ attitudes toward, 127
White American attitudes toward, 153–
154
health insurance coverage
for African Americans, 107
for Asians and Asian Americans, 120
for Hispanics and Latinos, 132, 137
for Native Americans and Pacific Is-
landers, 142
SES and treatment access, 20, 22
Health Resources and Services Administra-
tion (HRSA)
Administration Culture, Language and
Health Literacy Page, 288
CIHS (Center for Integrated Health So-
lutions), 98
domains of organizational cultural com-
petence, 75, 75–76, 266–268
Organizational Cultural Competence As-
sessment Profile, 266–268
Healthy People 2020, 21
Health and Human Services (HHS). See U.S.
Department of Health and Human Ser-
vices
Helms’s model of racial identity development,
298
hembrismo, 296
heritage. See history and heritage
HHS (Health and Human Services). See U.S.
Department of Health and Human Ser-
vices
high-context versus low-context cultural
groups, 17, 54
Hispanics and Latinos, 15, 128–138. See also
immigrants
CODs of, 131–132
cultural resources for, 292–293
distress, cultural concepts of, 284–285
evaluation and treatment planning for,
133–138
family role in culture of, 129–130, 135
gender roles, 19–20, 129, 134
geographic factors, 18
health, illness, and healing, attitudes to-
ward, 133
language and communication issues, 17
mental disorders, 131–132
recovery and relapse prevention, 138
religion and spirituality of, 137, 138
sexual identity and orientation, 29
substance use and abuse and drug cul-
tures, 35–36, 129–131, 130
traditional/alternative healing practices,
137–138
treatment patterns for, 132
history and heritage, 27–29. See also trauma,
personal or historical
of counselors, 43–44
of organizational cultural competence, 98,
99
HIV/AIDS, 105, 290
Hmong, 18, 30, 52, 126
Hogg Foundation for Mental Health, 86
Holocaust, 28
homosexuality, 29, 162–163
Ho’oponopono, 127
Hopi, 139–140
HRSA. See Health Resources and Services
Administration
humility, culturally competent counselors
showing, 50, 296
I
IHS (Indian Health Service), 139, 142, 293
iMCI (International MultiCultural Institute),
289
immersion, as stage in racial and cultural
identity development, 40, 296
immigrants, 22–27
acculturation and cultural identification,
23, 24, 24–27, 25, 27
culturagrams, 66
Cultural Orientation Resource Center, 23
317
Improving Cultural Competence
evaluation and treatment planning for,
23, 61, 66
family issues, 22, 23
history and heritage, effects of, 27–28
initial interview and assessment ques-
tions, 23
legal status of, 22, 66–67, 134
mental disorders and, 22–23
migrant/seasonal workers, 24
refugees, 23, 28, 52
substance abuse issues, 23, 25–26, 130
incarceration. See criminal justice system
Indian Health Service (IHS), 139, 142, 293
Indians. See Asian Indians; Native Americans
indigenous peoples, 52, 297. See also Native
Americans; Pacific Islanders
individual counselors. See behavioral health
service providers and counselors
infrastructure, organizational, 75, 96–98, 97–
98, 99
initial meeting, engaging clients at, 59, 59–60
institutional racism, 46, 297
Instruments for Measuring Acculturation
(University of Calgary), 288
integration of culturally relevant issues into
evaluation and treatment planning, 61–63,
61–64
integrative awareness, as stage in racial and
cultural identity development, 40
International MultiCultural Institute (iMCI),
289
International Statistical Classification of
Diseases and Related Health Problems, 68
interviews. See evaluation and treatment plan-
ning
introspection, as stage in racial and cultural
identity development, 40
Iowa Cultural Understanding Assessment, 86,
273–275
Islam, 32, 115, 156
J
jail. See criminal justice system
Japanese, 1, 14, 32, 126, 285. See also Asians
and Asian Americans
Jews and Judaism, 28, 30, 31–32, 156
jiryan, 284
Journey Mental Health Center (JMHC),
Wisconsin, 76
K
Kickapoo Reservation, Texas, 141
Kiowa gourd dance, 148
Koreans, 14, 16, 19, 61, 98, 117, 118, 120, 124,
126, 128. See also Asians and Asian Ameri-
cans
Kung San bushmen, 13
Kwanzaa, seven principles of, 297
L
Lakota version of the 12 Steps, 147
language and communication, 16–17
assessing cultural differences in, 53–54
counselor adjustment of communication
style, 52–54
culturagrams, 67
defined, 297
drug cultures, 164
emotional expression, 54–55, 69, 119
examples of cultural differences, 17
high-context versus low-context cultural
groups, 17, 54
improving cross-cultural communication,
59
