PSA6669 - SECTION 7: CULTURAL COMPETENCY
One of the challenges of doing a comprehensive psychosocial assessment is to work with sufficient knowledge of the client’s system of values and beliefs. When the patient comes from a similar background to the clinician, this is frequently easier for the clinician. When the patient comes from a background that is radically different from that of the clinician, this can be a much greater challenge.
A prerequisite for being able to handle this challenge is to have the capacity to understand one's own values and control one's own emotional responses – so that the focus of attention can remain on the client's values and concerns, instead of what is difficult or confusing for the clinician.
There are four elements to a culturally sensitive and responsive practice. These include Awareness of the existence of cultural differences, Knowledge of the individual’s culture community, the Ability to distinguish between culture and pathology in the assessment process and the Skill to integrate cultural preferences into the intervention plan.
This set of understandings is sufficiently important, that it will be expanded upon a little here. First, clinicians who work with clients from different cultural backgrounds are supposed to be culturally aware. (Sue and Sue, 1999) This is to say that – at the very least – clinicians should be aware of their own cultural background - and aware of how the socialization from that background has created certain assumptions and biases that shape how they see and interact with the world.
These assumptions and biases – left unattended – can create blinders on the eyes of the clinician when working with clients from different cultures. This is because these items are often embedded in value systems that are so familiar and comfortable for the clinician that they are almost invisible. These biases can cause the clinician to shape the therapeutic experience in ways that affirm and make comfortable the values of the clinician, while denying and discounting the experience and cultural material of the client.
Cultural awareness requires that the clinician remove his or her blinders and strive to become comfortable working with the cultural differences that exist between the client and clinician (Sue and Sue, 1999). The cognitive parts of this involve keeping one's thinking and perception flexible and remaining open to seeing and understanding different world views.
The emotional part of this may at times be even more difficult than the cognitive part. The emotional part requires the laying aside of any hidden or buried cultural biases and tolerating the discomfort of having one's own deeply held personal – and/or professional - values challenged by someone who may partially or wholly disagree with and reject those values.
The human and personal components of being a clinician can be sorely tested by this. The clinician's core defining values may be the central reason why he or she entered the mental health field in the first place. It may be for religious or spiritual reasons, or it may be for deeply held personal values and beliefs. However it is based, this set of core defining values often serves a very important centering function in the emotional life of the clinician, in addition to bringing comfort, certainty, and meaning to the work that he or she does.
For this reason, having one's most important values questioned or rejected can be a very disturbing or unsettling emotional experience. It can provoke powerful countertransference feelings and inclinations to translate those feelings into actions. This is a real risk or danger in cross-cultural work. With emotionally laden arenas, such as sexuality, or end of life concerns, the ability to maintain a sufficient degree of cultural neutrality can be even more difficult.
However, one of the ethical sacrifices that is required of those who choose this profession is the willingness to engage in these difficult questions - without running away too easily and too quickly towards that which is more personally comfortable. One cannot practice ethically without being able and willing to tolerate a certain amount of the discomfort that comes with sitting with cultural differences.
The final piece of being culturally aware is to know one's limitations when working with clients from different backgrounds (Sue and Sue, 1999). This falls under the category of operating within one's area of competence. When clinicians are not able to remove their own blinders or handle the emotional challenges of working with clients with different world views, the culturally aware clinician is at least able to know this about himself or herself, and know when to refer the client to another clinician who may be better able to respond to the cultural needs of the client.
The second level of cultural competence involves being culturally knowledgeable (Sue and Sue, 1999). This requires that the clinician possess a significant degree of understanding concerning the cultural elements of the client that are relevant to the definition of problems and solutions. This includes knowing the role - in relation to the dominant culture - of the minority group of which the client is a member.
(Not to state the obvious, but this also requires that the clinician has a quite clear picture of the landscape of the dominant culture, what its biases are, what its assumptions are, what the weaknesses, flaws, and internal contradictions in its perceptions and values are, etc.)
The culturally knowledgeable clinician should also have a solid background in the relevant practice literature concerning practice with non-dominant cultural groups, and also understand the institutional and cultural barriers that impede minority groups from using mental health services (Sue and Sue, 1999).
