A TreATmenT ImprovemenT proTocol

Improving Cultural
Competence

TIP 59
A TreATmenT ImprovemenT proTocol

Improving Cultural
Competence

TIP 59
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment

1 Choke Cherry Road

Rockville, MD 20857
 Improving Cultural Competence

Acknowledgments
This publication was produced by The CDM Group, Inc., under the Knowledge Application
Program (KAP) contract numbers 270-99-7072, 270-04-7049, and 270-09-0307 with the
Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of
Health and Human Services (HHS). Andrea Kopstein, Ph.D., M.P.H., Karl D. White, Ed.D.,
and Christina Currier served as the Contracting Officer’s Representatives.

Disclaimer
The views, opinions, and content expressed herein are those of the consensus panel and do not
necessarily reflect the views, opinions, or policies of SAMHSA or HHS. No official support of
or endorsement by SAMHSA or HHS for these opinions or for particular instruments, software,
or resources is intended or should be inferred.

Public Domain Notice

All materials appearing in this volume except those taken directly from copyrighted sources are
in the public domain and may be reproduced or copied without permission from SAMHSA or
the authors. Citation of the source is appreciated. However, this publication may not be
reproduced or distributed for a fee without the specific, written authorization of the Office of
Communications, SAMHSA, HHS.

Electronic Access and Copies of Publication

This publication may be ordered or downloaded from SAMHSA’s Publications Ordering Web
page at http://store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-726-
4727) (English and Español).

Recommended Citation
Substance Abuse and Mental Health Services Administration. Improving Cultural Competence.
Treatment Improvement Protocol (TIP) Series No. 59. HHS Publication No. (SMA) 14-4849.
Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

Originating Office
Quality Improvement and Workforce Development Branch, Division of Services Improvement,
Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services
Administration, 1 Choke Cherry Road, Rockville, MD 20857.

HHS Publication No. (SMA) 14-4849

First Printed 2014

ii
Please share your thoughts about this publication by completing a brief online survey at:

https://www.surveymonkey.com/r/KAPPFS

The survey takes about 7 minutes to complete and is anonymous.

Your feedback will help SAMHSA develop future products.
 Contents

Consensus Panel............................................................................................................. vii

KAP Expert Panel and Federal Government Participants ...................................................ix
What Is a TIP? .................................................................................................................xi
Foreword ....................................................................................................................... xiii
Executive Summary ......................................................................................................... xv
Chapter 1—Introduction to Cultural Competence ............................................................. 1
Purpose and Objectives of the TIP........................................................................................... 2
Core Assumptions..................................................................................................................... 4
What Is Cultural Competence? ................................................................................................ 5
Why Is Cultural Competence Important? .............................................................................. 7
How Is Cultural Competence Achieved? ................................................................................. 9
What Is Culture? .................................................................................................................... 11
What Is Race? ......................................................................................................................... 13
What Is Ethnicity? ................................................................................................................. 15
What Is Cultural Identity? .................................................................................................... 16
What Are the Cross-Cutting Factors in Race, Ethnicity, and Culture? ................................ 16
As You Proceed ....................................................................................................................... 33
Chapter 2—Core Competencies for Counselors and Other Clinical Staff ...........................35
Core Counselor Competencies ............................................................................................... 36
Self-Assessment for Individual Cultural Competence ........................................................... 55
Chapter 3—Culturally Responsive Evaluation and Treatment Planning.............................57
Step 1: Engage Clients............................................................................................................ 59
Step 2: Familiarize Clients and Their Families With Treatment and Evaluation Processes . 59
Step 3: Endorse Collaboration in Interviews, Assessments, and Treatment Planning........... 60
Step 4: Integrate Culturally Relevant Information and Themes ............................................ 61
Step 5: Gather Culturally Relevant Collateral Information .................................................. 64
Step 6: Select Culturally Appropriate Screening and Assessment Tools................................ 65
Step 7: Determine Readiness and Motivation for Change .................................................... 69
Step 8: Provide Culturally Responsive Case Management .................................................... 70
Step 9: Integrate Cultural Factors Into Treatment Planning ................................................. 71

iii
 Improving Cultural Competence

Chapter 4—Pursuing Organizational Cultural Competence ..............................................73

Cultural Competence at the Organizational Level ................................................................ 74
Organizational Values ............................................................................................................. 76
Governance ............................................................................................................................. 78
Planning .................................................................................................................................. 80
Evaluation and Monitoring .................................................................................................... 84
Language Services................................................................................................................... 88
Workforce and Staff Development ......................................................................................... 90
Organizational Infrastructure ................................................................................................. 96
Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups ................ 101
Introduction .......................................................................................................................... 102
Counseling for African and Black Americans ...................................................................... 103
Counseling for Asian Americans, Native Hawaiians, and Other Pacific Islanders .............. 116
Counseling for Hispanics and Latinos ................................................................................. 128
Counseling for Native Americans......................................................................................... 138
Counseling for White Americans ......................................................................................... 150
Chapter 6—Drug Cultures and the Culture of Recovery .................................................. 159
What Are Drug Cultures? .................................................................................................... 161
The Role of Drug Cultures in Substance Abuse Treatment ................................................ 171
Appendix A: Bibliography ............................................................................................. 177
Appendix B: Instruments To Measure Identity and Acculturation .................................... 253
Appendix C: Tools for Assessing Cultural Competence ................................................... 259
Appendix D: Screening and Assessment Instruments ...................................................... 277
Appendix E: Cultural Formulation in Diagnosis and Cultural Concepts of Distress .......... 283
Appendix F: Cultural Resources ..................................................................................... 287
Appendix G: Glossary .................................................................................................... 295
Appendix H: Resource Panel .......................................................................................... 299
Appendix I: Cultural Competence and Diversity Network Participants ............................ 301
Appendix J: Field Reviewers ........................................................................................... 303
Appendix K: Acknowledgments...................................................................................... 307
List of Exhibits
Exhibit 1-1: Multidimensional Model for Developing Cultural Competence ........................ 6
Exhibit 1-2: The Continuum of Cultural Competence ......................................................... 10
Exhibit 1-3: Common Characteristics of Culture .................................................................. 12
Exhibit 1-4: Education and Culture ....................................................................................... 22

iv
 Contents

Exhibit 1-5: Cultural Identification and Cultural Change Terminology ............................... 24

Exhibit 1-6: Five Levels of Acculturation .............................................................................. 25
Exhibit 1-7: Measuring Acculturation ................................................................................... 27
Exhibit 2-1: Stages of Racial and Cultural Identity Development ........................................ 40
Exhibit 2-2: Counselor Worldview......................................................................................... 43
Exhibit 2-3: ACA Counselor Competencies: Counselor s' Awareness of Their
Own Cultural Values and Biases....................................................................................... 46
Exhibit 2-4: ACA Counselor Competencies: Awareness of Clients' Worldviews ................. 47
Exhibit 2-5: Attitudes and Behaviors of Culturally Competent Counselors ......................... 49
Exhibit 2-6: ACA Counselor Competencies: Culturally Appropriate Intervention
Strategies ........................................................................................................................... 56
Exhibit 3-1: Client–Counselor Matching .............................................................................. 71
Exhibit 4-1: Requirements for Organizational Cultural Competence ................................... 75
Exhibit 4-2: Creating Culturally Responsive Treatment Environments ................................ 75
Exhibit 4-3: Hands Across Cultures Mission Statement ....................................................... 78
Exhibit 4-4: Critical Treatment Issues To Consider in Providing Culturally Responsive
Services ............................................................................................................................. 80
Exhibit 4-5: Qualities of Effective Cultural Competence Training ....................................... 92
Exhibit 4-6: OMH Staff Education and Training Guidelines............................................... 94
Exhibit 4-7: Cultural Competence Initiative Across Time in One Organization ................. 99
Exhibit 5-1: Core Culturally Responsive Principles in Counseling African Americans ..... 110
Exhibit 5-2: Lifetime Prevalence of Substance Use Disorders According to Ethnic
Subgroup and Immigration Status ................................................................................. 130
Exhibit 5-3: Native Americans and Community ................................................................. 143
Exhibit 5-4: The Lakota Version of the 12 Steps ................................................................. 147
Exhibit 6-1: How Drug Cultures Differ .............................................................................. 162
Exhibit 6-2: The Language of a Drug Culture .................................................................... 164
Exhibit 6-3: The Values and Beliefs of a Heroin Culture .................................................... 166
Exhibit 6-4: Music and Drug Cultures ................................................................................ 166
Exhibit 6-5: The Rituals of Drug Cultures .......................................................................... 168
Exhibit 6-6: Questions Regarding Knowledge and Skill Demands of Heroin Use ............. 168
Exhibit 6-7: 12-Step Group Values and the Culture of Recovery ....................................... 174

v
Consensus Panel

Note: Information given indicates each participant’s affiliation during the time the panel was
convened and may no longer reflect the individual’s current affiliation.

Chair Workgroup Leaders

Felipe González Castro, M.S.W., Ph.D. Virgil A. Gooding, Sr., M.A., M.S.W.,
Professor LISC
Department of Psychology Clinical Director
Arizona State University Foundation II, Inc.
Tempe, AZ Cedar Rapids, IA

Co-Chairs Ford H. Kuramoto, D.S.W.

President
Loretta J. Bradley, M.A., Ph.D.
National Asian Pacific American Families
Professor
Against Substance Abuse
Department of Educational Psychology
Los Angeles, CA
Texas Tech University
Lubbock, TX Harry Montoya, M.A.
President/Chief Executive Officer
Jacqueline P. Butler, M.S.W., CCDC,
Hands Across Cultures
LISW
Española, NM
Professor of Clinical Psychiatry
Substance Abuse Division Onaje M. Salim, M.A., NCAC-II, CCS
College of Medicine Director
University of Cincinnati Cork Institute Southeast Addiction
Cincinnati, OH Technology Transfer Center
Morehouse School of Medicine
Flanders Byford, M.S.W., LCSW
Atlanta, GA
Oklahoma City-County Health Department
Oklahoma City, OK Panelists
Ting-Fun May Lai, M.S.W., CSW, Barbara Lee Aragon, M.S.W.
CASAC Academic Fellow
Director Department of Health Services
Chinatown Alcoholism Center North Highlands, CA
Hamilton-Madison House
New York, NY

vii
 Improving Cultural Competence

Debra A. Claymore, M.Ed.Adm. Rafaela R. Robles, Ed.D.

D. Claymore & Associates, Inc. Director
Loveland, CO Technology Transfer Center
Caribbean Basin/Hispanic Addiction
E. Daniel Edwards, D.S.W. Centro de Estudios en Adicción
Director Universidad Central del Caribe
Ethnic Studies Program Bayamon, PR
University of Utah
Salt Lake City, UT Gloria M. Rodriguez, D.S.W.
Research Scientist
Tonda L. Hughes, M.S.N., Ph.D., FAAN Division of Addiction Services
Associate Professor New Jersey Department of Health and Senior
College of Nursing Services
University of Illinois at Chicago Trenton, NJ
Chicago, IL
Ann S. Yabusaki, M.Ed., M.A., Ph.D.
David Mathews, M.A., Ph.D. Director
Director of Adult Services Coalition for a Drug-Free Hawaii
Kentucky River Community Care, Inc. Honolulu, HI
Jackson, KY
Anthony (Tony) Taiwai Ng, M.D.
Consultant
Washington, DC
Barry Pilson, Ph.D.
Adjunct Professor
School of Social Work
Tulane University
Metairie, LA

viii
KAP Expert Panel and Federal
Government Participants

Note: Information given indicates each participant’s affiliation during the time the panel was
convened and may no longer reflect the individual’s current affiliation.

Barry S. Brown, Ph.D. Jerry P. Flanzer, D.S.W., LCSW, CAC

Adjunct Professor Chief of Services
University of North Carolina at Wilmington Division of Clinical and Services Research
Carolina Beach, NC National Institute on Drug Abuse
National Institutes of Health
Jacqueline Butler, M.S.W., LISW, LPCC,
Bethesda, MD
CCDC III, CJS
Professor of Clinical Psychiatry Michael Galer, D.B.A.
College of Medicine Independent Consultant
University of Cincinnati Westminster, MA
Cincinnati, OH
Renata J. Henry, M.Ed.
Deion Cash Director
Executive Director Division of Alcoholism, Drug Abuse and
Community Treatment and Correction Mental Health
Center, Inc. Delaware Department of Health and Social
Canton, OH Services
New Castle, DE
Debra A. Claymore, M.Ed.Adm.
D. Claymore & Associates, Inc. Joel Hochberg, M.A.
Loveland, CO President
Asher & Partners
Carlo C. DiClemente, Ph.D.
Los Angeles, CA
Chair
Department of Psychology Jack Hollis, Ph.D.
University of Maryland Baltimore County Associate Director
Baltimore, MD Center for Health Research
Kaiser Permanente
Catherine E. Dube, Ed.D.
Portland, OR
Independent Consultant
Brown University
Providence, RI

ix
 Improving Cultural Competence

Mary Beth Johnson, M.S.W. Everett Rogers, Ph.D.

Director Center for Communications Programs
Addiction Technology Transfer Center Johns Hopkins University
University of Missouri—Kansas City Baltimore, MD
Kansas City, MO
Jean R. Slutsky, P.A., M.S.P.H.
Eduardo Lopez, B.S. Director
Executive Producer Center for Outcomes and Evidence
EVS Communications Agency for Healthcare Research and Quality
Washington, DC Rockville, MD
Holly A. Massett, Ph.D. Nedra Klein Weinreich, M.S.
Academy for Educational Development President
Washington, DC Weinreich Communications
Canoga Park, CA
Diane Miller, Ph.D.
Chief Clarissa Wittenberg
Scientific Communications Branch Director
National Institute on Alcohol Abuse Office of Communications and
and Alcoholism Public Liaison
National Institutes of Health National Institute of Mental Health
Bethesda, MD National Institutes of Health
Bethesda, MD
Harry B. Montoya, M.A.
President/Chief Executive Officer Consulting Members of the KAP
Hands Across Cultures
Expert Panel
Española, NM
Paul Purnell, M.A
Richard K. Ries, M.D. Social Solutions, L.L.C.
Director/Professor Potomac, MD
Outpatient Mental Health Services
Dual Disorder Programs Scott Ratzan, M.D., M.P.A., M.A.
Seattle, WA Academy for Educational Development
Washington, DC
Gloria M. Rodriguez, D.S.W.
Research Scientist Thomas W. Valente, Ph.D.
Division of Addiction Services Director, Master of Public Health Program
New Jersey Department of Health and Senior Department of Preventive Medicine
Services School of Medicine
Trenton, NJ University of Southern California
Alhambra, CA
Patricia A. Wright, Ed.D.
Independent Consultant
Baltimore, MD

x
What Is a TIP?

Treatment Improvement Protocols (TIPs) are developed by the Substance Abuse and Mental
Health Services Administration (SAMHSA) within the U.S. Department of Health and Human
Services (HHS). TIPs are best practice guidelines for the treatment of substance use disorders.
TIPs draw on the experience and knowledge of clinical, research, and administrative experts to
evaluate the quality and appropriateness of various forms of treatment. TIPs are distributed to
facilities and individuals across the country. Published TIPs can be accessed via the Internet at
http://store.samhsa.gov.
Although each TIP strives to include an evidence base for the practices it recommends,
SAMHSA recognizes that the field of substance abuse treatment is continually evolving, and
research frequently lags behind the innovations pioneered in the field. A major goal of each TIP
is to convey front-line information quickly but responsibly. If research supports a particular
approach, citations are provided.

xi
Foreword

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency
within the U.S. Department of Health and Human Services that leads public health efforts to
advance the behavioral health of the nation. SAMHSA’s mission is to reduce the impact of
substance abuse and mental illness on America’s communities.
The Treatment Improvement Protocol (TIP) series fulfills SAMHSA’s mission to reduce the
impact of substance abuse and mental illness on America’s communities by providing evidence-
based and best practice guidance to clinicians, program administrators, and payers. TIPs are the
result of careful consideration of all relevant clinical and health services research findings,
demonstration experience, and implementation requirements. A panel of non-federal clinical
researchers, clinicians, program administrators, and patient advocates debates and discusses their
particular area of expertise until they reach a consensus on best practices. This panel’s work is
then reviewed and critiqued by field reviewers.
The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly
participatory process have helped bridge the gap between the promise of research and the needs
of practicing clinicians and administrators to serve, in the most scientifically sound and effective
ways, people in need of behavioral health services. We are grateful to all who have joined with us
to contribute to advances in the behavioral health field.

Pamela S. Hyde, J.D.

Administrator
Substance Abuse and Mental Health Services Administration

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM

Director
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration

xiii
Executive Summary

The development of culturally responsive assist readers in understanding the role of

clinical skills is vital to the effectiveness of culture in the delivery of behavioral health
behavioral health services. According to the services (both generally and with reference to
U.S. Department of Health and Human specific cultural groups). This TIP is organized
Services (HHS), cultural competence “refers to into six chapters and begins with an introduc-
the ability to honor and respect the beliefs, tion to cultural competence. The following
languages, interpersonal styles, and behaviors of subheadings provide a summary of each chap-
individuals and families receiving services, as ter and an overview of this publication.
well as staff members who are providing such
services. Cultural competence is a dynamic, Introduction to Cultural
ongoing developmental process that requires a
long-term commitment and is achieved over Competence
time” (HHS 2003a, p. 12). It has also been Why is the development of cultural compe-
called “a set of behaviors, attitudes, and policies tence and culturally responsive services
that . . . enable a system, agency, or group of important in the behavioral health field?
professionals to work effectively in cross- Culturally responsive skills can improve client
cultural situations” (Cross et al. 1989, p. 13). engagement in services, therapeutic relation-
This Treatment Improvement Protocol (TIP) ships between clients and providers, and
uses Sue’s (2001) multidimensional model for treatment retention and outcomes. Cultural
developing cultural competence. Adapted to competence is an essential ingredient in de-
address cultural competence across behavioral creasing disparities in behavioral health.
health settings, this model serves as a frame- The development of cultural competence can
work for targeting three organizational levels have far-reaching effects not only for clients,
of treatment: individual counselor and staff, but also for providers and communities. Cul-
clinical and programmatic, and organizational tural competence improves an organization’s
and administrative. The chapters target specif- sustainability by reinforcing the value of diver-
ic racial, ethnic, and cultural considerations sity, flexibility, and responsiveness in address-
along with the core elements of cultural com- ing the current and changing needs of clients,
petence highlighted in the model. These core communities, and the healthcare environment.
elements include cultural awareness, general Culturally responsive organizational strategies
cultural knowledge, cultural knowledge of and clinical services can help mitigate organi-
behavioral health, and cultural skill develop- zational risk and provide cost-effective treat-
ment. The primary objective of this TIP is to ment, in part by matching services to client

xv
 Improving Cultural Competence

needs more appropriately from the outset. So organize their world. Culture is not a definable
too, culturally responsive organizational poli- entity to which people belong or do not be-
cies and procedures support staff engagement long. Within a nation, race, or community,
in culturally responsive care by establishing people belong to multiple cultural groups and
access to training, supervision, and congruent negotiate multiple cultural expectations on a
policies and procedures that enable staff to daily basis. These expectations, or cultural
respond in a culturally appropriate manner to norms, are the spoken or unspoken rules or
clients’ psychological, linguistic, and physical standards for a given group that indicate
needs. whether a certain social event or behavior is
appropriate or inappropriate. The word “cul-
What is the process of becoming culturally
ture” is sometimes applied to groups formed
competent as a counselor or culturally
on the basis of age, socioeconomic status,
responsive as an organization? Cultural
disability, sexual orientation, recovery status,
competence is not acquired in a limited
common interest, or proximity. Counselors
timeframe or by learning a set of facts about
and administrators should understand that
specific populations; cultures are diverse and
each client embraces his or her culture(s) in a
continuously evolving. Developing cultural
unique way and that there is considerable
competence is an ongoing process that begins
diversity within and across races, ethnicities,
with cultural awareness and a commitment to
and culture heritages. Other cultures and
understanding the role that culture plays in
subcultures often exist within larger cultures.
behavioral health services. For counselors, the
first step is to understand their own cultures as What are race and ethnicity? Race is often
a basis for understanding others. Next, they referred to as a biological category based on
must cultivate the willingness and ability to genetic traits like skin color (HHS 2001), but
acquire knowledge of their clients’ cultures. there are no reliable means of identifying race
This involves learning about and respecting through biological criteria. Despite its limita-
client worldviews, beliefs, values, and attitudes tions, the concept of race is important to
toward mental health, help-seeking behavior, discussions of cultural competence. Race—
substance use, and behavioral health services. when defined as a social construct to describe
Behavioral health counselors should incorpo- people with shared physical characteristics—
rate culturally appropriate knowledge, under- can have tremendous social significance. The
standing, and attitudes into their actions (e.g., term ethnicity is often used interchangeably
communication style, verbal messages, treat- with race, although by definition, ethnicity—
ment policies, services offered), thereby con- unlike race—implies a certain sense of belong-
veying their cultural competence and their ing. It is generally based on shared values,
organizations’ cultural responsiveness during beliefs, and origins rather than shared physical
assessment, treatment planning, and the characteristics. With the exception of its final
treatment process. chapter, which examines drug cultures, this
TIP focuses on the major racial and ethnic
What is culture? Culture is the conceptual
groups identified by the U. S. Census Bureau
system developed by a community or society
within the United States: African and Black
to structure the way people view the world. It
Americans, Asian Americans (including Na-
involves a particular set of beliefs, norms, and
tive Hawaiians and other Pacific Islanders),
values that influence ideas about relationships,
Hispanics and Latinos, Native Americans, and
how people live their lives, and the way people
White Americans.

xvi
 Executive Summary

What constitutes cultural identity? Cultural including adequate allocation of resources,

identity, in the simplest terms, involves an reinforces the importance of sustaining
affiliation or identification with a particular cultural competence in counselors and
group or groups. An individual’s cultural other clinical staff.
identity reflects the values, norms, and • Advocating culturally responsive practices
worldview of the larger culture, but it is de- increases trust within the community,
fined by more than these factors. Cultural agency, and staff.
identity includes individual traits and attrib- • Achieving cultural competence requires
utes shaped by race, ethnicity, language, life the participation of racially and ethnically
experiences, historical events, acculturation, diverse groups and underserved popula-
geographic and other environmental influ- tions in the development and implementa-
ences, and other forces. Thus, no two individ- tion of treatment approaches and training
uals will possess exactly the same cultural activities.
identity even if they identify with the same • Consideration of culture is important at all
cultural group(s). Cultural identities are not levels of operation and in all stages of
static; they develop, evolve, and change across treatment and recovery.
the life cycle.
This TIP explores cultural identity and its Core Competencies for
influence on assessment, treatment planning, Counselors and Other
and therapeutic and healing practices. The
introduction it provides to the cross-cutting Clinical Staff
factors of race, ethnicity, and culture will help Cultural competence has come to mean more
counselors gain knowledge about the many than a discrete skill set or knowledge base;
forces that shape cultures, communities, and cultural competence also requires self-
the lives of clients, including, but not limited evaluation on the part of the practitioner.
to, families and kinships, gender roles, socioec- Culturally competent counselors are aware of
onomic status, religion, education, immigra- their own culture and values, and they
tion, and migration. acknowledge their own assumptions and
What core assumptions serve as the foun- biases about other cultures. Moreover, cultur-
dation of this TIP? The consensus panel ally competent counselors strive to understand
developed several core assumptions upon how these assumptions affect their ability to
which to structure the content of this TIP: provide culturally responsive services to clients
• An understanding of race, ethnicity, and from similar or diverse cultures.
culture (including one’s own) is necessary Counselors should begin the process of be-
to appreciate the diversity of human dy- coming culturally competent by identifying
namics and to treat clients effectively. and exploring their cultural heritage and
• Incorporating cultural competence into worldview along with their clinical worldview,
treatment improves therapeutic deci- uncovering how these views shape their per-
sionmaking and offers alternative ways to ceptions of and during the counseling process.
define and plan a treatment program firm- In addition to understanding themselves and
ly directed toward progress and recovery. how their culture and values can affect the
• Organizational commitment to supporting therapeutic process, culturally competent
culturally responsive treatment services, counselors possess a general understanding of

xvii
 Improving Cultural Competence

the cultures of the specific clients with whom organization as a whole. Chapter 3 presents
they work. Counselors should also understand culturally responsive evaluation and treatment
how individual cultural differences affect planning as a series of nine steps.
substance abuse, health beliefs, help-seeking
Step 1: Engage clients. Because the intake
behavior, and perceptions of behavioral health
meeting is often the first encounter clients
services. Culturally competent counselors:
have with the behavioral health system, it is
• Frame issues in culturally relevant ways.
vital that they leave the meeting feeling un-
• Allow for complexity of issues based on
derstood and hopeful. Counselors should try
cultural context.
to establish rapport with clients before launch-
• Make allowances for variations in the use
ing into a series of questions.
of personal space.
• Are respectful of culturally specific mean- Step 2: Familiarize clients and family
ings of touch (e.g., hugging). members with the evaluation and treatment
• Explore culturally based experiences of process. Often, clients and family members
power and powerlessness. are not familiar with treatment jargon, the
• Adjust communication styles to the cli- treatment program, the facility, or the expecta-
ent’s culture. tions of treatment; furthermore, not all clients
• Interpret emotional expressions in light of will have had an opportunity to express their
the client’s culture. own expectations or apprehension. Clinical
• Expand roles and practices as needed. and other treatment staff must not assume
that clients already understand the treatment
Chapter 2 addresses counselors’ core cultural
process. Instead, they need to take sufficient
competencies and presents clinical activities,
time to talk with clients (and their families, as
including clinical supervision tools. The key
appropriate) about how treatment works and
areas explored include cultural awareness and
what to expect from treatment providers.
cultural identity development, the cultural lens
of counseling, key components of cultural Step 3: Endorse a collaborative approach in
knowledge for behavioral health counselors, facilitating interviews, conducting assess-
and specific counseling skills that support ments, and planning treatment. Counselors
culturally responsive services. should educate clients about their role in
interview, assessment, and treatment planning
Culturally Responsive processes. From first contact, they should
encourage clients and their families to partici-
Evaluation and Treatment pate actively by asking questions, voicing
Planning specific treatment needs, and being involved in
treatment planning. Counselors should allow
The role of culture should be considered clients and family members to give feedback
during initial intakes and interviews, in on the cultural relevance of the treatment plan.
screening and assessment processes, and in the
development of treatment planning. Culturally Step 4: Obtain and integrate culturally
responsive treatment can only occur when the relevant information and themes. By explor-
making of clinical and programmatic decisions ing culturally relevant themes, counselors will
includes culturally relevant information and better understand each client and will be
practices and is endorsed and supported by better equipped to develop a culturally in-
clinical staff, clinical supervisors, and the formed evaluation and treatment plan. Areas

xviii
 Executive Summary

to explore include immigration and migration Like counselors, case managers should possess
history, cultural identity, acculturation status, cultural self-knowledge and a basic knowledge
health beliefs, healing practices, and other of other cultures. They should possess traits
information culturally relevant to the client. conducive to working well with diverse groups
and the ability to apply cultural competence in
Step 5: Gather culturally relevant collateral
practical ways. Case management includes the
information. Such information is a powerful
use, as necessary, of interpreters who can
tool in assessing clients’ presenting problems,
communicate well in the specific dialects
understanding the influence of cultural factors
spoken by each client and who are familiar
on clients, and gathering resources to support
with behavioral health vocabulary relevant to
treatment endeavors. By involving others in the
the specific behavioral health setting in which
early phases of treatment, providers will likely
service provision will occur. Case managers
obtain more external support for each client’s
should acquire cultural and community
engagement in treatment services. Counselors
knowledge to assist with the coordination of
can obtain supplemental information (with
social, health, and other essential services and
client permission) from family members, medi-
to secure culturally relevant services in and
cal and court records, probation and parole
outside the treatment facility. Case managers
officers, community members, and so on.
should also keep a list of culturally appropriate
Step 6: Select culturally appropriate screen- referral resources to help meet client needs.
ing and assessment tools. In selecting eval-
Step 9: Integrate cultural factors into
uation tools, counselors should note the
treatment planning. Counselors should be
availability of normative data for the popula-
flexible in designing a treatment plan to meet
tions to which their clients belong, the inci-
the cultural needs of clients and should inte-
dence of test item bias, the role of
grate traditional healing practices into treat-
acculturation in understanding test items, and
ment plans when appropriate, using resources
the adaptation of testing materials to each
available in the clients’ cultural communities.
client’s culture and language.
Treatment goals and objectives need to be
Step 7: Determine readiness and motiva- culturally relevant, and the treatment envi-
tion for change. Although few studies focus ronment must be conducive to client partici-
on the use of motivational interviewing with pation in treatment planning and to the
specific cultural groups, its theories and strate- gathering of client feedback on the cultural
gies may be more culturally appropriate for relevance of the treatment being provided.
most clients than other approaches. Through
reflective listening, motivational interviewing Pursuing Organizational
focuses on helping clients explore ambivalence
toward change, decisions, and subsequent Cultural Competence
treatment. It is a nonconfrontational, client- Organizational cultural competence is a dy-
centered approach that reinforces clients as the namic, ongoing process that begins with
experts on what will work and supports the awareness and commitment and evolves into
key idea that change is a process. culturally responsive organizational policies
Step 8: Provide culturally responsive case and procedures. A commitment to improving
management. Many core competencies for cultural competence must include resources to
counselors are also relevant to case managers. help support ongoing fidelity to these policies
and procedures along with an ongoing process