informing clients about language services,
88
nonverbal communication, 16–17, 54
organizational language services (transla-
tors), 75, 88, 88–90, 90
translators, 88, 88–90, 90, 287
White Americans’ issues with, 155
Laotians, 118. See also Asians and Asian
Americans
Latinos. See Hispanics and Latinos
LEARN mnemonic, 59, 60
legal status of immigrants, 22, 66–67, 134
LGBT community, 29, 162–163
Living in the Balance intervention, 111
318
Index
low-context versus high-context cultural
groups, 17, 54
M
machismo, 19, 137, 297
marianismo, 19, 297
matching clients, counselors, and programs,
71, 134
measurement
acculturation and cultural identity, 27,
253, 254–257, 288
communication styles, cultural differences
in, 53–54
drug cultures, 162–163
Medicare, 22, 265
mental disorders. See also co-occurring disor-
ders; specific conditions
of African Americans, 105–106
of Asians and Asian Americans, 57, 119–
120
cultural differences in understanding of,
30
diagnosis, 68–69
gender roles and, 20
geographic factors, 18
of Hispanics and Latinos, 131–132
immigrants and, 22–23, 26
of Native Americans, 141–142
religion and spirituality, 31
SES and, 21
trauma-induced, 28–29
of White Americans, 153
Mental Health: Culture, Race, and Ethnicity
(Surgeon General’s report, 2001), 290
methadone programs, 111, 132, 135
Mexicans and Mexican Americans, 18, 25, 26,
35–36, 128–129, 130, 131, 133, 134, 135,
137, 138, 167, 285. See also Hispanics and
Latinos
MHP (Minority Health Project), 288–289
migrant/seasonal workers, 24
Minority Health Project (MHP), 288–289
mission statements, 77–78, 78
mixed cultural identity/biculturalism, 5, 24,
57–58, 62, 116–117, 295
models of racial identity, 38
monitoring and evaluation
of organizational cultural competence, 74,
75, 84–87, 85, 86, 264–273
of staff performance, 95–96, 96
Monitoring the Future Study, 131
mood and affective disorders, 105–106, 153
motivation for change
determining, 69–70
Enhancing Motivation for Change in Sub-
stance Abuse Treatment (TIP 35), 69,
70, 157
motivational interviewing, 70
for African Americans, 110
defined, 297
for Hispanics and Latinos, 135
for Native Americans, 145
Multicultural Counseling Self-Efficacy Scale,
259
multicultural intake checklist, 64
Multiculturally Competent Service System
Assessment Guide, 268–273
multiracial or biracial people, 5, 13, 14, 62,
295, 297
music and drug cultures, 165, 166–167
Muslims, 32, 115, 156
mutual-help groups. See also 12-Step pro-
grams, under T
for African Americans, 113–114
for Asians and Asian Americans, 125–126
for Hispanics and Latinos, 136–137
for Native Americans, 146–147, 147
for White Americans, 155–156
N
NA (Narcotics Anonymous), 113, 160, 174
Na Wahine Makalapua Project, 127
naiveté, as stage in racial and cultural identity
development, 40
narcocorridos, 167
Narcotics Anonymous (NA), 113, 160, 174
National Alliance on Mental Illness, 156
National Ambulatory Medical Care Survey,
106
319
Improving Cultural Competence
National Association of Social Workers, 71
National Center for Cultural Competence
(NCCC), 86, 259, 289
National Center on Minority Health and
Health Disparities, 289
National Comorbidity Study, 142
National Congress of American Indians, 141
National Epidemiologic Survey on Alcohol
and Related Conditions (NESARC), 114,
115, 154
National Institute on Minority Health and
Health Disparities, 20
National Institutes of Health (NIH), 20, 68
National Latino and Asian American Study
(NLAAS), 118, 120
National Survey on Drug Use and Health
(NSDUH) data
on African Americans, 104, 108, 114
on Asians and Asian Americans, 117,
119, 120, 121, 125
on Hispanics and Latinos, 132, 133
on Native Americans, 139, 140, 142
on Pacific Islanders, 127
on racial and ethnic groups, 18, 21, 117
on White Americans, 152, 154
Native Americans, 14–15, 138–150
Behavioral Health Services for American Indians
and Alaska Natives (planned TIP), 139
case study (John), 101–102
CODs of, 141–142
community involvement, importance of,
101–102, 143, 144
complex cultural problems, counselors al-
lowing for, 51
confidentiality issues, 144
in criminal justice system, 143
cultural identification, importance of, 26–
27, 144–145
cultural resources for, 293–294
defined, 295
evaluation and treatment planning for,
143, 143–50, 145
family in culture of, 145–146
geographic factors, 18
health, illness, and healing, attitudes to-
ward, 143, 147–148
historical trauma of, 28, 140, 142
IHS and Tribal service providers, 139,
142, 293
