Question

• Identify and describe the various social and cultural factors of diversity that affect an individual’s institutional prejudice and discrimination.
• Define cultural competence and evaluate the importance to administering quality human and social service care.
• Identify areas of potential conflict between human and social service providers and a patient's cultural beliefs and values.
• Assess the role of one's own personal social and cultural identity in relation to others of similar and different backgrounds in the delivery of human services.

Answer 1

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 contact with family helped clients become honest about their substance 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 treatment and was participating in the program's continuing care program, 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 inappropriate 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 own worldviews as well as those of their clients will be able to work more effectively with clients who have substance use and mental disorders. Even when culture is not a conscious 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 behavioral health counseling results in greater counselor credibility, better client satisfaction, more client self-disclosure, and greater willingness among clients to continue with counseling (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 processes, 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 completed; such skills cannot be taught in any single book or training session. Nevertheless, this TIP provides a framework to help practitioners and administrators integrate cultural factors into their evaluation and treatment of clients with behavioral health disorders. It also seeks to motivate professionals and organizations to examine and broaden their cultural awareness, embrace diversity, and develop a heightened respect for people of all cultural groups. This TIP places significant importance on the role of program management and organizational commitment in the development of cultural competence. Organizational support allows counselors, case managers, and administrators to begin to integrate culturally congruent and responsive services more consistently across the continuum of care—including outreach and early intervention, assessment, treatment planning and intervention, 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 consider 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 prevention professionals, substance abuse counselors, mental health clinicians, and other behavioral health service providers and administrators. 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 audiences include educators, researchers, policymakers 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 counselor and for providing culturally responsive services in clinical settings as an organization. Chapter 1 defines cultural competence, presents a rationale for pursuing it, and describes the process of becoming culturally competent and responsive to client needs. The chapter highlights the consensus panel's core assumptions. It introduces a framework, adapting Sue's (2001) multidimensional model of cultural competence as the guiding model across chapters. The initial chapter ends with a broad overview of the concepts integral to an understanding of race, ethnicity, and culture.

Chapter 2 addresses the development of cultural awareness and describes core competencies 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 effectively with diverse client populations.

Chapter 3 provides guidelines for culturally responsive clinical services, including interviewing skills, assessment practices, and treatment 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 substance use patterns, beliefs and attitudes toward 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 relationship 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 substance abuse to describe any excessive use of addictive substances. In this TIP, the term refers to use of alcohol as well as other substances 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 disorders, 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 recovery support. Behavioral health conditions, taken together, are the leading causes of disability 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 disorders on communities in the United States, such as those described in this TIP, will help achieve nationwide improvements in health.

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 competence, in practice, has historically been on individual providers. However, counselors will not be able to sustain culturally responsive treatment without the organization's commitment 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 worldview 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 competence into treatment improves therapeutic decision-making and offers alternate ways to define and plan a treatment program that is firmly directed toward progress and recovery—as defined by both the counselor and client. Using culturally responsive practices is essential and provides many benefits for organizations, staff, communities, and clients.

Assumption 4: Consideration of culture is important at all levels of operation—individual, programmatic, and organizational—across behavioral health treatment settings. It is also important in all activities and at every treatment phase: outreach, initial contact, screening, assessment, placement, treatment, continuing care and recovery services, research, and education. Because organizations 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, standards, criteria, and requirements.

Assumption 5: Achieving cultural competence in an organization requires the participation of racially and ethnically diverse groups and underserved populations in the development and implementation of culturally responsive 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 communities should be invited to participate in the development of a cultural competence plan (an organization's plan to improve cultural competence and to provide culturally responsive services) and, subsequently, the design of culturally relevant treatment services and organizational policies and procedures