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Systems, agencies, or professionals do not start out being culturally competent. Like other types of competence, cultural competence is developed over time through training, experience, guidance, and self-evaluation. As stated earlier, attitudes, policy, and practice must all come together in a congruent whole called cultural competence. Attitudes can be cultivated through training, modeling, and experience. Policy evolves through research, goal setting, and advocacy. Practice grows with information, training, and the development of new alternatives. Change occurs in a complex interplay between practice and policy set in the context of politics and the culture of the system. This section is designed to address the question of how a culturally competent system of care might be developed. The “system” and its component parts have evolved over the last decade. The area of cultural competence has been no exception. The material that follows is a discussion of some concrete actions which some agencies have found useful in improving their services to minority clients. No one of the actions makes an agency culturally competent. Rather, the more an agency develops an aggregate of these and other similar actions, the further that agency moves toward the positive end of the continuum.
Movement toward the positive end of the continuum is necessary at every level of the system or agency. The policymaking, administrative, practice, and even the consumer levels are each arenas for growth. This section has been organized around each of these levels.
The policy makers or planners of services may be board members of private agencies, public agency officials, legislators, and commissioners, or advisory committee members. Anyone who has a role in the shaping of policy might be included. A number of actions at this level are possible. First and foremost is community involvement (Angrosino, 1978; Flaskerud, 1986b; Brown, E.F., 1977; Ryan, 1980; Lutz, 1980; Owan, 1982; Wilkinson, 1980; Gallegos, 1982; McDiarmid, 1983; Higginbotham, 1984; VanDenBerg and Minton, 1987). Minority community persons can be recruited and asked to serve on boards, advisory committees, and commissions that already exist in the agency or system. Special task forces or advisory groups can be created using the representatives of minority communities to study and address issues of that particular community. In addition, an agency might create an evaluation committee and submit its cross-cultural performance to minority community review. However the agency or system chooses to do so, minority community involvement is critical to the development of policy that is responsive to the needs of the community. To achieve this level of community involvement, the policymaker will need to establish linkages with existing minority networks.
Policy makers can set standards for cross-cultural services. An agency board may develop standards it expects its employees to follow. Standard-setting bodies can incorporate cultural competence into existing standards for services delivered by member agencies. States having licensing standards for mental health professionals might add cultural competence to the required skills of the profession. Training institutions also are subject to standards and have already benefited from this approach. Whatever the level, it is essential to determine what the standard should be through self-assessment and community input
Training policies that sanction, and in some cases require, participation in training that builds cultural knowledge and skills, can enhance cultural competence. Planners must also commit the resources to implement such policies and consult their cultural advisors on the necessary content (Cameron and Talavera, 1976; Zane, Sue, Castro, and George, 1982). It is not enough to require employees to get such training. The governing body must educate itself to the dynamics of difference, and develop some cultural knowledge in order to make decisions and take actions that are not ethnocentric. Training for board members on cultural competence can help avoid failures which inhibit further development and misguided efforts to rescue minority children.
Policy makers often use research findings to guide their decision making. Policy can be implemented that ensures data are kept on minority populations, that research is monitored (First, Roth, and Arewa, 1988; Ryan, 1980; Manson and Shore, 1981; Owan, 1982; Rueda, 1984; Taylor, 1979; Meinhardt and Vega, 1987) to avoid cultural bias or intrusion, and that minority researchers and research techniques are employed.
A decision-making structure in a system or agency that is flexible and empowers less powerful segments of the community contributes to the minority voice being heard. Agencies can adopt policies that allow minority participation in decision making (Angrosino, 1978; Flaskerud, 1986b; Brown, E.F., 1977; Ryan, 1980; Lutz, 1980; Wilkinson, 1980; Owan, 1982; Gallegos, 1982; McDiarmid, 1983; Higginbotham, 1984; VanDenBerg and Minton, 1987).
At the legislative level, policy can be both integrated into existing laws and be formulated into new laws. Legislators can be careful to evaluate legislation for methods of improving services for everyone, while enhancing services for minority children. Again, community input is essential.
Funding mechanisms and funding paths can be adapted to improve service access for minority children. For example, through the use of contracting, public agencies can put dollars into the hands of minority service providers who might not otherwise be able to respond to community need. Public services can often be delivered more cost effectively by community-based agencies.
Funding can be used as an incentive for developing cultural competence. Policies encouraging the improvement of services to minority children have clout when they are attached to funding. Funding agencies, such as the United Way and federal, state, and local governments, all have the capacity to greatly influence the development of cultural competence through placing service requirements on recipients of the funds. Funding sources are increasingly using these means as an incentive for agency cultural competence development
Progress at the policy level might be in the form of a written mission statement (Campfens, 1981; Comer and Hill, 1985; Spurlock, 1986; Hawkins and Salisbury, 1983) and a comprehensive plan to develop culturally competent services. Actions such as incorporating cultural competence development into an agency’s five year plan can help the policy maker break the process into manageable parts with reasonable timelines. As each policy of the agency is examined or revised, it is studied for its impact on service delivery to the minority population. Positive changes are incorporated systematically and cultural competence becomes institutionalized into the structure of the agency itself. In this way cultural competence does not become an “add on” but rather an integral part of the operation.
