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Center for Substance Abuse Treatment (US). Improving Cultural Competence. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014. (Treatment Improvement Protocol (TIP) Series, No. 59.)
Zhang Min, a 25-year-old first-generation Chinese woman, was referred to a counselor by her primary care physician because she reported having episodes of depression. The counselor who conducted the intake interview had received training in cultural competence and was mindful of cultural factors in evaluating Zhang Min. The referral noted that Zhang Min was born in Hong Kong, so the therapist expected her to be hesitant to discuss her problems, given the prejudices attached to mental illness and substance abuse in Chinese culture. During the evaluation, however, the therapist was surprised to find that Zhang Min was quite forthcoming. She mentioned missing important deadlines at work and calling in sick at least once a week, and she noted that her coworkers had expressed concern after finding a bottle of wine in her desk. She admitted that she had been drinking heavily, which she linked to work stress and recent discord with her Irish American spouse.
Further inquiry revealed that Zhang Min"s parents, both Chinese, went to school in England and sent her to a British school in Hong Kong. She grew up close to the British expatriate community, and her mother was a nurse with the British Army. Zhang Min came to the United States at the age of 8 and grew up in an Irish American neighborhood. She stated that she knew more about Irish culture than about Chinese culture. She felt, with the exception of her physical features, that she was more Irish than Chinese—a view accepted by many of her Irish American friends. Most men she had dated were Irish Americans, and she socialized in groups in which alcohol consumption was not only accepted but expected.
Zhang Min first started to drink in high school with her friends. The counselor realized that what she had learned about Asian Americans was not necessarily applicable to Zhang Min and that knowledge of Zhang Min"s entire history was necessary to appreciate the influence of culture in her life. The counselor thus developed treatment strategies more suitable to Zhang Min"s background.
Zhang Min"s case demonstrates why thorough evaluation, including assessment of the client"s sociocultural background, is essential for treatment planning. To provide culturally responsive evaluation and treatment planning, counselors and programs must understand and incorporate relevant cultural factors into the process while avoiding a stereotypical or “one-size-fits-all” approach to treatment. Cultural responsiveness in planning and evaluation entails being open minded, asking the right questions, selecting appropriate screening and assessment instruments, and choosing effective treatment providers and modalities for each client. Moreover, it involves identifying culturally relevant concerns and issues that should be addressed to improve the client"s recovery process.
This chapter offers clinical staff guidance in providing and facilitating culturally responsive interviews, assessments, evaluations, and treatment planning. Using Sue"s (2001) multidimensional model for developing cultural competence, this chapter focuses on clinical and programmatic decisions and skills that are important in evaluation and treatment planning processes. The chapter is organized around nine steps to be incorporated by clinicians, supported in clinical supervision, and endorsed by administrators.
Step 1. Engage Clients
Once clients are in contact with a treatment program, they stand on the far side of a yet-to-be-established therapeutic relationship. It is up to counselors and other staff members to bridge the gap. Handshakes, facial expressions, greetings, and small talk are simple gestures that establish a first impression and begin building the therapeutic relationship. Involving one"s whole being in a greeting—thought, body, attitude, and spirit—is most engaging.
Fifty percent of racially and ethnically diverse clients end treatment or counseling after one visit with a mental health practitioner (Sue and Sue 2013e). At the outset of treatment, clients can feel scared, vulnerable, and uncertain about whether treatment will really help. The initial meeting is often the first encounter clients have with the treatment system, so it is vital that they leave feeling hopeful and understood. Paniagua (1998) describes how, if a counselor lacks sensitivity and jumps to premature conclusions, the first visit can become the last:
Pretend that you are a Puerto Rican taxi driver in New York City, and at 3:00 p.m. on a hot summer day you realize that you have your first appointment with the therapist…later, you learned that the therapist made a note that you were probably depressed or psychotic because you dressed carelessly and had dirty nails and hands…would you return for a second appointment? (p. 120)
To engage the client, the counselor should try to establish rapport before launching into a series of questions. Paniagua (1998) suggests that counselors should draw attention to the presenting problem “without giving the impression that too much information is needed to understand the problem” (p. 18). It is also important that the client feel engaged with any interpreter used in the intake process. A common framework used in many healthcare training programs to highlight culturally responsive interview behaviors is the LEARN model (Berlin and Fowkes 1983). The how-to box on the next page presents this model.
Improving Cross-Cultural Communication
Health disparities have multiple causes. One specific influence is cross-cultural communication between the counselor and the client. Weiss (2007) recommends these six steps to improve communication with clients:
Step 2. Familiarize Clients and Their Families With Treatment and Evaluation Processes
Behavioral health treatment facilities maintain their own culture (i.e., the treatment milieu). Counselors, clinical supervisors, and agency administrators can easily become accustomed to this culture and assume that clients are used to it as well. However, clients are typically new to treatment language or jargon, program expectations and schedules, and the intake and treatment process. Unfortunately, clients from diverse racial and ethnic groups can feel more estranged and disconnected from treatment services when staff members fail to educate them and their families about treatment expectations or when the clients are not walked through the treatment process, starting with the goals of the initial intake and interview. By taking the time to acclimate clients and their families to the treatment process, counselors and other behavioral health staff members tackle one obstacle that could further impede treatment engagement and retention among racially and ethnically diverse clients.