language and communication issues, 17
mental disorders of, 141–142
monthly newsletters, 98
motivational interviewing, 70
personal space, cultural differences re-
garding, 51
recovery and relapse prevention, 148,
149–150
religion and spirituality, 102, 144, 149
substance use and abuse and drug cul-
tures, 26–27, 139–141
traditional/alternative healing practices,
72, 102, 144, 147–149, 148
treatment patterns, 142–143
Wellbriety movement, 49, 147
Navajo, 140
NCCC (National Center for Cultural Com-
petence), 86, 259, 289
nervios, 285
NESARC (National Epidemiologic Survey on
Alcohol and Related Conditions), 114, 115,
154
nguzo saba, 297
NIH (National Institutes of Health), 20, 68
NLAAS (National Latino and Asian Ameri-
can Study), 118, 120
node-link mapping, 111, 135
nonverbal communication, 16–17, 54
NSDUH. See National Survey on Drug Use
and Health (NSDUH) data
O
Office of Civil Rights, 289
Office of Minority Health (OMH), 289
definition of cultural competence, 5
Enhanced National Standards for Cultural-
ly and Linguistically Appropriate Services
in Health and Health Care (2013), 8,
75, 265–266
Resource Center (OMHRC), 289–290
320
Index
staff education and training guidelines,
93, 94
online drug cultures, 169–171
openness, culturally competent counselors
showing, 50
organizational cultural competence, xix–xx,
73–99
basic requirements for, 74, 75
benefits to organization, 8
case study (Cavin), 73–74
commitment to, throughout organization,
76–77, 77
community involvement in, 8, 80, 80–81,
84, 86, 96
continuum of cultural competence, or-
ganizations on, 10–11
defined, 297
diversity necessary for, 4–5, 90–91
engagement of all parties in, 80, 80–81
evaluation and monitoring of, 74, 75, 84–
87, 85, 86, 264–273
feedback, gathering, 85, 85–87, 86, 273–
275
fiscal support for, 96
governance, 75, 78–80, 80
historical perspective on, 98, 99
HRSA domains of, 75, 75–76
importance of organizational commit-
ment, 2, 4
infrastructure supporting, 75, 96–98, 97–
98, 99
language services, 75, 88, 88–90, 90
mapping racial and cultural identity de-
velopment and, 42
planning, 75, 80–83, 82, 87
self-assessments, 84–87, 85, 86, 264–273
senior management in charge of, 78–79
strategic planning, 78
in Sue’s multidimensional model for de-
veloping cultural competence, 6, 6–7,
74
values of organization and, 75, 76–78, 77,
78
workforce and administrative staff devel-
opment, 75, 90–96, 92–96
Organizational Cultural Competence Assess-
ment Profile (HRSA), 266–268
orgullo, 297
orientation sessions, 134
outreach strategies and access to care, 96–98,
97–98
P
Pacific Islanders, 14, 116–117, 127. See also
Asians and Asian Americans
access to care, 142
client–counselor matching, 71
cultural resources for, 291–292
defined, 297
evaluation and treatment planning for,
127
health, illness, and healing, attitudes to-
ward, 121, 127
substance abuse by, 127
pasmo, 285
peer-supported interventions and strategies,
110, 113–114. See also group therapy; mutu-
al-help groups
pelea nonga, 133–134
People Awakening Project, 150
perdida del alma, 285
performance evaluation
of organizational cultural competence, 74,
75, 84–87, 85, 86, 264–273
of staff performance, 95–96, 96
personal space, 51–52
personalismo, 17, 133, 138, 297
Pew Forum on Religion and Public Life
(2008), 30
planning. See also evaluation and treatment
planning
cultural competence plans, 81–82, 82, 84,
87, 296
fiscal support of organizational cultural
competence, 96
organizational cultural competence, 75,
80–83, 82, 87
plática, 17
policies and procedures, organizational review
of, 82–83
321
Improving Cultural Competence
posttraumatic stress disorder (PTSD), 105,
106, 119, 142
power and trust issues, 44, 52, 109–110
prejudices, of counselors, 43–44, 44
prison. See criminal justice system
procedures and policies, organizational review
of, 82–83
professional development programs, 91, 94
Prohibition, 151
Project MATCH, 70
promotion strategies for workforce and staff,
90–91
A Provider’s Introduction to Substance Abuse
Treatment for Lesbian, Gay, Bisexual, and
Transgender Individuals (CSAT, 2001), 29
psychoeducation, 9, 111, 113, 125, 157, 170–
171
PTSD (posttraumatic stress disorder), 105,
106, 119, 142
public advocacy of cultural competence, 5
Puerto Ricans, 59, 129, 130, 131, 132, 135,
136, 138. See also Hispanics and Latinos
purification ceremonies, 72, 148
R
R/CID (racial/cultural identity development)
model, 39, 40, 41, 42
racial and ethnic groups, xx–xxi, 3, 101–157.
