1. Statement on Cultural Competence

Cultural competence is about adapting mental health care to meet the needs of consumers from diverse cultures. One key aim is to improve their access to care. Others are to build trust and to promote their engagement and retention in care. Above all, cultural competence aims to improve the quality of care and to help consumers recover quicker and better. Its broader societal purpose is to reduce or eliminate mental health disparities affecting disenfranchised groups. This statement on cultural competence lays out ways for programs to tailor their evidence-based practices to the cultures they serve. It is meant as a guide, rather than a set of fidelity measures. The statement begins with the basics: what is culture, how does it affect care, what is cultural competence, and why is it important. It then gives examples of how cultural competence is translated into practice.

What Is Culture, and How Does It Affect Care?

A culture is broadly defined as a common heritage or set of beliefs, norms, and values shared by a group of people. People who are placed, either by census categories, or through self-identification, into the same racial or ethnic group are often assumed to share the same culture; however, not all members grouped together in a given category will share the same culture. There is great diversity within each of these broad categories and individuals may identify with a given racial or ethnic culture to varying degrees. Others may identify with multiple cultures, including those associated with their religion, profession, sexual orientation, region, or disability status.

Culture is dynamic. It changes continually and is influenced both by people’s beliefs and the demands of their environment. Immigrants from different parts of the world arrive in the United States with their own culture but gradually begin to adapt and develop new, hybrid cultures that allow them to function within the dominant culture. This process is referred to as acculturation. Even groups that have been in the United States for many generations may share beliefs and practices that maintain influences from multiple cultures. This complexity necessitates an individualized approach to understanding culture and cultural identity in the context of mental health services.

The culture someone comes from influences many aspects of care, starting with whether the person thinks care is needed or not. Culture influences what concerns that person brings to the clinical setting, what language is used to express those concerns, and what coping styles are adopted. Culture affects family structure, living arrangements, and how much support someone receives in time of difficulties.

Culture also influences patterns of help-seeking whether someone starts with a primary care doctor, a mental health program, or goes to a minister, spiritual advisor, or community elder. Finally, culture affects how much stigma someone attaches to mental health problems, and how much trust is placed in the hands of providers.

It’s easy to think of culture as only belonging to consumers without realizing how it also applies to providers and administrators. Their professional culture influences how they organize and deliver care. Some cultural influences are more obvious than others, like the manner in which clinicians ask questions or interact with consumers. Less obvious but equally important are what hours a clinic has, the importance the staff attaches to reaching out to family members and community leaders, and the respect they accord to the culture of each consumer entering their doors.

Knowing how culture influences so many aspects of mental health care underscores the importance of adapting programs to respond to, and be respectful of, the diversity of the surrounding community.

Why Cultural Competence?

For decades, many mental health programs neglected the growing diversity around them. Often, people from non-majority cultures found programs off-putting and hard to access. They avoided getting care, stopped looking for care, or, if they managed to find care, they dropped out. The result was troubling disparities: many minority groups faced lower access to care, lower use of care, and poorer quality of care. Altogether, those disparities translated into millions of people suffering needless disability from mental illness.

Disparities are most apparent for racial and ethnic minority groups such as African Americans, American Indians and Alaska Natives, Asian Americans, Hispanic Americans, and Native Hawaiians and other Pacific Islanders. But disparities also affect many other groups, such as women and men, children and older adults, people from rural areas, and people with different sexual orientations, or with physical or developmental disabilities.

Starting in the late 1980’s, the mental health profession responded with a new approach to care called “cultural competence.” Cultural competence was originally defined as a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enables that system, agency, or those professionals to work effectively in cross–cultural situations.

What Is Cultural Competence?

Cultural competence is an approach to delivering mental health services grounded in the assumption that services are more effective when they are provided within the most relevant and meaningful cultural, gender-sensitive, and age-appropriate context for the people being served. The Surgeon General defined cultural competence in the most general terms as “the delivery of services responsive to the cultural concerns of racial and ethnic minority groups, including their languages, histories, traditions, beliefs, and values.” In most cases, the term cultural competence refers to sets of guiding principles, developed to increase the ability of mental health providers, agencies, or systems to meet the needs of diverse communities, including racial and ethnic minorities.

While consumers, families, providers, policymakers, and administrators have long acknowledged the intrinsic value of cultural competence, insufficient research has been dedicated to identifying its key ingredients. Therefore, the field still struggles to define, operationalize, and measure cultural competence. The word “competence” is somewhat misleading. Competence usually implies a set of criteria on which to evaluate a program. But this is not yet true for cultural competence, which is still under researched.

The term “competence,” in this context, means that the responsibility to tailor care to different cultural groups belongs to the system, not to the consumer. Every provider or administrator involved in delivering care from mental health authorities down to clinical supervisors and practitioners bears responsibility for trying to make their programs accessible, appropriate, appealing, and effective for the diverse communities that they serve. Many do it naturally.

How Is Cultural Competence Related To Evidence-Based Practices?

Evidence-based practices are for every consumer who enters care, regardless of what culture they come from, according to the Surgeon General.1 But programs often need to make adjustments to evidence-based practices in order to make them accessible and effective for cultural groups that differ in language or behavior from

the original study populations. The adjustments should facilitate, rather than interfere with, a program’s ability to implement evidence-based practices using the fidelity measures in this toolkit.

In a nutshell, to deliver culturally competent evidence-based practices means tailoring either the practice itself or the context in which the practice is delivered to the unique communities served by a mental health program.

In time, there may be specific fidelity measures used to assess a program’s cultural competence. But this is not the case now. The concept of cultural competence is too new and the evidence base is too small. While the evidence is being collected, programs can and should take the initiative to tailor evidence-based practices to each of the cultural groups they serve, like translating their information brochures into the languages often used in their communities. Others steps are featured in the next section.

Many providers ask, how can we know if evidence-based practices apply to a particular ethnic, racial, or cultural group if the research supporting those practices was done on a very different population? The answer is that we will not know for sure until we try; but the limited research that does exist, suggests that evidence- based practices, with minor modifications or not, work well across cultures. Furthermore, because evidence-based practices represent the highest quality of care currently available, it is a matter of fairness and prudence to provide them to all people who may need them. Yet the question remains, how can we do this effectively?

How Can Cultural Competence Be Put Into Practice?

All programs are encouraged to be more culturally competent, even though research has not yet generated a set of evidence-based practices to achieve cultural competence.

A variety of straightforward steps can be taken to make programs more responsive to the people they serve. The steps might apply to all facets of a program and need not be restricted to the evidence-based practice covered by this toolkit.

The following steps are meant to be illustrative, not prescriptive:

• Understand the racial, ethnic, and cultural demographics of the population served
  
  
• Become most familiar with one or two of the groups most commonly encountered
  
  
• Create a cultural competence advisory committee consisting of consumers, family and community organizations
  
  
• Translate your forms and brochures
  
  
• Offer to match a consumer with a practitioner of a similar background
  
  
• Have access to trained mental health interpreters
  
  
• Ask each client about their cultural background and identity
  
  
• Incorporate cultural awareness into the assessment and treatment of each consumer
  
  
• Tap into natural networks of support, such as the extended family and community groups representing the culture of a consumer
  
  
• Reach out to religious and spiritual organizations to encourage referrals or as another network of support
  
  
• Offer training to staff in culturally responsive communication or interviewing skills
  
  
• Understand that some behaviors considered in one culture to be signs of psychopathology are acceptable in a different culture
  
  
• Be aware that a consumer from another culture may hold different beliefs about causes and treatment of illness

Cultural competence is also important for planners and for mental health authorities. Here are a few examples of the ways a public mental health authority or program administrators can become more culturally competent.