xix
 Improving Cultural Competence

of reassessment and adaptation as client and policies and procedures, will enable counselors
community needs evolve. Chapter 4 presents to respond more consistently to clients in a
20 organizational tasks that support counse- culturally competent manner.
lors’ development of cultural competence and
improve organizational development of cultur- Behavioral Health
ally responsive treatment services.
Treatment for Major Racial
Beginning with the organization’s vision and
mission statement, administrators and govern- and Ethnic Groups
ing boards need to develop, implement, and Knowledge of a culture’s attitudes toward
support a strategic planning process that mental illness, substance use, healing, and
demonstrates commitment to cultural compe- help-seeking patterns, practices, and beliefs is
tence. Key staff members assigned to oversee essential in understanding clients’ presenting
the development of culturally responsive problems, developing culturally competent
services act as liaisons and facilitators in estab- counseling skills, and formulating culturally
lishing a cultural competence committee and relevant agency policies and procedures.
conducting an organizational self-assessment Treatment providers need to learn and under-
of cultural competence. With the involvement stand how identification with one or more
of community members, staff, clients and their cultural groups influences each client’s
families, board members, and other invested worldview, beliefs, and traditions surrounding
individuals, the cultural competence commit- initiation of use, healing, and treatment.
tee supports and oversees organizational self-
assessment, using it to identify strengths and Chapter 5 provides a review of the literature as
specific areas for improvement in cultural it pertains to specific racial and ethnic groups
responsiveness. Based on the results of the identified by the U.S. Census Bureau. After a
self-assessment, the committee develops and brief introduction, the chapter explores each
implements a cultural competence plan. major racial and ethnic group’s specific pat-
terns of substance use and substance use dis-
An organizational self-assessment helps the orders, help-seeking patterns, beliefs about
committee prioritize the steps needed to and traditions involving substance use, beliefs
improve culturally responsive services. The and attitudes about treatment, assessment and
plan should address strategies for recruiting, treatment considerations (including co-
hiring, retaining, and promoting qualified, occurring disorders and culturally specific
diverse staff members; the use of interpreters disorders), and theoretical approaches and
or bilingual staff members; staff training, treatment interventions (including evidence-
professional development, and education; based and best practices as well as traditional
fostering community involvement; facilities healing practices).
design and operation; development of cultur-
ally appropriate program materials; how to Chapter 5 also offers assistance in providing
incorporate culturally relevant treatment treatment to African and Black Americans,
approaches; and development and implemen- Asian Americans (including Native Hawaiian
tation of supporting policies and procedures, and other Pacific Islanders), Latinos, Native
including reassessment processes. An organi- Americans, and White Americans. Counse-
zation’s commitment to and support of cultur- lors, clinical supervisors, and administrators
ally responsive services, including congruent are encouraged to use the information in this
chapter as a starting point for learning about

xx
 Executive Summary

the major cultural groups of their clients. learn to experience “getting high” as a pleasur-
Nonetheless, many forces shape how an indi- able activity; they also learn the skills needed
vidual identifies with, is influenced by, or to procure and use drugs effectively and to
portrays his/her culture, and numerous subcul- avoid the pitfalls of the drug-using lifestyle
tures can exist within any culture; thus, gener- (e.g., getting arrested, running out of money to
alizations about various population groups buy drugs). Perhaps most importantly, the
should be avoided. person who uses gains acceptance from a
group of peers even as mainstream society
Drug Cultures and the increasingly discriminates against him or her
because of his or her substance use or mental
Culture of Recovery illness. Prejudice from mainstream society may
This TIP emphasizes the concept that many make ties with the drug culture even stronger;
subcultures exist within and across diverse he or she may feel as if there is no other place
ethnic and racial populations and cultures. to turn for social and cultural support.
Drug cultures are a formidable example—they Within a treatment program, an understand-
can influence the presentation of mental, ing of drug cultures will help providers engage
substance use, and co-occurring disorders new clients and recognize the social and cul-
while also affecting prevention and treatment tural bonds that might lead them back to
strategies and outcomes. Drug cultures differ substance use or other high-risk behaviors that
from the types of cultures discussed in the rest are contraindicated for individuals who are
of this TIP, but they do share some common being treated for psychological symptoms
features. For instance, there is not a single and/or mental illness. However, unlike other
drug culture in the United States today, but types of cultural affiliations, the treatment
rather, a number of distinct (although some- provider’s relationship to the drug culture does
times related) drug cultures that differ accord- not just involve understanding; the provider
ing to substances used, geographic location, must actively work to weaken that connection
socioeconomic status, and other factors. Drug and replace it with other experiences that meet
cultures focusing on illicit substances may be the client’s social and cultural needs. In many
of greater importance in the lives of people cases, this involves helping the client connect
who use substances, but people who use legal with a “culture of recovery” to meet those
substances, such as alcohol, can also partici- needs over the long course of recovery.
pate in a drug culture. For example, people
who drink heavily at a bar or fraterni- In sum, this TIP was written to help counse-
ty/sorority house can develop their own drug lors and organizations provide culturally re-
culture that works to encourage new people to sponsive services. Practices and procedures
use, supports high levels of continued use or that improve one’s cultural competence will
binge use, and reinforces denial. likely result in better outcomes for clients in
treatment for mental and substance use disor-
Understanding the role that drug cultures play ders. Culturally competent counseling can
in clients’ lives is particularly important be- improve counselor credibility, client satisfac-
cause these cultures, more than any other tion, and client self-disclosure while increasing
cultural connections, influence clients’ sub- clients’ willingness to continue in treatment.
stance use or abuse and the behaviors in which
they engage to manage mental disorders.
Through drug cultures, people new to using

xxi
 1 Introduction to Cultural
Competence

Hoshi was born and grew up in Japan. He has been living in the
IN THIS CHAPTER United States for nearly 20 years, going to graduate school and
• Purpose and Objectives working as a systems analyst, while his family has remained in
of the TIP Japan. Hoshi entered a residential treatment center for alcohol
• Core Assumptions dependence where the treatment program expected every client to
• What Is Cultural notify his or her family members about being in treatment. This
Competence? had proven to be a positive step for many other clients and their
• Why Is Cultural families in this treatment program, where the belief was that con-
Competence Important? tact with family helped clients become honest about their sub-
• How Is Cultural stance abuse, reconnect with possibly estranged relatives, and take
Competence Achieved? responsibility for the decision to seek treatment.
• What Is Culture? He was reluctant, but staff members persuaded Hoshi to comply
• What Is Race? with program expectations. He wrote to his family, describing his
• What Is Ethnicity? current life and explaining his need for treatment. It was not until
• What Is Cultural Identity? weeks later, after he had been discharged from residential treat-
• What Are the Cross- ment and was participating in the program’s continuing care pro-
Cutting Factors in Race, gram, that he received a reply. Staff members were shocked to learn
Ethnicity, and Culture? that Hoshi’s parents had disowned him because he had “shamed”
• As You Proceed the family by disclosing the details of his life to the program staff,
publicly admitting that he had a drinking problem.
As Hoshi’s story demonstrates, a well-meaning but culturally inap-
propriate intervention can be counterproductive to recovery. The
program applied a “one size fits all” model without being sensitive
to the possibility that such an approach might harm the client.
Fortunately, Hoshi eventually reconciled with his family, and the
program administration and staff began to develop initiatives to
improve their cultural awareness and competence.
Counselors and other behavioral health service providers who are
equipped with a general understanding of how culture affects their

1
 Improving Cultural Competence

own worldviews as well as those of their cli- support allows counselors, case managers, and
ents will be able to work more effectively with administrators to begin to integrate culturally
clients who have substance use and mental congruent and responsive services more con-
disorders. Even when culture is not a con- sistently across the continuum of care—
scious consideration in providing interventions including outreach and early intervention,
and services, it is a dynamic force that often assessment, treatment planning and interven-
influences client responses to treatment and tion, and recovery services.
subsequent outcomes. Although outcome
The key objectives of this TIP are helping
research is limited, culturally responsive be-
readers understand:
havioral health counseling results in greater
• Why it is important for behavioral health
counselor credibility, better client satisfaction,
organizations and counselors who provide
more client self-disclosure, and greater will-
prevention and treatment services to con-
ingness among clients to continue with coun-
sider culture.
seling (Goode et al. 2006; Lie et al. 2011;
Ponterotto et al. 2000). This Treatment • The role culture plays in the treatment
Improvement Protocol (TIP) examines the process, both generally and with reference
significance of culture in substance abuse to specific cultural groups.
patterns, mental health, treatment-seeking
behaviors, assessment and counseling process-
Intended Audience
es, program development, and organizational The primary audiences for this TIP are pre-
practices in behavioral health services. vention professionals, substance abuse counse-
lors, mental health clinicians, and other
behavioral health service providers and admin-
Purpose and Objectives of istrators. Those who work with culturally
the TIP diverse populations will find it particularly
useful, though all behavioral health workers—
This TIP is intended to help counselors and regardless of their client populations—can
behavioral health organizations make progress benefit from an awareness of the importance
toward cultural competence. Gaining cultural of culture in shaping their own perceptions as
competence, like any important counseling well as those of their clients. Secondary audi-
skill, is an ongoing process that is never com- ences include educators, researchers, policy-
pleted; such skills cannot be taught in any makers for treatment and related services,
single book or training session. Nevertheless, consumers, and other healthcare and social
this TIP provides a framework to help practi- service professionals who work with clients
tioners and administrators integrate cultural who have behavioral health disorders.
factors into their evaluation and treatment of
clients with behavioral health disorders. It also Structure of the TIP
seeks to motivate professionals and organiza- This TIP focuses on the essential ingredients
tions to examine and broaden their cultural for developing cultural competence as a coun-
awareness, embrace diversity, and develop a selor and for providing culturally responsive
heightened respect for people of all cultural services in clinical settings as an organization.
groups. This TIP places significant im- Chapter 1 defines cultural competence, pre-
portance on the role of program management sents a rationale for pursuing it, and describes
and organizational commitment in the devel- the process of becoming culturally competent
opment of cultural competence. Organizational and responsive to client needs. The chapter

2
 Chapter 1—Introduction to Cultural Competence

highlights the consensus panel’s core assump- Terminology

tions. It introduces a framework, adapting Throughout the TIP, the term substance abuse
Sue’s (2001) multidimensional model of cul- is used to refer to both substance abuse and
tural competence as the guiding model across substance dependence. This term was chosen
chapters. The initial chapter ends with a broad partly because substance abuse treatment
overview of the concepts integral to an under- professionals commonly use the term sub-
standing of race, ethnicity, and culture. stance abuse to describe any excessive use of
Chapter 2 addresses the development of cul- addictive substances. In this TIP, the term
tural awareness and describes core competen- refers to use of alcohol as well as other sub-
cies for counselors and other clinical staff, stances of abuse. Readers should attend to the
beginning with self-knowledge and ending context in which the term occurs to determine
with skill development. It covers behaviors and what possible range of meanings it covers; in
skills for cultivating cultural competence as most cases, however, the term will refer to all
well as attitudes conducive to working effec- varieties of substance use disorders described
tively with diverse client populations. by the Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5;
Chapter 3 provides guidelines for culturally American Psychiatric Association, 2013).
responsive clinical services, including inter-
viewing skills, assessment practices, and treat- Throughout the TIP, the term behavioral
ment planning. health refers to a state of mental/emotional
being and/or choices and actions that affect
Chapter 4 provides organizational strategies to wellness. Behavioral health problems include
promote the development and implementation substance abuse or misuse, alcohol and drug
of culturally responsive practices from the top addiction, psychological distress, suicide, and
down, beginning with organizational self- mental and substance use disorders. This
assessment of current services and continuing includes a range of problems, from unhealthy
through implementation and oversight of an stress to diagnosable and treatable diseases like
organizational plan targeting initiatives to serious mental illness and substance use disor-
improve culturally responsive services. ders, which are often chronic in nature but
Chapter 5 provides a general introduction for from which people can and do recover. The
each major racial and ethnic group, providing term is also used in this TIP to describe the
specific cultural knowledge related to sub- service systems encompassing the promotion
stance use patterns, beliefs and attitudes to- of emotional health, the prevention of mental
ward help-seeking behavior and treatment, and substance use disorders, substance use and
and an overview of research- and practice- related problems, treatments and services for
based treatment approaches and interventions. mental and substance use disorders, and re-
covery support. Behavioral health conditions,
Chapter 6 closes the TIP with an exploration taken together, are the leading causes of disa-
of the concept of “drug culture”—the relation- bility burden in North America; efforts to
ship between the drug culture and mainstream improve their prevention and treatment will
culture, the values and rituals of drug cultures, benefit society as a whole. Efforts to reduce
how people “benefit” from participation in the impact of mental and substance use disor-
drug cultures, and the role of the drug culture ders on communities in the United States,
in substance abuse treatment. such as those described in this TIP, will help
achieve nationwide improvements in health.

3
 Improving Cultural Competence

importance of cultural competence in the

Core Assumptions delivery of effective behavioral health services.
The consensus panel developed assumptions
Assumption 3: Incorporating cultural compe-
that serve as the fundamental platform of this
tence into treatment improves therapeutic
TIP. Assumptions were derived from clinical
decision-making and offers alternate ways to
and administrative experiences, available
define and plan a treatment program that is
empirical evidence, conceptual writings, and
firmly directed toward progress and recov-
program and treatment service models.
ery—as defined by both the counselor and
Assumption 1: The focus of cultural compe- client. Using culturally responsive practices is
tence, in practice, has historically been on essential and provides many benefits for or-
individual providers. However, counselors will ganizations, staff, communities, and clients.
not be able to sustain culturally responsive
Assumption 4: Consideration of culture is
treatment without the organization’s commit-
important at all levels of operation—
ment to support and allocate resources to
individual, programmatic, and organization-
promote these practices. Organizations that
al—across behavioral health treatment set-
value diversity and reflect cultural competence
tings. It is also important in all activities and
through congruent policies and procedures are
at every treatment phase: outreach, initial
more likely to be successful in the ever-
contact, screening, assessment, placement,
changing landscape of communities, treatment
treatment, continuing care and recovery ser-
services, and individual client needs.
vices, research, and education. Because organi-
Assumption 2: An understanding of race, zations and systems have their own internal
ethnicity, and culture (including one’s own) is cultures, it is vital that treatment facilities,
necessary to appreciate the diversity of human training and educational programs on
dynamics and to treat all clients effectively. substance-related and mental disorders and
Before counselors begin to probe the cultures, treatment processes, and licensing agencies
races, and ethnicities of their clients and use and accrediting bodies incorporate culturally
this information to improve client treatment, responsive practices into their curricula, stand-
the consensus panel recommends first that ards, criteria, and requirements.
counselors examine and understand their own
Assumption 5: Achieving cultural compe-
cultural histories, racial and ethnic heritages,
tence in an organization requires the partici-
and cultural values and beliefs. This applies to
pation of racially and ethnically diverse groups
all practitioners regardless of race, ethnicity, or
and underserved populations in the develop-
cultural identity. Beyond that, clinicians
ment and implementation of culturally re-
should clearly identify the influences of their
sponsive practices, program structure and
own cultural experiences on the counseling
design, treatment strategies and approaches,
relationship. In other words, each counselor
and staff professional development. Culturally
must understand, embrace, and, if warranted,
congruent interventions cannot be successfully
reexamine and adjust his or her own world-
applied when generated outside a community
view to practice in a culturally competent
or without community participation. Clients,
manner. So too, all support staff, clinicians,
potential clients, their families, and their com-
administrators, and policymakers—including
munities should be invited to participate in the
those not from the mainstream culture—
development of a cultural competence plan (an
must become educated and convinced of the

4
 Chapter 1—Introduction to Cultural Competence

organization’s plan to improve cultural compe- among professionals that enables effective
tence and to provide culturally responsive work in cross-cultural situations. ‘Culture’ re-
fers to integrated patterns of human behavior
services) and, subsequently, the design of
that include the language, thoughts, communi-
culturally relevant treatment services and cations, actions, customs, beliefs, values, and
organizational policies and procedures. institutions of racial, ethnic, religious, or social
groups. ‘Competence’ implies having the ca-
Assumption 6: Public advocacy of culturally pacity to function effectively as an individual
responsive practices can increase trust among and an organization within the context of the
the community, agency, and staff. The com- cultural beliefs, behaviors, and needs presented
munity is thus empowered with a voice in by consumers and their communities. (p. 28)
organizational operations. Advocacy can Numerous evolving definitions and models of
further function as a secondary form of public cultural competence reflect an increasingly
education and awareness as well as outreach. complex and multidimensional view of how
High collective participation allows treatment race, ethnicity, and culture shape individu-
to be viewed as of and for the community. als—their beliefs, values, behaviors, and ways
of being (see Bhui et al. 2007 for a systemic
What Is Cultural review of cultural competence models in
mental health). In this TIP, Sue’s (2001)
Competence? multidimensional model of cultural compe-
In 1989, Cross et al. provided one of the more tence guides its overall organization and the
universally accepted definitions of cultural specific content of each chapter. The model
competence in clinical practice: “A set of was adapted to fit the unique topic areas
congruent behaviors, attitudes, and policies addressed by this TIP (Exhibit 1-1) and to
that come together in a system, agency, or target essential elements of cultural compe-
among professionals and enable the system, tence in providing behavioral health services
agency, or professionals to work effectively in across three main dimensions, as shown in the
cross-cultural situations” (p. 13). cube. (Note: Each subsequent chapter displays
a version of this cube shaded to emphasize the
Since then, others have interpreted this defini- focus of that chapter.)
tion in terms of a particular field or attempted
to refine, expand, or elaborate on earlier con- Dimension 1: Racially and
ceptions of cultural competence. At the root Culturally Specific Attributes
of this concept is the idea that cultural compe-
Exhibit 1-1 and this TIP focus on main popu-
tence is demonstrated through practical
lation groups as identified by the U.S. Census
means—that is, the ability to provide effective
Bureau (Humes et al. 2011), but this dimen-
services. Bazron and Scallet (1998) defined
sion is inclusive of other multiracial and cul-
culturally responsive services as those that are
turally diverse groups and can also include
“responsive to the unique cultural needs of
sexual orientation, gender orientation, socioec-
bicultural/bilingual and culturally distinct
onomic status, and geographic location. There
populations” (p. 2). The Office of Minority
are often many cultural groups within a given
Health (OMH 2000) merged several existing
population or ethnic heritage. For simplicity,
definitions to conclude that:
these groups are not represented on the actual
Cultural and linguistic competence is a set of model, and it is assumed that the reader
congruent behaviors, attitudes, and policies acknowledges the vast inter- and intragroup
that come together in a system, agency, or variations that exist in all population, ethnic,

5
 Improving Cultural Competence

Exhibit 1-1: Multidimensional Model for Developing Cultural Competence

and cultural groups. Refer to Chapters 5 and 6 skills that ensure delivery of culturally appro-
to gain further clinical knowledge about spe- priate treatment interventions. Several chap-
cific racial, ethnic, and cultural groups. ters capture the ingredients of this dimension.
Chapter 1 provides an overview of cultural
Dimension 2: Core Elements of competence and concepts, Chapter 2 provides
Cultural Competence an indepth look at the role and effects of the
This dimension includes cultural awareness, counselor’s cultural awareness and identity
cultural knowledge, and cultural skill devel- within the counseling process, Chapter 3
opment. To provide culturally responsive provides an overview of cultural considerations
treatment services, counselors, other clinical and essential clinical skills in the assessment
staff, and organizations need to become aware and treatment planning process, and Chapter
of their own attitudes, beliefs, biases, and 5 specifically addresses the role of culture
assumptions about others. Providers need to across specific treatment interventions.
invest in gaining cultural knowledge of the
populations that they serve and obtaining Dimension 3: Foci of Culturally
specific cultural knowledge as it relates to Responsive Services
help-seeking, treatment, and recovery. This This dimension targets key levels of treatment
dimension also involves competence in clinical services: the individual staff member level, the

6
 Chapter 1—Introduction to Cultural Competence

clinical and programmatic level, and the or- ing translation and interpreter services. For
ganizational and administrative level. Inter- clients, culturally responsive services honor the
ventions need to occur at each of these levels beliefs that culture is embedded in the clients’
to endorse and provide culturally responsive language and their implicit and explicit com-
treatment services, and such interventions are munication styles and that language-
addressed in the following chapters. Chapter 2 accommodating services can have a positive
focuses on core counselor competencies; effect on clients’ responses to treatment and
Chapter 3 centers on clinical/program attrib- subsequent engagement in recovery services.
utes in interviewing, assessment, and treat-
The Affordable Care Act, along with growing
ment planning that promote culturally
recognition of racial and ethnic health dispari-
responsive interventions; and Chapter 4 ad-
ties and implementation of national initiatives
dresses the elements necessary to improve
to reduce them (HHS 2011b), necessitates
culturally responsive services within treatment
enhanced culturally responsive services and
programs and behavioral health organizations.
cultural competence among providers. Most
behavioral health studies have found dispari-
Why Is Cultural ties in access, utilization, and quality in behav-
Competence Important? ioral health services among diverse ethnic and
racial groups in the United States (Alegria et
Foremost, cultural competence provides clients al. 2008b; Alegria et al. 2011; HHS 2011b; Le
with more opportunities to access services that Cook and Alegria 2011; Satre et al. 2010).
reflect a cultural perspective on and alternative, The lack of cultural knowledge among provid-
culturally congruent approaches to their pre- ers, culturally responsive environments, and
senting problems. Culturally responsive ser- diversity in the workforce contribute to dis-
vices will likely provide a greater sense of parities in healthcare. Even limited cultural
safety from the client’s perspective, supporting competence is a significant barrier that can
the belief that culture is essential to healing. translate to ineffective provider–consumer
Even though not all clients identify with or communication, delays in appropriate treat-
desire to connect with their cultures, culturally ment and level of care, misdiagnosis, lower
responsive services offer clients a chance to rates of consumer compliance with treatment,
explore the impact of culture (including his- and poorer outcome (Barr 2008; Carpenter-
torical and generational events), acculturation, Song et al. 2011; Dixon et al. 2011). Increas-
discrimination, and bias, and such services also ing the cultural competence of the healthcare
allow them to examine how these impacts workforce and across healthcare settings is
relate to or affect their mental and physical crucial to increasing behavioral health equity.
health. Culturally responsive practice recog-
nizes the fundamental importance of language Additionally, adopting and integrating cultur-
and the right to language accessibility, includ- ally responsive policies and practices into

What Are Health Disparities?

A health disparity is a particular type of health difference closely linked with social, economic, and/or
environmental disadvantage. Health disparities adversely affect groups of people who have systemat-
ically experienced greater obstacles to health based on their racial or ethnic group; religion; socioec-
onomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual or gender
orientation; geographic location; or other characteristics historically tied to discrimination or exclusion.

Source: U.S. Department of Health and Human Services (HHS) 2011a.

7
 Improving Cultural Competence

behavioral health services provides many establish community involvement in the ongo-
benefits not only for the client, but also for the ing implementation of culturally responsive
organization and its staff. Foremost, it increas- services, the community will be more aware of
es the likelihood of sustainability. Cultural available treatment services and thus will
competence supports the viability of services become more likely to use them as its in-
by bringing to the forefront the value of diver- volvement with and trust for the organization
sity, flexibility, and responsiveness in organiza- grows. Likewise, clients and staff are more apt
tions and among practitioners. Beyond the to be empowered and invested if they are
necessity of adopting culturally responsive involved in the ongoing development and
practices to meet funding, state licensing, delivery of culturally responsive services. Cli-
and/or national accreditation requirements, ent and staff satisfaction can increase if organ-
cultural competence essential in organizational izations provide culturally congruent
risk management (the process of making and treatment services and clinical supervision.
implementing decisions that will optimize
An organization also benefits from culturally
therapeutic outcomes and minimize adverse
responsive practices through planning for,
effects upon clients and, ultimately, the organ-
attracting, and retaining a diverse workforce
ization). For instance, implementing culturally
that reflects the multiracial and multiethnic
responsive services is likely to increase access
heritages and cultural groups of its client base
to care and improve assessment, treatment
and community. Developing culturally respon-
planning, and placement. So too, it is likely to
sive organizational policies includes hiring and
enhance effective communication between
promotional practices that support staff diver-
clients and treatment providers, thus decreas-
sity at all levels of the organization, including
ing risks associated with misunderstanding the
board appointments. Increasing diversity does
clients’ presenting problems or the needs of
not guarantee culturally responsive practices,
clients with regard to appropriate referrals for
but it is more likely that doing so will lead to
evaluation or treatment.
broader, varied treatment services to meet
Organizational investment in improving client and community needs. Organizations
cultural competence and increasing culturally are less able to ignore the roles of race, ethnici-
responsive services will likely increase use and ty, and culture in the delivery of behavioral
cost effectiveness because services are more health services if staff composition at each
appropriately matched to clients from the level of the organization reflects this diversity.
beginning. A key principle in culturally re-
Culturally responsive practice reinforces the
sponsive practices is engagement of the com-
counselor’s need for self-exploration of cultur-
munity, clients, and staff. As organizations
al identity and awareness and the importance
of acquiring knowledge and skills to meet
The Enhanced National Standards for clients’ specific cultural needs. Cultural com-
Culturally and Linguistically Appropriate
petence requires an understanding of the
Services in Health and Health Care (OMH
client’s worldview and the interactions be-
2013) are meant to reduce and eliminate
disparities, improve quality of care, and tween that worldview and the cultural identi-
promote health equality by establishing a ties of the counselor and the client in the
blueprint for health and the organization therapeutic process. Culturally responsive
of health care (see Appendix C or visit practice reminds counselors that a client’s
http://www.thinkculturalhealth.hhs.gov). worldview shapes his or her perspectives,

8
 Chapter 1—Introduction to Cultural Competence

beliefs, and behaviors surrounding substance changing an organization’s mission statement,

use and dependence, illness and health, seek- or attending a training on cultural compe-
ing help, treatment engagement, counseling tence. Becoming culturally competent is a
expectations, communication, and so on. developmental process that begins with
Cultural competence includes addressing the awareness and commitment and evolves into
client individually rather than applying gen- skill building and culturally responsive behav-
eral treatment approaches based on assump- ior within organizations and among providers.
tions and biases. It also can counteract a
Cultural competence is the ability to recognize
potentially omnipotent stance on the part of
the importance of race, ethnicity, and culture
counselors that they know what clients need
in the provision of behavioral health services.
more than the clients themselves do. Cultural
Specifically, it is awareness and acknowledg-
competence highlights the need for counselors
ment that people from other cultural groups
to take time to build a relationship with each
do not necessarily share the same beliefs and
of their clients, to understand their clients, and
practices or perceive, interpret, or encounter
to assess for and access services that will meet
similar experiences in the same way. Thus,
each client’s individual needs.
cultural competence is more than speaking
The importance and benefit of cultural com- another language or being able to recognize
petence does not end with changes in organi- the basic features of a cultural group. Cultural
zational policies and procedures, increases in competence means recognizing that each of
program accessibility and tailored treatment us, by virtue of our culture, has at least some
services, or enhancement of staff training. In ethnocentric views that are provided by that
programs that prioritize and endorse cultural culture and shaped by our individual interpre-
competence at all levels of service, clients, too, tation of it. Cultural competence is rooted in
will have more exposure to psychoeducational respect, validation, and openness toward
and clinical experiences that explore the roles someone whose social and cultural back-
of race, ethnicity, culture, and diversity in the ground is different from one’s own (Center for
treatment process. Treatment will help clients Substance Abuse Treatment [CSAT] 1999b).
address their own biases, which can affect
Nonetheless, cultural competence literature
their perspectives and subsequent relationships
highlights how difficult it is to appreciate
with other clients, staff members, and individ-
cultural differences and to address these dif-
uals outside of the program, including other
ferences effectively, because many people tend
people in recovery. Culturally responsive
to see things solely from their own culture-
services prepare clients not only to embrace
bound perspectives. For counselors, specific
their own cultural groups and life experiences,
cognitions, attitudes, and behaviors character-
but to acknowledge and respect the experienc-
ize the path to culturally competent counsel-
es, perspectives, and diversity of others.
ing and culturally responsive services. Exhibit
1-2 depicts the continuum of thoughts and
How Is Cultural behaviors that lead to cultural competence in
Competence Achieved? the provision of treatment. The “stages” are
not necessarily linear, and not all people begin
Cultural groups are diverse and continuously with a negative impression of other cultural
evolving, defying precise definitions. Cultural groups—they may simply fail to recognize
competence is not acquired merely by learning differences and diverse ways of being. For
a given set of facts about specific populations,

9
 Improving Cultural Competence

Exhibit 1-2: The Continuum of Cultural Competence

Stage 1: Cultural Destructiveness

Organizational Level: At best, the behavioral health organization negates the relevance of culture in
the delivery of behavioral health services. Agencies expect individuals from diverse ethnic and cultural
backgrounds to fit into the existing treatment program rather than adapting the program to each
client to provide culturally congruent services. Driving this expectation is the attitude that mainstream
culture and current services are superior and that other approaches (e.g., Native American traditional
healing practices) need not be considered. Organizations can also take a more adversarial role at this
level—failing to provide basic services, creating an uncomfortable environment to covertly discourage
the use of services, or expecting the individual to leave culture at the door.

Individual Level: Counselors can also operate from this stance, holding a myopic view of “effective”
treatment. However, it would likely be difficult to operate at this level as a counselor without organiza-
tional endorsement. Counselors can project superiority by stating with authority and conviction in
sessions that their approach is the best and expressing directly to clients that they should be grateful
to receive these services. At the same time, these counselors filter interactions through a biased lens
without engaging in self-reflection or examination of the impact of their prejudice.
Stage 2: Cultural Incapacity
Organizational Level: Due to lack of organizational responsiveness, services and organizational culture
may be biased, and clients may view them as oppressive. An agency functioning at cultural incapacity
expects clients from diverse backgrounds to conform to services rather than the agency being flexible
and adapting services to meet client needs. Treatment of diverse individuals is often paternalistic,
limiting their active participation in treatment planning or minimizing the need for culturally congruent
treatment services.
Individual Level: Counselors ignore the relevance of culture while using the dominant client popula-
tion and/or culture as the norm for assessment, treatment planning, and determination of services. At
this level, counselors can be aware of the need to approach treatment differently but likely believe that
they are powerless over circumstances or the organizational system.
Stage 3: Cultural Blindness
Organizational Level: The core belief that perpetuates cultural blindness is the assumption that all
cultural groups are alike and have similar experiences. Taking the position that individuals across
cultural groups are more alike than different, organizations can rationalize that “good” treatment
services will suffice for all clients regardless of ethnicity, race, religion, sexual orientation, national
origin, or class. Consequently, organizations that operate at this level will continue developing and
implementing policies and procedures that propagate discrimination.
Individual Level: At this stage, counselors uphold the belief that there are no essential differences
among individuals across cultural groups—that everyone experiences discrimination and is subject to
the biases of others. Counselors rationalize that approaching all clients as individuals negates the need
to focus specifically on cultural competence. For example, some counselors may believe that there is
(Continued on the next page.)