Finally, the third and highest level of cultural competence is being culturally skilled (Sue and Sue, 1999). This requires that the clinician possess a wide range of skills to use in interventions with clients from different cultural backgrounds, including fluency with verbal and non-verbal modes of communication that are well-received and understood by the clients within their own cultural experience (Sue and Sue, 1999).
This level of cultural competence also requires that the clinician be able – and willing – to intercede on the behalf of the client when the client's cultural components are "right" and the dominant culture's cultural components are "wrong" (Sue and Sue, 1999). When the dominant culture's values are "dysfunctional" for the client from a different cultural background, the clinician must not be blinded by his or her own biases, and unwilling or unable to grasp this.
Some of the indicators of cultural differences that will be encountered by the clinician include age, gender, ethnic origin, socio-economic status, education, alternative life styles, recent migration, language or manner of communication.
To illustrate the impact that culture has on the individual and how they perceive their every day existence, consider the remark that the elderly make about living in a world that they did not grow up in. People born in the 1940’s and earlier are the elderly of today. They grew up in a world without television, cell phones, email, personal computers or the internet. Commercial television began in the 1950’s.
The changes in society in the last 60 years represent a significant cultural change. The young and middle aged adults have never known a time without these conveniences. The have completely different expectations of what is necessary for a normal life style.
Another illustration of cultural differences is language and communication. Consider the differences in culture among native English speakers from the United States, United Kingdom, New Zealand and Australia.
The culture of native Spanish speakers differs significantly from Mexico, Cuba, Puerto Rico, Spain and South America. Language is a powerful influence on culture. Any group who uses language in a unique manner tends to develop cultural differences from the mainstream group.
Even individuals who are deaf or those who have no verbal language still communicate and develop complex cultural preferences. Health care professionals, the military, engineers, farmers, manufacturers, bankers, teenagers all use language in a unique manner that differs from the mainstream.
No one needs to question the power of language because it impacts everyone everyday through advertising, politics, religion and education. Practitioners need to have skill and competence to use language for the benefit of the individual during the assessment process and the intervention phase.
At the heart of this important issue lies the willingness and openness to seek clear and accurate information from the client about the cultural norms and expectations of the persons who present themselves for assessment - and how those norms and expectations operate in the real experience of the client. The practitioner can then use this knowledge to discriminate between cultural norms and pathology and to integrate cultural preferences into the intervention plan.
It is not appropriate or professional – nor therapeutically helpful - for the practitioner to be judgmental or critical of cultural norms and practices that differ from their own. Practitioners should take great care to avoid recommending interventions that are inconsistent or incompatible with the cultural practices of the individual. Initiating interventions based on cultural norms and values that are not accepted by the individual and or family system can be a source of harm rather than benefit.
Practitioners need to provide an opportunity to discuss how the individual functions within their own culture and also within the dominant culture, taking care to focus on the strengths of the individual, family unit and culture, as opposed to just the dysfunctions or problems. Practitioners can also compare and contrast how things are done in various cultures.
However, practitioners have a responsibility to report any illegal cultural practice. As mandatory reporters of suspected abuse or neglect, practitioners have a responsibility to prevent harm. Practitioners must clearly communicate their obligations in this regard to the individual prior to initiating the assessment process.
Practitioners of comprehensive psychosocial assessments are not, however, detectives or enforcers. They are required to report any suspected abuse or neglect to authorities.
If you find yourself in unfamiliar territory regarding a person’s culture, keep an open mind, ask for more information, listen to what is being communicated on both the verbal and non-verbal level and seek consultation from other professionals or experts on the culture.
Practitioners who are aware of their own cultural biases are better able to invite the kind of exchange of information that can provide a deeper level of understanding of the client's needs and challenges. No matter how culturally skilled, clinicians always need to be open to feedback on the accuracy of their thoughts, beliefs and perceptions about the different culture.
Practitioners need to remember that the point of conducting a comprehensive psychosocial assessment is to provide some benefit for the clients being assessed. For this reason alone, it is necessary for the practitioner to be culturally aware and knowledgeable.