See also African Americans; Asians and
Asian Americans; Hispanics and Latinos;
Native Americans; Pacific Islanders; White
Americans
Buddhists, 32
case studies, 41, 101–102
client–counselor matching, 71, 134
definitions of race and ethnicity, xvi, 13–
16, 15, 296, 297
diversity within, 17–18, 103
ethnic or token representatives, 90–91
families, concepts of and attitudes about,
19
gender roles, 19
geographical variations in, 17–18
global differences in, 13
health disparities among, 20
health, illness, and healing, cultural atti-
tudes toward, 29–30
Jewish, 31
language and communication issues, 16–
17, 17
mapping racial and cultural identity de-
velopment, 41, 42
models of racial identity, 38, 39, 40
Muslims, 32
self-knowledge of counselor regarding ra-
cial, ethnic, and cultural identities, 38,
39–41, 40, 41
sexual identity and orientation, 29
sizes and percentages, 13
in Sue’s multidimensional model for de-
veloping cultural competence, 5–6, 6,
102, 103
U.S. Census Bureau groupings, xvi, 13
worldviews, values, and traditions, differ-
ences in, 18–19
racial/cultural identity development (R/CID)
model, 39, 40, 41, 42
racism, 21, 28, 39, 40, 46, 50, 52, 56, 60, 109–
110, 119, 297
readiness and motivation for change, deter-
mining, 69–70
recovery and relapse prevention
for African Americans, 115–116
for Asians and Asian Americans, 128
culture of recovery, xxi, 173, 173–175,
174, 175
for Hispanics and Latinos, 138
for Native Americans, 148, 149–150
Relapse Prevention and Recovery Promotion
in Behavioral Health Services (planned
TIP), 128, 157, 173–174
for White Americans, 156–157
recovery camps, Native American, 149
recruitment strategies for workforce and staff,
90–91
reculturation, 297–298
refugees, 23, 28, 52
relapse prevention. See recovery and relapse
prevention
322
Index
religion and spirituality, 30–33. See also rituals
of African Americans, 114, 115
of Asians and Asian Americans, 126–128
Buddhists and Buddhism, 32–33, 123,
128, 156
Christians and Christianity, 31, 101, 115,
128, 138, 149, 156
culturagrams, 67
of Hispanics and Latinos, 137, 138
Islam, 32, 115, 156
Jews and Judaism, 28, 30, 31–32, 156
of Native Americans, 102, 144, 149
of Pacific Islanders, 127
substance abuse and mental illness, treat-
ing, 31
syncretistic, 138, 298
Taoist version of CBT, 124
of White Americans, 151, 152
resistance, as stage in racial and cultural iden-
tity development, 40
respect, culturally competent counselors show-
ing, 49
RESPECT mnemonic, 44
respeto, 134, 298
retention strategies for workforce and staff,
90–91
rituals
of cultures of recovery, 174
of drug cultures, 167, 168
Rural Hawai’i Behavioral Health Program,
127
S
SAMHSA. See Substance Abuse and Mental
Health Services Administration
Santería, 138
Save Our Selves, 156
Schedules for Clinical Assessment in Neuro-
psychiatry (SCAN), 68
schizophrenia, 18, 21, 105–106, 119
screening and assessment tools, 65–69, 68,
277, 277–281
seasonal/migrant workers, 24
Secular Organizations for Sobriety, 156
segmented assimilation, 24
selective perception, 298
self-assessment
of core competencies, 55, 259–263
for counselor training, 93
of organizational cultural competence,
84–87, 85, 86, 264–273
Self-Assessment Checklist for Personnel
Providing Services and Supports to Chil-
dren and Youth with Special Health Needs
and Their Families, 55, 259–262
self-knowledge, as core competency, 37–45
ACA Counselor Competencies, 46
benefits of, 4, 8–9, 37–38
case management and, 70
cultural awareness, 38
limitations and abilities, understanding,
44–45
racial, ethnic, and cultural identities,
identifying, 38, 39–41, 40, 41, 42
RESPECT mnemonic, 44
stereotyping, prejudices, and history, 43–
44, 44
trust and power issues, 44
worldviews, individual and clinical, 42–
43, 43, 72
Self-Management and Recovery Training, 156
sensitivity, culturally competent counselors
showing, 50
SES. See socioeconomic status
sexual identity and orientation, 29