• Designate someone with part-time or full-time responsibility for improving and monitoring cultural competence
  
  
• Create a strategic plan to incorporate cultural competence into programs throughout a system
  
  
• Establish an advisory committee that includes representatives of all the major racial, ethnic, and cultural groups being served
  
  
• Address barriers to care (cultural, linguistic, geographic or economic)
  
  
• Provide staffing that reflects the composition of the community being served
  
  
• Conduct regular organizational self-assessments of cultural competence
  
  
• Collect and analyze data to examine disparities in services
  
  
• Designate specific resources for cultural competence training
  
  
• Include cultural competence in quality assurance and quality improvement activities and projects

Case Studies of Cultural Competence

Vignette 1—Dual Diagnosis

Kevin is a 40-year-old African-American homeless man in Chicago who, for a decade, has cycled between jail, street, and shelter. At the shelter, he refuses getting help for what the staff believe is a longstanding combination of untreated schizophrenia and alcoholism. He becomes so drunk one night that he walks in front of a car and becomes seriously injured. While in the hospital, he is treated for his injuries, as well as placed on anti-psychotic medications after the psychiatrists diagnose him with schizophrenia.

At the time of hospital discharge, Kevin is referred to an outpatient program for individuals with dual diagnoses. Realizing that Kevin needs aggressive treatment to avoid re-spiraling into homelessness, the head of the treatment team recommends concurrent treatment of the alcoholism and the schizophrenia. The team leader is an African American psychiatrist who has an appreciation for the years of alienation, discrimination, and victimization that Kevin describes as having contributed to his dual disorders. The clinician works hard to develop a trusting relationship. He works with the treatment team to ensure that, in addition to mental health and drug abuse treatment, Kevin receives social skills training and a safe place to live. When Kevin is well enough, and while he continues to receive group counseling for his dual disorders, one of his first steps toward recovery is to reconnect with his elderly mother who had not heard from him in ten years.

Vignette 2—Assertive Community Treatment

A minister in Baltimore contacts the city’s ACT Program with an unusual concern: one of his congregants disclosed to him that another member of the congregation, an older woman from Jamaica, was beating her adult daughter for “acting crazy all the time.” The Jamaican mother may even be locking her adult daughter in the basement, according to the congregant.

One year before, the ACT team’s social worker had reached out to local ministers to tell them about the program. The ACT team had realized that better communication and referrals were needed. Stronger connections across organizations would improve chances for recovery by enhancing social support and adherence to treatment. Some of the consumers believed that treatment was counter to their religion.

The ACT social worker managed to obtain a court order to allow authorities to enter the Jamaican mother’s home. They discovered the traumatized 25-year old daughter locked in the basement, actively psychotic, and bearing marks of physical abuse. The ACT team diagnosed the daughter with schizophrenia and managed to find a group home for her. The team arranged for an intense combination of medications, individual and group therapy, including trauma care and social skills training. Through links to the church and the community, the ACT social worker helped the daughter to get clothing and spiritual support. The social worker discovered that the mother’s ethnic group from Jamaica believed that her daughter’s craziness was a sign of possession by the devil—the belief system behind her abuse. After all criminal charges were dropped, the social worker reached out to the mother to educate her about schizophrenia and to set the stage for the daughter’s eventual return to her mother’s household.

Vignette 3—Supported Employment

Jing is a bilingual vocational worker at a mental health program in San Francisco. By informally surveying her caseload, she estimates that about 30 percent of her clients are Asian. But they come from vastly different backgrounds, ranging from Taiwan to Cambodia, with vastly different educational backgrounds. One of her clients with bipolar disorder is a recent immigrant from China. He has a high school education, but speaks Mandarin and very little English. Fluent in Mandarin, Jing is able to conduct a careful assessment of the client’s job skills and a rapid, individualized job search. Because Jing is part of the treatment team, she’s aware that the client has progressed to the point of being ready for full-time employment. Jing identifies several import-export businesses in the area with monolingual Mandarin-speaking employees. She secures a position, but it pays less than one the client would qualify for if he spoke English. Jing succeeds in persuading the client to take the position while at the same time recommending a quick-immersion night program in English as a Second Language. Jing provides follow along job support during the next few months. When the client’s English is better, Jing searches for and manages to find a higher paying job for him. She stays in touch to be sure he can adjust to the greater demands of the new position, while continuing to receive treatment for his bipolar disorder.

Vignette 4— Medication Management

A primary care doctor at a rural Indian Health Service clinic tentatively diagnoses John, a 65-year old American Indian man, with a severe depression. But he is unsure whether he might have bipolar disorder. John had relied on a native healer for years but he had become so debilitated and despondent in recent weeks that his family drove him on the 4-hour trip to the doctor from their frontier area of South Dakota.

Upon examination, the primary care doctor discovers numerous medical conditions, including diabetes and hypertension, which had gone untreated. Uncertain of the diagnosis of John’s psychiatric illness, and the potential for interactions with the other medications he wishes to prescribe, the doctor arranges for a psychiatric consultation via telehealth.

Through video and other telecommunications equipment, John is interviewed by a psychiatrist 500 miles away at an Indian Health Service Facility. The psychiatrist is able to assess John’s appearance and body language. Having been advised by a cultural competence advisory committee, the psychiatrist knew how and what types of questions to ask John about his use of native healers and herbal remedies. She also is part of a program experienced in medication algorithms for mental disorders. She arrives at a diagnosis of bipolar disorder and recommends a medication regimen that would not interact with the diabetes and hypertension medications. Because of John’s older age, she recommends extremely low doses of the psychiatric medications. But she recognizes that the longer length of time for the antidepressants to take effect in older people (8 weeks rather than 4), combined with the lower dose, might leave John vulnerable to suicide. She suggests that the doctor work to establish communication with John’s native healer to monitor John carefully and to avoid giving him certain herbal therapies that might interfere with his medications.

Vignette 5— Illness Management and Recovery Skills

Lupita, a 17-year old high school senior, arrived in a San Antonio emergency room after a suicide attempt. The psychiatrist on call happened to be the same one who had diagnosed Lupita’s bipolar disorder a year ago. He thought that she had been taking her medications properly, but blood tests now revealed no traces of lithium or antidepressant.

The psychiatrist tried to communicate with Lupita’s anxious parents waiting in the visitor area, only to learn that they spoke only Spanish and no English. She had mistakenly assumed that because Lupita, a second generation Mexican American, was highly acculturated, so were her parents. She contacted the hospital’s bilingual social worker who discovered that the parents felt powerless for months as they watched their daughter sink into a severe depression, all the while lacking the motivation to take her medications. The social worker, whose family had similarly emigrated from a rural region of Mexico, knew to gently ask the parents if they could read and understand the dosage directions for Lupita’s medication. Finding that the parents had limited literacy in both English and Spanish helped the psychiatrist and social worker to tailor a treatment program that would not depend on the written word. Seeing the parents as essential to Lupita’s recovery and knowing she lived at home, the psychiatrist encouraged the parents, through the interpreter, to accompany their daughter to an illness management and recovery program. The hospital had organized programs for Spanish-speaking families because Latinos are a majority group in San Antonio.

During the weekly sessions, the social worker translated for the family and helped them with scheduling Lupita’s psychiatric visits and to apportion the correct combination of pills in a daily pill container. Understanding that the family had no phone, the social worker worked with them to find a close neighbor who might allow them use of the phone to relay messages from her and to contact her if Lupita stopped taking her medications.