10
 Chapter 1—Introduction to Cultural Competence

Exhibit 1-2: The Continuum of Cultural Competence (continued)

too much focus on cultural competence and that training in this area has become the “pop culture” in
the counseling field, or they may feel that too much time is spent on cultural issues when a good
assessment addressing individual issues and needs would suffice.
Stage 4: Cultural Precompetence
Organizational Level: Organizations at this stage begin to develop a basic understanding of and
appreciation for the importance of sociocultural factors in the delivery of care. Similar to the prepara-
tion stage identified in the stages of change model (Prochaska et al. 1992; Miller and Rollnick 2013),
this level involves recognition of the need for more culturally responsive services, further exploration of
steps toward creating more appropriate services for culturally diverse populations, and a general
commitment characterized by small organizational changes. Despite having incomplete knowledge,
agencies at this stage can evolve toward organizational cultural competence with support, planning,
and commitment from the governing and advisory boards, community, and administrators.
Individual Level: Counselors acknowledge a need for more training specific to the populations they
serve at this level of development. They acknowledge the need to attend more to ethnicity, race, and
culture in the provision of services, but they probably lack the information and skills necessary to
translate their recognition into behavioral change. Even so, they are open to training, recognize the
importance of developing cultural competence, and have taken small steps to improve their clinical
knowledge.
Stage 5: Cultural Competence and Proficiency
Organizational Level: Organizations are aware of the importance of integrating services that are
congruent with diverse populations. Organizations understand that a commitment to cultural compe-
tence begins with strategic planning to conduct an organizational self-assessment and adopt a cultural
competence plan. There is a willingness to be more transparent in evaluating current services and
practices and in developing policies and practices that meet the diverse needs of the treatment popu-
lation and the community at large. Proficiency on an organizational level is characterized by an ongo-
ing commitment to workforce development, training, and evaluation; development of culturally
specific and congruent services; and continual performance evaluation and improvement.
Individual Level: Recognition of the vital need to adopt culturally responsive practices is present.
Counselors acknowledge significant differences across and within races, ethnicities, and cultural
groups, and they know that these differences need to be integrated into assessment, treatment plan-
ning, and services. At this stage, counselors are committed to an ongoing process of becoming cultur-
ally competent.
Sources: Comas-Diaz 2012; Cross et al. 1989; Sue and Constantine 2005.

most people, the process of becoming cultural- and values concerning the nature of relation-
ly competent is complex, with movement back ships, the way people live their lives, and the
and forth along the continuum and with way people organize their environments.
feelings and thoughts from more than one Culture is a complex and rich concept. Under-
stage sometimes existing concurrently. standing it requires a willingness to examine
and grasp its many elements and to compre-
What Is Culture? hend how they come together. Castro (1998)
identified the elements generally agreed to
Culture is defined by a community or society. constitute a culture as:
It structures the way people view the world. It • A common heritage and history that is
involves the particular set of beliefs, norms, passed from one generation to the next.

11
 Improving Cultural Competence

• Shared values, beliefs, customs, behaviors, more or less equally well to cultural groups
traditions, institutions, arts, folklore, and based on nationality, ethnicity, region (e.g.,
lifestyle. Southern, Midwestern), profession, and social
• Similar relationship and socialization interests (Exhibit 1-3 reviews common char-
patterns. acteristics of culture).
• A common pattern or style of communica-
However, culture is not a definable entity to
tion or language.
which people belong or do not belong. Within
• Geographic location of residence (e.g.,
a nation, race, or community, people belong to
country; community; urban, suburban, or
multiple cultural groups, each with its own set
rural location).
of cultural norms (i.e., spoken or unspoken
• Patterns of dress and diet.
rules or standards that indicate whether a
Although these criteria cannot be strictly certain behavior, attitude, or belief is appropri-
applied to every cultural group, they do suffi- ate or inappropriate).
ciently define cultures so that groups are
distinguishable to their members and to others The word “culture” can be applied to describe
(Castro 1998). Note that these criteria apply the ways of life of groups formed on the bases

Exhibit 1-3: Common Characteristics of Culture

The following list provides examples of common elements that distinguish one culture from another.
Not every cultural group will define or endorse every item on this list, but most cultural groups will
uphold the most common characteristics, which include:
• Identity development (multiple identities and self-concept).
• Rites of passage (rituals and rites that mark specific developmental milestones).
• Broad role of sex and sexuality.
• Images, symbols, and myths.
• Religion and spirituality.
• View, use, and sources of power and authority.
• Role and use of language (direct or implied).
• Ceremonies, celebrations, and traditions.
• Learning modalities, acquisition of knowledge and skills.
• Patterns of interpersonal interaction (culturally idiosyncratic behaviors).
• Assumptions, prejudices, stereotypes, and expectations of others.
• Reward or status systems (meaning of success, role models, or heroes).
• Migration patterns and geographic location.
• Concepts of sanction and punishment.
• Social groupings (support networks, external relationships, and organizational structures).
• Perspectives on the role and status of children and families.
• Patterns and perspectives on gender roles and relationships.
• Means of establishing trust, credibility, and legitimacy (appropriate protocols).
• Coping behaviors and strategies for mediating conflict or solving problems.
• Sources for acquiring and validating information, attitudes, and beliefs.
• View of the past and future, and the group’s or individual’s sense of place in society and the
world.
• History and other past circumstances that have contributed to a group’s current economic,
social, and political status within the broader culture as well as the experiences associated with
developing certain beliefs, norms, and values.

Sources: American Psychological Association (APA) 1990; Center for Substance Abuse Prevention
1994; Charon 2004; Dogra and Karim 2010.

12
 Chapter 1—Introduction to Cultural Competence

of age, profession, socioeconomic status, disa- American Indian/Alaska Native, and Native
bility, sexual orientation, geographic location, Hawaiian/Pacific Islander—are limiting in
membership in self-help support groups, and that they are categories developed to describe
so forth. In this TIP, with the exception of the identifiable populations that exist currently
drug culture, the focus is on cultural groups within the United States. The U.S. Census
that are shaped by a dynamic interplay among defines Hispanics/Latinos as an ethnic group
specific factors that shape a person’s identity, rather than a racial group (see the “What Is
including race, ethnicity, religion, socioeco- Ethnicity?” section later in this chapter).
nomic status, and others.
Racial labels do not always have clear meaning
in other parts of the world; how one’s race is
What Is Race? defined can change according to one’s current
Race is often thought to be based on genetic environment or society. A person viewed as
traits (e.g., skin color), but there is no reliable Black in the United States can possibly be
means of identifying race based on genetic viewed as White in Africa. Racial categories
information (HHS 2001). Indeed, 85 percent also do not easily account for the complexity
of human genetic diversity is found within any of multiracial identities. An estimated 3 per-
“racial” group (Barbujani et al. 1997). Thus, cent of United States residents (9 million
what we perceive as diverse races (based largely individuals) indicated in the 2010 Census that
on selective physical characteristics, such as they are of more than one race (Humes et al.
skin color) are much more genetically similar 2011). The percentage of the total United
than they are different. Moreover, physical States population who identify as being of
characteristics ascribed to a particular racial mixed race is expected to grow significantly in
group can also appear in people who are not in coming years, and some estimate that it will
that group. Asians, for example, often have an rise as high as one in five individuals by 2050
epicanthic eye fold, but this characteristic is (Lee and Bean 2004).
also shared by the Kung San bushmen, an White Americans constitute the largest racial
African nomadic Tribe (HHS 2001). group in the United States. In the 2010
Although it lacks a genetic basis, the concept Census, 72 percent of the United States popu-
of race is important in discussing cultural lation consisted of non-Hispanic Whites, a
competence. Race is a social construct that classification that has been used by the Census
describes people with shared physical charac- Bureau and others to refer to non-Hispanic
teristics. It can have tremendous social signifi- people of European, North African, or Middle
cance in terms of behavioral health services, Eastern descent (Humes et al. 2011). The U.S.
social opportunities, status, wealth, and so on. Census Bureau predicts, however, that White
The perception that people who share physical Americans will be outnumbered by persons of
characteristics also share beliefs, values, atti- color sometime between the years 2030 and
tudes, and ways of being can have a profound 2050. The primary reasons for the decreasing
impact on people’s lives regardless of whether proportion of White Americans are immigra-
they identify with the race to which they are tion patterns and lower birth rates among
ascribed by themselves or others. The major Whites relative to Americans of other racial
racial groupings designated by the U.S. Census backgrounds (Sue and Sue 2003b).
Bureau—African American or Black, White Whites are often referred to collectively as
American or Caucasian, Asian American, Caucasians, although technically, the term

13
 Improving Cultural Competence

refers to a subgroup of White people from the The racial category of Asian is defined by the
Caucasus region of Eastern Europe and West U.S. Census Bureau (2001a) as people “having
Asia. To complicate matters, some Caucasian origins in any of the original peoples of the
people—notably some Asian Indians—are Far East, Southeast Asia, or the Indian sub-
typically counted as Asian (U.S. Census continent including, for example, Cambodia,
Bureau 2001a). Many subgroups of White China, India, Japan, Korea, Malaysia, Pakistan,
Americans (of European, Middle Eastern, or the Philippine Islands, Thailand, and Vietnam”
North African descent) have had very differ- (p. A-3). In the 2010 census, Asian Americans
ent experiences when immigrating to the accounted for 4.8 percent of the total United
United States. States population, or 5.6 percent when biracial
or multiracial Asians were included (Hoeffel
African Americans, or Blacks, are the second
et al. 2012). For those who identified with
largest racial group in the United States, mak-
only one Asian group, 23 percent of Asian
ing up about 13 percent of the United States
Americans were Chinese; 19 percent, Asian
population in 2010 (Humes et al. 2011).
Indian; 17 percent, Filipino; 11 percent,
Although most African Americans trace their
Vietnamese; 10 percent, Korean; and 5 per-
roots to Africans brought to the Americas as
cent, Japanese. Asian Americans comprised
slaves centuries ago, an increasing number are
about 43 ethnic subgroups, speaking more
new immigrants from Africa and the Caribbe-
than 100 languages and dialects (HHS 2001).
an. The terms African American and Black
The tremendous cultural differences among
are used synonymously at times in literature
these groups make generalizations difficult.
and research, but some recent immigrants do
not consider themselves to be African Until recently, Asian Americans were often
Americans, assuming that the designation grouped with Pacific Islanders (collectively
only applies to people of African descent born called Asians and Pacific Islanders, or APIs)
in the United States. The racial designation for data collection and analysis. Beginning
Black, however, encompasses a multitude of with the 2000 Census, however, the Federal
cultural and ethnic variations and identities Government recognized Pacific Islanders as a
(e.g., African Caribbean, African Bermudian, distinct racial group. As a result, this TIP does
West African, etc.). The history and experi- not combine Asians with Pacific Islanders.
ence of African Americans has varied consid- Nonetheless, remnants of the old classification
erably in different parts of the United States, system are evident in research based on the
and the experience of Black people in this API grouping. Where possible, the TIP uses
country varies even more when the culture and data solely for Asians; however, in some cases,
history of more recent immigrants is consid- the only research available is for the combined
ered. Today, African American culture embod- API grouping.
ies elements of Caribbean, Latin American,
Native American is a term that describes both
European, and African cultural groups. Not-
American Indians and Alaska Natives. Racially,
ing this diversity, Brisbane (1998) observed
Native Americans are related to Asian peoples
that “these cultures are so unique that practices
(notably, those from Siberia in Russia), but
of some African Americans may not be un-
they are considered a distinct racial category
derstood by other African Americans…there
by the U.S. Census Bureau, which further
is no one culture to which all African
stipulates that people categorized in this
Americans…belong” (p. 2).
fashion have to have a “Tribal affiliation

14
 Chapter 1—Introduction to Cultural Competence

or community attachment” (U.S. Census Bu-

reau 2001a, p. A-3). There are 566 federally Ethnicity differs from race in that groups of
people can share a common racial ancestry
recognized American Indian or Alaska Native
yet have very different ethnic identities.
Tribal entities (U.S. Department of the Interior, Thus, by definition, ethnicity—unlike race—
Indian Affairs 2013a), but there are numerous is an explicitly cultural phenomenon. It is
other Tribes recognized only by States and still based on a shared cultural or family herit-
others that go unrecognized by any govern- age as well as shared values and beliefs
ment agency. These Tribes, despite sharing a rather than shared physical characteristics.
racial background, represent a widely diverse
group of cultures with diverse languages, foreign-born population (Larsen 2004;
religions, histories, beliefs, and practices. Ramirez and de la Cruz 2003). Foreign-born
Latinos include legal immigrants, some of
whom have succeeded in becoming natural-
What Is Ethnicity? ized American citizens, as well as undocu-
The term ethnicity is sometimes used inter- mented or illegal immigrants to the United
changeably with “race,” although it is im- States. Approximately three-quarters (74
portant to draw distinctions between the two. percent) of the Nation’s unauthorized immi-
According to Yang (2000), ethnicity refers to grant population are Hispanics, mostly from
the social identity and mutual sense of belong- Mexico (Passel and Cohn 2008).
ing that defines a group of people through
common historical or family origins, beliefs, The terms “Hispanic” and “Latino” refer to
and standards of behavior (i.e., culture). In people whose cultural origins are in Spain or
some cases, ethnicity also refers to identifica- Portugal or the countries of the Western
tion with a clan or group whose identity can Hemisphere whose culture is significantly
be based on race as well as culture. Some influenced by Spanish or Portuguese coloniza-
Latinos, for example, self-identify in terms of tion. Regional and political differences exist
both their ethnicity (e.g., their Cuban herit- among various groups as to whether they
age) and their race (e.g., whether they are dark prefer one term over the other. The literature
or light skinned). currently uses both terms interchangeably, as
both terms are widely used and refer generally
Because Latinos can belong to a number of to the same Latin-heritage population of the
races, the Census Bureau defines them as an United States. That said, a distinction can
ethnic group rather than a race. In 2010, technically be drawn between Hispanic (liter-
Latinos comprised 16 percent of the United ally meaning people from Spain or its former
States population (Ennis et al. 2011). They are colonies) and Latino (which refers to persons
the fastest growing ethnic group in the United whose origins lie in countries ranging from
States; between 2000 and 2010, the number of Mexico to Central and South America and
Latinos in the country increased 43 percent, a the Caribbean, which were colonized by
rate nearly four times higher than that for the Spain, and including Portugal and its former
total population (Ennis et al. 2011). By 2050, colonies as well). For that reason, this TIP uses
Latinos are expected to make up 29 percent of the more inclusive term Latino, except when
the total population (Passel and Cohn 2008). research specifically indicates the other. The
Nearly 60 percent of Latino Americans were term Latinas is used to refer specifically to
born in the United States, but Latinos also women who are a part of this cultural group.
account for more than half of the nation’s

15
 Improving Cultural Competence

Within a racial group (e.g., Asian, White, can be more important than ethnic culture in
Black, Native American), there are many defining their sense of identity. The section
diverse ethnicities, and these diverse ethnici- that follows provides more detailed infor-
ties often reflect vast differences in cultural mation on the most important cross-cutting
histories. The White Anglo-Saxon Protestant factors involved in the creation of a person’s
peoples of England and Northern Europe cultural identity.
have, for example, many differing cultural
attributes and a very different history in the What Are the Cross-
United States than the Mediterranean peoples
of Southern Europe (e.g., Italians, Greeks). Cutting Factors in Race,
Ethnicity, and Culture?
What Is Cultural Identity?
Language and Communication
Cultural identity describes an individual’s
Language is a key element of culture, but
affiliation or identification with a particular
speaking the same language does not neces-
group or groups. Cultural identity arises
sarily mean that people share the same cultural
through the interaction of individuals and
beliefs. For example, English is spoken in
culture(s) over the life cycle. Cultural identities
Australia, Canada, Jamaica, India, Belize, and
are not static; they develop and change across
Nigeria, among other countries. Even within
stages of the life cycle. People reevaluate their
the United States, people from different re-
cultural identities and sometimes resist, rebel,
gions can have diverse cultural identities even
or reformulate them over time. All people,
though they speak the same language. Con-
regardless of race or ethnicity, develop a cul-
versely, those who share an ethnicity do not
tural identity (Helms 1995). Cultural identity
automatically share a language. Families who
is not consistent even among people who
immigrated to this country several generations
identify with the same culture. Two Korean
earlier may identify with their culture of origin
immigrants could both identify strongly with
but no longer be able to speak its language.
Korean culture but embrace or reject different
English is the most common language in the
elements of that culture based on their par-
United States, but 18 percent of the total
ticular life experiences (e.g., being raised in an
population report speaking a language other
urban or rural community, belonging to a
than English at home (Shin and Bruno 2003).
lower- or upper-class family). Cultural groups
may also place different levels of importance Styles of communication and nonverbal meth-
on various aspects of cultural identities. In ods of communication are also important
addition, individuals can hold two or more aspects of cultural groups. Issues such as the
cultural identities simultaneously. use of direct versus indirect communication,
appropriate personal space, social parameters
Some of the factors that are likely to vary
for and displays of physical contact, use of
among members of the same culture include
silence, preferred ways of moving, meaning of
socioeconomic status, geographic location,
gestures, degree to which arguments and
gender, education level, occupational status,
verbal confrontations are acceptable, degree of
sexuality, and political and religious affiliation.
formality expected in communication, and
For individuals whose families are highly
amount of eye contact expected are all cultur-
acculturated, some of these characteristics
ally defined and reflect very basic ethnic and
(e.g., geographic location, occupation, religion)
cultural differences (Comas-Diaz 2012;

16
 Chapter 1—Introduction to Cultural Competence

Franks 2000; Sue 2001). More specifically, the Americans (Franks 2000). Thus, African
relative importance of nonverbal messages Americans typically rely to a greater degree
varies greatly from culture to culture; high- than White Americans on nonverbal cues in
context cultural groups place greater im- communicating. Conversely, White American
portance on nonverbal cues and the context of culture is low context (as are some European
verbal messages than do low-context cultural cultural groups, such as German and British);
groups (Hall 1976). For example, most Asian communication is expected to be explicit, and
Americans come from high-context cultural formal information is conveyed primarily
groups in which sensitive messages are encod- through the literal content of spoken or writ-
ed carefully to avoid giving offense. ten messages.
A behavioral health service provider who lis- Geographic Location
tens only to the literal meaning of words can
Cultural groups form within communities and
miss clients’ actual messages. What is left un-
among people who interact meaningfully with
said, or the way in which something is said,
each other. Although one can speak of a na-
can be more important than the words used to
tional culture, the fact is that any culture is
convey the message. African Americans have
subject to local adaptations. Local norms or
a relatively high-context culture compared
community rules can significantly affect a
with White Americans but a somewhat
culture. Thus, it is important for providers to
lower-context culture compared with Asian
be familiar with the local cultural groups they

Advice to Counselors: Cultural Differences in Communication

The following examples provide broad descriptions that do not necessarily fit all cultural groups from
a specific racial or ethnic group. Counselors should avoid assuming that a client has a particular
expectation or expression of nonverbal and verbal communication based solely on race, ethnicity, or
cultural heritage. For example, a counselor could make an assumption during an interview that a
Native American client prefers a nondirective counseling style coupled with long periods of silence,
whereas the client expects a more direct, active, goal-oriented approach. Counselors should be
knowledgeable and remain open to differences in communication patterns that can be present when
counseling others from diverse backgrounds. The following are some examples of general differ-
ences among cultural groups:
• Individuals from many White/European cultural groups can be uncomfortable with extended
silences and can believe them to indicate that nothing is being accomplished (Franks et al. 2000),
whereas Native Americans, who often place great emphasis on the value of listening, can find
extended silences appropriate for gathering thoughts or showing that they are open to another’s
words (Coyhis 2000).
• Latinos often value personalismo (i.e., warm, genuine communication) in interpersonal relations
and value personal rapport in business dealings; they prefer personal relationships to formal
ones (Barón 2000; Castro et al. 1999a). Many Latinos also initially engage in plática (small talk) to
evaluate the relationship and often use plática prior to disclosing more personal information or
addressing serious issues (Comas-Diaz 2012). On the other hand, Asian Americans can be put off
by a communication style that is too personal or emotional, and some may lack confidence in a
professional whose communication style is too personal (Lee and Mock 2005a).
• Some cultural groups are more comfortable with a high degree of verbal confrontation and
argument; others stress balance and harmony in relationships and shun confrontation. For some,
forceful, direct communication can seem rude or disrespectful. In many Native American and
Latino cultural groups, cooperation and agreeableness (simpatía) is valued. Members often avoid
disagreement, contradiction, and disharmony within the group (Sue and Sue 2013a).

17
 Improving Cultural Competence

encounter—to not think, for example, in terms (Schoeneberger et al. 2006). Even among
of a homogeneous Mexican culture so much as members of the same culture, less substance
the Mexican culture of Los Angeles, CA, or use is observed in those who live in more rural
the Mexican culture of El Paso, TX. regions. For example, O’Connell and associ-
ates (2005) found that alcohol consumption
Geographical factors can also have a signifi-
was lower for American Indians living on
cant effect on a client’s culture. For example,
reservations than for those who were geo-
clients coming from a rural area—even if they
graphically dispersed (and typically living in
come from different ethnicities—can have a
urban areas). Likewise, individuals born or
great deal in common, whereas individuals
living in urban areas may be at greater risk for
from the same ethnicity who were raised in
serious mental illness. In one systematic study,
different geographic locales can have very
higher distribution rates of schizophrenia were
different experiences and, consequently, atti-
found in urban areas, particularly among
tudes. For example, although the vast majority
people who were born in metropolitan areas
of Asian Americans live in urban areas (95
(McGrath et al. 2004).
percent in 2002; Reeves and Bennett 2003), a
particular Asian American client may have Worldview, Values, and Traditions
been born in a rural community or come from
There are many ways of conceptualizing how
a culture (e.g., the Hmong) that developed in
culture influences an individual. Culture can
remote areas; the client may retain cultural
be seen as a frame through which one looks at
values and interests that reflect those origins.
the world, as a repertoire of beliefs and prac-
Other clients who currently live in cities may
tices that can be used as needed, as a narrative
still consider a rural locale as their home and
or story explaining who people are and why
regularly return to it. Many Native Americans
they do what they do, as a set of institutions
who live in urban areas or in communities
defining different aspects of values and tradi-
adjacent to reservations, for example, travel
tions, as a series of boundaries that use values
regularly back to their home reservations
and traditions to delineate one group of people
(Cornell and Kalt 2010; Lobo 2003).
from another, and so on. According to Lamont
In addition to its potential influence upon and Small (2008), such schemata recognize
culture, geography can strongly affect sub- that culture shapes what people believe (i.e.,
stance use and abuse, mental health and well- their values and worldviews) and what they do
being, and access to and use of health services to demonstrate their beliefs (i.e., their tradi-
(Baicker et al. 2005). In the Substance Abuse tions and practices). Cultural groups define
and Mental Health Services Administration’s the values, worldviews, and traditions of their
(SAMHSA’s) 2012 National Survey on Drug members—from food preferences to appropri-
Use and Health (NSDUH), past-month illicit ate leisure activities—including use of alcohol
drug use rates among individuals ages 12 and and/or drugs (Bhugra and Becker 2005). Thus,
older were 9.9 percent in large metropolitan it is impossible to review and summarize the
areas, 8.3 percent in nonmetropolitan urban- variety of cultural values, traditions, and
ized areas, 5.9 percent in less urbanized non- worldviews found in the United States in this
metropolitan areas, and 4.8 percent in rural publication. Providers are encouraged to
areas (SAMHSA 2013d). In very rural or speak with their clients to learn about their
remote areas, illicit drug use is likely to be worldviews, values, and traditions and to seek
even less common than in rural areas training and consultation to gain specific

18
 Chapter 1—Introduction to Cultural Competence

knowledge about clients’ cultural beliefs and therapy appear in TIP 39, Substance Abuse
practices. Treatment and Family Therapy (CSAT 2004b).

Family and Kinship Gender Roles

Although families are important in all cultural Gender roles are largely cultural constructs;
groups, concepts of and attitudes toward diverse cultural groups have different under-
family are culturally defined and can vary in a standings of the proper roles, attitudes, and
number of ways, including the relative im- behaviors for men and women. Even within
portance of particular family ties, the family’s modern American society, there are variations
inclusiveness, how hierarchical the family is, in how cultural groups respond to gender
and how family roles and behaviors are de- norms. For example, after controlling for
fined (McGoldrick et al. 2005). In some cul- income and education, African American
tural groups (e.g., White Americans of Western women are less accepting than White
European descent, such as German, English), American women of traditional American
family is limited to the nuclear family, where- gender stereotypes regarding public behavior
as in other groups (e.g., African Americans; but more accepting of traditional domestic
Asian Americans; Native Americans; White gender roles (Dugger 1991; Haynes 2000).
Americans of Southern European descent, such
Culturally defined gender roles also appear to
as Italian, Greek), the idea of family typically
have a strong effect on substance use and
includes many other blood or marital relations
abuse. This can perhaps be seen most clearly
(Almeida 2005; Hines and Boyd-Franklin
in international research indicating that, in
2005; Marinangeli 2001; McGill and Pearce
societies with more egalitarian relationships
2005; McGoldrick et al. 2005). Some cultural
between men and women, women typically
groups clearly define roles for different family
consume more alcohol and have drinking
members and carefully prescribe methods of
patterns more closely resembling those of men
behaving toward one another based on specific
in the society (Bloomfield et al. 2006). A
relationships. For example, in Korean culture,
similar effect can be seen in research conduct-
wives are expected to defer to their in-laws
ed in the United States with Latino men and
about many decisions (Kim and Ryu 2005).
women with varying levels of acculturation to
Even in cultural groups with carefully defined mainstream American society (Markides et al.
roles and rules for family members, family 2012; Zemore 2005).
dynamics may change as the result of internal
The terms for and definitions of gender roles
or external forces. The process of accultura-
can also vary. For example, in Latino cultural
tion, for instance, can significantly affect
groups, importance is placed on machismo (the
family roles and dynamics among immigrant
belief that men must be strong and protect
families, causing the dissolution of longstand-
their families), caballerismo (men’s emotional
ing cultural hierarchies and traditions within
connectedness), and marianismo (the idea that
the family and resulting in conflict between
women should be self-sacrificing, endure
spouses or different generations of the family
suffering for the sake of their families, and
(Hernandez 2005; Juang et al. 2012; Lee and
defer to their husbands) (Arciniega et al. 2008;
Mock 2005a). Information on family therapy
Torres et al. 2002). These strong gender roles
with major ethnic/racial groups is provided in
have benefits in Latino culture, such as simpli-
Chapter 5 of this TIP. Details of the role of
fying and clarifying roles and responsibilities,
family in treatment and the provision of family

19
 Improving Cultural Competence

but they are also sources of potential problems, Treatment: Addressing the Specific Needs of
such as limiting help-seeking behavior or the Women (CSAT 2009c), and TIP 56, Addressing
identification of difficulties. For example, the Specific Behavioral Health Needs of Men
because of the need to appear in control, a (SAMHSA 2013a). TIP 42, Substance Abuse
Latino man can have difficulty admitting that Treatment for Persons With Co-Occurring
his substance use is out of control or that he is Disorders, addresses the relationships among
experiencing psychological distress (Castro et gender, mental illness, and substance use
al. 1999a). For Latinas, the difficulties of disorders (CSAT 2005d).
negotiating traditional gender roles while
encountering new values through accultura- Socioeconomic Status and
tion can lead to increased substance use/abuse Education
and mental distress (Gil and Vazquez 1996; Sociologists often discuss social class as an
Gloria and Peregoy 1996; Mora 2002). important aspect in defining an individual’s
Negotiating gender roles in a treatment set- cultural background. In this TIP, socioeco-
ting is often difficult; providers should not nomic status (SES) is used as a category simi-
assume that a client’s traditional culture-based lar to class—the difference being that
gender roles are best for him or her or that socioeconomic status is a more flexible and
mainstream American ideas about gender are less hierarchically defined concept. SES in the
most appropriate. The client’s degree of accul- United States is related to many factors, in-
turation and adherence to traditional values cluding occupational prestige and education,
must be taken into consideration and respect- yet it is primarily associated with income level.
ed. Two TIPs explore the relationship of Thus, SES affects culture in several ways,
gender to substance abuse and substance namely through a person’s ability to accumu-
abuse treatment: TIP 51, Substance Abuse late material wealth, access opportunities, and

What Causes Health Disparities?

The National Institutes of Health (NIH; 2012, Overview, p. 1) define health disparities as “differences
in the incidence, prevalence, morbidity, and burden of diseases and other adverse health conditions
that exist among specific population groups.” Numerous studies have found longstanding health
disparities among racial/ethnic groups in the United States (Smedly et al. 2003), and the Agency for
Healthcare Research and Quality (AHRQ) issues yearly reports that provide updates on this topic
(AHRQ 2012). An Institute of Medicine report on disparities (Smedly et al. 2003) found multiple
causes for these disparities, including historical inequalities that have influenced the healthcare
system, persistent racial and ethnic discrimination, and distrust of the healthcare system among
certain ethnic and racial groups. However, the most persistent and prominent cause appears to be
disparities in SES, which affect insurance coverage and access to quality care (Russell 2011). These
economic disparities account for significantly higher death rates, particularly among African
Americans compared with non-Hispanic Whites (Arias 2010), as well as greater lack of insurance
coverage or worse coverage for people of color (Smedly et al. 2003).

Evidence-based interventions to reduce health disparities are limited (Beach et al. 2006; Carpenter-
Song et al. 2011). Current strategies generally focus on reducing risk factors that affect groups who
experience a greater burden from poor health (Murray et al. 2006). The Federal Government has
recognized the need to address health disparities and has made this issue a priority for agencies that
deal with health care (HHS 2011b). As part of this effort, it has created the National Institute on
Minority Health and Health Disparities (see http://ncmhd.nih.gov/). More specific information on
mental health and substance abuse treatment disparities is provided in Chapter 5 of this TIP.

20
 Chapter 1—Introduction to Cultural Competence

Social Determinants of Health

Per Healthy People 2020 (http://www.healthypeople.gov), a federal prevention agenda involving a
multiagency effort to identify preventable threats to health and set goals for reducing them, “social
determinants of health are conditions in the environments in which people are born, live, learn, work,
play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and
risks.” Social determinants include access to educational, economic, and vocational training; job oppor-
tunities; transportation; healthcare services; emerging healthcare technologies; availability of communi-
ty-based resources, basic resources to meet daily living needs, language services, and social support;
exposure to crime; social disorder; community and concentrated poverty; and residential segregation.