shame, 1, 32, 60, 61, 117, 119, 121, 122
shen-k’uei, 284
shenjing shuairuo, 285
silence, cultural comfort with, 17
simpatía, 17, 253, 298
skra prameha, 284
social constructs
gender as, 19
race as, 13
socioeconomic status (SES), 20–22
acculturation and substance abuse, 26
culturagrams, 66–67
drug cultures and, 162, 169
education and, 21–22, 22
health disparities and, 20
323
Improving Cultural Competence
health, social determinants of, 21
solution-focused interventions, 123
South and Central Americans, 32, 129, 131,
135, 285. See also Hispanics and Latinos
spirituality. See religion and spirituality
Standards of Practice for Case Management
(Case Management Society of America,
2010), 71
Standards on Cultural Competence in Social Work
Practice (National Association of Social
Workers, 2001), 71
Stanford University Curriculum in Ethnogeri-
atrics, 290
Star Trek terminology and crack cocaine use,
164
stereotyping, by counselors, 43–44, 44
strategic planning, by organizations, 78
strength-based interviews, 61
Subanun people, 30
subcultures, 62–63, 160, 161–162
substance abuse. See also co-occurring disor-
ders; drug cultures; Treatment Improve-
ment Protocols; 12-Step programs, under T
acculturation and, 25
by African Americans, 27, 104–105
by Asians and Asian Americans, 1, 57,
117–119
Buddhism and, 32–33
cultural identification and, 26–27
culture of recovery and, xxi, 173, 173–
175, 174, 175
defined, 3
diagnosing, 68–69
educational factors, 21–22
exercise on benefits, losses, and the fu-
ture, 170–171
gender roles and, 20
geographic factors, 18
by Hispanics and Latinos, 35–36, 129–
131, 130
historical trauma leading to, 28
immigrants and, 23, 25–26, 130
Islam and, 32
Judaism and, 31–32
by Native Americans, 26–27, 139–141
by Pacific Islanders, 127
religion and spirituality, 31
SES and, 21, 22, 26
sexual identity and orientation, 29
by White Americans, 150–152, 155
Substance Abuse and Mental Health Services
Administration (SAMHSA), 290. See also
Health Resources and Services Administra-
tion; National Survey on Drug Use and
Health (NSDUH) data; Treatment Im-
provement Protocols
guiding principles of recovery, 175
Targeted Capacity Expansion Program,
CSAT, 98
TTA (Tribal Training and Technical As-
sistance) Center, 293
Sue’s multidimensional model for developing
cultural competence, xv, 5–7, 6, 36, 37, 58,
74, 102, 103, 160, 161
suicide, 3, 141, 143
sun dance, 148
supportive-expressive psychotherapy, 111
surveys of clients, staff, and community mem-
bers, 85, 85–87, 86, 273–275
susto, 285
sweat lodges, 102, 148
syncretistic religions, 138, 298
T
taijin kyofusho, 285
talking circle, 158
Taoist version of CBT, 124
Targeted Capacity Expansion Program,
CSAT, 98
TEDS (Treatment Episode Data Sets; 2001-
2011), 107
Temperance Movement, 151
terapia dura, 137
TIPs. See Treatment Improvement Protocols
touch, culturally specific meanings of, 52
traditional/alternative healing practices
acupuncture, 126
adapting intervention strategies to, 72
African Americans and, 114–115
Asian Americans and, 126–128
324
Index
cao gio, 126
circles, in Native American philosophy,
147, 148
complex cultural problems, counselors al-
lowing for, 51
counselor attitudes to, 37
counselor awareness of, 49
dances, sacred, 148
in Hispanic and Latino culture, 137–138
mainstream attitudes to, 10
of Native Americans, 72, 102, 144, 147–
149, 148
organizational attitudes to, 10
purification ceremonies, 72, 148
sweat lodges, 102, 148
White Americans and, 156
yin/yang balance, 126
traditions and values. See worldviews, values,
and traditions
training
exercise on benefits, losses, and the fu-
ture, 170–171
in language services, 89–90
of workforce and staff, 91, 91–93, 92, 93
transculturation, 298
translators, 88, 88–90, 90, 287
trauma, personal or historical, 28–29
African American, 28, 108, 109–110
Asian or Asian American, 119–120
in evaluation and treatment planning, 63,