An agency may also enter into concrete actions such as resource development and program fostering. This means the agency actively works in conjunction with minority community members to enable the creation and healthy growth of a service. Established agencies can assist in the startup and nurturance of new minority programs and then spin them off to full community self-control (Cohen, 1984; VanDenBerg and Minton, 1987). Such agencies use their power and influence to empower the minority community to improve service delivery on its own behalf. None of these ideas are new concepts. Most have been tried or are in use to varying degrees across the country. They are not the only possibilities. What is new is the idea that as these actions come together in an agency’s policymaking body, the agency becomes more competent to make policy for services to minority populations.
The administrative level of service delivery is made up of agency directors, managers, department heads, and a variety of other people in both public and private organizations. This level interprets and implements policy in addition to creating it. Responsible for most aspects of the agency or public department, this level has many opportunities to move the organization toward cultural competence. It is at the administrative level that the commitment to a culturally competent system of care must be embraced. By accepting this commitment and communicating this to staff in organizational goals and objectives, the administrative level provides credence and direction for the development of cultural competence. The suggestions listed below may be more suited to either the public or private setting but could be adapted to either.
The administrator’s primary role is to set the context for the development of cultural competence. Essential to this process is some form of agency self-assessment. Such a self-assessment might be formal or informal but includes several basic elements. Agencies need to determine the demographic make-up of their service area and define the client population. A comparison of actual client population and community demographics gives some indication about directions for planning. Administrators will want to know if their staff and governing board are representative of the population to be served. Is the agency accessible to all segments of the community physically and culturally? Is the philosophical orientation of the agency compatible with the belief system of the community to be served? For example, an agency may be family centered or individually focused. Are the intake procedures compatible with the needs of the cultural groups to be served? For example, some groups may distrust or avoid written forms which some agencies require to be filled out prior to service delivery. The self-assessment should address whether the agency has the capacity to adapt its services to meet the needs of the minority client population.
Agencies can ensure that minority people are recruited and retained on the staff. Supporting minority students in institutions of higher learning is one means of recruitment which answers the agency’s need for minority staff, but at the same time empowers the minority individual. Agencies can also change hiring practices to ensure that non-minority staff are culturally competent or willing to become so. By including questions in the interviewing process about cultural differences and by requiring work experience with minority populations, agencies can screen potential employees for cultural knowledge and attitudes. When developing job descriptions, administrators can include cultural competence as a qualification for the position. Such qualifications might include being able to communicate with the client in their native language or dialect, awareness of cultural values and beliefs, the ability to use natural helpers from the community, a willingness to be flexible, and willingness to spend time in the minority community and examine one’s own cultural biases. When hiring minority staff, academic training is important, but should not be the only criteria for judging the capacity to deliver competent services. Agencies can develop criteria in which community recognition of a person as an effective helper can be considered in the hiring process or paraprofessional positions can be established to effectively utilize the uncredentialed.
Most agencies that provide training on minority issues/concerns or on cultural competence concentrate on developing cultural knowledge. Training should also focus on the function of culture in a person’s life, the dynamics of difference, and how to adapt skills to fit the client’s needs. Community “experts” who may not be credentialed, but have the respect of the community, are excellent training resources. Training should occur in both workshop settings and on-site in the community. Orientation to the minority client’s community should be mandatory. Such a process would include orientation to both formal and informal community resources, to information about the history of the minority group or groups served, and to predominant cultural variables of the client population. Training needs to be recurrent and comprehensive. Both the staff and community should participate in the selection of content. Rewards can be built into the system for those who obtain additional training. Some agencies may want to focus their training on workers designated within the agency as cultural resource persons.
Personnel policies can also be adapted to make an agency more culturally competent. Non-discriminatory policies can also be culturally sensitive. For example, leave time can be adjusted to accommodate cultural differences in holidays or an important community or family event. Career advancement opportunities can be built into the system as well as incentives and opportunities for minority paraprofessional staff to become credentialed. Staff evaluations may be used to enhance an agency’s cultural competence. Evaluations can include sections that rate an employee’s responsiveness to the unique needs of clients of various cultures. Agencies can require mandatory continuing education aimed at improving cross-cultural skills.
Program evaluations can specifically target minority clients to determine their perceptions of the agency’s effectiveness. Both the internal and external review of efforts to develop cultural competence will help an agency modify or change program goals as necessary.
The accessibility of services to minority communities can be improved through geographically locating services within the relevant communities (Owan, 1982; Flaskerud, 1986b). Such community-based services must be located in a place people frequent or recognize as a helping facility (e.g., schools, churches, temples, recreation centers, storefronts, and their own homes). Services should be available in some agencies on a 24-hour basis. Clients should feel secure that they will not be rejected or punitively discharged because of their minority status. Staff should be able to provide collateral as well as direct services (Flaskerud, 1986b; Brown, P.A., 1978; First, Roth, and Arewa, 1988; Comer and Hill, 1985; Edwards and Edwards, 1980; Lewis and Ho, 1975; Gallegos, 1982; Kurtz and Powell, 1987). Services should also be designed in such a way as to enable workers to help clients negotiate the service system. Practice should include attention to basic human needs as well as intrapsychic processes. The family must be included in the treatment process. Agencies must be flexible in their definition of “family” and work with family systems as defined by the culture of the client.