Vignette 6— Family Psychoeducation

When Kawelo lost his job as an electrician, his therapist asked Kawelo if he had a family elder who knew of community elders familiar with traditional Hawaiian healing practices for personal and family problems. The therapist knew that Native Hawaiians, in times of difficulties, rely on their elders, traditional healer, family, and/or teacher to provide them with wisdom and cultural practices to resolve problems. One such practice is ho‘oponopono, which is a traditional cultural process for maintaining harmonious relationships among families through structured discussion of conflicts. Ho‘oponopono is also used by individuals for personal healing and/or guidance in troubled times.

Kawelo’s therapist recognized the importance of tapping into this community support and suggested that his family seek out ho‘oponopono. The therapist contacted the family and elders to arrange a meeting concerning Kawelo’s problems with depression, for which he needed both medication and counseling. At the group meeting the therapist further explained that Kawelo was so ill hat he lacked the motivation to receive treatment, and that his condition was so serious that he may be at risk for suicide. The therapist asked the elders how the group could help to encourage Kawelo to stick with his treatment and how they could watch Kawelo for suicidal signs. After lengthy deliberations, the family decided that one way to help Kawelo was to participate in ho’oponopono to understand the types of problems that he is experiencing and identify how the family could help him heal himself. Some members of the family also agreed to participate in a bi-weekly family psychoeducation group held at the community mental health center to learn more about his mental illness, coping skills and strategies, and pharmacological and psychosocial treatments. Through family psychoeducation the family would participate in structured sessions using a variety of educational formats. Because an important level of healing in Native Hawaiian culture involves sharing feelings and positive and negative emotions, in an open, safe, and controlled environment, the family’s participation in a combination of ho’oponopono and family psychoeducation was ideal.

Some Thoughts on Four Cultural Concepts

A critical point in the discussion of multicultural issues in mental health services is the conceptualization of four cultural concepts: minority, diversity, race, and ethnicity (Paniagua, 1994). The first concept (minority) was, probably, a good concept to use 30 years ago, when members from the African American (or Black), American Indian, Asian, and Hispanic communities were most concerned about a comparison between the majority (Anglo Americans) and a given minority group in terms of social-economic status. Over the last 10 years, however, the term “diversity” appears to be taking the lead in the cross-cultural literature dealing with four traditionally “minority” groups in the United States of America (i.e., African Americans, American Indians, Asians, and Hispanics). This paper will provide some thoughts concerning possible reasons for this trend in the use of the term “diversity” and an apparent decline concerning the use of the concept of “minority.”

A controversy exists regarding the distinction between race and ethnicity. For some people, race is not equal to ethnicity; other people believe that race and ethnicity mean the same thing. This paper will not deal with theoretical or philosophical arguments regarding this controversy. This paper will, instead, present a practical approach in understanding why it seems crucial to make that distinction in health research and practice.

Minority versus Diverse Groups

In general, the term “minority” represents both a number and disadvantages in terms of socio-economic status (Ho, 1992, 1993; D. W. Sue & D. Sue, 1990; Wilkinson, 1993). Thus, in the United States of America (U.S.A.) Anglo Americans or Whites are not considered a “minority group” because we have too many of them (approximately 207.754 million in 1991) and their socio-economic status is often higher than other groups in the U.S.A. (U.S. Bureau of the Census, 1992). On the other hand, African Americans, for example, are considered a “minority group” because we only have approximately 30.8 million (U.S. Bureau of the Census, 1992) and their economic status is generally lower than that for the “majority” (i.e., Anglo Americans). Other examples of “minority groups” in terms of their number and socio-economic status in 1991 (U.S. Bureau of the Census, 1992) include American Indians, Asians/Pacific Islanders and Hispanics.

The term “minority”, however, may not be appropriate for three reasons: (1) discrepancy in income level across “minority” groups, (2) the impact of “minority” groups upon other groups, and (3) the implication that the term “minority” is another term for “inferiority” in the minds of some members of such groups.

Discrepancy in income levels across “minority” groups. This point may be illustrated by comparing median income levels across “minority” groups (e.g., Asians versus African Americans). For example, in 1991 the median income for the Asian and Pacific Islander population (e.g., Japanese, Chinese, Filipino, Hawaiian, etc.) was $42,245, and the median income for African Americans in the same year was $21,423 (in 1991, the national U.S. median income was $35,262) (U.S. Bureau of the Census, 1992). Asians, Pacific Islanders, and African Americans are examples of “minority groups” in this country in terms of their number (and in comparison with the Anglo Americans). In 1991, however the Asian and Pacific Islander population reported a median income far above the national average.

A similar point could be made when income levels across subgroups within the same ethnic group are compared. For example, the median income for Cubans (a subgroup of Hispanics) in 1991 was $31,439, whereas the median income for Puerto Ricans (another subgroup of Hispanics) was $18,008. In addition, in 1991 37.5% of Puerto Rican families and 40.6% of Puerto Ricans (persons) were below the poverty level, in comparison with only 13.8 (families) and 16.9% (persons) reported by the Cubans (U.S. Bureau of the Census, 1992). Cubans and Puerto Ricans are examples of “minority” groups in the U.S., but it is evident that the Cubans have a better standard of living in the U.S. than the Puerto Ricans.

Therefore, although a person could be considered by others as a “minority” because that person is a member of a small number of people in comparison with the “majority,” that person may not share the same “minority” status when income level is considered (either between “minority” groups or between subgroups within the same racial group).

Impact of “minority” groups upon other groups. Another problem with the use of the term “minority” is that it does not take into consideration the impact of the population size of a “minority” group upon another “minority” group (Wilkinson, 1986). For example, many African Americans and Hispanics reside in Florida. A major problem confronting the African Americans, however, is that in several sections of Florida (e.g., Miami) they constitute a “minority” group whereas the Hispanics constitute a “majority” group. Both groups are examples of “minority” populations when the number of people in the U.S. is considered in the definition of “minority.” In such sections of Florida, however, the African Americans are the “minority” and the Hispanics constitute the “majority.” A similar comparison could be made in the case of the population of the Lower Rio Grande Valley of Texas (which is concentrated around the U.S. - Mexican border). In this region, the Mexican- Americans are the majority; other Hispanics (e.g., Puerto Ricans, Cubans), Asians, African Americans, and American Indians are “minority” groups.

The concept of ‘’minority’’ as a case for “inferiority”. It is also important to recognize the fact that some people do not want to be called “minority” because this term implies “inferiority” and a sense of superiority by those in the majority (i.e., Anglo Americans). For example, in a letter sent to the San Antonio Express News an Hispanic wrote, “When an individual labels me a ‘minority,’ I feel small, weak and irrelevant. On the other hand, ‘ethnically diverse American’ is empowering and more accurate” (Martinez, 1993, p.5B). Furthermore, McAdoo (1993) pointed out that a major reason to avoid the term “minority” is that “it has an insidious implication of inferiority...A sense of superiority is assumed by those of the implied superior status” (p.6, italics added).

Thus it seems that the term “minority” may not be applicable when issues involving income level, the impact of minority groups upon other minority groups, and the potential use of the term as synonymous with “inferiority” are considered (Kim, McLeod, & Shantzis, 1992; McAdoo, 1993; Wilkinson, 1986).

Perhaps, the term “diversity” is gradually appearing in the literature in response t0 these difficulties with the term “minority” (e.g., Dana, 1993a, Lee, 1995; McAdoo, 1993; Tharp. 1991; Wilkinson, 1993). As noted by Chung (1992), traditional “minority” groups in cross-cultural research and practice share a series of cultural commonalities, differences across these groups exist in terms of primary language, generational status (e.g., earlier versus later immigrants), acculturation, socioeconomic status, and critical cultural values (Sue & Sue, 1990). Thus, the term “diversity” emphasizes the fact that two groups may share the same minority status in terms of their number in the U.S., relative to a majority (e.g., Anglo Americans), but the same groups might not share the same cultural values, their view about the world, and their place in this society.