Source: Office of Disease Prevention and Health Promotion, HHS 2013.

use resources. Discrimination and historical 2006; Room et al. 2003). However, other
racism have led to lasting inequalities in SES factors, such as the availability of social sup-
(Weller et al. 2012; Williams and Williams- port systems and education, as well as the
Morris 2000). SES affects mental health and individual’s acculturation level, can also play a
substance use. From 2005 to 2010, adults 45 role. Karriker-Jaffe and Zemore (2009) found
through 64 years of age were five times more that, in immigrants, a greater level of accul-
likely to have depression if they were poor turation was associated with increased heavy
(National Center for Health Statistics 2012). drinking for those with above-average SES
Serious mental illness among adults living in but not for those with lower SES. Besides
poverty has a prevalence rate of 9.1 percent lower socioeconomic status, neighborhood
(SAMHSA 2010). Some research demon- poverty (defined as having a high [≥20 per-
strates higher risk for schizophrenia from cent] proportion of residents living in poverty)
lower socioeconomic levels, but other studies was associated with binge drinking and higher
draw no definite conclusion (Murali and rates of substance-related problems, particu-
Oyebode 2010). Most literature suggests that larly for men (McKinney et al. 2012).
poverty and its consequences, including lim-
Education is also an important factor related
ited access to resources, increase stress and
to SES (Exhibit 1-4). Higher levels of educa-
vulnerability among individuals who may
tion are associated with increased income,
already be predisposed to mental illness. Of-
although the degree to which education in-
ten, theoretical discussions explaining a signif-
creases income varies among diverse ra-
icant relationship between mental illness and
cial/ethnic groups (Crissey 2009). Research in
SES suggest a bidirectional relationship in
the United States has found that problems
which stress from poverty leads to mental
with alcohol are often associated with lower
illness vulnerability and/or mental illness leads
SES and lower levels of education (Crum
to difficulty in maintaining employment and
2003; Mulia et al. 2008). However, other
sufficient income.
studies have shown that greater frequency of
Studies have had conflicting results as to drinking and number of drinks consumed are
whether people with high or low SES are generally associated with higher levels of
more likely to abuse substances ( Jones-Webb education and higher SES (Casswell et al.
et al. 1995). In international studies, increases 2003; van Oers et al. 1999). For example, the
in wealth on a societal level have been associ- 2012 NSDUH showed that adult rates of
ated with increases in alcohol consumption past-month alcohol use increased with in-
(Bergmark and Kuendig 2008; Kuntsche et al. creasing levels of education; among those with

21
 Improving Cultural Competence

Exhibit 1-4: Education and Culture

Culture has an effect on an individual’s attitudes toward education; for instance, a lack of cultural
understanding on the part of educational institutions affects student goals and achievements (Sue
2001). A number of factors besides culture also appear to affect educational attainment, including
immigration status and longstanding systemic biases. For example, 88 percent of the native-born
United States population ages 25 and older had at least a high school degree in 2007, but only 68
percent who were foreign-born were high school graduates (Crissey 2009). Research also highlights
large within-group differences in educational attainment. For example, among Asian Americans, who
overall have high levels of education, some groups had very low rates—only 16 percent of Vietnamese
Americans and 5 percent of other Southeast Asian Americans had a college degree in 2000 (Reeves
and Bennett 2003).

Immigration status does not always affect education status in the same way. For non-Latino Whites
and Blacks, being born outside the United States is associated with a greater likelihood of obtaining
at least a bachelor’s degree. African immigrants have the highest level of education of any immigrant
group, higher than White or Asian immigrants (African Immigrant 2000).

less than a high school education, 36.6 percent when they come from diverse ethnic/racial
were current drinkers, whereas 68.6 percent of backgrounds, typically share certain experienc-
college graduates were current drinkers. es and expectations in common. Often, they
(SAMHSA 2013d). Education can also affect encounter a difficult process of acculturation
substance use independently of SES. For (as discussed throughout this chapter). They
example, lower education levels seem to relate can also share concerns surrounding the re-
to heavy drinking independently of socioeco- newal of visas, obtainment of citizenship, or
nomic status (Kuntsche et al. 2006). fears of possible deportation depending on
their legal status. Immigration itself is stressful
The desperation associated with poverty and a
for immigrants, though the reasons for mi-
lack of opportunity—as well as the increased
grating and the legal status of the immigrant
exposure to illicit drugs that comes from living
affect the degree of stress. For documented
in a more impoverished environment—can
residents, the process of adaptation tends to be
also increase drug use (Bourgois 2003). Lower
smoother than for those who are undocu-
SES and the concurrent lack of either money
mented. Undocumented persons may be wary
or insurance to pay for treatment are associat-
of deportation, are less likely to seek social
ed with less access to substance abuse treat-
services, and frequently encounter hostility
ment and mental health services (Chow et al.
(Padilla and Salgado de Snyder 1992).
2003). For example, compared with Medicare
coverage, private insurance coverage increases Nonetheless, there are numerous variables that
the odds twofold that someone who has a contribute to or influence well-being, quality
substance use disorder will enter treatment of life, cultural adaptation, and the develop-
(Schmidt and Weisner 2005). Thus, lower ment of resilience (e.g., the capacity to mobi-
SES can have a dramatic effect on recovery. lize social supports and bicultural integration;
Castro and Murray 2010). Research suggests
Immigration and Migration that immigrants may not experience higher
With the exception of American Indians, rates of mental illness than nonimmigrants
Alaska Natives, Native Hawaiians, and other (Alegria et al. 2006), yet immigration nearly
Pacific Islanders, the United States is a coun- always includes separation from one’s family
try of immigrants. Recent immigrants, even and culture and can involve a grieving process

22
 Chapter 1—Introduction to Cultural Competence

higher rates than their parents or older mem-

The Cultural Orientation Resource
Center bers of the extended family. Parental frustra-
tion may occur if traditional standards of
The Cultural Orientation Resource Center, behavior conflict with mainstream norms
funded by the U.S. Department of State’s
acquired by their children. The differences in
Bureau of Population, Refugees, and Migration,
is a useful resource for clinicians to gain infor- parents’ values and expectations and adoles-
mation about topics including culture, reset- cents’ behavior can lead to distress in close-
tlement experiences, and historical and refugee knit immigrant families. This disruption,
background information. This site is also quite known as the acculturation gap, can result in
useful for refugees. It provides refugee orienta-
increased parent–child conflicts (APA 2012;
tion materials and guidance in establishing
housing, language, transportation, education, Falicov 2012; Telzer 2010). For some youth, it
and community services, among other pressing may contribute to experimentation with alco-
refugee concerns. hol and/or illicit drugs—increased accultura-
tion is typically associated with increased
as a result of these losses as well as other substance use and substance use disorders.
changes, including changes in socioeconomic
status, physical environment, social support, Overall, “old country” or traditional behavioral
and cultural practices. norms and expectations for appropriate behav-
ior become increasingly devalued in American
Immigrants who are refugees from war, fam- majority culture for members of various immi-
ine, oppression, and other dangerous environ- grant groups (Padilla and Salgado de Snyder
ments are more vulnerable to psychological 1992; Sandhu and Malik 2001). Research
distress (APA 2010). They are likely to have shows that family cohesion and adaptability
left behind painful and often life-threatening decrease with time spent in the United States,
situations in their countries of origin and can regardless of the amount of involvement in
still bear the scars of these experiences. Some mainstream culture. This suggests that other
refugees come to the United States with high factors may confound the relationship between
expectations for improved living conditions, family conflict and increased exposure to
only to find significant barriers to their full American culture (Smokowski et al. 2008).
participation in American society (e.g., lan-
guage barriers, discrimination, poverty). Expe- Advice to Counselors and Clinical
riencing such traumatic conditions can also Supervisors: Initial Interview and
increase substance use/abuse among some Assessment Questions
groups of immigrants (see TIP 57, Trauma- When working with clients who are recent
Informed Care in Behavioral Health Services immigrants or have immigrated to United States
[SAMHSA 2014]). Behavioral health services during their lifetime, the APA (1990) recom-
must assess the needs of refugee populations, mends exploring:
• Number of generations in the United States.
as the clinical issues for these populations may
• Number of years in the United States.
be considerably different than for immigrant • Fluency in English (or literacy).
groups (Kaczorowski et al. 2011). • Extent (or lack) of family support.
• Community resources.
For immigrant families, disruption of roles • Level of education.
and norms often occurs upon arrival in the • Change in social status due to immigration.
United States (for review, see Falicov 2012). • Extent of personal relationships with people
Generally, youth adopt American customs, from diverse cultural backgrounds.
Stress due to migration and acculturation.
values, and behaviors much more easily and at

23
 Improving Cultural Competence

Clients who are migrants (e.g., seasonal work- As a result, people may feel conflicted about
ers) pose a particular set of challenges for their identities—wanting to fit in with the
treatment providers because of the difficulties mainstream culture while also wanting to
involved in connecting clients to treatment retain the values of their culture of origin. For
programs and recovery communities. In the clients, sorting through these conflicting
United States, migrant workers are considered cultural expectations and forging a comforta-
one of most marginalized and underserved ble identity can be an important part of the
populations (Bail et al. 2012). Migrants face recovery process. Some of the more commonly
many logistical obstacles to treatment-seeking, used terms related to cultural identity are
such as lack of childcare, insurance, access to defined in Exhibit 1-5.
regular health care, and transportation (Hovey
All immigrants undergo some acculturation
2001; Rosenbaum and Shin 2005). Current
over time, but the rate of change varies from
data are limited but suggest high rates of
group to group, among individuals, and across
alcohol use, alcohol use disor-
ders, and binge drinking, often Exhibit 1-5: Cultural Identification and Cultural
occurring as a response to Change Terminology
stress or boredom associated
with the migrant lifestyle Acculturation is the process whereby an individual from one
cultural group learns and adopts elements of another cultural
(Hovey 2001; Worby and
group, integrating them into his or her original culture. Although
Organista 2007). In addition, it can refer to any process of cultural integration, it is typically
limited data on migrant men- used to describe the ways in which an immigrant or nonmajority
tal health reflect mixed find- individual or group adopts cultural elements from the majority or
ings regarding increased risk mainstream culture, as the incentive is typically greater for accul-
turation to occur in this direction (see Lopez-Class et al. 2011 for
for mental illness or psycho-
a historical review of acculturation concepts).
logical distress (Alderete et al.
2000). One factor associated Assimilation is one outcome of acculturation. It involves the
with mental health status is complete adoption of the ways of life of the new cultural group,
resulting in the assimilated group losing nearly all of its original or
the set of circumstances lead- native culture.
ing up to the migrant worker’s
decision to migrate for em- Segmented assimilation describes a more complicated process
of assimilation whereby an immigrant group does not assimilate
ployment (Grzywacz et al. entirely with mainstream culture but adopts aspects of other
2006). diverse cultural groups that are themselves outside mainstream
culture (e.g., involvement in the drug culture; see Chapter 6 of
Acculturation and this TIP and Portes et al. 2005).
Cultural Identification Biculturalism occurs when an individual acquires the knowledge,
Many factors contribute to an skills, and identity of both his or her culture of origin and the
individual’s cultural identity, mainstream/majority culture and is equally (or nearly equally)
capable of social and cultural interaction in both societies.
and that identity is not a static
attribute. There are many Enculturation can denote a process whereby an individual adopts
forces at work that pressure a the culture that surrounds him or her (similar to acculturation),
but the term has more recently been used to describe the pro-
person to alter his or her
cess by which individuals come to value their native cultures and
cultural identity to conform to begin to learn about and adopt their native cultural lifeways.
the mainstream culture’s
Sources: LaFromboise et al. 1993; Paniagua 1998; Portes et al.
concept of a “proper” identity. 2005; Smokowski et al. 2008; Stone et al. 2006.

24
 Chapter 1—Introduction to Cultural Competence

different periods of history. Earlier theories and with higher rates of substance use disor-
suggested that immigrants generally assimilat- ders among White, Asian, and Latino immi-
ed within three generations from the time of grants (Alegria et al. 2006; Grant et al. 2004a;
immigration and that assimilation was associ- Grant et al. 2004b; Vega et al. 2004). Place of
ated with socioeconomic gains. More recent birth is most strongly associated with higher
scholarship suggests that this is changing rates of substance use and disorders thereof.
among some cultural groups who may lack the For example, research suggests a rate of sub-
financial or human capital necessary to suc- stance use disorders about three times higher
ceed in mainstream society or who may find for Mexican Americans born in the United
that continued involvement in their native or States than for those born in Mexico (Alegria
traditional culture has benefits that outweigh et al. 2008a; Escobar and Vega 2000). Asian
those associated with acculturation (Portes et adolescents born in the United States present
al. 2005; Portes and Rumbaut 2005). a higher rate of past-month alcohol use than
Asian adolescents not born in the United
Acculturation typically occurs at varying speeds
States (8.7 versus 4.7 percent); however, the
for different generations, even within the same
rate of nonmedical use of prescription drugs is
family. Acculturation can thus be a source of
higher among Asian adolescents not born in
conflict within families, especially when parents
the United States than among those born in
and children have different levels of accultura-
the United States (2.7 versus 1.4 percent;
tion (Exhibit 1-6) (Castro and Murray 2010;
SAMHSA, Center for Behavioral Health
Farver et al. 2002; Hernandez 2005). Others
Statistics and Quality 2012).
have suggested that acculturation can negative-
ly affect mental health because it erodes tradi- Acculturation can increase substance
tional family networks and/or because it results use/abuse, in part because the process of accul-
in the loss of traditional culture, which other- turation is itself stressful (Berry 1998; Vega et
wise would have a protective function (Escobar al. 2004). Mora (2002) asserts that the stress
and Vega 2000; Sandhu and Malik 2001). associated with acculturation has a significant
effect on increasing substance use and abuse
Many studies have found that increased accul-
among Latinas; this can be observed most
turation or factors related to acculturation are
clearly in the increases in substance use associ-
associated with increased alcohol and drug use
ated with being a second- or third-generation

Exhibit 1-6: Five Levels of Acculturation

Numerous models have been developed to explain the process of acculturation. Choney et al. (1995)
proposed a model, applicable to a number of different contexts, that features five levels:
1. A traditional orientation: The individual is entirely oriented toward his or her native culture.
2. A transitional orientation: The individual is more oriented toward traditional culture but has some
familiarity with mainstream culture.
3. A bicultural orientation: The individual is equally comfortable with and knowledgeable of both
traditional and mainstream culture.
4. An assimilated orientation: The individual is mostly oriented toward mainstream culture but has
some familiarity with the traditional/native culture.
5. A marginal orientation: The individual is not comfortable with either culture.
Note: This is not a stage model in which a person naturally moves from one orientation to the next,
nor does this model place greater value on one level versus another. The authors emphasize that
each level of acculturation has strengths.

25
 Improving Cultural Competence

Latina from an immigrant family. The stress equality in a society, the more similar alcohol
associated with acculturation could also con- consumption patterns are for men and women
tribute to rates of mental disorders and co- (Bloomfield et al. 2006). Many immigrants to
occurring disorders (CODs), which are higher the United States (where gender equality is
among more acculturated groups of immi- relatively strong) come from societies with less
grants (Cherpitel et al. 2007; Escobar and gender equality and thus with greater prohibi-
Vega 2000; Grant et al. 2004a; Organista et al. tions against alcohol use for women.
2003; Vega et al. 2009; Ward 2008). In fact,
Karriker-Jaffe and Zemore (2009) found that
American-born Latinos who have used sub-
higher levels of acculturation are associated
stances are three times more likely to have
with increased alcohol consumption only
CODs than foreign-born Latinos who have
when combined with above-average SES (and
used substances (Vega et al. 2009). Research
not with lower SES), suggesting that income
also suggests that acculturation could interact
is another factor to consider when evaluating
with factors such as culture or stress in in-
the effect of acculturation on alcohol use.
creasing mental disorders.
There are exceptions to the idea that accul-
Rates of substance use/abuse in the United
turation increases substance use/abuse. Most
States are among the highest in the world
notably, immigrants coming from countries
(United Nations, Office on Drugs and Crime
with unusually high levels of drinking do not
2008, 2012), so for many immigrants, adopt-
necessarily experience a change in their use,
ing mainstream American cultural values and
and they may even consume less alcohol and
lifestyles can also entail changing attitudes
fewer drugs that they did in their native coun-
toward substance use. As an example, Marin
tries. Even among those born in the United
(1998) found that, compared with Whites,
States, however, data suggest that greater
Mexican Americans expected significantly
identification with one’s traditional culture has
more negative consequences and fewer posi-
a protective function. For example, in the
tive ones from drinking, but Marin also found
National Latino and Asian American Study,
that the more acculturated the Mexican
the largest national survey specifically target-
American participants were, the more closely
ing these population groups to date, greater
their expectations resembled those of Whites.
ethnic identification was associated with
Other factors that can contribute to increased significantly lower rates of alcohol use disor-
substance use among more acculturated clients ders among Asian Americans (Chae et al.
include changes in traditional gender roles, 2008), and the use of Spanish with one’s
exposure to socially and physically challenging family was linked with significantly lower
inner-city environments (Amaro and Aguiar rates of alcohol use disorders in Latinos
1995), and employment outside the home (Canino et al. 2008).
(often a role-transforming change that can
Less research is available on the relationship of
contribute to increased risk of alcohol depend-
acculturation to substance use and substance
ence). Although much of the research has
use disorders among nonimmigrants, but some
focused on the relationship of acculturation to
data suggest that a lower level of identification
male substance use/abuse patterns, women can
with one’s native culture is linked with heavier,
be even more affected by acculturation. Multi-
lengthier substance use among American
ple studies using international samples have
Indians living on reservations (Herman-Stahl
found that the greater the amount of gender
et al. 2003). For some American Indians, more

26
 Chapter 1—Introduction to Cultural Competence

involvement in Tribal culture and traditional the mainstream culture and retain the tradi-
spiritual activities is associated with better tions and beliefs of their cultures of origin. For
posttreatment outcomes for alcohol use disor- such clients, sorting through these conflicting
ders (Stone et al. 2006). American Indians cultural expectations and forging a comforta-
who drink heavily but live a traditional life- ble identity can be an important part of the
style have better recovery outcomes than those recovery process. Familiarity with cultural
who do not live a traditional lifestyle (Kunitz identity formation models and theories of
et al. 1994). Likewise, African Americans may acculturation (including acculturation meas-
have greater motivation for treatment if they urement methods; see Exhibit 1-7) can help
recognize that they have a drug problem and behavioral health workers provide services
also have a strong Afrocentric identity with greater flexibility and sensitivity (see
(Longshore et al. 1998b). Strong cultural or Appendix B for instruments that measure
racial/ethnic identity can have protective aspects of cultural identity and acculturation).
features, whereas acculturation can lead to a
loss of cultural identity that increases sub- Heritage and History
stance abuse and contributes to poorer recov- A culture’s history and heritage explain the
ery outcomes for both Native Americans and culture’s development through the actions of
African Americans. members of that culture and also through the
actions of others toward the specific culture.
Overall, acculturation and cultural identifica-
Providers should be knowledgeable about the
tion have tremendous implications for behav-
many positive aspects of each culture’s history
ioral health services. Research has shown an
and heritage and resourceful in learning how
association between low levels of acculturation
to integrate these into clinical practice.
and low usage rates of mainstream healthcare
services. Individuals can feel conflicted about Nearly all immigrant groups have experienced
their identities—wanting to both fit in with some degree of trauma in leaving behind

Exhibit 1-7: Measuring Acculturation

Acculturation is a construct that includes factors relating to behavior, knowledge, values, self-
identification, and language use (Zea et al. 2003). One of the biggest problems in analyzing the
effects of acculturation is determining how to define and evaluate it. In research literature, accultura-
tion is inconsistently defined and measured. In some large-scale surveys, it is not defined at all, but
only implied in other factors, such as length of stay in the United States, English language use, or
place of birth. Overall, instruments that assess acculturation do not ask the same questions or ad-
dress the same factors, thus making it unclear whether acculturation is truly being evaluated (Zane
and Mak 2003). More research is warranted on how to conceptualize and evaluate acculturation and
cultural identity.

Many acculturation tools focus on specific racial or ethnic groups (for example, see Wallace et al.
2010). Acculturation and cultural identity instruments typically ask questions about language use and
preference (e.g., whether English is used at home), media preferences (e.g., preference for foreign
language programming), social interactions (e.g., friendships with persons from other ethnici-
ties/cultural groups), cultural knowledge (e.g., knowledge of beliefs, traditions, and ceremonies
specific to a cultural or ethnic group), and cultural values (Zea et al. 2003). Others evaluate accultura-
tion simply by asking which culture a person identifies with most. Organista et al. (2003) and Zane
and Mak (2003) reviewed measures designed to evaluate acculturation and cultural identity.
Appendix B provides a sample of acculturation and cultural identity instruments.

27
 Improving Cultural Competence

family members, friends, and/or familiar review in Williams and Williams-Morris

places. Their eagerness to assimilate or remain 2000).
separate depends greatly on the circumstances
According to theories of historical trauma, the
of their immigration (Castro and Murray
traumas of the past continue to affect later
2010). Additionally, some immigrants are
generations of a group of people. This concept
refugees from war, famine, natural disasters,
was first developed to explain how the trauma
and/or persecution. The depths of suffering
of the Holocaust continued to affect the de-
that some clients have endured can result in
scendants of survivors (Duran et al. 1998;
multiple or confusing symptoms. For example,
Sotero 2006). In the United States, it has
a traumatized Congolese woman could speak
perhaps been best explored in relation to the
of hearing voices, and it could be unclear
traumas endured by Native American peoples
whether these voices suggest an issue requiring
during the colonization and expansion of the
spiritual healing within a cultural framework,
United States. One can extend this concept
a traumatic stress reaction, or a mental disor-
to other groups (e.g., African Americans,
der involving the onset of auditory hallucina-
Cambodians, Rwandans) who suffered trau-
tions. Those who have watched close family
matic events like slavery or genocide.
members die violently can have “survivor guilt”
as well as agonizing memories. Amodeo et al. Among Native Americans in treatment for
(1997) report that “somatic complaints, in- substance use and/or mental disorders, histori-
cluding trouble sleeping, loss of appetite, cal trauma is an important clinical issue (Brave
stomach pains, other bodily pains, headaches, Heart et al. 2011; Duran et al. 1998; Evans-
fatigue or lack of energy, memory problems, Campbell 2008). Some research indicates that
mood swings and social withdrawal have been thinking about historical loss or displaying
reported to be among the refugees’ most fre- symptoms associated with historical trauma
quent presenting problems” (p. 70). For an plays into increases in alcohol use disorders,
overview of the impact of trauma, see TIP 57, other substance use, and lower family cohesion
Trauma-Informed Care in Behavioral Health (Whitbeck et al. 2004; Wiechelt et al. 2012).
Services (SAMHSA 2014). Brave Heart (1999) theorizes that historical
traumas perpetuate their effects among Native
Abueg and Chun (1998) caution, however,
Americans by harming parenting skills and
that “traumatic experience is not homogenous”
increasing abuse of children, which creates a
(p. 292). Experiences before, during, and after
cyclical pattern—greater levels of mental and
migration and/or encampment vary depending
substance use disorders in the next generation
on the country of origin as well as the time
along with continued poor parenting skills.
and motivation for migration. Within the
Specifically, Libby et al. (2008) found that
United States, cultural groups such as African
substance use was involved in the intergenera-
Americans and Native Americans have long
tional transmission of trauma. Additional
histories of traumatic events, which have had
research highlights a relationship between
lasting effects on the descendants of those
elevated chronic trauma exposure and preva-
who experienced the original trauma. Conse-
lence of both mental and substance use disor-
quently, past as well as present discrimination
ders among large samples of American Indian
and racism are related to a number of negative
adults living on reservations (Beals et al. 2005;
consequences across diverse populations, in-
Manson et al. 2005).
cluding lower SES, health disparities, and fewer
employment and educational opportunities (see

28
 Chapter 1—Introduction to Cultural Competence

Sotero (2006) reviews research on historical 2002). As a result of a lack of acceptance

trauma across diverse populations and propos- within both mainstream and diverse eth-
es a similar explanation of how deliberately nic/racial communities, various gay cultures
perpetrated, large-scale traumatic events con- have developed in the United States. For some
tinue affecting communities years after they individuals, gay culture provides an alternative
occur. She argues that the generation that to their culture of origin, but unfortunately,
directly experiences the trauma suffers material cultural pressures can make the individual feel
(e.g., displacement), psychological (e.g., post- like he or she has to select which identity is
traumatic stress disorder), economic (e.g., loss most important (Greene 1997). However, a
of sources of income/sustenance), and cultural person can be, for example, both gay and
(e.g., lost knowledge of traditions and beliefs) Latino without experiencing any conflicts
effects. These lasting sequelae of trauma then about claiming both identities at the same
affect the next generation, who can suffer in time. For more information on substance
many similar ways, resulting in poorer coping abuse treatment for persons who identify as
skills or in attempts to self-medicate distress gay, lesbian, or bisexual, refer to the CSAT
through substance abuse. (2001) publication, A Provider’s Introduction to
Substance Abuse Treatment for Lesbian, Gay,
Sexuality Bisexual, and Transgender Individuals.
Attitudes toward sexuality in general and
Heterosexual behaviors are carefully prescribed
toward sexual identity or orientation are cul-
by a culture. Typically, these prescriptions are
turally defined. Each culture determines how
determined based on gender; behaviors con-
to conceptualize specific sexual behaviors, the
sidered acceptable for men can be considered
degree to which they accept same-sex relation-
unacceptable for women and vice versa. In
ships, and the types of sexual behaviors con-
addition, cultures define the role of alcohol or
sidered acceptable or not (Ahmad and Bhugra
other substances in courtship, sexual behaviors,
2010). In any cultural group, diverse views and
and relationships (Room 1996). Other factors
attitudes about appropriate gender norms and
that can vary across cultural groups include the
behavior can exist. For example, in some Latino
appropriate age for sexual activity, the rituals
cultural groups, homosexual behavior, espe-
and actions surrounding sexual activity, the use
cially among men, is not seen as an identity but
of birth control, the level of secrecy or open-
as a curable illness or immoral behavior (Kusnir
ness related to sexual acts, the role of sex
2005). In some Latino cultural groups, self-
workers, attitudes toward sexual dysfunction,
identifying as other than heterosexual may
and the level of sexual freedom in choosing
provoke a more negative response than engag-
partners.
ing in some homosexual behaviors (de Korin
and Petry 2005; Greene 1997; Kusnir 2005).
Perspectives on Health, Illness,
For individuals from various ethnic/racial and Healing
groups in United States, having a sexual iden- Beliefs, attitudes, and behaviors related to
tity different from the norm can result in health, illness, and healing vary across racial,
increased substance use/abuse, in part because ethnic, and cultural groups. Many cultural
of increased stress. Additionally, alcohol and groups hold views that differ significantly
drug use can be more acceptable within some from those of Western medical practice and
segments of gay/lesbian/bisexual cultures thus can affect treatment (Sussman 2004). The
(Balsam et al. 2004; CSAT 2001; Mays et al. field of medical anthropology was developed,

29
 Improving Cultural Competence

in part, to analyze these differences, and much describes cultural concepts of distress recog-
has been written about the range of cultural nized by the DSM-5. Other specific examples
beliefs concerning health and healing. In of cultural differences relating to the use of
general, cultural groups differ in how they health care and alternative approaches to
define and determine health and illness; who medical diagnosis and treatment are also
is able to diagnosis and treat an illness; their presented in Chapter 5.
beliefs about the causes of illness; and their
remedies (including the use of Western medi- Religion and Spirituality
cines), treatments, and healing practices for Religious traditions or spiritual beliefs are
illness (Bhugra and Gupta 2010; Comas-Diaz often very important factors for defining an
2012). In addition, there are complex rules individual’s cultural background. In turn,
about which members of a community or attention to religion and spirituality during
family can make decisions about health care the course of treatment is one facet of cultur-
across cultural groups (Sussman 2004). ally competent services (Whitley 2012).
Christians, Muslims, Jews, and Buddhists
In mainstream American society, healthcare
(among others) can be members of any racial
professionals are typically viewed as the only
or ethnic group; in the same vein, people of
ones who have real expertise about health and
the same ethnicity who belong to different
illness. However, other societies have different
religions sometimes have less in common than
views. For instance, among the Subanun peo-
people of the same religion but different
ple of the Philippines, all members of the
ethnicities. In some cases, religious affiliation
community learn about healing and diagnosis;
is an especially important factor in defining a
when an individual is sick, the diagnosis of his
person’s culture. For instance, the American
or her problem is an activity that involves the
Religious Identification Survey reported that
whole community (Frake 1961). Cultural
47 percent of the respondents who identified
groups also differ in their understanding of the
culturally as Jewish were not practicing Jews
causes of illness, and many cultural groups
(Kosmin et al. 2001).
recognize a spiritual element in physical ill-
ness. The Hmong, for example, believe that According to the American Religious Identifi-
illness has a spiritual cause and that healing cation Survey (Kosmin and Keysar 2009), only
may require shamans who communicate with 15 percent of Americans identified as not
spirits to diagnose and treat an illness having a religion; of those, less than 2 percent
(Fadiman 1997; Gensheimer 2006). identified as atheist or agnostic. In another
survey from the Pew Forum on Religion and
With respect to mental health, providers
Public Life (2008), 1.6 percent of respondents
should be aware that any mental disorder or
stated that they were atheist; 2.4 percent,
symptom is only considered a disorder or
agnostic; and 6.3 percent, secular and unaffili-
problem by comparison with a socially defined
ated with a religion. Many religions are prac-
norm. For instance, in some societies, someone
ticed in the United States today. This TIP
who hears voices can be considered to have
cannot cover them all in detail in. However,
greater access to the spirit world and to be
this TIP does briefly describe the four most
blessed in some way. Furthermore, there are
common (by size of self-identified member-
mental disorders that only present in a specific
ship) religious traditions.
cultural group or locality; these are called
cultural concepts of distress. Appendix E

30
 Chapter 1—Introduction to Cultural Competence

Advice to Counselors: Spirituality, Religion, Substance Abuse, and Mental Illness

For people in treatment and recovery, it can be especially important to distinguish between spirituali-
ty and religion. For example, some clients are willing to think of themselves as spiritual but not
necessarily religious. Religion is organized, with each religion having its own set of beliefs and prac-
tices designed to organize and further its members’ spirituality. Spirituality, on the other hand, is
typically conceived of as a personal matter involving an individual’s search for meaning; it does not
require an affiliation with any religious group (Cook 2004). People can have spiritual experiences or
develop their own spirituality outside of the context of an organized religion.