Administrative staff also have the capacity to adapt physical facilities to be more inviting to minority clients. The environment should be comfortable and acceptable to a variety of cultures. Art work may be displayed within the facility to reflect the culture or cultures of the community. Agencies may want to consider locating facilities in settings that are non-threatening and not usually or exclusively associated with mental health services. Reception services are particularly important and, as such, staff assigned to these services need careful screening for cultural sensitivity. When a specific culture makes up a identifiable segment of the client population, an agency may set aside a room in which the decor is specific to that culture. Clients and community members should participate in the process to ensure the appreciation of cultural artifacts. Such actions help minority clients feel that their culture is valued and respected.
Administrators can ensure that data regarding services to minority clients are collected and used in planning .and evaluating the agency’s activities. That data should be made available to the community in the form of special or annual reports.
Administrative staff also have the capacity to develop new approaches or adjust existing ones. Efforts to make services fit the client rather than the client fit the service are useful (Flaskerud, 1986b; Campfens, 1981; Flaskerud, 1988; Owan, 1982; Hendricks, 1987; Tolmach, 1985; Kumabe, Nishida, and Hepworth, 1985). Programs such as home-based models identify the needs of the family and then seek to meet those needs. The agency should be able to respond to the needs of the family as the family perceives them. Flexibility and the capacity to outreach and link to informal systems are essential. Because of the existing differential application of services, agencies may want to design program components that capture minority children entering the juvenile justice or other service systems at an earlier point. Agencies should address alcohol and drug abuse or other issues threatening to the community. Another possible service adaptation is the incorporation of client advocacy into practice. Often the minority client’s basic needs must be addressed before psychotherapeutic services can be effective. Finally, agency administrators can find ways to make use of the natural networks of the minority community. Through written agreements, systematic communication. and sustained formal and informal contact, administrators can encourage agency access to natural helping networks in the community.
Administrators responsible for areas such as contracting or issuing requests for proposals can require that contractors or grantees meet certain cultural competence requirements. Using a self-assessment scale, such as the one developed by the Research and Training Center of Portland State University, administrators could determine the position of contractors and grantees on the cultural competence continuum. Where indicated, contractors or grantees would be required to specify the manner in which they would move to the next higher level(s) of the cultural competence continuum. Under a weighted rating system, positive points would be designated for approaching and achieving higher levels on the cultural competence continuum. Review procedures and contract monitoring may also incorporate cultural competence concepts. For example, staffing requirements can be designed requiring that staff be trained in culturally competent practice and be representative of the community served. Administrators also have a role in the development and implementation of licensing and recertification of licensees to perform certain functions within the system of care. Guidelines for incorporation of cultural competence can be institutionalized through the licensing process. Actions at this level provide strong financial incentives for change. They must, however, be coupled with guidelines and resources that enable programs to respond positively.
While actions at the administrative level alone cannot bring an agency to cultural competence, they are key elements. Administrative personnel set the tone for the practice staff and provide the structure for the continuing development of effective services. The activities described above have been implemented in various degrees. Moreover, the activities described are only illustrative of the possibilities. Thoughtful, creative thinking on the part of agency staff may produce additional ideas that further the development of the agency’s cultural competence.
Sound cross-cultural practice begins with a commitment from the worker to provide culturally competent services. To succeed, workers need an awareness and acceptance of cultural differences, an awareness of their own cultural values, an understanding of the “dynamics of difference” in the helping process, a basic knowledge about the client’s culture, knowledge of the client’s environment, and the ability to adapt practice skills to fit the client’s cultural context. Five essential elements for becoming a culturally competent helping professional are described below.
Each element described here builds a context for cross-culturally competent practice. The worker can adapt or adjust the helping approach to compensate for cultural differences. Styles of interviewing, who is included in “family” interventions, and treatment goals are but a few things that can be changed to meet cultural needs. When workers understand the impact of social and cultural oppression on mental health they can develop empowering interventions. For example, minority children repeatedly receive negative messages from the media about their respective cultural groups. Treatment can be provided that incorporates alternative, culturally enriching experiences and teaches the origins of stereotypes and prejudices. By writing such interventions into treatment plans, practitioners can begin to institutionalize cultural interventions as legitimate helping approaches.
Only as professionals examine their practice and articulate effective helping approaches will practice improve. Each worker will add to the knowledge base, through both positive and negative experiences, developing his or her expertise over time.
