In the world of mental health and overall healthcare, many understand cultural competence to mean a combination of the level of knowledge a provider possesses regarding how their patients from different cultural backgrounds are affected by and approach certain health issues, the professional’s ability to embrace that diversity, and the necessary action taken towards reducing the obvious disparities patients face. But there tends to be a gap between what it means to be culturally competent on paper, and the actual embodiment of a culturally competent clinician in practice. We have the option to pursue continued education and cultural competency trainings to increase our effectiveness in treatment which should be the minimal requirement to uphold basic standard of care. However, beyond what can be taught in these educational courses is the personal level of consciousness and commitment to be self-aware and self-reflective, while also taking into consideration the inherent biases in how we apply everyday tools and its impact on patients.
There continues to be stigma associated with mental illness and mental health care in BIPOC and other marginalized communities, and for many the first point of contact for treatment tends to be a trusted primary care provider. Having that initial rapport between a patient and their doctor is critical for a successful warm hand off to a mental health professional. However, studies have shown that up to 25% of physicians who have recently graduated medical school report feeling unprepared to provide effective cross-cultural care to patients (Kripalani et al., 2011). If there continues to be a struggle with providing culturally competent care, it will only serve to perpetuate the justifiable fear patients have of seeking help due to the possibility of not being understood or of being treated unfairly.
Looking Inward
It’s unrealistic to assume that we should know everything about everyone’s culture, but we can start by examining how our own culture has shaped our lives. The RESPECTFUL model (D’Andrea & Daniels, 2001, 2015) consists of ten factors which affect an individual’s psychological development and personal wellbeing. They are:
- Religion/spirituality
- Economic/social class background
- Sexual identity
- Personal style and education/Psychological maturity
- Ethnic/racial identity
- Chronological/lifespan status and challenges
- Trauma/crisis
- Family background and history
- Unique physical characteristics
- Location of residence, language differences
While not an exhaustive list, it’s a start to begin identifying your multicultural self (Ivey et al., 2018). Have an honest conversation with yourself about any biases or assumptions you may have about certain populations. How would you identify on the different multicultural dimensions? What strengths have you drawn from these? Challenges? In the past, how have you interacted with those who differ from you on each of the above dimensions? Begin to think about your patients more holistically and explore therapeutic techniques and interventions that effectively address the needs of the patient in front of you. Remember, it is not your patient’s job to educate you on their oppression or how experiences of racial injustice and inequities have impacted them and their communities. Take it upon yourself to learn about the populations you work with, combining a strength based and trauma informed approach to begin bridging the gaps towards more effective and meaningful communication.
Assessment, Diagnosis, Theory, and Culture
When assessing a patient, ask yourself if there is any way you may be biased in your assessment and if any countertransference experienced may still be present and impacting your work with them. Learn how your patient experiences the world, any cultural beliefs, or meanings they may be associating with their psychological or physical symptom(s), and how your recommended course of treatment will impact them not just on an individual level, but in relation to their family and community.
We want to assure that we are not taking a ‘one size fits all’ approach to treatment, and that starts by acknowledging how the framework for many theoretical orientations have centered whiteness and heterosexuality, and how the DSM5 fails to fully acknowledge the effects of racial trauma, oppression, and discrimination on marginalized individuals. Post-traumatic stress disorder is currently a diagnosis that can be provided for those who have experienced trauma due to exposure to actual or threatened death, serious injury, or sexual violence (American Psychiatric Association, 2013). However, racism would only be considered a trauma when the patient meets this criterion in relation to a specific violent and racist event, such as being assaulted during a hate crime. The issue with this is that it excludes those who can’t narrow down the trauma from racism to a single event, and yet still experience trauma in the form of systemic and institutionalized racism such as microaggressions at work, racial slurs, hiring discrimination, and a cumulation of other traumatic experiences. And what ends up happening is providers are left trying to fit all other reported traumatic events and symptoms into other categories that quite frankly fail to grasp the full impact of these traumas.
We always want to make sure that the interventions we are choosing to match the patient’s experiences, and that includes how we assess and diagnose. To reduce diagnostic bias, take the necessary time needed to make an accurate diagnosis. Consider all other possible contributing factors for a patient’s symptoms including co-occurring disorders, be mindful of self-confirmatory bias and narrowing in on information only because it is consistent with your existing beliefs, and the different stereotypes that surround certain diagnoses. Remember to continue embracing diversity to promote equitable care and work cultural competency into all aspects of your profession.
This post is graciously contributed by Suhailey Núñez, LMHC
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
D’Andrea, M., & Daniels, J. (2001). RESPECTFUL counseling: An integrative model for counselors. In D. Pope-Davis & H. Coleman (Eds.), The interface of class, culture and gender in counseling (pp. 417-466). Thousand Oaks, CA: Sage.
Ivey, A.E. & Ivey, M. B. , & Zalaquett (2018). Intentional interviewing and counseling: Facilitating client development in a multicultural society (9th ed). Pacific Grove, CA: Brooks/ Cole.
Kripalani, S., Bussey-Jones, J., Katz, M. G., & Genao, I. (2006). A prescription for cultural competence in medical education. Journal of General Internal Medicine, 21(10), 1116–1120. https://doi-org.proxy.wexler.hunter.cuny.edu/10.1111/j.1525-1497.2006.00557.x
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