For example, among Hispanics the cultural values of manianismo and machismo are often accepted by this group as central codes of behavior, particularly in the regulation of traditional sex roles (Ramos-McKay, Comas-Diaz, & Rivera, 1988). In general, the “manianismo” role emphasizes a social context in which Hispanic women in traditional Hispanic families are expected to be submissive, obedient, timid, and stay at home to take care of children. In the case of the “machismo” role, Hispanic men are expected to be in control of the family and make crucial decisions regarding his children and wife. These roles, however, are not generally accepted by other “minority” groups. Hispanics and African Americans, for example, are often classified as examples of “minority” groups, but they markedly differ in terms of what specific role husband and wife should take in the management of their families. In general, Anglo American also share African American’s rejection of the cultural values of “manianismo” and “machismo.” For this reason, in the present definition of “diversity,” Anglo Americans are also examples of diverse groups in the U.S., despite the fact that this group (Anglo Americans) belongs to a “majority.” Other diverse groups seen with less frequency in mental health services in the U.S. include the Greek, Italian, Irish, and Polish Americans, and the West Indian Islanders (Allen, 1988; Jalali, 1988).

Race versus Ethnicity

A controversy exists regarding the use of the terms race and ethnicity interchangeably. Phinney (1996) argued that “the term ethnicity is used...to encompass race (p. 918), and added that the term race should be avoided “because of the wide disagreement on its meanings and usage” (p. 918). Both terms, however, seem to label two different processes (Berry, Pooringan, Segall, & Darsen, 1992; Betancourt & Lopez, 1993; Wilkinson, 1993). An understanding of these processes could be an important factor in mental health research and practice. As noted by Wilkinson (1993), the term race “is a category of persons who are related by a common heredity or ancestry and who are perceived and responded to in terms of external features or traits” (p. 19). The term ethnicity, on the other hand, often refers to “a shared culture and lifestyles” (Wilkinson, 1993, p. 19).

An important implication of that distinction is that an individual could belong to a particular race without sharing ethnic identity with that race. For example, the fact that two Hispanic clients share a common heredity or ancestry does not necessarily mean that they also share the same ethnic identity (e.g., culture, values, lifestyles, beliefs, norms, etc.). This difference in ethnic identity could be explained in terms of the process of acculturation, which may have a tremendous implication in the assessment and treatment of many diverse groups (Cuellar, Arnold, & Maldonado, 1995; Grieger & Ponterotto, 1995; Paniagua, 1994; Ramirez, Wassef, Paniagua, Linskey, & O’Boyle, 1994). For example, Hispanic mental health professionals acculturated into the American culture would probably find it difficult to share with a traditional Hispanic family the values of mananismo and machismo. Thus, an important point to make is that one should not assume that because two individuals (e.g., a therapist and a client) share the same racial group (e.g., both are Hispanics) they also share the same ethnicity (e.g., values and lifestyles).

References

Allen, A. (1988). West Indians. In L. Comas-Diaz & E.E.H. Griffith (Eels.). Clinical guidelines in cross-cultural mental health (pp. 305-333). New York: John Wiley & Sons.

Betancourt, H., & Lopez, S.R. (1993). The study of culture, ethnicity, and race in American psychology. American Psvchologist, 48, 629-637.

Berry, J.W., Pooringan, Y.H., Segall, M.H., & Darsen, P.R. (1992). Cross-cultural psychology: Research and applications. Cambridge, Massachusetts: Cambridge University Press.

Chung, D.K. (1992). Asian cultural commonalities: A comparison with mainstream American culture. In A.M. Furuto, R. Biswas, D.K. Chung, Murase, K., & Ross- Sheriff, F (Eds.), Social work practice with Asian Americans (pp.27-44). Newbury Park, CA: Sage.

Ramos-McAay, J.M., Comas-Diaz, L., & Rivera, L.A. (1998). Puerto Ricans. In L. Comas-Diaz & E.E.H. Griffith (Eels.), Clinical guidelines in cross-cultural mental health (pp. 204-232). New York: John Wiley & Sons.

Cuellar, 1., Arnold, B., & Maldonado, R. (1995). Acculturation rating scale for Mexican Americans-IT: A revision of the original ARSMA scale. Hispanic Journal of the Behavioral Sciences, 17,275-304.

Dana, R.H. (1993). Multicultural assessment perspectives for professional psychology. Boston: Allyn and Bacon.

Grieger, 1., & Ponterotto, J.G. (1995). A framework for assessment in multicultural counseling. In J.G. Ponterotto, J.M. Casas, L.A. Suzuki, & C.M. Alexander (Eds.), Handbook of multicultural counseling (pp. 357-374).

Ho, M.K. (1992). Minority children and adolescents in therapy. Newbury Park, CA: Sage Publications.

Ho, M.K. (1993). Family therapy with ethnic minorities. Newbuy Park, CA: Sage.

Jalali, B. (1988). Ethnicity, cultural adjustment, and behavior: Implications for family therapy. In L. Comas-Diaz & E.E.H. Griffith (Eels.) Clinical guidelines in cross-cultural mental health (pp. 9-32). New York: John Wiley & Sons.

Lee, C.C. (1995) (Ed.) Counseling for diversitv. Needham Heights, Mass.: Allyn and Bacon.

Martinez, R. E. (1993, August). Minority label “dehumanizing” [Letter to the editor]. San Antonio Express News, p. 5B.

McAdoo, H.P. (Ed.). (1993). Family ethnicity: Strength in diversity. Califonia: Sage Publications.

Paniagua, F.A. (1994). Assessing and treating culturally diverse clients: A practical guide. Thousand Oaks, CA: Sage Publications.

Phinney,I.S. (1996). When we talk about American ethnic groups what do we mean? American Psychologist, 21,918-927.

Ramirez, S.2., Wassef, A., Paniagua, F.A., Linskey, A.D., & O’Boyle, M. (1994) Perceptions of mental health providers concerning cultural factors in the evaluation of Hispanic children and adolescents. Hispanic Journal of the Behavioral Sciences, 16,28-42.

Sue, D.W., & Sue, D. (1990). Counseling the culturally different: Theory and practice, 2nd edition. New York: John Wiley & Sons.

Tharp, R.G. (1991). Cultural diversity and treatment of children. Journal of Consulting and Clinical Psychology, 59, 799-812.

U.S. Bureau of the Census (1992). Statistical Abstract of the United States. Washington, D.C.: Government Printing Office.

Wilkinson, C.B. (1986). Introduction. In C.B. Wilkinson (Ed.), Ethnic psychiatry (pp. 1-11). New York: Plenum Medical Book Company.

Wilkinson, D. (1993). Family ethnicity in America. In H.P. McAdoo (Ed.), Family ethnicity: Strength in diversity (pp. 15-59). Newbury, CA: Sage.

Reprinted with Permission.
Freddy A. Paniagua, Ph.D.
Psychiatry and Behavioral Sciences
The University of Texas Medical Branch
Galveston, Texas

Shift in Goal From Assimilation to Biculturalism

Since there is growing awareness that the melting pot ideology is a myth and that adherence to Anglo-dominance often does not produce the results (i.e., social integration and acceptance) that white immigrants experienced, many ethnic minority group members are redefining their goals vis-à-vis the dominant mainstream culture of America. Since assimilation for these groups often meant and means accepting negative stereotypes and beliefs about one’s ethnic group (and, therefore, one’s self), there has been increased understanding that denying the importance of ethnicity may create just as many problems. Although many argue that much of the discrimination and racism in American institutions and attitudes is directly related to socioeconomic status and not race (Wilson 1987), the example of Asian Americans cited above, as well as countless personal anecdotes among prominent African American and Latino/Hispanic professionals, tend to refute the notion that ethnicity has ceased to be a barrier to acceptance into the American mainstream. Nor is socioeconomic status always a buffer against the discrimination and racism often directed towards people of color by dominant society members.