Spirituality often plays an important role in recovery from mental illness and substance abuse, and
higher ratings of spirituality (using a variety of scales) have been associated with increased rates of
abstinence (Laudet et al. 2006; Zemore and Kaskutas 2004). If substance abuse represents a lack of
personal control, discipline, and order, then spirituality and religion can help counter this by provid-
ing a sense of purpose, order, self-discipline, humility, serenity, and acceptance. In addition, spiritual-
ity can help a person with mental illness gain a sense of meaning or purpose, develop inner strength,
and learn acceptance and tolerance. Chappel (1998) maintains that the development of spirituality
requires a concerted and consistent effort through such activities as prayer, meditation, discussion
with others, reading, and participation in other spiritual activities. Counselors, he says, have an obli-
gation to understand the role that spirituality can play in promoting and supporting recovery. The
first step in this process is for counselors to learn about and respect clients’ beliefs; understanding
the roles of religion and spirituality is one form of cultural competence (Whitley 2012).

Christianity has dispersed over time and now exists in

Christianity, in its various forms, remains the various geographic regions. The majority of
predominant religion in the United States Jews in the United States would be considered
today. According to Kosmin and Keysar White, but Ethiopian Jews (the Beta Israel)
(2009), 76 percent of the population in 2008 and members of other African-Jewish com-
identified as Christian, with the largest denom- munities would likely be seen as African
ination being Catholics (25.1 percent), fol- Americans; the Jewish community from India
lowed by Baptists (15.8 percent). Christianity (Bene Israel), as Asian Americans; and Jews
encompasses a variety of denominations with who immigrated to the United States from
different beliefs and attitudes toward issues Latin America, as Latinos. In 2001, approxi-
such as alcohol and/or other substance use. mately 5 percent of people who identified as
Most mainstream Christian religions support adherents to Judaism (the religion, as opposed
behavioral health treatment, and many church- to people who identify as culturally Jewish)
es serve as sites for self-help groups or for were Latinos, and approximately 1 percent
Christian recovery programs. Some Christian were African Americans (Kosmin et al. 2001).
sects, however, are not as amenable to sub- Regarding beliefs about and practices sur-
stance abuse and mental health treatment as rounding substance use, there are no prohibi-
others. tions against alcohol use (or other substance
use) in Judaism, but rates of alcohol abuse and
Judaism
dependence are significantly lower for Jews
Judaism is the second most common religion than for other populations (Bainwol and
in the United States (1.2 percent of the popu- Gressard 1985; Straussner 2001). This could
lation as of 2008; Kosmin and Keysar 2009). be partially attributable to genetics, yet there is
Most Jews believe that they share a common also a definite cultural component (Hasin et al.
ancient background. However, the population 2002). Conversely, rates of use and abuse of

31
 Improving Cultural Competence

other substances are about the same or slightly appear to have low rates of substance use
higher for Jews in the United States compared disorders. Despite there being no current data
with other populations (Straussner 2001). regarding levels of alcohol and other substance
Because some Jewish people will feel uncom- use among Muslim immigrants in the United
fortable in 12-Step groups that meet in States, Cochrane and Bal (1990) found that, in
churches and are largely Christian in composi- a comparison of Sikh, Hindu, Muslim, and
tion, mutual-help groups designed specifically White (probably Christian) men in a British
for Jewish people have been developed. The community, Muslims by far drank the least, yet
largest of these is Jewish Alcoholics, Chemi- those Muslims who consumed the most alco-
cally Dependent Persons and Significant hol experienced a greater number of alcohol-
Others (see http://www.jbfcs.org/programs- related problems on average. High levels of
services/jewish-community-services-2/jacs/ alcohol consumption among Muslims who do
for more information). Other Jewish people in drink could be related to feelings of guilt and
recovery may prefer participating in secular shame about their behavior, thus potentially
self-help programs (Straussner 2001). Most leading to further abuse and avoidance of
Jewish people support behavioral health seeking substance abuse treatment when
treatment. problems arise (Abudabbeh and Hamid 2001).

Islam Buddhism
In 2008, roughly 1.3 million people identified In 2008, about 1.2 million Buddhists were
as Muslims in the United States, making it the living in the United States (Kosmin and
third most common religion (Kosmin and Keysar 2009). In 2001, according to Kosmin et
Keysar 2009). Many Americans assume that al (2001), the majority of Buddhists were
all Arabs are Muslim, but the majority of Arab Asian Americans (61 percent), but a signifi-
Americans are Christian; Muslims can come cant number of White Americans have em-
from any ethnic background (Abudabbeh and braced the religion (they make up 32 percent
Hamid 2001). Islam is the most ethnically of Buddhists in the United States), as have
diverse religion in America, with a member- African Americans (4 percent) and Latinos (2
ship that is 15 percent White, 27 percent percent). In China and Japan, Buddhism is
Black, 34 percent Asian, and 10 percent often combined with other religious tradi-
Latino (Kosmin et al. 2001). tions, such as Taoism or Shintoism, and some
immigrants from those countries combine the
Attitudes of Muslims toward mental illness
beliefs and practices of those religions with
and seeking formal mental health services are
Buddhism.
likely to be affected by cultural and religious
beliefs about mental health problems, Buddhists believe that the choices made in
knowledge and familiarity with formal ser- each life create karma that influences the next
vices, perceived societal prejudice, and the use life and can affect behavior (McLaughlin and
of informal indigenous resources (Aloud Braun 1998). The Fifth Precept of Buddhism
2004). Attitudes toward substance use, abuse, is not to use intoxicating substances, and thus,
and treatment will likely be shaped by Islam’s the expectation for devout believers is that
prohibition of the use of alcohol and other they will not use alcohol or other substances of
intoxicants. Many Muslim countries have abuse (Assanangkornchai et al. 2002). In the
harsh penalties for the use of alcohol and United States, no specific substance abuse
other drugs. For these reasons, Muslims treatment programs specialize in treating

32
 Chapter 1—Introduction to Cultural Competence

Buddhist clients. Buddhist substance abuse within each group as well—there are cultures
and mental health treatment programs do within cultures. Clinicians and organizations
exist in other countries (e.g., Thailand) and need to develop skills to create an environ-
report high outcome rates (70 percent) using ment that is responsive to the unique attrib-
culturally specific practices (e.g., herbal sau- utes and experiences of each client, as outlined
nas) and religious practices (Barrett 1997). earlier in this chapter in the “What Are the
Cross-Cutting Factors in Race, Ethnicity, and
As You Proceed Culture?” section. As you read this TIP, re-
member that many cross-cutting factors influ-
This chapter has established the foundation ence the counselor–client relationship, the
and rationale of this TIP; reviewed the core client’s presentation and identification of
concepts, models, and terminology of cultural problems, the selection and interpretation of
competence; and provided an overview of screening and assessment tools, the client’s
factors that are common among diverse racial, responsiveness to specific clinical services, and
ethnic, and cultural groups. As you proceed, be the effectiveness of program delivery and
aware that diversity occurs not only across organizational structure and planning.
racially and ethnically diverse groups, but

33
 2 Core Competencies for
Counselors and Other
Clinical Staff

Gil, a 40-year-old Mexican American man, lives in an upper mid-

IN THIS CHAPTER dle class neighborhood. He has been married for more than 15
• Core Counselor years to his high school sweetheart, a White American woman, and
Competencies they have two children. Gil owns a fleet of street-sweeping
• Self-Assessment for trucks—a business started by his father-in-law that Gil has ex-
Individual Cultural panded considerably. Of late, Gil has been spending more time at
Competence work. He has also been drinking more than usual and dabbling in
illicit drugs. As his drinking has increased, tensions between Gil
and his wife have escalated. From Gil’s perspective and that of
some family members and friends, Gil is just a hard-working guy
who deserves to have a beer as a reward for a hard day’s work.
Many people in his Mexican American community do not consid-
er Gil’s low-level daily drinking a problem, especially because he
drinks primarily at home.
Recently, Gil had an accident while working on one of his trucks.
The treating physician identified alcohol abuse as one of several
health problems and referred him to a substance abuse treatment
center. Gil attended, but argued all the while that he was not a
borracho (drunkard) and did not need treatment. He distrusted the
counselors, stating that seeking help from professionals for a men-
tal disorder was something that only gabachos (Whites) did. Gil was
proud of his capacity to “hold his liquor” and felt anger and hostili-
ty toward those who encouraged him to reduce his drinking. Gil’s
feelings and attitudes were valid; they stemmed from and were in-
fluenced by the Mexican American culture and community in
which he had been raised from infancy. Gil dropped out of treat-
ment. When his wife threatened to divorce him if he did not take
immediate action to deal with his drinking problem, he reluctantly

35
 Improving Cultural Competence

enrolled in an outpatient treatment program. assist client recovery. Gaining regard, respect,
Gil, like all people, is a product of his envi- and trust from clients is crucial for successful
ronment—an environment that has provided counseling outcomes (Ackerman and Hilsen-
him with a rich cultural and spiritual back- roth 2003; Sue and Sue 2003a).
ground, a strong male identity, a deep attach-
Effective therapy is an ongoing process of
ment to family and community, a strong work
building relational bridges that engender trust
ethic, and a sense of pride in being able to
and confidence. Sensitivity to the client’s
support his family. In many Mexican American
cultural and personal perspectives, genuine
cultural groups, illness disrupts family life,
empathy, warmth, humility, respect, and ac-
work, and the ability to earn a living. Illness
ceptance are the tenets of all sound therapy.
has psychological costs as well, including
This chapter expands on these concepts and
threats to a man’s self-identity and sense of
provides a general overview of the core com-
manhood (Sobralske 2006). Given this back-
petencies needed so that counselors may
ground, Gil would understandably be reluctant
provide effective treatment to diverse racial
to enter treatment, to accept the fact that his
and ethnic groups. Using Sue’s (2001) multi-
drinking was a problem or an illness, and to
dimensional model for developing cultural
jeopardize his ability to care for his family and
competence, the content focuses on the coun-
his company. A culturally competent counselor
selor’s need to engage in and develop cultural
would recognize, legitimize, and validate Gil’s
awareness; cultural knowledge in general; and
reluctance to enter and continue in treatment.
culturally specific skills and knowledge of
In an ideal situation, the treatment counselor
wellness, mental illness, substance use, treat-
would have experience working with people
ments, and skill development.
with similar backgrounds and beliefs, and the
treatment program would be structured to
change Gil’s behavior and attitudes in a man- Core Counselor
ner that was in keeping with his culture and Competencies
community. His initial treatment might have
succeeded if the counselor had been culturally Since Sue et al. introduced the phrase “multi-
competent and the treatment program had cultural counseling competencies” in 1992,
been culturally responsive. researchers and academics have elaborated on
the core skill sets that enable counselors to
Like Gil, all clients enter treatment carrying work with diverse populations (American
beliefs, attitudes, conflicts, and problems Psychological Association [APA] 2002;
shaped by their cultural roots as well as their Council of National Psychological
present-day realities. As with Gil, many clients Associations for the Advancement of Ethnic
enter treatment with some reluctance and Minority Interests 2009; Pack-Brown and
denial. Research shows that if clients such as Williams 2003; Tseng and Streltzer 2004).
Gil are greeted by a culturally competent Cultural competence has evolved into more
counselor, they are more likely to respond than a discrete skill set or knowledge base; it
positively to treatment (Damashek et al. 2012; also requires ongoing self-evaluation on the
Griner and Smith 2006; Kopelowicz et al. part of the practitioner. Culturally competent
2012; Whaley and Davis 2007). The presence counselors are aware of their own cultural
of counselors of any race or gender who are groups and of their values, assumptions, and
culturally competent in responding to the biases regarding other cultural groups. Moreo-
needs and issues of their clients can greatly ver, culturally competent counselors strive to

36
 Chapter 2—Core Competencies for Counselors and Other Clinical Staff

Multidimensional Model for Developing Cultural Competence: Individual Staff

Level

understand how these factors affect their Self-Knowledge

ability to provide culturally effective services Counselors with a strong belief in evidence-
to clients. based treatment methods can find it hard to
Given the complex definition of culture and relate to clients who prefer traditional healing
the fact that racially and ethnically diverse methods. Conversely, counselors with strong
clients represent a growing portion of the trust in traditional healers and culturally ac-
client population, the need to update and cepted methods can fail to understand clients
expand guidelines for cultural competence is who seek scientific explanations of, and solu-
increasing. The consensus panel thus adapted tions to, their substance abuse and mental
existing guidelines from the Association of health problems. To become culturally compe-
Multicultural Counseling for culturally re- tent, counselors should begin by exploring
sponsive behavioral health services; some of their own cultural heritage and identifying
their key suggestions for counselors and other how it shapes their perceptions of normality,
clinical staff are outlined in this chapter. abnormality, and the counseling process.

37
 Improving Cultural Competence

Counselors who understand themselves and Models of Racial Identity

their own cultural groups and perceptions are
better equipped to respect clients with diverse Models of racial identity, often structured in
stages, highlight the process that individuals
belief systems. In gaining an awareness of their undertake in becoming aware of their sense of
cultures, attitudes, beliefs, and assumptions self in relation to race and ethnicity within the
through self-examination, training, and clini- context of their families, communities, socie-
cal supervision, counselors should consider the ties, and cultural histories. Influenced by the
factors described in the following sections. Civil Rights Movement, earlier racial identity
models in the United States focused on White
and Black racial identity development (Cross
Cultural awareness
1995; Helms 1990; Helms and Carter 1991).
Counselors who are aware of their own cultural Since then, models have been created to
backgrounds are more likely to acknowledge incorporate other races, ethnicities, and
and explore how culture affects their client– cultures.
counselor relationships. Without cultural Although this chapter highlights two formative
awareness, counselors may provide counseling racial identity models (see next page), addi-
that ignores or does not address obvious issues tional resources highlight racial identity models
that specifically relate to race, ethnic heritage, that incorporate other diverse groups, includ-
ing those individuals who identify as multiracial
and culture. Lack of awareness can discount
(e.g., see Wijeyesinghe and Jackson 2012).
the importance of how counselors’ cultural
backgrounds—including beliefs, values, and
the constructs of these identities are complex
attitudes—influence their initial and diagnos-
and difficult to define briefly, what follows is
tic impressions of clients. Without cultural
an overview. Racial identity “refers to a sense
awareness, counselors can unwittingly use
of group or collective identity based on one’s
their own cultural experiences as a template to
perception that he or she shares a common
prejudge and assess client experiences and
heritage with a particular racial group” (Helms
clinical presentations. They may struggle to
1990, p. 3). Ethnic and cultural identity is
see the cultural uniqueness of each client,
“often the frame in which individuals identify
assuming that they understand the client’s life
consciously or unconsciously with those with
experiences and background better than they
whom they feel a common bond because of
really do. With cultural awareness, counselors
similar traditions, behaviors, values, and be-
examine how their own beliefs, experiences,
liefs” (Chavez and Guido-DiBrito 1999, p.
and biases affect their definitions of normal
41). Culture includes, but is not limited to,
and abnormal behavior. By valuing this aware-
spirituality and religion, rituals and rites of
ness, counselors are more likely to take the
passage, language, dietary habits (e.g., attitudes
time to understand the client’s cultural groups
toward food/food preparation, symbolism of
and their role in the therapeutic process, the
food, religious taboos of food), and leisure
client’s relationships, and his or her substance-
activities (Bhugra and Becker 2005).
related and other presenting clinical problems.
Cultural awareness is the first step toward Aspects of racial, ethnic, and cultural identities
becoming a culturally competent counselor. are not always apparent and do not always
factor into conscious processes for the counse-
Racial, ethnic, and cultural identities lor or client, but these factors still play a role
A key step in attaining cultural competence is in the therapeutic relationship. Identity devel-
for counselors to become aware of their own opment and formation help people make sense
racial, ethnic, and cultural identities. Although of themselves and the world around them. If

38
 Chapter 2—Core Competencies for Counselors and Other Clinical Staff

positive racial, ethnic, and cultural messages the same race requests a White American
are not available or supported in behavioral counselor for therapy during an initial inter-
health services, counselors and clients can lack view), or view a client’s behavior through a veil
affirmative views of their own identities and of societal biases or stereotypes. By acknowl-
may internalize negative messages or feel edging and endorsing the active process of
disconnected from their racial and cultural racial and cultural identity development, coun-
heritages. Counselors from mainstream society selors from diverse groups can normalize their
are less likely to be actively aware of their own own development processes and increase their
ethnic and cultural identities; in particular, awareness of clients’ parallel processes of
White Americans are not naturally drawn into identity development. In counseling, racial,
examining their cultural identities, as they ethnic, and cultural identities can be pivotal to
typically experience no dissonance when the treatment process in the relationships not
engaging in cultural activities. only between the counselor and client, but
among everyone involved in the delivery of the
In working to attain cultural competence,
client’s behavioral health and primary care
counselors must explore their own racial and
services (e.g., referral sources, family members,
cultural heritages and identities to gain a
medical personnel, administrators). The case
deeper understanding of personal develop-
study on page 41 uses stages from the two
ment. Many models and theories of racial,
models in Exhibit 2-1 to show the interactive
ethnic, and cultural development are available;
process of racial and cultural identity devel-
two common processes are presented below.
opment in the treatment context.
Exhibit 2-1 highlights the racial/cultural
identity development (R/CID) model (Sue Cultural and racial identities are not static
and Sue 1999b) and the White racial identity factors that simply mediate individual identity;
development (WRID) model (Sue 2001). they are dynamic, interactive developmental
Although earlier work focused on a linear processes that influence one’s willingness to
developmental process using stages, current acknowledge the effects of race, ethnicity, and
thought centers on a more flexible process culture and to act against racism and disparity
whereby identification status can loop back to across relationships, situations, and environ-
an earlier process or move to a later phase. ments (for a review of racial and cultural
identity development, see Sue and Sue 2013c).
Using either model, counselors can explore
For counselors and clinical supervisors, it is
relational and clinical challenges associated
essential to understand the dynamic nature of
with a given phase. Without an understanding
cultural identity in all exchanges. Starting with
of the cultural identity development process,
a personal appraisal, clinical staff members can
counselors—regardless of race or ethnicity—
begin to reflect—without judgment—on how
can unwittingly minimize the importance of
their own racial and cultural identities influ-
racial and ethnic experiences. They may fail to
ence their decisions, treatment planning, case
identify cultural needs and secure appropriate
presentation, supervision, and interactions
treatment services, unconsciously operate from
with other staff members. Clinicians can map
a superior perspective (e.g., judging a specific
the interactive influences of cultural identity
behavior as ineffectual, a sign of resistance, or a
development among clients, the clients’ fami-
symptom of pathology), internalize a client’s
lies, staff members, the organization, other
reaction (e.g., an African American counselor
agencies, and any other entities involved in the
feeling betrayed or inadequate when a client of
client’s treatment. Using mapping (see the

39
 Improving Cultural Competence

Exhibit 2-1: Stages of Racial and Cultural Identity Development

R/CID Model WRID Model
Conformity: Has a positive attitude toward Naiveté: Had an early childhood developmental
and preference for dominant cultural values; phase of curiosity or minimal awareness of race;
places considerable value on characteristics may or may not receive overt or covert messages
that represent dominant cultural groups; may about other racial/cultural groups; possesses an
devalue or hold negative views of own race or ethnocentric view of culture.
other racial/ethnic groups.
Conformity: Has minimal awareness of self as a
Dissonance and Appreciating: Begins to racial person; believes strongly in the universality
question identity; recognizes conflicting mes- of values and norms; perceives White American
sages and observations that challenge be- cultural groups as more highly developed; may
liefs/stereotypes of own cultural groups and justify disparity of treatment; may be unaware of
value of mainstream cultural groups; develops beliefs that reflect this.
growing sense of one’s own cultural heritage
Dissonance: Experiences an opportunity to
and the existence of racism; moves away from
examine own prejudices and biases; moves
seeing dominant cultural groups as all good.
toward the realization that dominant society
Resistance and Immersion: Embraces and oppresses racially and culturally diverse groups;
holds a positive attitude toward and prefer- may feel shame, anger, and depression about
ence for his or her own race and cultural the perpetuation of racism by White American
heritage; rejects dominant values of society cultural groups; and may begin to question
and culture; focuses on eliminating oppression previously held beliefs or refortify prior views.
within own racial/cultural group; likely to
Resistance and Immersion: Increases awareness
possess considerable feelings—including
of one’s own racism and how racism is projected
distrust and anger—toward dominant cultural
in society (e.g., media and language); likely feels
groups and anything that may represent them;
angry about messages concerning other racial
places considerable value on characteristics
and cultural groups and guilty for being part of an
that represent one’s own cultural groups
oppressive system; may counteract feelings by
without question; develops a growing appre-
assuming a paternalistic role (knowing what is
ciation for others from racially and culturally
best for clients without their involvement) or
diverse groups.
overidentifying with another racial/cultural group.
Introspection: Begins to question the psycho-
Introspection: Begins to redefine what it means
logical cost of projecting strong feelings
to be a White American and to be a racial and
toward dominant cultural groups; desires to
cultural being; recognizes the inability to fully
refocus more energy on personal identity
understand the experience of others from di-
while respecting own cultural groups; realigns
verse racial and cultural backgrounds; may feel
perspective to note that not all aspects of
disconnected from the White American group.
dominant cultural groups—one’s own ra-
cial/cultural group or other diverse groups— Integrative Awareness: Appreciates racial,
are good or bad; may struggle with and expe- ethnic, and cultural diversity; is aware of and
rience conflicts of loyalty as perspective understands self as a racial and cultural being; is
broadens. aware of sociopolitical influences of racism;
internalizes a nonracist identity.
Integrative Awareness: Has developed a
secure, confident sense of racial/cultural Commitment to Antiracist Action: Commits to
identity; becomes multicultural; maintains social action to eliminate oppression and disparity
pride in racial identity and cultural heritage; (e.g., voicing objection to racist jokes, taking
commits to supporting and appreciating all steps to eradicate racism in institutions and public
oppressed and diverse groups; tends to policies); likely to be pressured to suppress efforts
recognize racism as a societal illness by which and conform rather than build alliances with
all can be victimized. people of color.

Sources: Sue 2001; Sue and Sue 1999b.

40
 Chapter 2—Core Competencies for Counselors and Other Clinical Staff

Case Study for Counselors: Racial and Cultural Identity

The client is a 20-year-old Latino man. His father immigrated to the United States from Mexico as a
child, and his mother (of Latino/Middle Eastern descent) grew up near Albuquerque, New Mexico.
Throughout the initial phase of mental health treatment, the client presented feelings, attitudes, and
behavior consistent with the resistance and immersion stage of the R/CID model. During group
counseling in a partial hospitalization program, the client said that he did not think treatment was
going to work. He believed that no one in treatment, except other Latino men, really understood
him or his life experiences. He thought that his low mood was due, in part, to his recent job loss.

The client’s current concerns, symptoms, and diagnosis (bipolar I) were presented and discussed
during the treatment team meeting. The client’s counselor (a White American man in the dissonance
stage of the WRID model) was concerned that the client might leave treatment against medical
advice and also stated that this would not be the first time a Latino client had done so. The team
recognized that a Latino counselor would likely be useful in this situation (depending on the counse-
lor’s cultural competence). However, no Latino counselor was available, so the team decided that
the client’s current counselor should try to gain support from the client’s parents to encourage the
client to stay in treatment.

Because the client had signed an appropriate release of information, his counselor was able to
contact the parents and arrange a family session. During the family session, the counselor brought
up the client’s need for a Latino counselor. His parents disagreed, expressing their belief that it was
important for their son to learn to relate to the counselor. They said that this was just an excuse their
son was using to leave treatment, which had happened before. The parents’ reaction exemplified a
conformity response, although other information would need to have been gathered to determine
their current stage more accurately.

The counselor, client, parents, and organization were operating from different stages of racial and
cultural identity development. Considering the lack of a proactive plan to provide appropriate
resources—including the hiring of Latino staff or the development of other culturally appropriate
resources (e.g., a peer counselor program)—the organization was most likely in the conformity
phase of the WRID model. The counselor had some awareness of the client’s racial and cultural
needs and of the organization’s failure to meet them, but he alienated the client despite his good
intentions and reinforced mistrust by engaging the client’s parents before working directly with the
client. Had the counselor taken the time to understand the client’s concerns and needs, he would
likely have created an opportunity to challenge his own beliefs, learn more about the client’s racial
and cultural experiences and values, advocate for more appropriate resources for the client within
the organization, be more flexible with treatment solutions, and enable the client to have an experi-
ence that exceeded his expectations of the treatment provider.

“How To Map Racial and Cultural Identity about, experiences, and interprets the world
Development” box on the next page) as prepa- (Koltko-Rivera 2004). Starting in early child-
ration for counseling, treatment planning, or hood, worldview development is facilitated by
clinical supervision, clinicians can gain aware- significant relationships (particularly with
ness of the many forces that influence cultur- parents and family members) and is shaped by
ally responsive treatment. the individual’s environment and life experi-
ences, influencing values, attitudes, beliefs, and
Worldview: The cultural lens of behaviors. In more simplistic terms, each
counseling person’s worldview is like a pair of glasses with
The term “worldview” refers to a set of colored lenses—the person takes in all of life’s
assumptions that guide how one sees, thinks experiences through his or her own uniquely

41
 Improving Cultural Competence

How To Map Racial and Cultural Identity Development

Completing this diagram can give a clearer perspective on past and anticipated dialog among key
stakeholders. The diagram can be used as a training tool to teach racial and cultural identity devel-
opment, to help clinicians and organizations recognize their own development, to explore clinical
issues and dialogs that occur when diverse parties are at similar or different developmental stages,
and to develop tools and resources to address issues that arise from this developmental process.
Using case studies, this diagram can serve as an interactive educational exercise to help counselors,
clinical supervisors, and agencies gain awareness of the effects of race, ethnicity, and cultural groups.
Materials needed: Paper and pencils; handouts on the R/CID and WRID models.
Instructions:
• Identify all relevant parties, including client, counselor, family, supervisor, referral source, other
staff members, and staff from other agencies (e.g., probation/parole, medical center/office, child
and youth services). Include yourself. Place the names at each intersection of the hexagon.
• List the common statements and behaviors (including lack of verbal responses) that you witness
regarding the cultural needs of the client and/or the general statements made by each party re-
garding race, ethnicity, and culture. Write these as one-line abbreviated phrases that represent
each person/agency’s stance under the appropriate entry on the diagram.
• Using current information, choose the cultural identity development stage that best fits the
statements or behaviors (knowing that you may be inaccurate); write it under each name.

tinted view. Not unlike clients, counselors time; definition of family; organization of
enter the treatment process with their own priorities and responsibilities; orientation to
cultural worldviews that shape their concept of self, family, and/or community; religious or

42
 Chapter 2—Core Competencies for Counselors and Other Clinical Staff

spiritual beliefs; ideas about success; and so on approaches. In sum, culturally responsive
(Exhibit 2-2). practice involves an understanding of multiple
perspectives and how these worldviews inter-
However, counselors also contend with anoth-
act throughout the treatment process—
er worldview that is often invisible but still
including the views of the counselor, client,
powerful—the clinical worldview (Bhugra and
family, other clients and staff members, treat-
Gupta 2010; Tilburt and Geller 2007; Tseng
ment program, organization, and other agen-
and Streltzer 2004). Influenced by education,
cies, as well as the community.
clinical training, and work experiences, coun-
selors are introduced into a culture that re- Stereotypes, prejudices, and history
flects specific counseling theories, techniques, Cultural competence involves counselors’
treatment modalities, and general office prac- willingness to explore their own histories of
tices. This worldview, coupled with their prejudice, cultural stereotyping, and discrimi-
personal cultural worldview, significantly nation. Counselors need to be aware of how
shapes the counselor’s beliefs pertaining to the their own perceptions of self and others have
nature of wellness, illness, and healing; inter- evolved through early childhood influences
viewing skills and behavior; diagnostic impres- and other life experiences. For example, how
sions; and prognosis. Moreover, it influences were stereotypes of their own races and ethnic
the definition of normal versus abnormal or heritages perpetuated in their upbringing?
disordered behavior, the determination of What myths and stereotypes were projected
treatment priorities, the means of intervention, onto other groups? What historical events
and the definitions of successful outcomes and shaped experiences, opportunities, and percep-
treatment failures. tions of self and others?
Foremost, counselors need to remember that Regardless of their race, cultural group, or
worldviews are often unspoken and inconspic- ethnic heritage, counselors need to examine
uous; therefore, considerable reflection and how they have directly or indirectly been
self-exploration are needed to identify how affected by individual, organizational, and
their own cultural worldviews influence their societal stereotypes, prejudice, and discrimina-
interactions both inside and outside of coun- tion. How have certain attitudes, beliefs, and
seling. Clinical staff members need to question behaviors functioned as deterrents to obtain-
how their perspectives are perpetuated in and ing equitable opportunities? In what ways
shape client–counselor interactions, treatment have discrimination and societal biases provid-
decisions, planning, and selected counseling ed benefits to them as individuals and as
counselors? Even though these questions can
Exhibit 2-2: Counselor Worldview be uncomfortable, difficult, or painful to ex-
plore, awareness is essential regarding how
these issues affect one’s role as a counselor,
status in the organization, and comfort level in
Individual exploring clients’ life experiences and percep-
Clinical
Cultural Worldview tions during the treatment process. If counse-
Worldview lors avoid or minimize the relevance of bias
and discrimination in self-exploration, they
will likely do the same in the assessment and
counseling process.

43
 Improving Cultural Competence

Trust and power

All counselors should examine their
stereotypes, prejudices, and emotional Counselors need to understand the impact of
reactions toward others, including their role and status within the client–
individuals from their own races or cultural counselor relationship. Client perceptions of
backgrounds and individuals from other counselors’ influence, power, and control vary
groups. They should examine how these in diverse cultural contexts. In some contexts,
attitudes and biases may be detrimental to counselors can be seen as all-knowing profes-
clients in treatment for substance-related sionals, but in others, they can be viewed as
and mental disorders.
representatives of an unjust system. Counse-
Clients can have behavioral health issues and lors need to explore how these dynamics affect
healthcare concerns associated with discrimi- the counseling process with clients from
nation. If counselors are blind to these issues, diverse backgrounds. Do client perceptions
they can miss vital information that influences inhibit or facilitate the process? How do they
client responses to treatment and willingness affect the level of trust in the client–counselor
to follow through with continuing care and relationship? These issues should be identified
ancillary services. For example, a counselor and addressed early in the counseling process.
may refer a client to a treatment program Clients should have opportunities to talk
without noting the client’s history or percep- about and process their perceptions, past
tions of the recommended program or type of experiences, and current needs.
program. The client may initially agree to
Practicing within limits
attend the program but not follow through
A key element of ethical care is practicing
because of past negative experiences and/or
within the limits of one’s competence. Coun-
the perception within his or her racial/ethnic
selors must engage in self-exploration, critical
community that the service does not provide
thinking, and clinical supervision to under-
adequate treatment for clients of color.
stand their clinical abilities and limitations

Advice to Counselors and Clinical Supervisors: Using the RESPECT Mnemonic To

Reinforce Culturally Responsive Attitudes and Behaviors
• Respect—Understand how respect is shown within given cultural groups. Counselors demon-
strate this attitude through verbal and nonverbal communications.
• Explanatory model—Devote time in treatment to understanding how clients perceive their pre-
senting problems. What are their views about their own substance abuse or mental symptoms?
How do they explain the origin of current problems? How similar or different is the counselor’s
perspective?
• Sociocultural context—Recognize how class, race, ethnicity, gender, education, socioeconomic
status, sexual and gender orientation, immigrant status, community, family, gender roles, and so
forth affect care.
• Power—Acknowledge the power differential between clients and counselors.
• Empathy—Express, verbally and nonverbally, the significance of each client’s concerns so that he
or she feels understood by the counselor.
• Concerns and fears—Elicit clients’ concerns and apprehensions regarding help-seeking behavior
and initiation of treatment.
• Therapeutic alliance/Trust—Commit to behaviors that enhance the therapeutic relationship;
recognize that trust is not inherent but must be earned by counselors.
Sources: Bigby and American College of Physicians 2003; Campinha-Bacote et al. 2005.