Wilson (1982) listed 24 attributes, knowledge areas, and skills that are essential to the development of cultural or ethnic competence:
Personal Attributes
Knowledge
The practitioner can gain these skills and this knowledge through training and experience. The personal attributes can be developed through exposure to the positive aspects of minority cultures. Further, workers can develop relationships within minority communities with both professionals and natural helpers who can help facilitate their learning. Information is a strong tool in the development of cultural competence, and practitioners will want to avail themselves of every opportunity to build their cultural knowledge. Such knowledge must, however, be coupled with a willingness to let clients and cultural groups detennine their own future.
Families, as service consumers, also have a role in the development of the cultural competence of the system. Families can become more effective advocates for their children when they gain the skills to articulate the importance of their culture. Families and the groups that represent them can become effective advocates by preparing themselves with information about how the dynamics of difference operate and how a bicultural existence affects the mental health of their children. Families can also be resources in the system’s training process. Families can accomplish this by talking about the natural networks and insisting that significant parts of their networks be included in the helping process for their children. For example, the family may ask that grandparents be involved in helping plan for a child’s needs.
Groups of minority parents can help open lines of communication and advocate for changes to better meet their needs if necessary. Parents can enlist the support of larger civil rights advocacy groups so that broader forces can be brought to bear in the effort to improve services to minority children with emotional disabilities. Families encountering insensitive services can turn to each other for aid in interfacing with the system. As consumers become aware of services that are responsive to cultural needs, they can provide encouragement to other minority families to use the system. Families linked with other families can provide mutual support and help define mental health from their own perspective.
To summarize, each level of the service delivery system has a role in contributing to the cultural competence of the agency or system. As various actions at different levels are implemented, the agency moves toward greater cultural competence. As the agency moves it will encounter new challenges. For example, an agency hiring minority professionals will encounter issues of cross-cultural supervision. Growth along the path is not inevitable, however, and an agency and the system of which it is a part must always be aware of the tendency for institutions to reflect the values and attitudes of the societal context in which they exist. Since this country is far from being culturally competent, the system of care will need to be especially diligent to move itself toward more effective services for minority populations.
The delivery of effective services cross-culturally requires that existing services be adapted to fit the needs of the targeted minority group or individual. The possible ways of adapting services are endless. Adaptation requires flexibility and creativity. Most service adaptations are not costly but should be approached thoughtfully and sensitively. Since there are great variations among the four minority groups considered here, it is essential to not create stereotypic responses. The service adaptations described in this section are intended to illustrate the application of the cultural competence philosophy. It is not being suggested that these are ways to serve all Blacks, all Asians, etc. Services should be adapted to fit the needs of the group and the individual client based on identity, degree of assimilation, and subcultural grouping. Including culture as a regular part of every case assessment or evaluation will help the worker determine the type of practice adaptations necessary. Community and professional minority consultation will help agencies know what types of structural, procedural, or policy adaptations to make. The system of care can work with grassroots, non-traditional agencies in a variety of ways. Many minority agencies have gotten their start with the aid and technical assistance of established agencies or publicly supported efforts. In this section, both policy and practice adaptations are examined.
Agencies, practitioners, and researchers have documented successes and failures in their attempts to combat institutional racism. Four models frequently appear: (a) mainstream agencies providing outreach services to minorities; (b) mainstream agencies supporting services by minorities within minority communities; (c) agencies providing bilingual/bicultural services; and (d) minority agencies providing services to minority people.
The outreach model is one frequently used by agencies beginning to recognize their need to improve services to minority clients. The outreach model consists of a special effort to reach a target client population. Minority groups or communities are seen to require the same services as do mainstream groups; services are perceived as "color-blind." This model does not acknowledge the oppression minority groups face, and may appear paternalistic, no matter how well intended. When an outreach program fails to take into account local minority cultural norms and values, it is likely to be rejected by community members (Angrosino, 1978).
The mainstream agency support of services by minorities within minority communities model is relatively new. This model has been adopted by federal, state, and local agencies that previously attempted to serve minorities with services not specific to their cultural needs. Agencies using this model appear to believe that minority populations or communities are best served by trained natural helpers with nominal supervision by agency professionals. The model seems to acknowledge that mainstream services are culturally inappropriate for minority people, and that mainstream services and workers may inadvertently perpetuate an oppression of minority people through institutional racism. The concept of noninterference is a base for this model. This model has met with success in Canada (Cohen, Y., 1984) and in three Alaskan Native villages (VanDenBerg and Minton, 1987).
Bilingual and bicultural services are advocated by Barrera (1978), Dana (1984), and Gallegos (1982). These researchers suggest that linguistic and cultural barriers are best overcome through multicultural staff who have more than one language. In this model it is assumed that cultural groups adapt or react to each other and that no one culture is likely to remain unchanged. Therefore staff who identify with, participate in, or are members of two or more cultures are likely to provide a maximum level of service. Services in this model may be less dominated by one culture and be more egalitarian than mainstream-supported services. Clients are more likely to respond to staff of the same or similar culture, and staff are more likely to appropriately identify and address client needs.