Many are beginning to recognize that the practice of denigrating the cultures and achievements of people of color in American society is having a negative impact on their children. Spencer and Markstrom-Adams (1990) note that “throughout the nation over the last 200 years, the experiences of Hispanics, American Indians, and African Americans are consistent in one respect: The children of each group have been exposed to negative imagery and a nascent sense of invisibility in school materials. A recent review suggests the absence may have implications for schooling and that it is important for minorities to internalize and maintain traditional values for maximizing educability beginning at the preschool level for both cultural and language-different minorities” (pp. 299-3(0). It should be noted that the Asian American community also reacts strongly and experiences the feeling of invisibility in educational materials for their youngsters as well.

The recognition of this invisibility and exclusion has been growing since the failure of the integration thrust of the 1960s and has resulted in a shift in ethnic minority groups towards the importance of biculturalism rather than assimilation as the appropriate and crucial identity pattern for children of color. The notion of biculturalism suggests the ability to function effectively and successfully in the American mainstream and yet maintain positive and significant cultural connections to the ethnic community if that is desired (Pinderhughes 1989). Biculturalism also includes the teaching of cultural values and traditions that may often conflict with those of the dominant mainstream culture. Therefore, ethnic identity becomes a major complicating factor for adolescents of color who must add this dimension to all the other identity issues experienced during this period. However, the formation of a positive and supportive ethnic identity seems to be an important criteria for successful interactions with the dominant culture (Spencer and Markstrom Adams 1990). Harrison et al. (1990) found that a study of a national sample of African American three-generational families indicated that “the manner in which parents oriented their children toward racial barriers was a significant element in children’s motivation, achievement, and prospects for upward mobility. Parents of successful children emphasized ethnic pride, self-development, awareness of racial barriers, and egalitarian values” (p. 355).

Adopting the concept of biculturalism rather than assimilation has led to cries of a return to “separate but equal” practices among white Americans and even some members of ethnic minority populations. They believe that the focus on cultural and ethnic differences reinforces and encourages segregation and separation. Given all of the civil rights activities dedicated to removal of Jim Crow laws and other separatist policies, especially in the South, the movement towards biculturalism on the part of people of color seems regressive and alarming. In a recent paper, Hanley (1991) explored the impact of the civil rights movement on the South and suggests that culturally competent programs have not developed as quickly there as in other regions of the country because the primary role of civil rights in the South was to achieve a state of “cultural blindness.”

Often, those choosing to dissent from the concept of cultural competence cannot accept that the melting pot ideology has failed; color-blindness only leads to services and practices that do not address the real structural barriers and value differences that ethnic minorities encounter in American institutions. Such approaches lead to major frustration, disappointments, and anger for many children of color. Biculturalism and/or immersion in positive cultural values tend to produce children and adolescents of color that have higher self-esteem levels and greater confidence and competence (Gibbs and Huang 1989; Spencer and Markstrom-Adams 1990). It also serves to decrease the marginality and schizoid living style that often accompanies people of color as they become upwardly mobile in American society (Isaacs 1984).

Biculturalism also suggests that the goal of American society should be pluralism and multiculturalism, rather than Anglo-dominance disguised as the colorblind melting pot. The bicultural nature of the American experience for ethnic groups of color is constantly reinforced by external factors to which they are subjected— discrimination, racism, and powerlessness. In fact, through his review of the literature on assimilation, Menchaca (1989) observes that it is the very “practice of social segregation which has contributed to the maintenance and persistence of an ethnic identity among racial minorities” (p. 210).

Often, the cultural values and orientation of the ethnic group are different from those of the American mainstream society. As can be seen in the table below, Elizabeth Randall-David (1989) identifies some of the differences in cultural values and orientations between Anglo-Americans and other ethnic/cultural groups. These differences suggest that children of color have to undergo a more complex socialization process than Euro-American children. To deny the additional processes that must occur, through a color-blind approach to services and interventions, inflicts real injustice and harm in understanding both the psychological makeup and functioning of children and families of color.

Critical Aspects of Cultural Competence

In order to truly head programs and policies towards cultural competence, there are some critical factors that should always be kept in mind. These include:

• All of us, both Euro Americans and members of ethnic minority groups, are ethnocentric. That means that we usually value our own group above all others. The concept of cultural competence applies not just to Euro Americans but to all of us who have been born, educated, and live on American soil. Very few things in the American institutional structure have prepared us to live harmoniously in a pluralistic and multicultural society. Therefore, every one of us needs to learn and practice from a culturally competent perspective.
  
  
• It is not necessary or possible to learn all about the numerous cultural groups and customs in this country. To try to do so often leaves one overwhelmed. Rather, the important thing in bringing about a true shift in attitudes and behavior is to accept one’s own ethnicity and another’s without judgment. In other words, the key attribute to learn is non-judgmental tolerance based on the recognition that we all operate from an ethnocentric perspective.
  
  
• It is imperative to recognize the importance and acceptability of culture as a viable concept for ethnic groups since, in our society, ethnic cultures are often confused with the culture of poverty or other socioeconomic conditions. We must rid ourselves of the common belief that many ethnic minority groups do not have cultures that are worth respecting or that the major culture of these groups is a “culture of poverty” (e.g., African Americans) or a “culture of alcoholism” (e.g., Native Americans). We must accept that there are viable cultures within ethnic groups that have allowed them to survive and grow in the midst of alien and often hostile environments. Cultures of “alcoholism or poverty” are not the African American or Native American culture, but rather adaptations, for better or worse, that have come about in interactions with the dominant society. It is important, therefore, to accept, seek, understand, and utilize those cultural values and factors that have provided strength and sustenance to ethnic minority groups over time and incorporate them into treatment interventions and program designs.
  
  
• There is no one model or approach to cultural competence and knowledge development. Therefore, in our zealous attempts to become more sensitive to other cultures, we must avoid substituting one set of stereotypes for another (for example, the shift from viewing Asian Americans as the “yellow peril” to viewing them as the “model minority”). Any stereotype or overgeneralization, whether positive or negative, reflects cultural insensitivity.
  
  
• Cultural competence is a dynamic, developmental process and a state towards which we should strive, but it takes a long-term and consistent commitment to achieve. It is not something that comes to the individual, the agency, or the system through a one-shot, quick-fix approach. The process is ongoing and continuous.
  
  
• Cultural competence tends to evoke strong feelings and reactions. Although some of these reactions stem from the generalized response to any change, many are related to the historical interactions, hostilities, and fears that have often marked relationships between ethnic minority groups and the dominant society. In order to move towards cultural competence, there must be a willingness and courage to confront all the feelings and attitudes that cultural competence and change connote for the individual, the agency, and society in general. As Pinderhughes (1989) states: “... multicultural staff must be able to engage in dialogue about their differences in perceptions and experiences. Failure to provide the opportunity to understand and process these differences within a multicultural staff will lead to one of two outcomes both of which constitute unhealthy contextual conditions for empowering people: (1) staff will cover over the conflict in perceptions and orientation and block off the confusion, frustration, and strong feelings, causing an undercurrent of stress, tension, distrust, and suspicion. . . or (2) conflict will erupt and staff will become burned out and fatigued if they try to hammer out program and policy before they have an opportunity to understand cultural dynamics and the significance of cultural identity and meaning in relation to themselves, their clients, and their work together” (pp. 205-206). In other words, ongoing sharing, communication, and dialogue are essential. Opportunities for such sharing and dialogue must be built into the structure of the agency or organization seeking to become more culturally competent.
  