44
 Chapter 2—Core Competencies for Counselors and Other Clinical Staff

regarding the services that they are able to Knowledge of Other Cultural
provide, the populations that they can serve, Groups
and the treatment issues that they have suffi-
In addition to an understanding of themselves
cient training to address. Cultural competence
and how their cultural groups and values can
requires an ability to assess accurately one’s
affect the therapeutic process, culturally com-
clinical and cultural limitations, skills, and
petent counselors work to acquire cultural
expertise. Counselors risk providing services
knowledge and understanding of clients and
beyond their expertise if they lack awareness
staff with whom they work. From the outset,
and knowledge of the influence of cultural
counselors need general knowledge and
groups on client–counselor relationships,
awareness when working with other cultural
clinical presentation, and the treatment pro-
groups in counseling. For example, they should
cess or if they minimize, ignore, or avoid
acknowledge that culture influences commu-
viewing treatment in a cultural context.
nication patterns, values, gender roles and
Some counselors may assume that they have socialization, clinical presentations of distress,
cultural competence based on having similar counseling expectations, and behavioral norms
experiences as clients, being from the same and expectations in and outside the counseling
race as clients, identifying as a member of the session (e.g. , touching, greetings, gift-giving,
same ethnic heritage or cultural group as accompaniment in sessions, level of formality
clients, or attending training on cultural com- between counselor and client). Counselors
petence. Other counselors may assume compe- should filter and interpret client presentation
tence based on their current or prior from a broad cultural perspective instead of
relationships with others from the same race using only their own cultural groups or previ-
or cultural background as their clients. These ous client experiences as reference points.
experiences can be helpful and filled with
Counselors also need to invest the time to
many potential learning opportunities, but
know clients and their cultures. Culturally
they do not make an individual eligible or
responsive practice involves a commitment to
competent to provide multicultural counseling.
obtaining specific cultural knowledge, not
Likewise, the assumption that a person from
only through ongoing client interactions, but
the same cultural group, race, or ethnic herit-
also through the use of outside resources,
age will intrinsically understand a client from
cultural training seminars and programs,
a similar background is operating out of two
cultural events, professional consultations,
common myths: the “myth of sameness” (i.e.,
that people from the same cultural group, race,
or ethnicity are alike) and the myth that “fa- “Become familiar with the community in
miliarity equals competence” (Srivastava which the client lives and the general
cultural norms of the individual client. This
2007). The Association for Multicultural
can be accomplished by visiting with
Counseling and Development adopted a set people who know the community well,
of counselor competencies that was endorsed attending important community
by the American Counseling Association celebrations and other events, asking
(ACA) for counselors who work with a mul- open-ended questions about community
ticultural clientele (Exhibit 2-3). Competen- concerns and quality of life, and
cies address the attitudes, beliefs, knowledge, identifying community capacities that
and skills associated with the counselor’s need affect wellness in the community.”
for self-knowledge. (Perez and Luquis 2008, p. 177)

45
 Improving Cultural Competence

Exhibit 2-3: ACA Counselor Competencies: Counselors’ Awareness of Their Own

Cultural Values and Biases
Attitudes and beliefs:
• Culturally skilled counselors have moved from being culturally unaware to being aware and
sensitive to their own cultural heritages and to valuing and respecting differences.
• Culturally skilled counselors are aware of how their own cultural backgrounds, experiences,
attitudes, values, and biases influence psychological processes.
• Culturally skilled counselors recognize the limits of their multicultural competence and expertise.
• Culturally skilled counselors are comfortable with differences that exist between themselves and
their clients in terms of race, ethnicity, culture, and beliefs.

Knowledge:
• Culturally skilled counselors have specific knowledge about their own racial and cultural heritage
and how it personally and professionally affects their definitions of normality, abnormality, and
the process of counseling.
• Culturally skilled counselors possess knowledge and understanding of how oppression, racism,
discrimination, and stereotyping affect them personally and in their work. This allows them to
acknowledge their own racist attitudes, beliefs, and feelings. Although this standard applies to
all groups, for White American counselors, it can mean that they understand how they may have
directly or indirectly benefited from individual, institutional, and cultural racism.
• Culturally skilled counselors possess knowledge about their social impact on others. They are
knowledgeable about communication style differences and how their style may clash with or fos-
ter the counseling process with minority clients. They anticipate the impact their style may have
on others.

Skills:
• Culturally skilled counselors seek out educational, consultative, and training experiences to
improve their understanding and effectiveness in working with culturally diverse populations. Be-
ing able to recognize the limits of their competencies, they seek consultation, seek further train-
ing or education, refer out to more qualified individuals or resources, or engage in a
combination of these.
• Culturally skilled counselors are constantly seeking to understand themselves as racial and
cultural beings and are actively seeking a nonracist identity.
Source: American Counseling Association Web site (http://www.counseling.org/docs/competencies/
cross-cultural_competencies_and_objectives.pdf). Adapted with permission.

cultural guides, and clinical supervision. throughout the counseling and treatment
Counselors need to be mindful that they will relationship. For a review of content areas
not know everything about a specific popula- essential in knowing other cultural groups,
tion or initially comprehend how an individual refer to the ”What Are the Cross-Cutting
client endorses or engages in specific cultural Factors in Race, Ethnicity, and Culture” sec-
practices, beliefs, and values. For instance, tion in Chapter 1. These cultural knowledge
some clients may not identify with the same content areas include:
cultural beliefs, practices, or experiences as • Language and communication.
other clients from the same cultural groups. • Geographic location.
Nevertheless, counselors need to be as knowl- • Worldview, values, and traditions.
edgeable as possible and attend to these cul- • Family and kinship.
tural attributes—beginning with the intake • Gender roles.
and assessment process and continuing • Socioeconomic status and education.

46
 Chapter 2—Core Competencies for Counselors and Other Clinical Staff

• Immigration, migration, and acculturation treatment. For example, a young adult two-
stress. spirited (gay) American Indian man may be
• Acculturation and cultural identification. more concerned with having access to tradi-
• Heritage and history. tional healing practices than to specialized
• Sexuality. services for gay men. Counselors and clients
• Religion and spirituality. should collaboratively examine presenting
• Health, illness, and healing. treatment issues and obstacles to engaging in
behavioral health treatment and maintaining
Counselors should not make assumptions
recovery, and they should discuss how cultural
about clients’ race, ethnic heritage, or culture
groups and cultural identities can serve as
based on appearance, accents, behavior, or
guideposts in treatment planning.
language. Instead, counselors need to explore
with clients their cultural identity, which can Exhibit 2-4 lists ACA-endorsed counselor
involve multiple identities (Lynch and Hanson competencies for knowledge of the worldviews
2011). Counselors should discuss what cultural of clients from diverse cultural groups.
identity means to clients and how it influences

Exhibit 2-4: ACA Counselor Competencies: Awareness of Clients’ Worldviews

Attitudes and beliefs:
• Culturally skilled counselors are aware of their negative and positive emotional reactions toward
other racial and ethnic groups and recognize that these reactions may prove detrimental to the
counseling relationship. They are willing to contrast their own beliefs and attitudes with those of
clients from diverse cultures in a nonjudgmental fashion.
• Culturally skilled counselors are aware of the stereotypes and preconceived notions they may
hold toward other racial and ethnic minority groups.

Knowledge:
• Culturally skilled counselors possess specific knowledge and information about the particular
group(s) with whom they are working. They are aware of the life experiences, cultural heritages,
and historical backgrounds of clients from cultures other than their own. This competence is
strongly linked to the minority identity development models available in the literature.
• Culturally skilled counselors understand how race, cultural group, ethnicity, and other factors can
affect personality formation, vocational choices, manifestation of mental disorders, help-seeking
behavior, and the appropriateness or inappropriateness of various counseling approaches.
• Culturally skilled counselors understand and have knowledge of sociopolitical influences upon
the lives of racial and ethnic minorities. They understand that factors such as immigration issues,
poverty, racism, stereotyping, and powerlessness can affect self-esteem and self-concept in the
counseling process.

Skills:
• Culturally skilled counselors familiarize themselves with relevant research and the latest findings
regarding mental health and mental disorders that affect various ethnic and racial groups. They
actively seek out educational experiences that enrich their knowledge, understanding, and cross-
cultural skills for more effective counseling behavior.
• Culturally skilled counselors are actively involved with minority individuals outside of the counsel-
ing setting (community events, social and political functions, celebrations, friendships, neighbor-
hood groups, etc.); their perspective of minorities is more than an academic/helping exercise.

Source: American Counseling Association Web site (http://www.counseling.org/docs/competencies/

cross-cultural_competencies_and_objectives.pdf). Adapted with permission.

47
 Improving Cultural Competence

Cultural Knowledge of Behavioral diverse racial and cultural backgrounds.

Health • Beliefs and traditions surrounding sub-
stance use, including cultural norms con-
Counselors should learn how culture interacts
cerning the use of alcohol and drugs.
with health beliefs, substance use, and other
• Beliefs about treatment, including expecta-
behavioral health issues. They can access litera-
tions and attitudes toward health care and
ture and training that address cultural contexts
counseling.
and meanings of substance use, behavioral and
• Community perceptions of behavioral
emotional reactions, help-seeking behavior, and
health treatment.
treatment. Chapter 5 gives information on
• Obstacles encountered by specific popula-
culturally responsive behavioral health services
tions that make it difficult to access treat-
for major ethnic and racial groups. The how-
ment, such as geographic distance from
to box below lists ways to improve one’s cul-
treatment services.
tural knowledge of health issues by acquiring
• Patterns of co-occurring disorders and
knowledge in key areas to work successfully
conditions specific to people from diverse
with diverse clients:
racial and cultural backgrounds (e.g., cul-
• Patterns of substance use and treatment-
turally specific syndromes, earlier onset of
seeking behavior specific to people of

How To Improve Cultural Knowledge of Health, Illness, and Healing

To promote culturally responsive services, counselors need to acquire cultural knowledge regarding
concepts of health, illness, and healing. The following questions highlight many of the culturally
related issues that are prevalent in and pertinent to assessment, treatment planning, and case
management. This list of considerations can help facilitate discussions in counseling and clinical
supervision contexts:
• Does the cultural group in question consider psychological, physical, and spiritual health or well-
being as separate entities or as unified aspects of the whole person?
• How are illnesses and healing practices defined and conceptualized?
• What are acceptable behaviors for managing stress?
• How do people who belong to the culture in question typically express emotions and emotional
distress?
• What behaviors, practices, or customs do members of this culture consider to be preventive?
• What words do people from this cultural group use to describe a particular problem?
• How do members of the group explain the origins or causes of a particular condition?
• Are there culturally specific conditions or cultural concepts of distress?
• Are there specific biological and physiological variations among members of this population?
• What are the common symptoms that lead to misdiagnosis within this population?
• Where do people from this cultural group typically seek help?
• What traditional healing practices and treatments are endorsed by members of this group?
• Are there biomedical treatments or procedures that would typically be unacceptable?
• Are there specific counseling approaches more congruent with the beliefs of most members?
• What are common health inequities, including social determinants of health, for this population?
• What are acceptable caregiving practices?
• Do members of this group attach honor to caring for family members with specific diseases?
• Are individuals with specific conditions shunned from the community?
• What are the roles of family members in providing health care and in making decisions?
• Is discussing consequences of and prognosis for behaviors, conditions, or diseases acceptable?
Is it customary for family members to withhold prognosis from the client?

48
 Chapter 2—Core Competencies for Counselors and Other Clinical Staff

diabetes, higher prevalence of depression groups; in essence, counselors should commit

and substance dependence). to cultural competence and the process of
• Assessment and diagnosis, including growth. This commitment is evidenced via
culturally appropriate screening and as- investment in ongoing learning and the pur-
sessment and awareness of common diag- suit of culturally congruent skills. Counselors
nostic biases associated with symptom can demonstrate commitment to cultural
presentation. competence through the attitudes and corre-
• Individual, family, and group therapy sponding behaviors indicated in Exhibit 2-5.
approaches that hold promise in address-
Beyond the commitment to and development
ing mental and substance-related disorders
of these fundamental attitudes and behaviors,
specific to the racial and cultural back-
counselors need to work toward intervention
grounds of diverse clients.
strategies that integrate the skills discussed in
• Culturally appropriate peer support,
the following sections.
mutual-help, and other support groups
(e.g., the Wellbriety movement, a cultural- Frame issues in culturally relevant
ly appropriate 12-Step program for Native ways
American people).
Counselors should frame clinical issues with
• Traditional healing and complementary
culturally appropriate references. For example,
methods (e.g., use of spiritual leaders,
in cultural groups that value the community or
herbs, and rituals).
family as much as the individual, it is helpful
• Continuing care and relapse prevention,
to address substance abuse in light of its con-
including attention to clients’ cultural en-
sequences to family or the community. The
vironments, treatment needs, and accessi-
counselor might ask, “How are your family
bility of care within their communities.
and community affected by your use? How do
• Treatment engagement/retention patterns.
family and community members feel when
they see you high?” For clients who place more
Skill Development
value on their independence, it can be more
Becoming culturally competent is an ongoing
effective to point out how substance depend-
process—one that requires introspection,
ence undermines their ability to manage their
awareness, knowledge, and skill development.
own lives through questions like “How might
Counselors need to develop a positive attitude
your use affect your ability to reach your goals?”
toward learning about multiple cultural

Exhibit 2-5: Attitudes and Behaviors of Culturally Competent Counselors

Attitude Behavior
Respect • Exploring, acknowledging, and validating the client’s worldview
• Approaching treatment as a collaborative process
• Investing time to understand the client’s expectations of treatment
• Using consultation, literature, and training to understand culturally specific
behaviors that demonstrate respect for the client
• Communicating in the client’s preferred language
Acceptance • Maintaining a nonjudgmental attitude toward the client
• Considering what is important to the client

(Continued on the next page.)

49
 Improving Cultural Competence

Exhibit 2-5: Attitudes and Behaviors of Culturally Competent Counselors

(continued)
Attitude Behavior
Sensitivity • Understanding the client’s experiences of racism, stereotyping, and discrimi-
nation
• Exploring the client’s cultural identity and what it means to her/him
• Actively involving oneself with individuals from diverse backgrounds outside
the counseling setting to foster a perspective that is more than academic or
work related
• Adopting a broader view of family and, when appropriate, including other
family or community members in the treatment process
• Tailoring treatment to meet the cultural needs of the client (e.g., providing
outside resources for traditional healing)
Commitment • Proactively addressing racism or bias as it occurs in treatment (e.g., pro-
to equality cessing derogatory comments made by another client in a group counseling
session)
• Identifying the specific barriers to treatment engagement and retention
among the populations being served
• Recognizing that equality of treatment does not translate to equity—that
equity is defined as equality in opportunity, access, and outcome (Srivastava
2007)
• Endorsing counseling strategies and treatment approaches that match the
unmet needs of diverse populations to ensure treatment engagement, reten-
tion, and positive outcomes
Openness • Recognizing the value of traditional healing and help-seeking practices
• Developing alliances and relationships with traditional practitioners
• Seeking consultation with traditional healers and religious and spiritual lead-
ers when appropriate
• Understanding and accepting that persons from diverse cultural groups can
use different cognitive styles (e.g., placing more attention on reflecting and
processing than on content; being task oriented)
Humility • Recognizing that the client’s trust is earned through consistent and compe-
tent behavior rather than the potential status and power that is ascribed to
the role of counselor
• Acknowledging the limits of one’s competencies and expertise and referring
clients to a more appropriate counselor or service when necessary
• Seeking consultation, clinical supervision, and training to expand cultural
knowledge and cultural competence in counseling skills
• Seeking to understand oneself as influenced by ethnicity and cultural groups
and actively seeking a nonracist identity
• Being sensitive to the power differential between client and counselor
Flexibility • Using a variety of verbal and nonverbal responses, approaches, or styles to
suit the cultural context of the client
• Accommodating different learning styles in treatment approaches (e.g., the
use of role-plays or experiential activities to demonstrate coping skills or al-
cohol and drug refusal skills)
• Using cultural, socioeconomic, environmental, and political contextual factors
in conducting evaluations
• Integrating cultural practices as treatment strategies (e.g., Alaska Native
traditional practices, such as tundra walking and sustenance activities)

50
 Chapter 2—Core Competencies for Counselors and Other Clinical Staff

Allow for complexity of issues based Make allowances for variations in

on cultural context the use of personal space
Counselors must take care with suggesting Cultural groups have different expectations
simple solutions to complex problems. It is and norms of propriety concerning how close
often better to acknowledge the intricacies of people can be while they communicate and
the client’s cultural context and circumstances. how personal communications can be depend-
For instance, a Native American single mother ing on the type of relationship (e.g., peers
who upholds traditional values could balk at a versus elders). The concept of personal space
suggestion to stop spending time with family involves more than the physical distance
members who drink heavily. Here, the counse- between people. It also involves cultural expec-
lor might encourage the woman to broaden tations regarding posture or stance and the use
support within her community by connecting of space within a given environment. These
with an elder who supports recovery or by cultural expectations, although they are subtle,
engaging in a women’s talking circle. Likewise, can have an impact on treatment. For example,
a referral for a psychiatric evaluation for major an Alaska Native may feel more comfortable
depression may not be an appropriate initial sitting beside a counselor, whereas a European
recommendation for a Chinese client who may prefer to be separated from a counselor by
relies on cultural remedies and healing tradi- a desk (Sue and Sue 2013a). The use of space
tions. An alternative approach would be to can also be a nonverbal expression of power.
explore the client’s beliefs in healing, develop Standing too close to someone can, for exam-
steps that respect and incorporate the client’s ple, suggest power over them. Standing too far
help-seeking practices, and coordinate services away or sitting behind a desk can indicate
to secure a culturally responsive intervention aloofness. Acceptable or expected degrees of
(Cardemil et al. 2011; Gallardo et al. 2012; closeness between people are culturally specific;
Lynch and Hanson 2011). counselors should be educated on the general

Advice to Counselors and Clinical Supervisors: Behaviors for Counselors To Avoid

• Addressing clients informally; counselors should not assume familiarity until they grasp cultural
expectations and client preferences.
• Failing to monitor and adjust to the client’s verbal pacing (e.g., not allowing time for clients to
respond to questions).
• Using counseling jargon and treatment language (e.g., “I am going to send you to our primary
stabilization program to obtain a biopsychosocial and then, afterwards, to partial”).
• Using statements based on stereotypes or other preconceived ideas generated from experiences
with other clients from the same culture.
• Using gestures without understanding their meaning and appropriate context within the given
culture.
• Ignoring the relevance of cultural identity in the client–counselor relationship.
• Neglecting the client’s history (i.e., not understanding the client’s individual and cultural back-
ground).
• Providing an explanation of how current difficulties can be resolved without including the client
in the process to obtain his or her own explanations of the problems and how he or she thinks
these problems should be addressed.
• Downplaying the importance of traditional practices and failing to coordinate these services as
needed.
Sources: Fontes 2008; Lynch and Hanson 2011; Pack-Brown and Williams 2003; Srivastava 2007.

51
 Improving Cultural Competence

parameters and expectations of the given negative connotations for clients with histories
population. However, counselors should not of discrimination and multiple experiences
predetermine the clients’ expectations; instead, with racism, for some women, for indigenous
they should follow the clients’ lead and inquire peoples with histories of colonization, and for
about their preferences. refugees or immigrants who have left oppres-
sive regimes. In this regard, counselors should
Display sensitivity to culturally use these words carefully. For example, a
specific meanings of touch Hmong refugee who experienced trauma in
Some treatment and many support groups her country of origin could already feel help-
have opening or closing traditions that include less and powerless over the events that oc-
holding hands or giving hugs. This form of curred; thus, the concept of powerlessness,
touching can be very uncomfortable to new often used in drug and alcohol treatment
clients regardless of cultural groups; cultural programs, can be contraindicated in address-
prescriptions, including religious beliefs, con- ing her substance-related disorder. However, a
cerning appropriate touching can compound White American business executive who has
this effect (Comas-Diaz 2012). Many cultural authority over others and a history of financial
groups use touch to acknowledge or greet influence may need help acknowledging that
someone, to show respect or convey status or he cannot control his substance abuse.
power, or to display comfort. As counselors, it
is essential to understand cultural norms about Adjust communication styles to the
touch, which often are guided by gender and client’s culture
age, and the contexts surrounding “appropri- Cultural groups all have different communica-
ate” touch for specific cultural groups (Sri- tion styles. Norms for communicating vary in
vastava 2007). Counselors need to devote time and between cultural groups based on class,
to understanding their clients’ norms for and gender, geographic origins, religion, subcul-
interpretations of touch, to assisting clients in tures, and other individual variations. Counse-
negotiating and upholding their cultural lors should educate themselves as much as
norms, and to helping clients understand the possible regarding the patterns of communi-
context and cultural norms that are likely to cating in the client’s cultural, racial, or ethnic
prevail in support and treatment groups. population while also being aware of his/her
own communication style. For a comprehen-
Explore culturally based experiences sive guide in self-assessment and understand-
of power and powerlessness ing of communication styles, refer to Culture
Ideas about power and powerlessness are Matters: The Peace Corps Cross-Cultural
influenced by the client’s culture and social Workbook (Peace Corps Information
class. What constitutes power and powerless- Collection and Exchange 2012).
ness varies from culture to culture according to
the individual’s gender, age, occupation, ances- The following are general guidelines for ascer-
try, religious affiliation, and a host of other taining the client’s communication style:
factors. For example, power can be defined in • Understand the client’s verbal and nonver-
terms of one’s place within the family, with the bal ways of communicating. Be aware of
oldest member being the most powerful and the possible need to move away from
the youngest being the least powerful. Even comprehending and interpreting client re-
the words “power” and “powerlessness” carry sponses in conventional professional ways
cultural meaning. These words can carry

52
 Chapter 2—Core Competencies for Counselors and Other Clinical Staff

How To Assess Differences in Communication Styles

This exercise can be used by counselors and clinical supervisors as a self-assessment tool and a means
of exploring differences in communication styles among counselors, clients, and supervisors. It can also
serve as a group exercise to help clients discuss and understand cultural differences in communicating
with others. This self-administered tool promotes self-understanding and cultural knowledge. It is not
an empirically based instrument, nor is it meant to assess client communication styles or skills formally.

Materials needed: Colored pencils/pens and copies of the exercise.

Instructions:
• First, place an X along the line for each item that best matches your style or pattern of communi-
cation overall. Communication patterns can change across situations and environments depend-
ing on expectations, stress level, and familiarity, (e.g., attending a staff meeting versus spending
time with friends); try to assign the style that best reflects your patterns across situations.
• After reviewing your own patterns, compare differences between you and your client, clinical
supervisor, or fellow staff member. For example, select a recent client you treated and place a
second X (using a different color pen) on each line to mark your perceived view of this client’s
communication style. Then examine the differences between you and your client and generate a
list of potential misunderstandings that could occur due to these differences. Use clinical supervi-
sion to discuss how your own patterns can hinder and/or promote the counseling process.

NONVERBAL PATTERNS
Eye Contact
When talking:
Direct, sustained Indirect or not sustained
When listening:
Direct, sustained Indirect or not sustained
Vocal Pitch/Tone
High/loud Low/soft
More expressive Less expressive
Speech Rate
Fast Slow
Pauses or Silence
Little use of silence in dialog Pauses; uses silence in dialog
Facial Expressions
Frequent expression Little expression
Use of Other Gestures
Frequent expression Little expression

VERBAL PATTERNS
Emotional Expression
Does express and identify feel- Does not express or identify
ings in speech feelings in speech
Self-Disclosure
Frequently Rarely or little
Formality Formal in addressing others
Informal and showing respect

(Continued on the next page.)

53
 Improving Cultural Competence

How To Assess Differences in Communication Styles (continued)

Directness Indirect; subtle; doesn’t
Verbally explicit believe in saying everything
Context High context: verbal and
Low context; relies more on nonverbal cues convey
words to convey meaning much of the meaning
Orientation Orientation to others, use of
Orientation to self; use of “I” plural and third-person
statements pronouns (e.g., we, he)
Other Things To Consider in Exploring Communication Styles:
• Are there known differences in body language and expression within the given cultural group?
• What are the common, culturally appropriate parameters of touch across situations? For exam-
ple, a handshake could be appropriate as a means of introduction for one cultural group but not
for another.
• How is personal space used in and outside of the office? Are there known cultural patterns in the
use of space and proximity of communication?
• What verbal and nonverbal counselor behaviors may affect trust in the counseling process?

Sources: Cormier et al. 2009; Fontes 2008; Srivastava 2007; Sue and Sue 2013a.

(Bland and Kraft 1998). Always be curious not said can possibly be more important
about the client’s cultural context and be than what is said.
willing to seek clarification and better un- • Listen to storytelling carefully, as it can be
derstanding from the client. It is as im- a way of communicating with the thera-
portant for counselors to access and pist. As in any good therapy, follow the as-
engage in cultural consultation to acquire sociations and listen for possible
more specific knowledge and experience. metaphors to better understand relational
• Styles of communication and nonverbal meaning, cognition, and emotion within
methods of communication are important the context of the conversation.
aspects of cultural groups. Issues such as
the appropriate space to have between Interpret emotional expressions in
people; preferred ways of moving, sitting, light of the client’s culture
and standing; the meaning of gestures; and Feelings are expressed differently across and
the degree of eye contact expected are all within cultural groups and are influenced by
culturally defined and situation specific the nature of a given event and the individuals
(Hall 1976). As an example, high-context involved in the situation. A certain level of
cultural groups place greater importance emotional expression can be socially appropri-
on nonverbal cues and message context, ate within one culture yet inappropriate in
whereas low-context cultural groups rely another. In some cultural groups, feelings may
largely on verbal message content. Most not be expressed directly, whereas in other
Asian Americans come from high-context cultural groups, some emotions are readily
cultural groups in which sensitive messages expressed and others suppressed. For example,
are encoded carefully to avoid offending expressions of sadness may at first be more
others. A provider who listens only to the readily shared by some clients in counseling
content could miss the message. What is settings, whereas others may find it more

54
 Chapter 2—Core Competencies for Counselors and Other Clinical Staff

comfortable to express anger as their initial

Providing good care goes beyond counse-
response. Counselors must recognize that not lors’ general knowledge, clinical skills, and
all cultures place the same value on verbalizing approaches; it involves understanding the
feelings. In fact, clients from some cultures multicultural context of clients and of
may not perceive that emotional expression is themselves as counselors. Cultural compe-
a worthy course of treatment and healing at tence is an ethical issue requiring counse-
all. Thus, counselors should not impose a lors to be invested in developing the tools
prescribed approach that measures progress to provide culturally congruent care—care
and equates healing with the ability to display that matches the needs and context of the
client. For a review of ethics and ethical
emotions. Likewise, counselors should be
dilemmas in a multicultural context, refer
careful not to attribute meaning based on their to Pack-Brown and Williams (2003).
own cultural backgrounds or to project their
own feelings onto clients’ experiences. Instead, Results from the counselor’s understanding of
counselors need to assist their clients in iden- and sensitivity to the values, cultures, and
tifying and labeling feelings within their own special needs of the individuals and groups
cultural contexts. being served (Sue and Sue 2013d). Counselors
need to adopt an ongoing commitment to
Expand roles and practices developing skills and endorsing practices that
Counselors need to acquire a mindset that assist clients in receiving and experiencing the
allows for more flexible roles and practices— best possible care. Exhibit 2-6 lists counselor
while still maintaining appropriate profession- competencies endorsed by ACA for culturally
al boundaries—when working with clients. appropriate intervention strategies.
Some clients whose culture places considera-
ble emphasis upon and orientation toward
family could look to counselors for advice with Self-Assessment for
unrelated issues pertaining to other family Individual Cultural
members. Other clients may expect a more
prescribed and structured approach in which
Competence
counselors give specific recommendations and Several instruments for evaluating an individ-
advice in the session. For example, Asian ual’s cultural competence have been developed
American clients appear to expect and benefit and are available online. One assessment tool
from a more directive and highly structured that has been widely circulated is Goode’s Self-
approach (Fowler et al. 2011; Lee and Mock Assessment Checklist for Personnel Providing
2005a; Sue 2001; Uba 1994). Still others could Services and Supports to Children and Youth
expect that counselors be connected to their With Special Health Needs and Their Families. It
communities through participation in com- can be adapted for counselors treating adult
munity events, in working with traditional clients with behavioral health concerns. This
healers, or in building collaborative relation- tool and other additional resources are provid-
ships with other community agencies. As ed in Appendix C. For an interactive Web-
counselors, it is important to understand the based tool on cultural competence awareness,
cultural contexts of clients and how this trans- visit the American Speech-Language-Hearing
lates to expectations in the client–counselor Association Web site (http://www.asha.org).
relationship. The appropriate role usually

55
 Improving Cultural Competence

Exhibit 2-6: ACA Counselor Competencies: Culturally Appropriate Intervention

Strategies
Attitudes and beliefs:
• Culturally skilled counselors respect clients’ religious and/or spiritual beliefs and values, includ-
ing attributions and taboos, because they affect worldview, psychosocial functioning, and ex-
pressions of distress.
• Culturally skilled counselors respect traditional helping practices and intrinsic help-giving net-
works in minority communities.
• Culturally skilled counselors value bilingualism and do not view another language as an impedi-
ment to counseling.