Minority agencies providing services to members of minority communities without mainstream agency sponsors are few in number. These agencies appear to be based on the belief that not only do minority groups know what services they need, but they can most appropriately meet their own needs without mainstream agency involvement. Such agencies focus upon minority groups that live in specific cultural communities (such as the Alaskan Native villages) or that have recently left such communities and intend to maintain their cultural support system structures. As there is no mainstream involvement, the agency may not be as racially oppressive or paternalistic as some previously mentioned models. One successful program is the Urban Indian Child Resource Center in Oakland, California. The Center established Indian foster homes, developed a system of “family representatives” who work as service coordinators with families newly from the reservations, and offers homemaker “surrogate grandmothers” who provide family support (Fields, 1976). McDiarmid (1983) studied the Chevak Village Youth Association in western Alaska—another example of this model—and found that it played a distinct role in prevention as youth developed their responsibility, sense of competency, and ability to locate and use resources.
Three of the four models described above base services on emphasizing cultural values and helping systems: mainstream-supported minority services within minority communities, bilingual/bicultural agencies, and minority agencies. These services seem to have a high rate of satisfaction (Cameron and Talavera, 1976; Charleston, 1987; Chestang, 1981; Fields, 1976; Gary, 1987a; Keefe, Padilla, and Carlos, 1979; Kenyatta, 1980; Lutz, 1980). By enhancing existing helping systems, cultural dissonance is reduced as mental and emotional health is increased. Many authors indicate the importance of local ownership of services in order to provide a maximum level of services for the highest level of satisfaction.
Assessing the type of services to provide to the minority populations of a particular area appears crucial to the reception and use of services by minority people. Similarly, minority communities seeking to meet their own needs or seeking an agency to provide services may benefit from an assessment process. Dana, Hornby, and Hoffman (1984) suggest an assessment of local norms. Angrosino (1978) suggests that assessing potential community responses may affect the type of services an agency might provide. Manson and Shore (1981) offer a research design to assess the need for service, types of service, and service delivery system.
Agencies striving for cultural competence should be willing to accept the values of the minority culture and to develop skills for working with the client population (Lutz, 1980). They should be aware of the leadership values of the minority culture (Lewis and Gingerich, 1980) and understand minority expectations of agencies (Gallegos, 1982).
In general, service adaptations should be designed so that the service fits the client in the context of the client’s culture. Individualizing of case planning is essential; however, the individual cannot be viewed in isolation. He or she is part of a family, community, and culture. A minority client’s unique needs are shaped by his or her culture. Helpers outside of the client's culture should avoid projecting their own culturally defined needs onto the client and his or her family. Natural helping systems, such as extended family, healers, and other helpers, must be considered as additional components of the system of care.
The concepts of unconditional care and least restrictive alternatives should be applied in service adaptations. Adaptations that provide the minority family with a range of care alternatives from least restrictive to most restrictive provide a continuum of care that is currently lacking for most children. Programs can strive to provide a normalizing experience for minority clients in which normal is defined by the culture of origin. Service adaptations should also be characterized by being community-based with strong outreach components. To the extent possible, services should be home-based and aimed at preserving families. Services must address the whole person within the context of community and culture. The following components, while not an exhaustive list, should be considered as part of service adaptations for minority children and families: crisis intervention, individual or group counseling, task- and training-oriented homemaker services, financial planning, maintenance assistance, 24-hour service availability, health and mental health service access, food assistance and nutritional consultation, diagnostic and assessment services, employment services, drug and alcohol services, and independent living preparation.
To compensate for situations in which large numbers of minority children enter the system through more restrictive environments, it is important to identify such situations early so as to intervene in ways that would divert as many of these children as possible into appropriate treatment environments. Stronger interagency collaboration and aggressive outreach are possible solutions. Approaches such as “in-home” services are useful in bringing various elements of the system together to preserve families. Such services must be designed by and for the community and culture in which they will be applied. Two other possible approaches are early intervention and prevention. To provide these services, programs need to develop the mechanisms to identify children. To prevent the loss of these children in the system and to insure that they are appropriately served, agencies might adopt policies such as zero reject/no punitive discharge. Such programming would place an emphasis on normalization and on maintaining intact families. "Family" would be defined by the person or persons receiving services. Important concepts in service adaptation for minority children include: flexibility of service systems, outreach, prevention and early identification, home-based services, and family and culturally centered case management
Coordination among agencies is essential and interagency collaboration should include natural helpers and community systems. Models of service that follow the child and are flexible enough to recognize the family as the identified client can encourage the provision of appropriate services.
Below are several examples of possible service adaptations for specific cultures. Examples have been divided into some representative service elements for the sake of illustration. It is not an exhaustive list. Possible service adaptations are endless and may be as varied as the cultures served.