67
Native American, 28, 140, 142
PTSD, 105, 106, 119, 142
of racial and ethnic groups, 28–29, 106
Trauma-Informed Care in Behavioral
Health Services (TIP 57), 23, 28, 157
treatment, attitudes toward. See health, illness,
and healing
Treatment Episode Data Sets (TEDS; 2001-
2011), 107
Treatment Improvement Protocols (TIPs)
Addressing the Specific Behavioral Health
Needs of Men (TIP 56), 20
Behavioral Health Services for American
Indians and Alaska Natives (planned
TIP), 139
Brief Interventions and Brief Therapies for
Substance Abuse (TIP 34), 157
Enhancing Motivation for Change in Sub-
stance Abuse Treatment (TIP 35), 69,
70, 157
Relapse Prevention and Recovery Promotion
in Behavioral Health Services (planned
TIP), 128, 157, 173–174
Substance Abuse: Clinical Issues in Intensive
Outpatient Treatment (TIP 47), 157
Substance Abuse Treatment: Addressing the
Specific Needs of Women (TIP 51), 20,
123, 157
Substance Abuse Treatment and Family
Therapy (TIP 39), 19, 146, 157
Substance Abuse Treatment for Adults in the
Criminal Justice System (TIP 44), 157
Substance Abuse Treatment for Persons With
Co-Occurring Disorders (TIP 42), 20,
157
Substance Abuse Treatment: Group Therapy
(TIP 41), 155, 157
Trauma-Informed Care in Behavioral
Health Services (TIP 57), 23, 28, 157
treatment planning. See evaluation and treat-
ment planning
Tribal service providers, 139, 142
Tribal Training and Technical Assistance
(TTA) Center, SAMHSA, 293
tripa ida, 285
trust and power issues, 44, 52, 109–110
TTA (Tribal Training and Technical Assis-
tance) Center, SAMHSA, 293
12-Step programs
for African Americans, 111, 113–114
for Asians and Asian Americans, 125
culture of recovery and, 174
for Hispanics and Latinos, 136–137
for Jewish people, 32
Lakota version, 147
for Native Americans, 49, 102, 146–147,
147
for White Americans, 155, 156
325
Improving Cultural Competence
U
undocumented immigrants, 22, 66–67, 134
Urban Indian Health Institute, 140
U.S. Census Bureau racial and ethnic groups,
xvi, 13
U.S. Department of Health and Human Ser-
vices (HHS). See also Office of Minority
Health
definition of cultural competence, xv
health disparities, defined, 7
Healthy People 2020, 21
Mental Health: Culture, Race, and Ethnici-
ty (Surgeon General’s report, 2001),
290
Office of Civil Rights, 289
U.S. Department of Veterans Affairs, 116
V
value statements, of organizations, 77–78, 78
values. See worldviews, values, and traditions
Veterans Affairs, U.S. Department of, 116
veterans, Native American, 142
Vietnamese, 14, 22, 118, 119, 126, 292. See also
Asians and Asian Americans
Village Sobriety Project, 148
vision statements, 77–78, 78
W
Wellbriety movement, 49, 147
White Americans, 13–14, 150–157. See also
immigrants
CODs, 153
cultural identities of, 39, 154
defined, 298
evaluation and treatment planning for,
154–156
families, concepts of and attitudes about,
19
gender roles, 19
health, illness, and healing, attitudes to-
ward, 153–154
language and communication issues, 17
mental disorders, 153
personal space, cultural differences re-
garding, 51
power and trust issues, 52
recovery and relapse prevention for, 156–
157
religion and spirituality, 151, 152
substance use and abuse and drug cul-
tures, 150–152, 155
traditional/alternative healing practices,
156
treatment patterns, 153
White Bison program, 147, 294
White privilege, 298
White racial identity development (WRID)
model, 39, 40, 41, 42
WHO (World Health Organization), 68
Women for Sobriety, 156
World Health Organization (WHO), 68
worldviews, values, and traditions
clinical worldview, 43
of counselors, 42–43, 43, 72
culturagrams, 66–67
cultural differences in, 18–19
of culture of recovery, 174
of drug cultures, 165, 166
organizational cultural competence and,
75, 76–78, 77, 78
WRID (White racial identity development)
model, 39, 40, 41, 42
Y
yin/yang balance, 126
Yup’ik Eskimo, 148
326
327
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—