  
• The development of cultural awareness and cultural competence must be a distinct and separate activity and, at the same time, woven into every aspect of an agency’s or system’s operation. It must meet the paradox of being separate but integrated in order to be effective. When cultural diversity is simply integrated, it is observed that, like many American attempts at integration, it soon loses its relevancy and uniqueness and is quickly forgotten. Like the task facing most people of color, agencies must learn to be “bicultural”; that is, they must learn how to offer services that are relevant to the ethnic population that they serve and at the same time assist them in becoming more skillful and adept at handling the larger Euro American mainstream that controls and has power over the critical resources that determine success. The agency must incorporate ethnicity while at the same time providing the bridge to the rewards and benefits of the dominant culture. This is certainly no easy task.
  
  
• It should be acknowledged and recognized that cultural diversity and cultural competence require an understanding of the sociopolitical environment in which an agency operates. The goals and activities must take into account regional differences—the size of the ethnic minority population, the diversity of the ethnic minority population, and other factors that impact on the success of social change and movement.

In conclusion, the degree of cultural competence that agencies achieve is not dependent on any one factor. Attitudes, structures, policies, and practices are the major arenas wherein development can and must occur. Attitudes change to become less ethnocentric, patronizing, or biased. Policies change to become more flexible and culturally impartial. Practices become more congruent with the culture of the client, from initial contact through termination. Organizational structures support and enhance the growth of cultural competence. Cultural competence is based on valuing “differences” and the belief that it is all right to be different. Neither systems, agencies, nor professionals start out being culturally competent. Like other types of competencies, cultural competence is developed over time through training, experience, guidance, and self-evaluation.

Source: Towards a Culturally Competent System of Care, Vol. II
Georgetown University Child Development Center
Washington, D.C.

Selected Resources on Cultural Competence

The resources listed below are for consumers and families, mental health authorities, administrators, program leaders and practitioners. They may be useful for all stakeholders in mental health services.

National Resources for Consumers and Families

Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
National Mental Health Information Center
(800) 789-2497
http://mentalhealth.samhsa.gov/

First Nations Behavioral Health Confederacy
(406) 732-4240 Montana
(505) 275-3801 Albuquerque, NM
pauletterunningwolf@hotmail.com

National Alliance for the Mentally Ill
Colonial Place Three
2107 Wilson Blvd., Suite 300
Arlington, VA 22201-3042
1-800-950-NAMI (6264)
Fax: (703) 524-9094
TTY: (703) 516-7227
http://www.nami.org/

National Asian American Pacific Islander Mental Health Association
1215 19th St. Suite A
Denver, Colorado 80202
(303) 298-7910
Fax: (303) 298-8081
www.naapimha.org

National Institute of Mental Health (NIMH)
Office of Communications
6001 Executive Boulevard, Room 8184, MSC 9663
Bethesda, MD 20892-9663
(866) 615-NIMH (6464)
Fax: (301) 443-4279
TTY: (301) 443-8431
www.nimh.nih.gov

National Latino Behavioral Health Association
PO Box 387
506 Welch, Unit B
Berthoud, CO 80513
(970) 532-7210
Fax: (970) 532-7209
www.nlbha.org

National Leadership Council on African American Behavioral Health
6904 Tulane Drive
Austin, Texas
(512) 929-0142
Fax: (512) 471-9600
tkjohnson@mail.utexas.edu

National Mental Health Association
2001 N. Beauregard Street, 12th Floor
Alexandria, VA 22311
(800) 969-NMHA
Fax: (703) 684-5968
TDD: (800) 433-5959
www.nmha.org

Resources for Mental Health Authorities

Aponte, C., Mason, J. “A Demonstration Project of Cultural Competence Self-Assessment of 26 .Agencies” in M. Roizner, A Practical Guide for the Assessment of Cultural Competence in Children’s Mental Health Organizations (Boston: Judge Baker Children’s Center, 1996) 72–73.

California Mental Health Ethnic Services Managers with the Managed Care Committee. Cultural Competency Goals, Strategies and Standards for Minority Health Care to Ethnic Clients (Sacramento: California Mental Health Directors’ Association, 1995).

Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. Cultural Competence Standards in Managed Mental Health Care Services: Four Underserved/Underrepresented Racial/Ethnic Groups (2000).

This is the final report from four working groups: African americans, Asian Americans, and Pacific Islanders, Latinos, and Native Americans. It contains a series of standards for culturally competent mental health care and a plan for implementation. The report does not represent the official positions of the U.S. Department of Health and Human Services. A glossary is included. Information and recommendations are provided on the following:

• guiding principles
• overall system standards and implementation guidelines
• clinical standards and implementation guidelines
• provider competencies

Dillenberg, J., Carbone, C.P. Cultural Competency in the Administration and Delivery of Behavioral Health Services (Phoenix: Arizona Department of Health Services, 1995).

Knisley, M.B. Culturally Sensitive Language: Community Certification Standards (Columbus, OH: Ohio Department of Mental Health, 1990).

National Implementation Research Network. Consensus Statement on Evidence- Based Programs and Cultural Competence (Tampa, FL:Louis de la Parte Florida Mental Health Institute, 2003).

New York State Office of Mental Health. Cultural Competence Performance Measures for Managed Behavioral Healthcare Programs (Albany, NY: New York State Office of Mental Health, 1998).

New York State Office of Mental Health. Final Report: Cultural and Linguistic Competency Standards (Albany, NY: New York State Office of Mental Health, 1998).

Pettigrew, G.M. Plan for Culturally Competent Specialty Mental Health Services (Sacramento, CA: California Mental health Planning Council, 1997).

Phillips, D., Leff, H.S., Kaniasty, E., Carter, M., Paret, M., Conley, T., Sharma, M.P.Culture, Race and Ethnicity (C/R/E) in Performance Measurement: A Compendium of Resources; Version 1. (Cambridge, MA: Evaluation Center@HSRI, Human Services Research Institute, 1999).

Siegel, C., Davis-Chambers, E., Haugland, G., Bank, R., Aponte, C., McCombs, H. “Performance Measures of Cultural Competency in Mental Health Organizations.”Administration and Policy in Mental Health 28(2000): 91–106.

U.S. Department of Health and Human Services. Consumer Mental Health Report Card. Final Report: Task Force on a Consumer-Oriented Mental Health Report Card (Rockville, MD: Substance Abuse and Mental Health Services Administration, 1996).

U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General (Washington, DC: U.S. Department of Health and Human Services, 1999).

Western Interstate Commission for Higher Education (WICHE) Mental Health Program and the Evaluation Center@HSRI (Human Services Research Institute). Notes from a Roundtable on Conceptualizing and Measuring Cultural Competence (WICHE, Mental Health Program and the Evaluation Center at Human Services Research Institute, 1999).

WICHE. Cultural Competence Standards in Managed Mental Health Care for Four Underserved/ Underrepresented Racial/Ethnic Groups (Boulder, CO: WICHE Publications, 1997).

Resources for Mental Health Administrators

Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
5600 Fishers Lane
Rockville, MD 20857
301-443-7790

Lopez, L., Jackson, V.H. “Cultural Competency in Managed Behavioral Healthcare: An Overview” in V.H. Jackson, L. Lopez (Eds) Cultural Competency in Managed Behavioral Healthcare (Providence, RI: Manisses Communications Group, Inc., 1999).