The service adaptations involving intake and client identification include recommendations primarily directed at the administrative level. Many agencies use written forms to gather social or developmental history during the intake process. The client may be responsible for completing a form either with or without a worker’s help. Many people have learned to distrust that which is written (Lockart, 1981). Tens of thousands of Latinos, primarily in the Southwest, are undocumented (so called “aliens”). Many are very sensitive to filling out legal documents which they believe will ultimately serve as a means to deport them back to their country, and therefore the potential client will decline the service or complete the form inaccurately. They may feel uneasy about how information will be used, or not feel they can represent themselves well on a form. One service adaptation is to spend time with the client in polite social interaction prior to doing business. This helps establish person-to-person rapport that may be inhibited if the form comes first. If forms must be used, their use must be explained, including who reads them and why they are necessary. The worker should ask for the client’s permission to record information and share what has been written. Personal contact with the worker who will actually provide the service is also useful. People are often reluctant to share their troubles with others. They bring a historic distrust into the encounter; consequently, the fewer people to whom they have to reveal themselves, the better.
The system often relies on the referral process to identify the client population. This pattern has helped create the differential service provision that exists today. This is particularly a concern for Black youth. Because Black youth end up more often in the juvenile justice system rather than in the mental health system, they tend to get caught in a system that is not necessarily appropriate to their needs. Without special service adaptations there is no mechanism in the system to correct this problem. One possible adaptation is an outreach to juvenile justice, youth diversion, or other programs to identify Black youth who could be better served in mental health settings (Hawkins and Salisbury, 1983). Interagency collaboration models in which the service dollar follows the child might be effective in reducing differential treatment of minority youth.
One dilemma is how to get minority children who are emotionally disturbed into particular services. Methods of outreach and community education can be adapted for various communities. Programs reaching out to the Black community are most successful when they work through churches, social fraternities and sororities, community-controlled media, and community and civic leaders (Gary, 1987b). Reaching out to the Native American community requires a more personal approach using a door-to-door, neighbor and relatives network building process (Good Tracks, 1973). In the Hispanic community the process may call for the inclusion of natural helpers and clergy. The need for outreach is especially acute.
The Asian community presents a clear illustration of some of the issues to consider. Outreach in the Asian community may require a more formalized, faceto- face process of involving key community leaders, elders, clergy, and self-help associations (Gould, 1988; Sue and Morishima, 1982; Chin, 1982). Outreach to the Asian community is largely ignored because of the belief that the community takes care of its own. Recent research suggests that the low number of Asian people entering the mental health system is due more to culturally defined, help-seeking patterns rather than to a lack of need. (Sue and Morishima, 1982). Cultural attitudes about bringing shame to one’s family and formalized patterns regulating help seeking powerfully affect the utilization of mental health services and require that adaptations be made in the ways in which children in need of treatment get access to the system. Some ways that have been suggested include locating service sites within the community. This approach has been shown to dramatically increase utilization rates (Catell, 1962; Murase, 1977). The use of bilingual media to inform the community is seen as particularly important to educate the community about services and (for more recent immigrants) how the system works (Li, 1972; Munoz, 1980).
One way in which the system of care does not fit well with minority community needs is the prevailing practice of labeling the child as the “identified client.” In family and extended family-focused culture, this practice tends to restrict how services are provided and even how workers think about interventions. A possible alternative would be to identify the family as client. This would make the family the point of intervention and shape the services to fit their needs. Similarly, the means of financing services may be adapted to allow more flexibility in the system of care so that the family unit can be served across system boundaries without a loss of continuity.
Adaptations to assessment and treatment approaches are essential to improved services. The dynamics of difference can be most problematic at the assessment phase. The Latino child may have caretakers whom the child refers to as “Mom” and “Dad” who may not legally be guardians. Indian mothers may leave younger children in the care of older children (Dana, 1981; Padilla and Ruiz, 1973). In Black families a man may not be an “official” part of the household but is an integral part of the family system (Zollar, 1985; McAdoo, 1978). In some Asian communities, the primary caretaker for children can be someone other than the biological mother. In Latino and Indian groups, time concepts may be different and formal appointment times may be foreign concepts (Lewis, 1975). In minority communities in general, work hours, spiritual practices, or family obligations may conflict with mental health appointments. Each of these situations could be interpreted as weaknesses, resistance, or family dysfunction if the evaluator is not aware of the cultural behaviors of the client. Adaptations to the usual assessment process involve learning what is “normal” in the context of the client’s culture.
Psychological testing needs to be interpreted in the context of the client’s culture. For example, the Native American or Asian child may exhibit symbology in projective testing which is unique to his or her tribe or group and which should not be interpreted on the basis of norms established for the mainstream (Dana, Hornby, and Hoffman, 1984). Other forms of assessment must take precedence over the use of testing with most minority children. Interviewing and gathering collateral information from family and community resources is essential.
Asian Americans are often diagnosed and served incorrectly due to differences in the expression of emotional problems (Gould, 1988). Such problems are often somatized. Workers must be prepared to help the client address the concrete issue of the health problem before the emotional issues can be addressed (Tsui and Schultz, 1985).
For Black children the diagnostic label “conduct disorder” is overused. Practitioners must use this label carefully and learn the culturally different indicators for depression, attachment and loss issues, and attention deficit problems (Solomon, 1987; Gary, 1987a). More important, they must be aware of how such labels tend to channel Black children toward a criminal justice treatment path as opposed to a mental health path.