Replaced by TIP 43
TIP 2 Pregnant, Substance-Using Women—
Replaced by TIP 51
TIP 3 Screening and Assessment of Alcohol- and
Other Drug-Abusing Adolescents—Replaced
by TIP 31
TIP 4 Guidelines for the Treatment of Alcohol-
and Other Drug-Abusing Adolescents—
Replaced by TIP 32
TIP 5 Improving Treatment for Drug-Exposed
Infants
TIP 6 Screening for Infectious Diseases Among
Substance Abusers—Archived
TIP 7 Screening and Assessment for Alcohol and
Other Drug Abuse Among Adults in the
Criminal Justice System—Replaced by TIP 44
TIP 8 Intensive Outpatient Treatment for Alcohol
and Other Drug Abuse—Replaced by TIPs 46
and 47
TIP 9 Assessment and Treatment of Patients With
Coexisting Mental Illness and Alcohol and
Other Drug Abuse—Replaced by TIP 42
TIP 10 Assessment and Treatment of Cocaine-
Abusing Methadone-Maintained Patients—
Replaced by TIP 43
TIP 11 Simple Screening Instruments for Outreach
for Alcohol and Other Drug Abuse and
Infectious Diseases—Replaced by TIP 53
TIP 12 Combining Substance Abuse Treatment
With Intermediate Sanctions for Adults in
the Criminal Justice System—Replaced by
TIP 44
TIP 13 Role and Current Status of Patient
Placement Criteria in the Treatment of
Substance Use Disorders
Quick Guide for Clinicians
Quick Guide for Administrators
KAP Keys for Clinicians
TIP 14 Developing State Outcomes Monitoring
Systems for Alcohol and Other Drug Abuse
Treatment
TIP 15 Treatment for HIV-Infected Alcohol and
Other Drug Abusers—Replaced by TIP 37
Improving Cultural Competence
328
TIP 16 Alcohol and Other Drug Screening of
Hospitalized Trauma Patients
Quick Guide for Clinicians
KAP Keys for Clinicians
TIP 17 Planning for Alcohol and Other Drug
Abuse Treatment for Adults in the Criminal
Justice System—Replaced by TIP 44
TIP 18 The Tuberculosis Epidemic: Legal and
Ethical Issues for Alcohol and Other Drug
Abuse Treatment Providers—Archived
TIP 19 Detoxification From Alcohol and Other
Drugs—Replaced by TIP 45
TIP 20 Matching Treatment to Patient Needs in
Opioid Substitution Therapy—Replaced by
TIP 43
TIP 21 Combining Alcohol and Other Drug Abuse
Treatment With Diversion for Juveniles in
the Justice System
Quick Guide for Clinicians and
Administrators
TIP 22 LAAM in the Treatment of Opiate
Addiction—Replaced by TIP 43
TIP 23 Treatment Drug Courts: Integrating
Substance Abuse Treatment With Legal
Case Processing
Quick Guide for Administrators
TIP 24 A Guide to Substance Abuse Services for
Primary Care Clinicians
Concise Desk Reference Guide
Quick Guide for Clinicians
KAP Keys for Clinicians
TIP 25 Substance Abuse Treatment and Domestic
Violence
Linking Substance Abuse Treatment and
Domestic Violence Services: A Guide for
Treatment Providers
Linking Substance Abuse Treatment and
Domestic Violence Services: A Guide for
Administrators
Quick Guide for Clinicians
KAP Keys for Clinicians
TIP 26 Substance Abuse Among Older Adults
Substance Abuse Among Older Adults: A
Guide for Treatment Providers
Substance Abuse Among Older Adults: A
Guide for Social Service Providers
Substance Abuse Among Older Adults:
Physician’s Guide
Quick Guide for Clinicians
KAP Keys for Clinicians
TIP 27 Comprehensive Case Management for
Substance Abuse Tr
eatment
Case Management for Substance Abuse
Treatment: A Guide for Treatment Providers
Case Management for Substance Abuse
Treatment: A Guide for Administrators
Quick Guide for Clinicians
Quick Guide for Administrators
TIP 28 Naltrexone and Alcoholism Treatment—
Replaced by TIP 49
TIP 29 Substance Use Disorder Treatment for
People With Physical and Cognitive
Disabilities
Quick Guide for Clinicians
Quick Guide for Administrators
KAP Keys for Clinicians
TIP 30 Continuity of Offender Treatment for
Substance Use Disorders From Institution
to Community
Quick Guide for Clinicians
KAP Keys for Clinicians
TIP 31 Screening and Assessing Adolescents for
Substance Use Disorders
See companion products for TIP 32.