National Alliance of Multi-ethnic Behavioral Health Associations
Howard University, School of Social Work
601 Howard Place N.W.
Washington, DC 20059
202-806-4727
misaacs@howard.edu
www.nambha.org

National Center for Cultural Competence
Georgetown University Center for Child and Human Development
3307 M Street, NW
Suite 401
Washington, D.C. 20007
Tel: 202.687.5387 TTY 202/687-5503
cultural@georgetown.edu
http://gucdc.georgetown.edu/nccc/

The Evaluation Center@HSRI
2336 Massachusetts Avenue
Cambridge, MA 02140
617-876-0426
www.tecenter@hsri.org

Western Interstate Commission for Higher Education (WICHE)
Mental Health Program
P.O. Box 9752
Boulder, CO 80301-9752

Resources for Program Leaders

Barrio, C. “The Cultural Relevance of Community Support Programs.” Psychiatric Services 51 (2000): 879–874.

Issacs, M.R., Benjamin, M.P. Toward a Culturally Competent System of Care: Programs Which Utilize Culturally Competent Principles (Washington, DC: Georgetown University Child Development Center, 1991).

Leong, F. “Delivering and Evaluating Mental Health Services for Asian Americans.” in Report of the Roundtable on Multicultural Issues in Mental Health Services Evaluation (Tucson, AZ: The Evaluation Center, Human Services Research Institute, 1998).

Musser-Granski, J., Carrillo, D.F. “The Use of Bilingual, Bicultural Paraprofessionals in Mental Health Services: Issues for Hiring, Training, and Supervision” Community Mental Health Journal 33 (1997): 51–60.

National Institute of Mental Health (NIMH) www.nimh.gov

Phillips, D. et al. Culture, Race and Ethnicity (C/R/E) in Performance Measurement: A Compendium of Resources; Version 1 (Cambridge, MA: Evaluation Center, Human Services Research Institute, 1999).

Organizational names, contact names, websites, e-mail addresses and mailing addresses are included. This publication has extensive lists of resources, standards, and selected readings. Information is provided on such topics as: training, language, service satisfaction and dissatisfaction, stakeholder involvement, social environments, community outreach, service planning, access and delivery, recruitment and retention, data collection and analysis, assessment, impact of practitioner identity, indigenous practitioners/services, attitudes, needs assessment, and additional readings on translated versions of instruments. Readings are included on African Americans, Hispanics/Latinos, Native Americans, and Asian Americans and Pacific Islanders. The compendium contains the following sections for diverse cultural, racial and ethnic groups:

• standards for behavioral health competence
• behavioral health disorder prevalence and service utilization
• measures of identity
• behavioral health diagnostic, assessment and outcomes measures
• instruments to assess behavioral health service competence

Ponterotto, J.G., Alexander, C.M. “Assessing the Multicultural Competence of Counselors and Clinicians” in L.A.

Suzuki, P.J. Meller, J.G. Ponterotto (Eds.) Handbook of Multicultural Assessment: Clinical, Psychological, and Educational Applications (San Francisco: Jossey- Bass, 1996) 651–672.

Tirado, M.D. Tools for Monitoring Cultural Competence in Health Care (San Francisco: Latino Coalition for a Healthy California, 1996).

U.S. Surgeon General. Mental Health: A Report of the Surgeon General (Washington, DC: U.S. Department of Health and Human Services, 1999).

U.S. Surgeon General. Mental Health: Culture, Race, and Ethnicity. A Supplement to Mental Health: A Report of the Surgeon General (Washington, DC: U.S. Department of Health and Human Services, 2001).

Instruments for Program Leaders to Assess Cultural Competence

Cross-Cultural Counseling Inventory (CCCI). LaFromboise, Coleman, and Hernandez (1991).

• Observer rates 20 items.
• Measures counseling effectiveness.

Multicultural Counseling Awareness Scale (MCAS). Ponterotto, Reiger, Barrett, and Sparks (1994).

• Self-report of 45 items.
• Assesses cultural awareness, knowledge and skills.

Multicultural Counseling Inventory (MCI). Sodowski, Taffe, Gutkin, and Wise (1994).

• Self-report of 43 items.
• Assesses awareness, knowledge, skills, and relations.

Resources for Practitioners

Aguirre-Molina M., Molina C.W., Zambrana R.E. (Eds.) Health Issues in the Latino Community (San Francisco, CA: John Wiley & Sons, Inc., 2001).

Alvidrez, J. “Ethnic Variations in Mental Health Attitudes and Service Among Low Income African American, Latina, and European American Young Women.” Community Mental Health Journal 35 (1999): 515–530.

American Medical Association, Council on Scienti. c Affairs, Ad Hoc Committee on Health Literacy. Health Literacy: Report of the Council on Scientific Affairs (JAMA, Dec. 6, 1995): 1677– 1682.

Aranda, M.P. “Culture Friendly Services for Latino Elders.” Generations 14 (1990): 55–57.

Atkinson, D., Morten, G., Sue, D. Counseling American Minorities (Dubuque, IA: Wm. C. Brown, 1983).

Atkinson, D.R., Gim, R.H. “Asian-American Cultural Identity and Attitudes towards Mental Health Services” Journal of Counseling Psychology 36 (1989): 209–213.

Baldwin, J.A., Bell, Y. “The African Self-Consciousness Scale: An Afrocentric Personality Questionnaire” The Western Journal of Black Studies 9 (1985): 61– 68.

Bauer, H., Rodriguez, M.A., Quiroga, S., Szkupinkski, S., Flores-Ortiz, Y.G. “Barriers to Health Care for Abused Latina and Asian Immigrants” Journal of Health Care for the Poor and Underserved 11 (2000): 33–44.

Belgrave, F.Z. Psychosocial Aspects of Chronic Illness and Disability Among African Americans (Westport, CT: Auburn House /Greenwood Publishing Group, Inc., 1998).

Berkanovic, E. “The Effect of Inadequate Language Translation on Hispanics’ Responses to Health Surveys” American Journal of Public Health 70 (1980): 1273–1276.

Bichsel, R.J. “Native American Clients’ Preferences in Choosing Counselors” Dissertation Abstracts International: Section B: Science and Engineering 58 (1998): 3916.

Branch C. Fraser, I. “Can Cultural Competency Reduce Racial and Ethnic Health Disparities? A Review and Conceptual Model” Med Care Res Rev Suppl 1 (2000): 181–217.

Browne, C.T. “An Anguished Relationship: The White Institutionalized Client and the Non-White Paraprofessional Worker” Journal of Gerontological Social Work Special Issue: Ethnicity and Gerontological Social Work 9 (1986): 3–12.

Bull Bear, M. Flaherty, M.J. The Continuing Journey of Native American People with Serious Mental Illness: Building Hop (Boulder, CO: WICHE, 1997).

Carter, R.T., Qureshi, A. “A Typology of Philosophical Assumptions in Multicultural Counseling and Training” in J.G. Ponterotto, J.M. Casas, C.M. Alexander (Eds.) Handbook of Multicultural Counseling (Thousand Oaks, CA: Sage Publications, 1995) 239–262.

Center for Substance Abuse Treatment. Cultural Issues in Substance Abuse Treatment (Rockville, MD: CSAT, SAMHSA, 1999).

Chinese Culture Connection Chinese Values and the Search for Culture-Free Dimensions of Culture. Journal of Cross-Cultural Psychology 8 (1987): 143– 164.

Cross, T.L., Bazron, B.J., Dennis, K.W., Issacs, M.R. Toward a Culturally Competent System of Care. (Washington, DC: Georgetown University Child Development Center, 1989).

Cuellar, I., Harris, C., Jasso, R. “An Acculturation Scale for Mexican-American Normal and Clinical Populations” Hispanic Journal of Behavioral Sciences 2 (1980):199–217.

Dana, R.H. Understanding Cultural Identity in Intervention and Assessment (Thousand Oaks, CA: Sage Publication, Inc., 1998).