Persons evaluating minority children should be aware of the behaviors typical of the bicultural encounter. When a minority family or individual encounters a system or helper who is different than they are, they will exhibit some adjustment behavior to that situation. Such families are likely to be more reserved than usual as they look for cues on how to act in this new situation. They may be apprehensive and fearful that the service provider will judge them negatively or be prejudiced against their racial or cultural group. They may try to fit in as best they can or display a false bravado as a defense against a potentially hostile environment. If the evaluator judges the client on the basis of such behavior, the evaluator may well diagnose the client as resistant, passive, or undersocialized. Workers can adapt their expectations to accept adjustments to difference as a standard part of every cross-cultural encounter. These behaviors are, in fact, healthy survival skills (Chin, 1983).
Assessment can also be biased by misinterpretations of language usage and emotional expressiveness. Behaviors such as eye contact, firmness of a handshake, tone of voice, or greetings are culturally dependent and varied. Evaluators run the risk of an incorrect assessment if they interpret the behavior only on the basis of what it means in the mainstream culture. For example, in some Native American groups children are taught to express their remorse about a misdeed by not looking at the adult who is correcting them. This behavior is opposite to the expected behavior in the mainstream and can be misjudged as resistance or sullenness. Interventions can be planned to include the entire family system as defined by the client. In addition, the family system can be viewed in its cultural context. For example, Hispanic families often have a strong role definition. In families where the male head of household acts as spokesperson for the family, a worker will be more effective if he or she works through the spokesperson to set appointments and discuss treatment objectives (Aguilar, 1972).
For many Asian families, one therapist for the entire family helps avoid disruption of family integrity. For minority families whose needs are economic as well as emotional, concrete and rapid relief from environmental stress is necessary if the family is to stay engaged in mental health services. Some clients will present a concrete issue to a worker to test the worker’s sincerity and willingness to help (Lewis and Ho, 1975). The helper should be able to help the client address a variety of needs.
It can be helpful to assist clients and families in understanding their own situations in the context of the larger society. Culture can sometimes provide the basis for intervention. Many minority organizations have developed specific treatment approaches that incorporate culture as the core component. For example, the Afrocentric approach developed for Black youth or the Talking Circle approach to group work used by some Native American programs (Brown, 1981) help to build positive identity and self-esteem through use of cultural strengths. Some approaches focus on understanding racial history, others look at bicultural survival tasks, and still others focus on acculturation and its costs (Sue, D.W., 1981). Clients learn how they and their problems fit in the larger society and gain a sense of belonging and dignity (NWICWI, 1987).
Effective service delivery is dependent on communication. Nowhere is this issue more keenly felt than by minority communities whose first language is not English. Hispanic, Asian, and some Native American groups are likely to be assessed in a language that is not their own and asked to talk about emotional issues for which English has no equivalence to such concepts in their native language. Services can be adapted by making bilingual services available to all who need it. Community educational materials, agency literature, brochures, and treatment plans should all be available in the first language of the client. When bilingual staff are not available, interpreters should be provided. The agency should avoid using the family’s children as interpreters. Such use of children is contrary to the family norms of many Asian groups, which require children to listen and obey (Ho, 1976).
One aspect of communication is etiquette. Workers in cross-cultural situations can adapt their practices to accommodate the rules of social decorum their clients practice. For example, if on a home visit in the Black community one is offered food, it is polite to accept. This also holds true for American Indian people as well. In most Hispanic groups, a period of social conversation is considered polite before conducting business. This polite exchange is necessary to develop the relationship and is referred to as “personalismo” (McRoy, 1985). A worker should address Black clients formally, by their last name, until invited to do otherwise. With Asian clients a worker should be prepared to answer polite but personal questions which may be used to seek some common ground for developing a relationship (fsui and Schultz, 1985). These bits of basic etiquette are easy to adapt to and learn and can even be discussed directly with the client.
Practitioners may also have to adapt to differing ways of conceptualizing problems and different orientations to time. For example, many Native American and Hispanic groups view mental health as directly related to the spiritual side of life and to imbalances in the forces that impact their lives (Sue, D.W., 1981). This is in contrast to the cause and effect theory base of the mental health system which values history as important to understanding the present. Workers can adapt their information-gathering skills to include the client’s perception of the problem which may be much more present-oriented or spiritually based. Agencies often find in developing networks in minority communities that the emphasis on time in the dominant society is not shared by the other culture. One means of dealing with this is to make it the subject of discussion and to negotiate compromises with which both sides can live.
Interviewing is one form of communication that can easily be adapted. Native American communication patterns are characterized by pauses between “turns at talk” that are longer than those common in the mainstream (Philips,. 1983). Silence is considered a part of communication because words should be carefully chosen (Lewis, 1975; NWICWI, 1987). Workers can adapt their styles by simply remaining quiet and giving the client time to think through their responses. Direct questions are considered intrusive. Accordingly, questions or subject opening comments are sometimes more revealing (NWICWI, 1987). In Hispanic or Asian cultures, a family may have a spokesperson determined by sex or generation roles as defined by the culture. In these situations the interviewer should be prepared to speak through the spokesperson (Aguilar, 1972; Aragon de Valdez and Gallegos, 1982; Tsui and Schultz, 1985).