TIP 32 Treatment of Adolescents With Substance
Use Disorders
Quick Guide for Clinicians
KAP Keys for Clinicians
TIP 33 Treatment for Stimulant Use Disorders
Quick Guide for Clinicians
KAP Keys for Clinicians
TIP 34 Brief Interventions and Brief Therapies for
Substance Abuse
Quick Guide for Clinicians
KAP Keys for Clinicians
TIP 35 Enhancing Motivation for Change in
Substance Abuse Treatment
Quick Guide for Clinicians
KAP Keys for Clinicians
TIP 36 Substance Abuse Treatment for Persons
With Child Abuse and Neglect Issues
Quick Guide for Clinicians
KAP Keys for Clinicians
Helping Yourself Heal: A Recovering Woman’s
Guide to Coping With Childhood Abuse
Issues
Also available in Spanish
Helping Yourself Heal: A Recovering Man’s
Guide to Coping With the Effects of
Childhood Abuse
Also available in Spanish
SAMHSA TIPs and
Publications
Based on TIPs
329
TIP 37 Substance Abuse Treatment for Persons
With HIV/AIDS
Quick Guide for Clinicians
KAP Keys for Clinicians
Drugs, Alcohol, and HIV/AIDS: A Consumer
Guide
Also available in Spanish
Drugs, Alcohol, and HIV/AIDS: A Consumer
Guide for African Americans
TIP 38 Integrating Substance Abuse Treatment and
Vocational Services
Quick Guide for Clinicians
Quick Guide for Administrators
KAP Keys for Clinicians
TIP 39 Substance Abuse Treatment and Family
Therapy
Quick Guide for Clinicians
Quick Guide for Administrators
Family Therapy Can Help: For People in
Recovery From Mental Illness or Addiction
TIP 40 Clinical Guidelines for the Use of
Buprenorphine in the Treatment of Opioid
Addiction
Quick Guide for Physicians
KAP Keys for Physicians
TIP 41 Substance Abuse Treatment: Group
Therapy
Quick Guide for Clinicians
TIP 42 Substance Abuse Treatment for Persons
With Co-Occurring Disorders
Quick Guide for Clinicians
Quick Guide for Administrators
KAP Keys for Clinicians
TIP 43 Medication-Assisted Treatment for Opioid
Addiction in Opioid Treatment Programs
Quick Guide for Clinicians
KAP Keys for Clinicians
TIP 44 Substance Abuse Treatment for Adults in
the Criminal Justice System
Quick Guide for Clinicians
KAP Keys for Clinicians
TIP 45 Detoxification and Substance Abuse
Treatment
Quick Guide for Clinicians
Quick Guide for Administrators
KAP Keys for Clinicians
TIP 46 Substance Abuse: Administrative Issues in
Outpatient Treatment
Quick Guide for Administrators
TIP 47 Substance Abuse: Clinical Issues in
Outpatient Treatment
Quick Guide for Clinicians
KAP Keys for Clinicians
TIP 48 Managing Depressive Symptoms in
Substance Abuse Clients During Early
Recovery
TIP 49 Incorporating Alcohol Pharmacotherapies
Into Medical Practice
Quick Guide for Counselors
Quick Guide for Physicians
KAP Keys for Clinicians
TIP 50 Addressing Suicidal Thoughts and
Behaviors in Substance Abuse Treatment
Quick Guide for Clinicians
Quick Guide for Administrators
TIP 51 Substance Abuse Treatment: Addressing the
Specific Needs of Women
Quick Guide for Clinicians
Quick Guide for Administrators
KAP Keys for Clinicians
TIP 52 Clinical Supervision and Professional
Development of the Substance Abuse
Counselor
Quick Guide for Clinical Supervisors
Quick Guide for Administrators
TIP 53 Addressing Viral Hepatitis in People With
Substance Use Disorders
Quick Guide for Clinicians and
Administrators
KAP Keys for Clinicians
TIP 54 Managing Chronic Pain in Adults With or
in Recovery From Substance Use Disorders
Quick Guide for Clinicians
KAP Keys for Clinicians
You Can Manage Your Chronic Pain To Live a
Good Life: A Guide for People in Recovery
From Mental Illness or Addiction
TIP 55 Behavioral Health Services for People Who
Are Homeless
TIP 56 Addressing the Specific Behavioral Health
Needs of Men
TIP 57 Trauma-Informed Care in Behavioral
Health Services
TIP 58 Addressing Fetal Alcohol Spectrum
Disorders (FASD)
TIP 59 Improving Cultural Competence
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