Knowledge:
• Culturally skilled counselors have a clear and explicit knowledge and understanding of the
generic characteristics of counseling and therapy (culture bound, class bound, and monolingual)
and how they could clash with the cultural values of various minority groups.
• Culturally skilled counselors are aware of institutional barriers that prevent minorities from using
behavioral health services.
• Culturally skilled counselors know of the potential biases in assessment instruments and use pro-
cedures and interpret findings in keeping with the cultural and linguistic characteristics of clients.
• Culturally skilled counselors have knowledge of minority family structures, hierarchies, values,
and beliefs. They are knowledgeable about family and community characteristics and resources.
• Culturally skilled counselors are aware of relevant discriminatory practices at the social and com-
munity levels that could be affecting the psychological welfare of the populations being served.

Skills:
• Culturally skilled counselors are able to engage in a variety of verbal and nonverbal helping
responses. They are able to send and receive both verbal and nonverbal messages accurately
and appropriately. They are not tied down to only one method or approach, recognizing that
helping styles and approaches can be culture bound. When they sense that their helping style is
limited and potentially inappropriate, they can anticipate and ameliorate its negative impact.
• Culturally skilled counselors are able to exercise institutional intervention skills on behalf of their
clients. They can help clients determine whether a problem stems from racism or bias in others
(the concept of health paranoia) so that clients do not inappropriately personalize problems.
• Culturally skilled counselors are not averse to seeking consultation with traditional healers,
religious and spiritual leaders, and practitioners in the treatment of culturally diverse clients
when appropriate.
• Culturally skilled counselors take responsibility for interacting in the languages requested by
their clients; if not feasible, they make appropriate referrals. A serious problem arises when the
linguistic skills of a counselor do not match the language of the client. When language matching
is not possible, counselors should seek a translator with cultural knowledge and appropriate pro-
fessional background and/or refer to a knowledgeable and competent bilingual counselor.
• Culturally skilled counselors have training and expertise in the use of traditional assessment and
testing instruments, understand their technical aspects, and are aware of their cultural limita-
tions. This allows counselors to use test instruments for the welfare of diverse clients.
• Culturally skilled counselors are aware of and work to eliminate biases, prejudices, and discrimi-
natory practices. They are aware of sociopolitical contexts in conducting evaluation and provid-
ing interventions and are sensitive to issues of oppression, sexism, elitism, and racism.
• Culturally skilled counselors educate clients about the processes of psychological intervention,
explaining such elements as goals, expectations, legal rights, and the counselor’s theoretical orien-
tation.

Source: American Counseling Association Web site (http://www.counseling.org/docs/competencies/

cross-cultural_competencies_and_objectives.pdf). Adapted with permission.

56
 3 Culturally Responsive
Evaluation and
Treatment Planning

Zhang Min, a 25-year-old first-generation Chinese woman, was

IN THIS CHAPTER referred to a counselor by her primary care physician because she
• Step 1: Engage Clients reported having episodes of depression. The counselor who con-
• Step 2: Familiarize Clients ducted the intake interview had received training in cultural com-
and Their Families With petence and was mindful of cultural factors in evaluating Zhang
Treatment and Evaluation Min. The referral noted that Zhang Min was born in Hong Kong,
Processes so the therapist expected her to be hesitant to discuss her prob-
• Step 3: Endorse lems, given the prejudices attached to mental illness and substance
Collaboration in abuse in Chinese culture. During the evaluation, however, the
Interviews, Assessments, therapist was surprised to find that Zhang Min was quite forth-
and Treatment Planning
coming. She mentioned missing important deadlines at work and
• Step 4: Integrate calling in sick at least once a week, and she noted that her cowork-
Culturally Relevant ers had expressed concern after finding a bottle of wine in her desk.
Information and Themes
She admitted that she had been drinking heavily, which she linked
• Step 5: Gather Culturally to work stress and recent discord with her Irish American spouse.
Relevant Collateral
Information Further inquiry revealed that Zhang Min’s parents, both Chinese,
• Step 6: Select Culturally went to school in England and sent her to a British school in Hong
Appropriate Screening Kong. She grew up close to the British expatriate community, and
and Assessment Tools her mother was a nurse with the British Army. Zhang Min came to
• Step 7: Determine the United States at the age of 8 and grew up in an Irish American
Readiness and Motivation neighborhood. She stated that she knew more about Irish culture
for Change than about Chinese culture. She felt, with the exception of her
• Step 8: Provide Culturally physical features, that she was more Irish than Chinese—a view
Responsive Case accepted by many of her Irish American friends. Most men she had
Management dated were Irish Americans, and she socialized in groups in which
• Step 9: Incorporate alcohol consumption was not only accepted but expected.
Cultural Factors Into
Treatment Planning Zhang Min first started to drink in high school with her friends.
The counselor realized that what she had learned about Asian

57
 Improving Cultural Competence

Multidimensional Model for Developing Cultural Competence: Clinical/Program

Level

Americans was not necessarily applicable to in planning and evaluation entails being open
Zhang Min and that knowledge of Zhang minded, asking the right questions, selecting
Min’s entire history was necessary to appreci- appropriate screening and assessment instru-
ate the influence of culture in her life. The ments, and choosing effective treatment pro-
counselor thus developed treatment strategies viders and modalities for each client. Moreover,
more suitable to Zhang Min’s background. it involves identifying culturally relevant con-
cerns and issues that should be addressed to
Zhang Min’s case demonstrates why thorough
improve the client’s recovery process.
evaluation, including assessment of the client’s
sociocultural background, is essential for treat- This chapter offers clinical staff guidance in
ment planning. To provide culturally responsive providing and facilitating culturally responsive
evaluation and treatment planning, counselors interviews, assessments, evaluations, and
and programs must understand and incorporate treatment planning. Using Sue’s (2001) multi-
relevant cultural factors into the process while dimensional model for developing cultural
avoiding a stereotypical or “one-size-fits-all” competence, this chapter focuses on clinical
approach to treatment. Cultural responsiveness and programmatic decisions and skills that are

58
 Chapter 3—Culturally Responsive Evaluation and Treatment Planning

important in evaluation and treatment plan-

Improving Cross-Cultural Communication
ning processes. The chapter is organized
around nine steps to be incorporated by clini- Health disparities have multiple causes. One
cians, supported in clinical supervision, and specific influence is cross-cultural communication
between the counselor and the client. Weiss
endorsed by administrators. (2007) recommends these six steps to improve
communication with clients:
Step 1: Engage Clients 1. Slow down.
2. Use plain, nonpsychiatric language.
Once clients are in contact with a treatment 3. Show or draw pictures.
4. Limit the amount of information provided at
program, they stand on the far side of a yet-to-
one time.
be-established therapeutic relationship. It is up 5. Use the “teach-back” method. Ask the client,
to counselors and other staff members to bridge in a nonthreatening way, to explain or show
the gap. Handshakes, facial expressions, greet- what he or she has been told.
ings, and small talk are simple gestures that 6. Create a shame-free environment that en-
courages questions and participation.
establish a first impression and begin building
the therapeutic relationship. Involving one’s
whole being in a greeting—thought, body, to understand the problem” (p. 18). It is also
attitude, and spirit—is most engaging. important that the client feel engaged with
any interpreter used in the intake process. A
Fifty percent of racially and ethnically diverse common framework used in many healthcare
clients end treatment or counseling after one training programs to highlight culturally
visit with a mental health practitioner (Sue and responsive interview behaviors is the LEARN
Sue 2013e). At the outset of treatment, clients model (Berlin and Fowkes 1983). The how-to
can feel scared, vulnerable, and uncertain about box on the next page presents this model.
whether treatment will really help. The initial
meeting is often the first encounter clients have
with the treatment system, so it is vital that
Step 2: Familiarize Clients
they leave feeling hopeful and understood. and Their Families With
Paniagua (1998) describes how, if a counselor
lacks sensitivity and jumps to premature con-
Treatment and Evaluation
clusions, the first visit can become the last: Processes
Pretend that you are a Puerto Rican taxi driv- Behavioral health treatment facilities maintain
er in New York City, and at 3:00 p.m. on a
their own culture (i.e., the treatment milieu).
hot summer day you realize that you have
your first appointment with the thera- Counselors, clinical supervisors, and agency
pist…later, you learned that the therapist administrators can easily become accustomed
made a note that you were probably depressed to this culture and assume that clients are used
or psychotic because you dressed carelessly to it as well. However, clients are typically new
and had dirty nails and hands…would you
to treatment language or jargon, program
return for a second appointment? (p. 120)
expectations and schedules, and the intake and
To engage the client, the counselor should try treatment process. Unfortunately, clients from
to establish rapport before launching into a diverse racial and ethnic groups can feel more
series of questions. Paniagua (1998) suggests estranged and disconnected from treatment
that counselors should draw attention to the services when staff members fail to educate
presenting problem “without giving the im- them and their families about treatment ex-
pression that too much information is needed pectations or when the clients are not walked

59
 Improving Cultural Competence

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.

through the treatment process, starting with intrusive if too much information is requested
the goals of the initial intake and interview. By or if the content is a source of family dishonor
taking the time to acclimate clients and their or shame. Other clients may resist or distrust
families to the treatment process, counselors the process based on a long history of racism
and other behavioral health staff members and oppression. Still others feel inhibited from
tackle one obstacle that could further impede actively participating because they view the
treatment engagement and retention among counselor as the authority or sole expert.
racially and ethnically diverse clients.
The counselor can help decrease the influence
of these issues in the interview process
Step 3: Endorse through a collaborative approach that allows
Collaboration in time to discuss the expectations of both coun-
selor and client; to explain interview, intake,
Interviews, Assessments, and treatment planning processes; and to
and Treatment Planning establish ways for the client to seek clarifica-
tion of his or her assessment results (Mohatt
Most clients are unfamiliar with the evalua- et al. 2008a). The counselor can encourage
tion and treatment planning process and how collaboration by emphasizing the importance
they can participate in it. Some clients may of clients’ input and interpretations. Client
view the initial interview and evaluation as feedback is integral in interpreting results and

60
 Chapter 3—Culturally Responsive Evaluation and Treatment Planning

can identify cultural issues that may affect

Advice to Counselors: Conducting
intake and evaluation (Acevedo-Polakovich et Strength-Based Interviews
al. 2007). Collaboration should extend to client
preferences and desires regarding inclusion of By nature, initial interviews and evaluations can
overemphasize presenting problems and con-
family and community members in evaluation
cerns while underplaying client strengths and
and treatment planning. supports. This list, although not exhaustive,
reminds clinicians to acknowledge client
Step 4: Integrate strengths and supports from the outset.

Culturally Relevant Strengths and supports:

• Pride and participation in one’s culture
Information and Themes • Social skills, traditions, knowledge, and
practical skills specific to the client’s culture
By exploring culturally relevant themes, • Bilingual or multilingual skills
counselors can more fully understand their • Traditional, religious, or spiritual practices,
beliefs, and faith
clients and identify their cultural strengths • Generational wisdom
and challenges. For example, a Korean wom- • Extended families and nonblood kinships
an’s family may serve as a source of support • Ability to maintain cultural heritage and
and provide a sense of identity. At the same practices
time, however, her family could be ashamed • Perseverance in coping with racism and
oppression
of her co-occurring generalized anxiety and • Culturally specific ways of coping
substance use disorders and respond to her • Community involvement and support
treatment as a source of further shame be-
Source: Hays 2008.
cause it encourages her to disclose personal
matters to people outside the family. The
following section provides a brief overview of important clues about the client’s degree of
suggested strength-based topics to incorpo- acculturation in early life and at present, cul-
rate into the intake and evaluation process. tural identity, ties to culture of origin, potential
cultural conflicts, and resources. Specific ques-
Immigration History tions should elicit information about:
Immigration history can shed light on client • Length of time in the United States,
support systems and identify possible isolation noting when immigration occurred or the
or alienation. Some immigrants who live in number of generations who have resided in
ethnic enclaves have many sources of social the United States.
support and resources. By contrast, others may • Frequency of returns and psychological
be isolated, living apart from family, friends, and personal ties to the country of origin.
and the support systems extant in their coun- • Primary language and level of English
tries of origin. Culturally competent evalua- proficiency in speaking and writing.
tion should always include questions about the • Psychological reactions to immigration
client’s country of origin, immigration status, and adjustments made in the process.
length of time in the United States, and con- • Changes in social status and other areas as
nections to his or her country of origin. Ask a result of coming to this country.
American-born clients about their parents’ • Major differences in attitudes toward
country of origin, the language(s) spoken at alcohol and drug use from the time of
home, and affiliation with their parents’ cul- immigration to now.
ture(s). Questions like these give the counselor

61
 Improving Cultural Competence

Cultural Identity and Advice to Counselors: Asking About

Acculturation Culture and Acculturation
As shown in Zhang Min’s case at the begin- A thoughtful exploration of cultural and ethnic
ning of this chapter, cultural identity is a identity issues will provide clues for determin-
unique feature of each client. Counselors ing cultural, racial, and ethnic identity. There
should guard against making assumptions are numerous clues that you may derive from
your clients’ answers, and they cannot all be
about client identity based on general ethnic
covered in this TIP; this is only one set of
and racial identification by evaluating the sample questions (Fontes 2008). Ask these
degree to which an individual identifies with questions tactfully so they do not sound like an
his or her culture(s) of origin. As Castro and interrogation. Try to integrate them naturally
colleagues (1999b) explain, “for each group, into a conversation rather than asking one after
another. Not all questions are relevant in all
the level of within-group variability can be
settings. Counselors can adapt wording to suit
assessed using a core dimension that ranges clients’ cultural contexts and styles of commu-
from high cultural involvement and ac- nication, because the questions listed here and
ceptance of the traditional culture’s values to throughout this chapter are only examples:
low or no cultural involvement” (p. 515). For • Where were you born?
• Whom do you consider family?
African Americans, for example, this dimen-
• What was the first language you learned?
sion is called “Afrocentricity.” Scales for Af- • Which other language(s) do you speak?
rocentricity have been developed in an attempt • What language or languages are spoken in
to provide an indicator of an individual’s level your home?
of involvement within the traditional or core • What is your religion? How observant are
you in practicing that religion?
African-oriented culture (Baldwin and Bell
• What activities do you enjoy when you are
1985; Cokley and Williams 2005; Klonoff and not working?
Landrine 2000). Many other instruments • How do you identify yourself culturally?
based on models of identity evaluate accul- • What aspects of being ________ are most
turation and identity. A detailed discussion of important to you? (Use the same term for
the identified culture as the client.)
the theory behind such models is beyond the
• How would you describe your home and
scope of this Treatment Improvement Proto- neighborhood?
col (TIP); however, counselors should have a • Whom do you usually turn to for help when
general understanding of what is being meas- facing a problem?
ured when administering such instruments. • What are your goals for this interview?
The “Asking About Culture and Accultura-
American culture, White American culture, or
tion” advice box at right addresses exploration
both. When a client has two or more ra-
of culture and acculturation with clients. For
cial/ethnic identities, counselors should assess
more information on instruments that measure
how the client self-identifies and how he or
acculturation and/or identity, see Appendix B.
she negotiates the different worlds.
Other areas to explore include the cross-
cutting factors outlined in Chapter 1, such as Membership in a Subculture
socioeconomic status (SES), occupation, Clients often identify initially with broader
education, gender, and other variables that can racial, ethnic, and cultural groups. However,
distinguish an individual from others who each person has a unique history that warrants
share his or her cultural identity. For example, an understanding of how culture is practiced
a biracial client could identify with African and has evolved for the person and his or her

62
 Chapter 3—Culturally Responsive Evaluation and Treatment Planning

family; accordingly, counselors should avoid

Advice to Counselors: Eliciting Client
generalizations or assumptions. Clients are Views on Presenting Problems
often part of a culture within a culture. There
is not just one Latino, African American, or Some clients do not see their presenting physi-
cal, psychological, and/or behavioral difficulties
Native American culture; many variables
as problems. Instead, they may view their
influence culture and cultural identity (see the presenting difficulties as the result of stress or
“What Are the Cross-Cutting Factors in Race, another issue, thus defining or labeling the
Ethnicity, and Culture” section in Chapter 1). presenting problem as something other than a
For example, an African American client from physical or mental disorder. In such cases,
word the following questions using the clients’
East Carroll Parish, LA, might describe his or
terminology rather than using the word “prob-
her culture quite differently than an African lem.” These questions help explore how clients
American from downtown Hartford, CT. view their behavioral health concerns:
• I know that clients and counselors some-
Beliefs About Health, Healing, times have different ideas about illness and
diseases, so can you tell me more about
Help-Seeking, and Substance Use your idea of your problem?
Just as culture shapes an individual’s sense of • Do you consider your use of alcohol and/or
identity, it also shapes attitudes surrounding drugs a problem?
health practices and substance use. Cultural • How do you label your problem? Do you
think it is a serious problem?
acceptance of a behavior, for instance, can • What do you think caused your problem?
mask a problem or deter a person from seek- • Why do you think it started when it did?
ing treatment. Counselors should be aware of • What is going on in your body as a result of
how the client’s culture conceptualizes issues this problem?
related to health, healing and treatment prac- • How has this problem affected your life?
• What frightens or concerns you most about
tices, and the use of substances. For example, this problem and its treatment?
in cases where alcohol use is discouraged or • How is your problem viewed in your family?
frowned upon in the community, the client Is it acceptable?
can experience tremendous shame about • How is your problem viewed in your com-
drinking. Chapter 5 reviews health-related munity? Is it acceptable? Is it considered a
disease?
beliefs and practices that can affect help- • Do you know others who have had this
seeking behavior across diverse populations. problem? How did they treat the problem?
• How does your problem affect your stature
Trauma and Loss in the community?
Some immigrant subcultures have experienced • What kinds of treatment do you think will
help or heal you?
violent upheavals and have a higher incidence • How have you treated your drug and/or
of trauma than others. The theme of trauma alcohol problem or emotional distress?
and loss should therefore be incorporated into • What has been your experience with treat-
general intake questions. Specific issues under ment programs?
this general theme might include: Sources: Lynch and Hanson 2011; Tang and
• Migration, relocation, and emigration Bigby 1996; Taylor 2002.
history—which considers separation from
homeland, family, and friends—and the • Clients’ personal or familial experiences
stressors and loss of social support that can with American Indian boarding schools.
accompany these transitions. • Experiences with genocide, persecution,
torture, war, and starvation.

63
 Improving Cultural Competence

How To Use a Multicultural Intake Checklist

Some clients do not see their presenting physical, psychological, and/or behavioral difficulties as
problems. Instead, they may view their presenting difficulties as the result of stress or another issue,
thus defining or labeling the presenting problem as something other than a physical or mental
disorder. In such cases, word questions about the following topics using the client’s terminology,
rather than using the word “problem.” Asking questions about the following topics can help you
explore how a client may view his or her behavioral health concerns:

 Immigration history  Sexual and gender orientation

 Relocations (current migration pat-  Health concerns
terns)  Traditional healing practices
 Losses associated with immigration  Help-seeking patterns
and relocation history  Beliefs about wellness
 English language fluency  Beliefs about mental illness and mental health
 Bilingual or multilingual fluency treatment
 Individualistic/collectivistic orientation  Beliefs about substance use, abuse, and depend-
 Racial, ethnic, and cultural identities ence
 Tribal affiliation, if appropriate  Beliefs about substance abuse treatment
 Geographic location  Family views on substance use and substance
 Family and extended family concerns abuse treatment
(including nonblood kinships)  Treatment concerns related to cultural differences
 Acculturation level (e.g., traditional,  Cultural approaches to healing or treatment of
bicultural) substance use and mental disorders
 Acculturation stress  Education history and concerns
 History of discrimination/racism  Work history and concerns
 Trauma history  SES and financial concerns
 Historical trauma  Cultural group affiliation
 Intergenerational family history and  Current network of support
concerns  Community concerns
 Gender roles and expectations  Review of confidentiality parameters and concerns
 Birth order roles and expectations  Cultural concepts of distress (DSM-5*)
 Relationship and dating concerns  DSM-5 culturally related V-codes

*Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American Psychiatric Associa-
tion [APA] 2013).
Sources: Comas-Diaz 2012; Constantine and Sue 2005; Sussman 2004.

own perspective and may not recall certain

Step 5: Gather Culturally events or be aware of how his or her behavior
Relevant Collateral affects his or her well-being and that of oth-
ers. Collateral information—supplemental
Information information obtained with the client’s permis-
A client who needs behavioral health treat- sion from sources other than the client—can
ment services may be unwilling or unable to be derived from family members, medical and
provide a full personal history from his or her court records, probation and parole officers,

64
 Chapter 3—Culturally Responsive Evaluation and Treatment Planning

community members, and others. Collateral instruments and their appropriateness for
information should include culturally relevant specific cultural groups. Counselors should
information obtained from the family, such as continue to explore the availability of mental
the organizational memberships, beliefs, and health and substance abuse screening and
practices that shape the client’s cultural identi- assessment tools that have been translated into
ty and understanding of the world. or adapted for other languages.
As families can be a vital source of infor- Culturally Appropriate Screening
mation, counselors are likely to attain more
support by engaging families earlier in the
Devices
treatment process. Although counselor inter- The consensus panel does not recommend any
actions with family members are often limited specific instruments for screening or assessing
to a few formal sessions, the families of racially mental or substance use disorders. Rather,
and ethnically diverse clients tend to play a when selecting instruments, practitioners
more significant and influential role in clients’ should consider their cultural applicability to
participation in treatment. Consequently, the client being served (AACE 2012; Jome
special sensitivity to the cultural background and Moody 2002). For example, a screening
of family members providing collateral infor- instrument that asks the respondent about his
mation is essential. Families, like clients, or her guilt about drinking could be ineffective
cannot be easily defined in terms of a generic for members of cultural, ethnic, or religious
cultural identity (Congress 2004; Taylor et al. groups that prohibit any consumption of
2012). Even families from the same racial alcohol. Al-Ansari and Negrete’s (1990) re-
background or ethnic heritage can be quite search supports this point. They found that
dissimilar, thus requiring a multidimensional the Short Michigan Alcoholism Screening
approach in understanding the role of culture Test was highly sensitive with people who use
in the lives of clients and their families. Using alcohol in a traditional Arab Muslim society;
the culturagram tool on the next page in however, one question—“Do you ever feel
preparation for counseling, treatment plan- guilty about your drinking?”—failed to distin-
ning, or clinical supervision, clinicians can guish between people with alcohol dependency
learn about the unique attributes and histories disorders in treatment and people who drank
that influence clients’ lives in a cultural context. in the community. Questions designed to
measure conflict that results from the use of
alcohol can skew test results for participants
Step 6: Select Culturally from cultures that expect complete abstinence
Appropriate Screening from alcohol and/or drugs. Appendix D sum-
marizes instruments tested on specific popula-
and Assessment Tools tions (e.g., availability of normative data for
Discussions of the complexities of psychologi- the population being served).
cal testing, the interpretation of assessment
measures, and the appropriateness of screen- Culturally Valid Clinical Scales
ing procedures are outside the scope of this As the literature consistently demonstrates,
TIP. However, counselors and other clinical co-occurring mental disorders are common in
service providers should be able to use assess- people who have substance use disorders.
ment and screening information in culturally Although an assessment of psychological
competent ways. This section discusses several problems helps match clients to appropriate

65
 Improving Cultural Competence

How To Use a Culturagram for Mapping the Role of Culture

The culturagram is an assessment tool that helps clinicians understand culturally diverse clients and
their families (Congress 1994, 2004; Congress and Kung 2005). It examines 10 areas of inquiry,
which should include not only questions specific to clients’ life experiences, but also questions
specific to their family histories. This diagram can guide an interview, counseling, or clinical supervi-
sion session to elicit culturally relevant multigenerational information unique to the client and the
client’s family. Give a copy of the diagram to the client or family for use as an interactive tool in the
session. Throughout the interview, the client, family members, and/or the counselor can write brief
responses in each box to highlight the unique attributes of the client’s history in the family context.
This diagram has been adapted for clients with co-occurring mental and substance use disorders;
sample questions follow.
Legal and Time in
socioeconomic community
status

Reasons for Language

relocation or spoken at home
migration and in
community

Family: List
each member
Values about and circle the Health beliefs
structure, client’s name and beliefs
power, myths, about drug
and rules and alcohol
use

Values about Impact of trauma,

education and substance abuse,
work Religious and Oppression and other crisis
cultural and events
institutions, discrimination
food, clothing,
and holidays

Values about family structure, power, myths, and rules:

• Are there specific gender roles and expectations in your family?
• Who holds the power within the family?
• Are family needs more important than, or equally as important as, individual needs?
• Whom do you consider family?

Reasons for relocation or migration:

• Are you and your family able to return home?
• What were your reasons for coming to the United States?
• How do you now view the initial reasons for relocation?
• What feelings do you have about relocation or migration?
• Do you move back and forth from one location to another?
• How often do you and your family return to your homeland?
• Are you living apart from your family?

Legal status and SES:

• Has your SES improved or worsened since coming to this country?
• Has there been a change in socioeconomic status across generations?
(Continued on the next page.)

66
 Chapter 3—Culturally Responsive Evaluation and Treatment Planning

How To Use a Culturagram for Mapping the Role of Culture (continued)

• What is the family history of documentation? (Note: Clients often need to develop trust before
discussing legal status; they may come from a place where confidentiality is unfamiliar.)
Time in the community:
• How long have you and your family members been in the country? Community?
• Are you and your family actively involved in a culturally based community?
Languages spoken in and outside the home:
• What languages are spoken at home and in the community?
• What is your and your family’s level of proficiency in each language?
• How dependent are parents and grandparents on their children for negotiating activities sur-
rounding the use of English? Have children become the family interpreters?
Health beliefs and beliefs about help-seeking:
• What are the family beliefs about drug and alcohol use? Mental illness? Treatment?
• Do you and your family uphold traditional healing practices?
• How do help-seeking behaviors differ across generations and genders in your family?
• How do you and your family define illness and wellness?
• Are there any objections to the use of Western medicine?
Impact of trauma and other crisis events:
• How has trauma affected your family across generations?
• How have traumas or other crises affected you and/or your family?
• Has there been a specific family crisis?
• Did the family experience traumatic events prior to migration—war, other forms of violence,
displacement including refugee camps, or similar experiences?
Oppression and discrimination:
• Is there a history of oppression and discrimination in your homeland?
• How have you and your family experienced discrimination since immigration?
Religious and cultural institutions, food, clothing, and holidays:
• Are there specific religious holidays that your family observes?
• What holidays do you celebrate?
• Are there specific foods that are important to you?
• Does clothing play a significant cultural or religious role for you?
• Do you belong to a cultural or social club or organization?
Values about education and work:
• How much importance do you place on work, family, and education?
• What are the educational expectations for children within the family?
• Has your work status changed (e.g., level of responsibility, prestige, and power) since migration?
• Do you or does anyone in your family work several jobs?
Sources: Comas-Diaz 2012; Congress 1994, 2004; Singer 2007.

treatment, clinicians are cautioned to proceed equally imperfect psychological constructs that
carefully. People who are abusing substances or were created to organize and understand
experiencing withdrawal from substances can clinical patterns and thus better treat them;
exhibit behaviors and thinking patterns con- they do not provide absolute answers. As
sistent with mental illness. After a period of research and science evolve, so does our under-
abstinence, symptoms that mimic mental standing of mental illness (Benuto 2012).
illness can disappear. Moreover, clinical in- Assessment tools are generally developed for
struments are imperfect measurements of particular populations and can be inapplicable

67
 Improving Cultural Competence

to diverse populations (Blume et al. 2005; Shafer (1996) found that diagnostic criteria
Suzuki and Ponterotto 2008). Appendix D seemed to identify alcohol dependency con-
summarizes research on the clinical utility of sistently across race and ethnicity, but their
instruments for screening and assessing co- sample was limited to African Americans,
occurring disorders in various cultural groups. Latinos, and Whites. Other research has
shown mixed results.
Diagnosis
In 1972, the World Health Organization
Counselors should consider clients’ cultural
(WHO) and the National Institutes of Health
backgrounds when evaluating and assessing
(NIH) embarked on a joint study to test the
mental and substance use disorders (Bhugra
cross-cultural applicability of classification
and Gupta 2010). Concerns surrounding
systems for various diagnoses, including sub-
diagnoses of mental and substance use disor-
stance use disorders. WHO and NIH identi-
ders (and the cross-cultural applicability of
fied factors that appeared to be universal
those diagnoses) include the appropriateness
aspects of mental and substance use disorders
of specific test items or questions, diagnostic
and then developed instruments to measure
criteria, and psychologically oriented concepts
them. These instruments, the Composite
(Alarcon 2009; Room 2006). Research into
International Diagnostic Interview (CIDI)
specific techniques that address cultural differ-
and the Schedules for Clinical Assessment in
ences in evaluative and diagnostic processes so
Neuropsychiatry (SCAN), include some DSM
far remains limited and underrepresentative of
and International Statistical Classification of
diverse populations (Guindon and Sobhany
Diseases and Related Health Problems criteria.
2001; Martinez 2009).
Studies report that both the CIDI and SCAN
Does the DSM-5 accurately diagnose mental were generally accurate, but the investigators
and substance use disorders among immi- urge caution in translation and interview pro-
grants and other ethnic groups? Caetano and cedures (Room et al. 2003).

Advice to Counselors and Clinical Supervisors: Culturally Responsive Screening

and Assessment
• Assess the client’s primary language and language proficiency prior to the administration of any
evaluation or use of testing instruments.
• Determine whether the assessment materials were translated using specific terms, including
idioms that correspond to the client’s literacy level, culture, and language. Do not assume that
translation into a stated language exactly matches the specific language of the client. Specifically,
the client may not understand the translated language if it does not match his or her ways of
thinking or speaking
• Educate the client on the purpose of the assessment and its application to the development of
the treatment plan. Remember that testing can generate many emotional reactions.
• Know how the test was developed. Is normative data available for the population being served?
Test results can be inflated, underestimated, or inaccurate due to differences within the client’s
population.
• Consider the role of acculturation in testing, including the influence of the client’s worldview in
responses. Unfamiliarity with mainstream United States culture can affect interpretation of ques-
tions, the client–evaluator relationship, and behavior, including participation level during evalua-
tion and verbal and behavioral responses.

Sources: Association for Assessment in Counseling and Education (AACE) 2012; Saldaña 2001.