Davies, J., McCrae, B.P., Frank, J., Dochnahl, A., Pickering, T., Harrison, B., Dembo, R., Ikle, D.N., Ciarlo, J.A. “The Influence of Client-Clinician Demographic Match on Client Treatment Outcomes” Journal of Psychiatric Treatment and Evaluation 5 (1983): 45–53.

Diagnostic and Statistical Manual of Mental Disorders-IV. DSM-IV. Appendix I: Outline for Cultural Formulation and Glossary of Culture-Bound Syndromes (Washington, DC: American Psychiatric Association, 1994).

Feliz-Ortiz, M., Newcomb, M.D., Meyers, H. “A Multidimensional Measure of Cultural Identity for Latino and Latina Adolescents” Hispanic Journal of Behavioral Sciences, 16 (1994): 99-115.

Gallimore, R. “Accommodating Cultural Differences and Commonalities in Research and Practice” in Report of the Roundtable on Multicultural Issues in Mental Health Services Evaluation (Cambridge, Mass: The Evaluation Center, Human Services Research Institute, 1998).

Gaw, A.C. (Ed.) Culture, Ethnicity, and Mental Illness (American Psychiatric Press, Washington, DC, 1993).

Gaw, A.C. (Ed.) Concise Guide to Cross-Cultural Psychiatry (American Psychiatric Press, Washington, DC, 2001).

Gilvarry, C.M., Walsh, E., Samele, C., Hutchinson, G., Mallett, R., Rabe-Hesketh, S., Fahy, T., van Os, J., Murray, R.M. “Life Events, Ethnicity and Perceptions of Discrimination in Patients with Mental Illness” Social Psychiatry and Psychiatric Epidemiology 34 (1999): 600–608.

Gopaul-McNicol, S.A., Brice-Baker, J. Cross-Cultural Practice: Assessment, Treatment and Training. (New York, NY: John Wiley & Sons, Inc., 1998).

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Lefley, H. Culture and Chronic Illness. Hospital and Community Psychiatry 41 (1990): 277–286.

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Lin, T., Lin, M. “Service Delivery Issues in Asian-North American Communities” American Journal of Psychiatry 135 (1978): 454–456.

Lopez, S. “Cultural Competence in Psychotherapy: A Guide for Clinicians and Their Supervisors” in C.E. Watkins, Jr. (Ed.) Handbook of Psychotherapy Supervision (New York: John Wiley & Sons, Inc., 1997): 570–588.

Marin, G., Sabogal, F., Van Oss Marin, B., Otero-Sabogl, R., Perez-Stable, E. “Development of a Short Acculturation Scale for Hispanics” Hispanic Journal of Behavioral Sciences 9 (1987): 183–205.

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Saldana, D.H. “Acculturative Stress: Minority Status and Distress” Hispanic Journal of Behavioral Sciences 16 (1994): 116–128.

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Sandhu, D.S., Portes, P.R., McPhee, S.A. “Assessing Cultural Adaptation: Psychometric Properties of the Cultural Adaptation Pain Scale” Journal of Multicultural Counseling and Development 24 (1996): 15–25.

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Sue, D.W., Carter, R.T., Casas, J.M., Fouad, N.A., Ivey, A.E., Jensen, M., LaFromboise, T., Manese, J.E., Ponterotto, J.G., Vazquez-Nutall, E. Multicultural Counseling Competencies: Individual and Organizational Development (Thousand Oaks, CA: Sage Publications, Inc., 1998).

Suinn, R.M., Richard-Figueroa, K., Lew, S., Vigil, P. “The Suinn-Lew Asian Self- Identity Acculturation Scale: An Initial Report” Educational and Psychological Assessment 47 (1987): 401–407.

Trevino, F.M. “Standardized Terminology for Hispanic Populations” American Journal of Public Health 77 (1986): 69–72.

Thompson, V.L. “The Multidimensional Structure of Racial Identification” Journal of Research in Personality 29 (1995): 208–222.

Tseng, W.S. (Ed.) Handbook of Cultural Psychiatry (San Diego, CA: Academic Press, 2001).

Tseng, W.S., Seltzer J.S. (Eds.) Culture and Psychotherapy (Washington, DC: American Psychiatric Press, 2001).

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Vega, W.A., Rumbaut, R.G. “Ethnic Minorities and Mental Health” Annual Review of Sociology 17 (1991): 351–383.

Yeh, M., Eastman, K., Cheung, M.K. “Children and Adolescents in Community Health Centers: Does the Ethnicity or the Language of the Therapist Matter?” Journal of Community Psychology 22 (1994): 153–163.

Scales for Practitioners to Recognize Cultural Identity

Acculturation/Cultural Identity Scales

Acculturation Rating Scale for Mexican-Americans (ARSMA)
Cuellar, I., Harris, C., Jasso, R. “An Acculturation Scale for Mexican-American Normal and Clinical Populations” Hispanic Journal of Behavioral Sciences 2 (1980): 199–217.

Multidimensional Measure of Cultural Identity for Latino and Latina Adolescents
Feliz-Ortiz, M., Newcomb, M.D., Meyers, H. “A Multidimensional Measure of Cultural Identity for Latino and Latina Adolescents” Hispanic Journal of Behavioral Sciences 16 (1994): 99–115.

Short Acculturation Scale for Hispanics (SASH)
Marin, G., Sabogal, F., Van Oss Marin, B., Otero-Sabogl, R., Perez-Stable, E. “Devel opment of a Short Acculturation Scale for Hispanics” Hispanic Journal of Behavioral Sciences 9 (1987): 183–205.

Suinn-Lew Asian Self-Identity Acculturation Scale (SL-ASIA)
Suinn, R.M., Richard-Figueroa, K., Lew, S., Vigil, P. “The Suinn-Lew Asian Self- Identity Acculturation Scale: An Initial Report” Educational and Psychological Assessment 47 (1987): 401–407.

Group Identification/Cultural Identity Scales

African Self-Consciousness Scale
Baldwin, J.A., Bell, Y. “The African Self-Consciousness Scale: An Afrocentric Personality Questionnaire” The Western Journal of Black Studies 9 (1985): 61–68.

Black Racial Identity Attitude Scale-Form B (BRIAS-Form B)
Helms, J.E. (Ed.). Black and White Racial Identity: Theory, Research, and Practice (New York: Greenwood Press, 1990).

Multidimensional Racial Identity Scale (MRIS)-Revised
Thompson, V.L. “The Multidimensional Structure of Racial Identification” Journal of Research in Personality 29 (1995): 208–222.

Multigroup Ethnic Identity Measure (MEIM)
Phinney, J. “The Multigroup Ethnic Identity Measure: A New Scale For Use with Adolescents And Young Adults From Diverse Groups” Journal of Adolescent Research 7 (1992): 156–176.

White Racial Identity Attitude Scale (WRIAS)
Helms, J.E. and Carter, R.T. “Development of the White Racial Identity Inventory” in J.E. Helms (Ed.) Black and White Racial Identity: Theory, Research, and Practice (New York: Greenwood Press, 1990) 67–80.

Value Orientation Scales

Chinese Values Survey
Chinese Culture Connection. “Chinese Values and the Search for Culture-free Dimensions of Culture” Journal of Cross-Cultural Psychology 8 (1987): 143–164.

Cultural Adaptation Pain Scale (CAPS)
Sandhu, D.S., Portes, P.R., McPhee, S.A. “Assessing Cultural Adaptation: Psychometric Properties of the Cultural Adaptation Pain Scale” Journal of Multicultural Counseling and Development 24 (1996): 15–25.

Cultural Information Scale (CIS)
Saldana, D.H. “Acculturative Stress: Minority Status and Distress” Hispanic Journal of Behavioral Sciences 16 (1994): 116–128.