How To Use the LEARN Mnemonic for Intake Interviews
Listen to each client from his or her cultural perspective. Avoid interrupting or posing questions before the client finishes talking; instead, find creative ways to redirect dialog (or explain session limitations if time is short). Take time to learn the client"s perception of his or her problems, concerns about presenting problems and treatment, and preferences for treatment and healing practices.
Explain the overall purpose of the interview and intake process. Walk through the general agenda for the initial session and discuss the reasons for asking about personal information. Remember that the client"s needs come before the set agenda for the interview; don"t cover every intake question at the expense of taking time (usually brief) to address questions and concerns expressed by the client.
Acknowledge client concerns and discuss the probable differences between you and your clients. Take time to understand each client"s explanatory model of illness and health. Recognize, when appropriate, the client"s healing beliefs and practices and explore ways to incorporate these into the treatment plan.
Recommend a course of action through collaboration with the client. The client must know the importance of his or her participation in the treatment planning process. With client assistance, client beliefs and traditions can serve as a framework for healing in treatment. However, not all clients have the same expectations of treatment involvement; some see the counselor as the expert, desire a directive approach, and have little desire to participate in developing the treatment plan themselves.
Negotiate a treatment plan that weaves the client"s cultural norms and lifeways into treatment goals, objectives, and steps. Once the treatment plan and modality are established and implemented, encourage regular dialog to gain feedback and assess treatment satisfaction. Respecting the client"s culture and encouraging communication throughout the process increases client willing to engage in treatment and to adhere to the treatment plan and continuing care recommendations.
Sources: Berlin and Fowkes 1983; Dreachslin et al. 2013; Ring 2008.
Step 3. Endorse Collaboration in Interviews, Assessments, and Treatment Planning
Most clients are unfamiliar with the evaluation and treatment planning process and how they can participate in it. Some clients may view the initial interview and evaluation as intrusive if too much information is requested or if the content is a source of family dishonor or shame. Other clients may resist or distrust the process based on a long history of racism and oppression. Still others feel inhibited from actively participating because they view the counselor as the authority or sole expert.
The counselor can help decrease the influence of these issues in the interview process through a collaborative approach that allows time to discuss the expectations of both counselor and client; to explain interview, intake, and treatment planning processes; and to establish ways for the client to seek clarification of his or her assessment results (Mohatt et al. 2008a). The counselor can encourage collaboration by emphasizing the importance of clients" input and interpretations. Client feedback is integral in interpreting results and can identify cultural issues that may affect intake and evaluation (Acevedo-Polakovich et al. 2007). Collaboration should extend to client preferences and desires regarding inclusion of family and community members in evaluation and treatment planning.
Step 4. Integrate Culturally Relevant Information and Themes
By exploring culturally relevant themes, counselors can more fully understand their clients and identify their cultural strengths and challenges. For example, a Korean woman"s family may serve as a source of support and provide a sense of identity. At the same time, however, her family could be ashamed of her co-occurring generalized anxiety and substance use disorders and respond to her treatment as a source of further shame because it encourages her to disclose personal matters to people outside the family. The following section provides a brief overview of suggested strength-based topics to incorporate into the intake and evaluation process.
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Advice to Counselors: Asking About Culture and Acculturation
A thoughtful exploration of cultural and ethnic identity issues will provide clues for determining cultural, racial, and ethnic identity. There are numerous clues that you may derive from your clients" answers, and they cannot all be covered in this TIP; this is only one set of sample questions (Fontes 2008). Ask these questions tactfully so they do not sound like an interrogation. Try to integrate them naturally into a conversation rather than asking one after another. Not all questions are relevant in all settings. Counselors can adapt wording to suit clients" cultural contexts and styles of communication, because the questions listed here and throughout this chapter are only examples:
Immigration history can shed light on client support systems and identify possible isolation or alienation. Some immigrants who live in ethnic enclaves have many sources of social support and resources. By contrast, others may be isolated, living apart from family, friends, and the support systems extant in their countries of origin. Culturally competent evaluation should always include questions about the client"s country of origin, immigration status, length of time in the United States, and connections to his or her country of origin. Ask American-born clients about their parents" country of origin, the language(s) spoken at home, and affiliation with their parents" culture(s). Questions like these give the counselor important clues about the client"s degree of acculturation in early life and at present, cultural identity, ties to culture of origin, potential cultural conflicts, and resources. Specific questions should elicit information about:
Length of time in the United States, noting when immigration occurred or the number of generations who have resided in the United States.