Only through the development of cross-cultural communication skills can the worker become more effective. Only a few examples have been given to illustrate this point. This kind of information is representative of the type of cultural knowledge helpers need to develop.
Culturally competent case management is an essential aspect of service delivery to minority children and youth with serious emotional handicaps and to their families. While it is evident that children and youth benefit from therapeutic interventions, many minority clients will need help in the form of concrete or tangible services (e.g., housing, employment, health and dental care, transportation, respite care, etc.). In such cases, the overarching goal is to coordinate, integrate, and maintain a network of services that, together with natural helping resources, establishes and supports a functioning balance between child, family, and environment (Young, 1987).
Many minority children, youth, and their families expect formal helpers to be able to deal with a variety of problems, and form their judgment of the helpers’ skills, empathy, and commitment by how well workers handle what many clients see as “real life” problems. If the helper exhibits caring concern and an ability to help, the client is more likely to trust the worker’s skill in dealing with more serious issues (Lewis and Ho, 1975).
Case management should be more than simply referring the child elsewhere. It may include speaking for and with both child and parent to representatives from other organizations, such as schools, mental health clinics, churches, juvenile courts, and recreational programs. The goal is to persuade other people to join a collaborative effort to design, develop, and sustain a system of care for the child and his family (Young, 1987). Case management should be seen as an opportunity to teach self-advocacy, to assess the client’s strengths, and to learn about the client’s natural support network (Green, 1982). Creating such a system of care will validate the client’s (child and family) role in the treatment process, while relieving professionals of the burden of providing services in isolation from other professionals and the family’s natural support network (Mason, 1987).
The informal support network presents a special challenge for the case manager. It is often the greatest resource available to the client and at the same time the least accessible to the formal helper. This dual system can work to the client’s benefit if services can be coordinated to support one another. Sometimes the formal system only needs to not stand in the way of the natural system. For example, a Hispanic parent who wants to consult a natural healer about his or her child’s emotional problems should not be prevented from doing so. An agency might even be able to facilitate such an action through the use of paraprofessionals or special liaison persons (McRoy, Shorkey, and Garcia, 1985).
Other parts of natural networks can include churches, schools, and associations, but also less traditional agencies such as self-help, cultural enrichment, spiritual growth, or business organizations. These organizations often have valuable services to offer, including emergency support and volunteer assistance. They also fill an important need for socialization within one’s own group. Case managers can learn the function of these groups and also turn to these groups for advice and consultation (Green, 1982).
Service adaptations in the area of out-of-home care are necessary to help curb the high placement rates of minority children (Stehno, 1982). Home-based service models are the most promising alternatives at this point (Stroul, 1988). Several minority agencies have adopted this model and converted it to fit the unique needs of their own communities.
One service model largely unfamiliar to the dominant society is the use of extended family placements. The Indian Child Welfare Act specifically begins with extended family as a placement preference (V.S.C., see 1901 et aI, 1978). Many Indian tribes have developed services designed specifically to work with the unique needs involved in extended family placements. Any of the cultural groups that rely on an extended family kinship system can benefit from this service model. The flow of money, however, usually does not facilitate the model. In many states, the extended family cannot receive state reimbursement for such care. An example of a policy adaptation is a law passed in Oregon in 1987 that authorized foster care payments to relatives in Indian Child Welfare cases. This adaptation has greatly enhanced the capacity of the natural system to fulfill its natural function.
Transracial adoptions present a particularly difficult issue in service delivery. While non-minority couples still desire to adopt racial minority children, it remains in the minds of many minorities one of the greatest indignities leveled against them. The mental health issues of these children are thought to be severe but are undocumented. The adoptions sometimes fail and the child is left without the natural support system of their extended family or cultural group and without an adequately formed identity (Berlin, 1978). Service alternatives include extended family adoption, more vigorous recruitment campaigns for same race adoptive families, and long-term planned guardianship (NWICWI, 1987).
Family reunification services should also be considered. These alternatives must be coupled with policy changes that end the practice of transracial adoption and help focus resources on the preservation of families. There exists a need for a partnership between the system, the families of the children served, and the communities to which they belong. The effort of developing cultural competence needs to be coupled with the concept of families as allies. Out-of-home placement should not mean out-of-culture nor out-of-family if that culture or extended family can provide the needed support.
In summary, service delivery adaptations can be made at the policy or practice level and must be tailored to the needs of the population being served. The examples given here are intended to illustrate the concepts of developing cultural competence through a clustering of actions that impact attitude, practice, and policy.
These are but a few of the possible actions and service areas that should be examined. New service technology is rapidly developing, and as each agency makes progress all benefit from the experience of the other. Several guiding principles are helpful in developing service adaptations:
Source: Towards a Culturally Competent System of Care, Vol. I
Georgetown University Child Development Center Washington, D.C.