68
 Chapter 3—Culturally Responsive Evaluation and Treatment Planning

Overall, psychological concepts that are ap- to culturally diverse populations. This model
propriate for and easily translated by some divides the change process into several stages:
groups are inappropriate for others. In some • Precontemplation. The individual does not
Asian cultures, for example, feeling refers more see a need to change. For example, a per-
to a physical than an emotive state; questions son at this stage who abuses substances
designed to infer emotional states are not does not see any need to alter use, denies
easily translated. In most cases, these issues that there is a problem, or blames the
can be remedied by using culture-specific problem on other people or circumstances.
resources, measurements, and references while • Contemplation. The person becomes aware
also adopting a cultural formulation in the of a problem but is ambivalent about the
interviewing process (see Appendix E for the course of action. For instance, a person
APA’s cultural formulation outline). The struggling with depression recognizes that
DSM-5 lists several cultural concepts of dis- the depression has affected his or her life
tress (see Appendix E), yet there is little em- and thinks about getting help but remains
pirical literature providing data or treatment ambivalent on how he/she may do this.
guidance on using the APA’s cultural formula- • Preparation. The individual has deter-
tion or addressing cultural concepts of distress mined that the consequences of his or her
(Martinez 2009; Mezzich et al. 2009). behavior are too great and that change is
necessary. Preparation includes small steps
Step 7: Determine toward making specific changes, such as
when a person who is overweight begins
Readiness and Motivation reading about wellness and weight man-
for Change agement. The client still engages in poor
health behaviors but may be altering some
Clients enter treatment programs at different behaviors or planning to follow a diet.
levels of readiness for change. Even clients • Action. The individual has a specific plan
who present voluntarily could have been for change and begins to pursue it. In rela-
pushed into it by external pressures to accept tion to substance abuse, the client may
treatment before reaching the action stage. make an appointment for a drug and alco-
These different readiness levels require differ- hol assessment prior to becoming absti-
ent approaches. The strategies involved in nent from alcohol and drugs.
motivational interviewing can help counselors • Maintenance. The person continues to
prepare culturally diverse clients to change engage in behaviors that support his or her
their behavior and keep them engaged in decision. For example, an individual with
treatment. To understand motivational inter- bipolar I disorder follows a daily relapse
viewing, it is first necessary to examine the prevention plan that helps him or her as-
process of change that is involved in recovery. sess warning signs of a manic episode and
See TIP 35, Enhancing Motivation for Change reminds him or her of the importance of
in Substance Abuse Treatment (Center for engaging in help-seeking behaviors to
Substance Abuse Treatment [CSAT] 1999b), minimize the severity of an episode.
for more information on this technique.
Progress through the stages is nonlinear, with
Stages of Change movement back and forth among the stages at
Prochaska and DiClemente’s (1984) classic different rates. It is important to recognize
transtheoretical model of change is applicable that change is not a one-time process, but

69
 Improving Cultural Competence

rather, a series of trials and errors that eventu- interfere with or prevent access to treatment
ally translates to successful change. For exam- and ancillary services, compromise appropriate
ple, people who are dependent on substances referrals, impede compliance with treatment
often attempt to abstain several times before recommendations, and produce poorer treat-
they are able to acquire long-term abstinence. ment outcomes. Obstacles may include immi-
gration status, lower SES, language barriers,
Motivational Interviewing cultural differences, and lack of or poor cov-
Motivational interventions assess a person’s erage with health insurance.
stage of change and use techniques likely to
Case management provides a single profes-
move the person forward in the sequence.
sional contact through which clients gain
Miller and Rollnick (2002) developed a thera-
access to a range of services. The goal is to
peutic style called motivational interviewing,
help assess the need for and coordinate social,
which is characterized by the strategic thera-
health, and other essential services for each
peutic activities of expressing empathy, devel-
client. Case management can be an immense
oping discrepancy, avoiding argument, rolling
help during treatment and recovery for a
with resistance, and supporting self-efficacy.
person with limited English literacy and
The counselor’s major tool is reflective listen-
knowledge of the treatment system. Case
ing and soliciting change talk (CSAT 1999c).
management focuses on the needs of individu-
This nonconfrontational, client-centered al clients and their families and anticipates
approach to treatment differs significantly how those needs will be affected as treatment
from traditional treatments in several ways, proceeds. The case manager advocates for the
creating a more welcoming relationship. TIP client (CSAT 1998a; Summers 2012), easing
35 (CSAT 1999c) assesses Project MATCH the way to effective treatment by assisting the
and other clinical trials, concluding that the client with critical aspects of life (e.g., food,
evidence strongly supports the use of motiva- childcare, employment, housing, legal prob-
tional interviewing with a wide variety of lems). Like counselors, case managers should
cultural and ethnic groups (Miller and possess self-knowledge and basic knowledge
Rollnick 2013; Miller et al. 2008). TIP 35 is a of other cultures, traits conducive to working
good motivational interviewing resource. For well with diverse groups, and the ability to
specific application of motivational interview- apply cultural competence in practical ways.
ing with Native Americans, see Venner and
colleagues (2006). For improvement of treat- Cultural competence begins with self-
ment compliance among Latinos with depres- knowledge; counselors and case managers
sion through motivational interviewing, see should be aware of and responsive to how
Interian and colleagues (2010). their culture shapes attitudes and beliefs.
This understanding will broaden as they
gain knowledge and direct experience with
Step 8: Provide Culturally the cultural groups of their client popula-
tion, enabling them to better frame client
Responsive Case issues and interact with clients in culturally
Management specific and appropriate ways. TIP 27,
Comprehensive Case Management for
Clients from various racial, ethnic, and cultur- Substance Abuse Treatment (CSAT
al populations seeking behavioral health ser- 1998a), offers more information on effec-
vices may face additional obstacles that can tive case management.

70
 Chapter 3—Culturally Responsive Evaluation and Treatment Planning

Exhibit 3-1 discusses the cultural matching of

Exhibit 3-1: Client–Counselor Matching
counselors with clients. When counselors
cannot provide culturally or linguistically The literature is inconclusive about the value of
competent services, they must know when and client–counselor matching based on race,
ethnicity, or culture (Imel et al. 2011; Larrison et
how to bring in an interpreter or to seek other
al. 2011; Suarez-Morales et al. 2010). Sue et al.
assistance (CSAT 1998a). Case management (1991) found that for people whose primary
includes finding an interpreter who communi- language was not English, counselor–client
cates well in the client’s language and dialect matching for ethnicity and language predicted
and who is familiar with the vocabulary re- longer time in treatment (more sessions) with
better outcomes for all ethnic groups studied:
quired to communicate effectively about sensi-
Asian Americans, African Americans, Mexican
tive subject matter. The case manager works Americans, and White Americans.
within the system to ensure that the interpret-
Ethnic matches may work better for Latinos in
er, when needed, can be compensated. Case
treatment; gender congruence seems more
managers should also have a list of appropriate important than race or ethnicity in client–
referrals to meet assorted needs. For example, counselor matching, particularly for female
an immigrant who does not speak English clients (Sue and Sue 2013a). For Asian Americans
may need legal services in his or her language; and Pacific Islanders, the many different ethnic
subgroups make a cultural match more difficult.
an undocumented worker may need to know
In multicultural communities, racial and ethnic
where to go for medical assistance. Culturally matching may help develop a working alliance
competent case managers build and maintain between the therapist and the consumer (Chao
rich referral resources for their clients. et al. 2012). Other relevant variables of both the
client and therapist are age, marital status,
The Case Management Society of America’s training, language, and parental status. The
Standards of Practice for Case Management extent to which a cultural match is necessary in
(2010) state that case management is central therapy depends on client preferences, charac-
teristics, presenting problems, and treatment
in meeting client needs throughout the course
needs. For example, gender matching could be
of treatment. The standards stress understand- more important than race/ethnicity matching to
ing relevant cultural information and com- female sexual abuse survivors, who may have
municating effectively by respecting and being difficulty discussing their trauma with male
responsive to clients and their cultural contexts. counselors.
For standards that are also applicable to case Most clients want to know that their counselors
management, refer to the National Association understands their worldviews, even if they do
of Social Workers’ Standards on Cultural not share them. Counselors’ understanding of
their clients’ cultures improves treatment out-
Competence in Social Work Practice (2001).
comes (Suarez-Morales et al. 2010). Fiorentine
and Hillhouse (1999) found that empathy,
Step 9: Incorporate regardless of race or ethnicity of counselor and
client, was the most important predictor of
Cultural Factors Into favorable treatment outcomes. Sue et al. (1991)
found that clients using outpatient mental
Treatment Planning health services more readily attended treatment
and stayed longer if services were culturally
The cultural adaptation of treatment practices responsive. In the treatment planning process,
is a burgeoning area of interest, yet research is matching clients with providers according to
limited regarding the process and outcome of cultural (and subcultural, when warranted)
culturally responsive treatment planning in backgrounds can help provide treatment that is
responsive to the personal, cultural, and clinical
behavioral health treatment services for
needs of clients (Fontes 2008).

71
 Improving Cultural Competence

diverse populations. How do counselors and

organizations respond culturally to the diverse Group Clinical Supervision Case Study
needs of clients in the treatment planning Beverly is a 34-year-old White American who
process? How effective are culturally adaptive feels responsible for the tension and dissension
treatment goals? (For a review, see Bernal and in her family. Beverly works in the lab of an
Domenech Rodriguez 2012.) Typically, pro- obstetrics and gynecology practice. Since early
childhood, her younger brother has had prob-
grams that provide culturally responsive ser-
lems that have been diagnosed differently by
vices approach treatment goals holistically, various medical and mental health profession-
including objectives to improve physical als. He takes several medications, including one
health and spiritual strength (Howard 2003). for attention deficit disorder. Beverly’s father
Newer approaches stress implementation of has been out of work for several months. He is
seeing a psychiatrist for depression and is on an
strength-based strategies that fortify cultural
antidepressant medication. Beverly’s mother
heritage, identity, and resiliency. feels burdened by family problems and ineffec-
tive in dealing with them. Beverly has always
Treatment planning is a dynamic process that helped her parents with their problems, but she
evolves along with an understanding of the now feels bad that she cannot improve their
clients’ histories and treatment needs. Fore- situation. She believes that if she were to work
most, counselors should be mindful of each harder and be more astute, she could lessen her
client’s linguistic requirements and the availa- family’s distress. She has had trouble sleeping.
In the past, she secretly drank in the evenings to
bility of interpreters (for more detail on inter- relieve her tension and anxiety.
preters, see Chapter 4). Counselors should be
flexible in designing treatment plans to meet Most counselors agree that Beverly is too sub-
missive and think assertiveness training will help
client needs and, when appropriate, should
her put her needs first and move out of the
draw upon the institutions and resources of family home. However, a female Asian American
clients’ cultural communities. Culturally re- counselor sees Beverly’s priorities differently,
sponsive treatment planning is achieved saying that “a morally responsible daughter is
through active listening and should consider duty-bound to care for her parents.” She thinks
that the family needs Beverly’s help, so it would
client values, beliefs, and expectations. Client
be selfish to leave them.
health beliefs and treatment preferences (e.g.,
purification ceremonies for Native American Discuss:
• How does the counselor’s worldview affect
clients) should be incorporated in addressing prioritizing the client’s presenting problems?
specific presenting problems. Some people seek • How does the counselor’s individualistic or
help for psychological concerns and substance collectivistic culture affect treatment plan-
abuse from alternative sources (e.g., clergy, ning?
elders, social supports). Others prefer treatment • How might a counselor approach the initial
interview and evaluation to minimize the in-
programs that use principles and approaches fluence of his or her worldview in the evalu-
specific to their cultures. Counselors can sug- ation and treatment planning process?
gest appropriate traditional treatment resources
to supplement clinical treatment activities. Sources: The Office of Nursing Practice and
Professional Services, Centre for Addiction and
In sum, clinicians need to incorporate culture- Mental Health & Faculty of Social Work, Univer-
based goals and objectives into treatment plans sity of Toronto 2008; Zhang 1994.
and establish and support open client–
counselor dialog to get feedback on the pro- client engagement in treatment services, com-
posed plan’s relevance. Doing so can improve pliance with treatment planning and recom-
mendations, and treatment outcomes.

72
 4 Pursuing Organizational
Cultural Competence

Cavin, a 42-year-old African American man, arrived at a well-

IN THIS CHAPTER known private substance abuse treatment center confused and
• Cultural Competence at unable to provide his medical history at intake. Referred to the
the Organizational Level center through his employee assistance program, he was accom-
• Organizational Values panied by his spouse and 14-year-old son. Cavin’s wife provided
• Governance his medical history and recounted her husband’s 2-year decline
• Planning from a promising career as a journalist, researcher, and social
• Evaluation and commentator to a bitter, often paranoid man who abused cocaine
Monitoring and alcohol. Cavin, she explained, had become increasingly un-
• Language Services predictable.
• Workforce and Staff Upon admission, Cavin was initially cooperative and grateful to
Development his spouse for her efforts, but as withdrawal continued, he became
• Organizational increasingly agitated, insisting that he could detoxify on his own.
Infrastructure He resisted any intervention by staff members whom he perceived
to be critical or patronizing. On his fourth day in treatment,
Cavin began to note the treatment center’s “White” environment.
There were almost no African American employees—none at the
clinical level. He noted how decor reflected only White American
culture. Driven in part by his substance use disorder, he was look-
ing for reasons to leave. Later that evening, he checked out.
Cavin was unable to relate to his treatment. He found no cultural
cues with which to identify or connect. Therefore, he started
searching for reasons to leave—behavior typical in persons who
abuse substances. People often leave treatment with the conscious
hope of managing their substance abuse themselves and the un-
conscious drive to relive positive experiences associated with sub-
stance use; meanwhile, they all too easily forget the pain imposed
by the use of alcohol and other substances. Cavin may have re-
mained in treatment if services had been more culturally respon-
sive. This is an example of how behavioral health programs benefit

73
 Improving Cultural Competence

Multidimensional Model for Developing Cultural Competence: Organizational/

Administrative Level

from commitment to culturally responsive ongoing process; it is not something that is

services, staffing, and treatment—if they make achieved once and is then complete. Organiza-
no such commitment, their services may be tional structures and components change. The
underused, unwelcome, and ineffective. demographics and needs of communities
change. Employees and their job descriptions
Cultural Competence at change. Consequently, the commitment to
increase cultural competence must also involve
the Organizational Level a commitment to maintain it through periodic
At the organizational level, cultural compe- reassessments and adjustments. Based on the
tence or responsiveness refers to a set of con- Cross et al. (1989) definition of the culturally
gruent behaviors, attitudes, and policies that competent organization, Goode (2001) identi-
enable a system, agency, or group of profes- fies three principal components (Exhibit 4-1)
sionals to work effectively in multicultural that coincide with Sue’s (2001) multidimen-
environments (Cross et al. 1989). Organiza- sional model for developing cultural compe-
tional cultural responsiveness is a dynamic, tence in behavioral health services.

74
 Chapter 4—Pursuing Organizational Cultural Competence

Exhibit 4-1: Requirements for Exhibit 4-2: Creating Culturally

Organizational Cultural Competence Responsive Treatment Environments
• The organization needs a defined set of Organizational values tasks:
values and principles, along with demon- • Commit to cultural competence.
strated behaviors, attitudes, policies, and • Review and update vision, mission, and
structures that enable effective work across value statements.
cultures. • Address cultural competence in strategic
• The organization must value diversity, planning processes.
conduct self-assessment, manage the dy-
Governance tasks:
namics of difference, acquire and institu-
• Assign a senior manager to oversee the
tionalize cultural knowledge, and adapt to
organizational development of culturally re-
diversity and the cultural contexts of the
sponsive practices and services.
communities it serves.
• Develop culturally competent governing and
• The organization must incorporate the
advisory boards.
above in all aspects of policymaking, ad-
• Create a cultural competence committee.
ministration, and service delivery and sys-
tematically involve consumers and families. Planning tasks:
• Engage clients, staff, and community in the
Source: Goode 2001.
planning, development, and implementation
of culturally responsive services.
This chapter provides a broad overview of • Develop a cultural competence plan.
how behavioral health organizations can create • Review and develop policies and procedures
an institutional framework for culturally to ensure culturally responsive organiza-
tional practices.
responsive program delivery, staff develop-
ment, policies and procedures, and administra- Evaluation and monitoring tasks:
• Create demographic profiles of the commu-
tive practices. Built on the U.S. Department of
nity, clientele, staff, and board.
Health and Human Services’ (HHS’s) Office • Conduct an organizational self-assessment
of Minority Health (OMH) Enhanced of cultural competence.
National Standards for Culturally and Language services tasks:
Linguistically Appropriate Services in Health • Plan for language services proactively.
and Health Care (OMH 2013; for review, see • Establish practice and training guidelines for
Appendix C), this chapter is organized around the provision of language services.
the Health Resources and Services Workforce and staff development tasks:
Administration’s (HRSA’s) domains of organi- • Develop staff recruitment, retention, and
zational cultural competence: organizational promotion strategies that reflect the popula-
tion(s) served.
values, governance, planning, evaluation and
• Create training plans and curricula that
monitoring, communication (language ser- address cultural competence.
vices), workforce and staff development, and • Give culturally congruent clinical supervision.
organizational infrastructure (Linkins et al. • Evaluate staff performance on culturally
2002). (Another domain, services and inter- congruent and complementary attitudes,
knowledge, and skills.
ventions, is covered in Chapter 3.)
Organizational infrastructure:
Within each domain, specific organizational • Invest in long-range fiscal planning to pro-
tasks are suggested to aid program and ad- mote cultural competence.
ministrative staff in developing a culturally • Create an environment that reflects the
populations served.
responsive clinical, work, and organizational
• Develop outreach strategies to improve
environment (Exhibit 4-2); these domains and access to care.

Source: Linkins et al. 2002.

75
 Improving Cultural Competence

tasks are adapted to behavioral health services. Cultural competence demands an ongoing
Task overlap across domains may require work commitment to openness and learning, taking
time and taking risks, sitting with uncertainty
on several tasks at once. HRSA’s organizational and discomfort, and not having quick solu-
cultural competence assessment profile is avail- tions or easy answers. It involves building
able online (http://www.hrsa.gov/cultural trust, mentoring, and developing and nurtur-
competence/healthdlvr.pdf; Linkins et al. ing a frame of reference that considers alli-
2002). ances across culture as enriching rather than
threatening shared goals.

Organizational Values Task: Commit to Cultural

Journey Mental Health Center ( JMHC), a Competence
large outpatient mental health and substance Counselors are typically a part of a larger
abuse treatment clinic in Wisconsin, is an organization or system, but the focus on and
organization that is committed to providing responsibility for developing culturally respon-
accessible, community-focused, culturally sive services has historically fallen on individ-
responsive behavioral health services. JMHC ual practitioners rather than on organizations.
offers the following commentary on the im- Most literature on cultural competence ad-
portance of clear, culturally responsive organi- dresses the cultural awareness, knowledge, and
zational values ( JMHC 2013, paragraphs 1-3): skills of the practitioner, but until recently, it
has failed to apply these same concepts to
…cultural competence is fundamental to
agencies. Cultural competence among coun-
providing quality services that promote indi-
vidual and family strengths, dignity, and self- selors is only as effective as their agencies’
reliance. Cultural competence broadens and commitment to and support of cultural com-
enriches the delivery of mental health and petence and ability to value diversity through
alcohol and other drug abuse (AODA) ser- culturally congruent administrative practices,
vices by providing a more holistic, relevant
including—but not limited to—policies and
view of the world and the helping process.
Cultural competence does not stand apart procedures, programming, staffing, and com-
from, but is intrinsic to good clinical practice. munity involvement.
Its threads are woven into the tapestry of ef-
fective assessment, treatment planning, inter- Counselors are unlikely to affect organization-
vention, advocacy, and support. In addition, al change to the same degree as the agency’s
cultural competence is intrinsic to effective overall administration can. Hence, culturally
staff relationships and business practices. responsive treatment cannot be sustained
Cultural competence promotes relationships without an agency’s commitment and support.
based upon understanding and knowledge of In fact, the organization itself can prevent
how one’s own cultural beliefs and values in-
clients from receiving culturally responsive
fluence the organization of information, per-
ceptions, feelings, experiences, and coping services or treatment opportunities. Organiza-
strategies. It involves being able to identify, tions that are unaware of cultural issues can
learn from, and incorporate these into the fail to recognize that diverse groups may have
helping process. When cultural competence is difficulty accessing and engaging in treatment.
an integral part of personal competence, there
Also, counselors who attempt to use culturally
is the maximum opportunity to increase the
amount and quality of information and the responsive practices—such as the involvement
speed with which that information can be of family members (as defined by the client)
shared and processed and to form healthy al- and traditional healers—can encounter insur-
liances. mountable hurdles if their agencies’ policies

76
 Chapter 4—Pursuing Organizational Cultural Competence

Organizations that fail to endorse and

evolving, respond to unforeseen barriers, and
make a commitment to cultural compe- revise innovations that are not working as
tence will more than likely displace the intended. It is important that leadership be
responsibility of cultural competence onto genuinely committed to the effort and that
counselors or clients. If the responsibility is their support be tangibly apparent in the
on the clients, it is likely that the clients will allocation of relevant resources. A strong
have to “fit” or change to match the commitment to improving organizational
treatment or program rather than treat- cultural competence should include the obli-
ment services being adapted to fit the gation to monitor procedures after they have
needs of clients.
been implemented, maintain and reevaluate
and resources do not support these practices. new practices, and provide resources and
The system can actually impede efforts made opportunities for ongoing training and cultur-
by counselors invested and trained in cultural ally competent supervision.
competence. Thus, the development of cultural
competence begins at the top level of the
Task: Review and Update Vision,
organization, with an initial focus on systemic Mission, and Value Statements
changes. The organization’s mission, vision, and value
statements are vitally important in creating a
Cultural competence does not occur by acci- conceptual framework that promotes cultur-
dent. To maximize its effectiveness in working ally responsive behavioral health services.
with diverse groups, the organization must Agencies should examine how these state-
first view diversity as an asset. As importantly, ments are developed. Are stakeholders in-
the organization must ensure that its process volved in the development process? In what
of developing cultural competence has the ways does the organization ensure that its
genuine, full, and lasting support of the organ- values and mission reflect the community and
ization’s leadership. The chief executive officer populations that it serves? Does the organiza-
(CEO), senior management, and board of tion see this task as a singular event, or has it
directors play critical roles. A strong mandate planned for periodic review of its values and
from the board or CEO, coupled with a com- mission to ensure continued organizational
mitment to provide resources, can be a good responsiveness as needs, populations, or envi-
motivator for staff and committees to under- ronments change?
take major organizational change. Support of
cultural competence must be made clear Initially, the planning committee should de-
throughout the organization and community termine how the culture of the organization as
in meaningful ways, in words and actions. well as the surrounding community can sup-
port achievement of the mission and vision
Leadership can make a difference in the im- statements. Culturally responsive organiza-
plementation of culturally responsive practices tional statements cannot provide a tangible
by creating an organizational climate that framework unless supported by community,
encourages and supports such practices. This referral, and client demographics; a needs
includes a willingness to discuss the im- assessment; and an implementation plan.
portance of cultural competence, try new Mission and vision statements need to be
practices or approaches, tolerate the uncertain- operationalized through identified goals as
ty that accompanies transitional periods dur- well as measurable indicators to track progress.
ing which practices and procedures are The Hands Across Cultures Corporation of

77
 Improving Cultural Competence

northern New Mexico, which serves Native organizations can begin to gain insight into
peoples within pueblos (American Indians), the demands and challenges of providing
the City of Española, Pojoaque Valley, and culturally responsive services. Moreover, stra-
surrounding communities (predominantly tegic planning is an opportunity to explore
Latino), addresses the importance of the and develop short- and long-term goals that
cultural context of its work in its mission and focus on incorporating culturally responsive
philosophy statements (Exhibit 4-3). delivery systems while addressing issues of
sustainability (i.e., how to provide resources
Task: Address Cultural and support the implementation of culturally
Competence in Strategic Planning responsive policies and procedures over time).
Processes A formal strategic planning meeting should be
The strategic planning process provides an held to determine specific goals, objectives,
opportunity to reevaluate an agency’s values, and tasks that will ensure quality improvement
mission, and vision regarding cultural compe- in culturally responsive services. The develop-
tence. A comprehensive process involves eval- ment of timelines and methods to evaluate
uating the organization’s internal and external progress, obstacles, and directions for each
environments prior to holding planning meet- goal are equally important. For organizations
ings; this evaluation involves conducting staff, that do not have a specific cultural competence
client, and community assessments. From plan prior to the strategic planning meeting,
assessing current needs to evaluating global this process can provide the forum for devel-
factors that influence the direction and deliv- oping the steps needed to create a formal plan.
ery of services (e.g., funding sources, treat-
ment mandates, changes in health insurance), Governance
Task: Assign a Senior Manager To
Exhibit 4-3: Hands Across Cultures Oversee the Development of
Mission Statement
Culturally Responsive Practices
Mission and Services
To improve the health, education and well
being of the people of Northern New Mexico From the outset, a senior staff member with
through family-centered approaches deeply the authority to implement change should be
rooted in the multicultural traditions of their assigned to oversee the developmental process
communities. of planning, evaluating, and implementing
Philosophy culturally responsive administrative and clini-
To believe in culture as the foundation of cal services. Key responsibilities include the
human growth; spirituality as the strength of ongoing development and facilitation of cul-
the people; each person’s need to love and be tural competence committees and advisory
loved; family preservation; individual responsi-
bility; and the pursuit of human potential.
boards, management of evaluative processes,
facilitation of the development of a cultural
With a firm commitment to these beliefs, competence plan and its implementation, and
Hands Across Cultures’ Board of Directors,
oversight of policies and procedures to ensure
staff, and collaborators hold that:
cultural competence within the organization
Culture Is the Cure and among staff. Cultural competence cannot
La Cultura Cura
come to fruition with only one voice being
Source: Hands Across Cultures 2014. heard, but assigning a key person to oversee

78
 Chapter 4—Pursuing Organizational Cultural Competence

the process will more likely keep top-priority other community agencies. Moreover, this
goals and objectives in view. board can help identify community leaders
and culturally appropriate resources for the
Task: Develop Culturally client population to supplement treatment
Competent Governing and activities, such as traditional healing practices
Advisory Boards (Castro et al. 1999a). The advice box on the
Beyond having the foresight to plan for and next page reviews strategies for engaging
develop culturally responsive services, it is vital communities in the development of culturally
that executive staff members on governing and responsive services.
advisory boards and committees are educated
about and invested in the organization’s mis- Task: Establish a Cultural
sion and plan. For example, the board’s hu- Competence Committee
man resources committee may be more By creating a committee within the organiza-
invested in developing and reinforcing cultur- tion to guide the process of becoming cultur-
ally responsive recruitment and hiring policies ally competent and responsive, the
and practices if they are involved in the strate- organization ensures that a core group will
gic planning process and educated about the provide oversight and direction. This commit-
organization’s mission, values, and vision. At tee should be inclusive not only in terms of
the same time, the organization should seek the racial and ethnic composition of the popu-
outside direction. Given that sharing infor- lation served, but also in terms of drawing
mation about the agency’s activities with from all levels of the organization (Whaley
others outside the organization can create and Longoria 2008). Representatives of the
some hesitancy or be a potential barrier, the advisory board should also be included. Pro-
executive staff can frame the planning process gram administrators should provide direction
as an opportunity for positive development to the cultural competence committee. The
and community involvement as a powerful person assigned to take the lead on cultural
resource. The organization should establish a competence should chair the committee, and
community advisory board that includes the CEO should be noticeably involved.
stakeholders, specialists, and/or experts in The cultural competence committee will
multicultural behavioral health services along oversee the organization’s self-assessment
with key administrators and staff. This adviso- process while also creating the demographic
ry board should consist of local community profile of the organization’s community, devel-
members from whom the organization can oping a cultural competence plan, and formu-
solicit valuable advice, input, and potential lating and monitoring procedures that evaluate
support for the development of culturally the implementation and effectiveness of the
responsive treatment (Minnesota Department organization’s plan in developing culturally
of Human Services 2004). responsive services and practices. The commit-
Representation should include clients, alumni, tee should ensure that the organization’s plans
family members, and community-based are continually updated. To succeed, this team
organizations and institutions (e.g., commu- must be empowered to influence, formulate,
nity centers, faith communities, social service implement, and enforce initiatives on all levels
organizations). Developing an inclusive advi- and throughout every department of the
sory board of community members can en- organization (Constantine and Sue 2005;
hance and extend use of and referral from Fung et al. 2012), including, for example,

79
 Improving Cultural Competence

Advice to Administrators: Strategies To Engage Communities in Developing

Culturally Responsive Treatment Services
• Ask board members to help recruit key members of the local community.
• Create a community advisory group to complement the governing boards in assessing and
recommending culturally responsive policies, procedures, and practices.
• Develop local community focus groups to discuss key treatment needs, health beliefs, and atti-
tudes and behaviors related to substance use, mental illness, and help-seeking that could be un-
known to others outside of the community and in the organization.
• Develop a policy that supports the use of culturally congruent communication modalities and
technologies for sharing information with communities.
• Provide inservice training, continuing education, and other professional development activities
(e.g., networking events) that focus on strengthening skills for collaboration with culturally and
linguistically diverse communities.
• Develop policies and procedures to support community involvement in the treatment setting
(e.g., incorporating peer support programs, having a presence at community housing events,
developing partnerships with traditional healers).
• Develop local outreach and educational programs in multiple languages (e.g., provide family
education on substance use patterns and community issues in Spanish at a community center).
• Participate in community events to raise awareness of services, to develop trust and build rela-
tionships, and to gain further knowledge of local cultural groups and community practices.
• Periodically analyze community demographic trends and populations served by the treatment
organization; ensure representation of these diverse populations on the advisory board.
• Become knowledgeable about and use available local goods and services.

Sources: Goode 2001; National Center for Cultural Competence 2013; Washington State De-
partment of Social and Health Services 2011.

presenting data and subsequent recommenda- appear less time consuming, complex, and
tions to the administration and boards based expensive, but it can also represent paternalism
on employee feedback about their experiences whereby organizations or administrators
with newly adopted, culturally responsive assume that they inherently know what is best
procedures in the organization. Exhibit 4-4 for the program, clients, staff, and community.
highlights key issues in behavioral health Instead, organizations and the services that
treatment that must be addressed in providing
culturally responsive services. Exhibit 4-4: Critical Treatment Issues
To Consider in Providing Culturally
Responsive Services
Planning
• Access: Degree to which services for clients
Task: Engage Clients, Staff, and are quickly and readily available.
• Engagement: Having appropriate skills and
the Community in the Planning, an environment that have a positive per-
Development, and sonal impact on the quality of clients’
Implementation of Culturally commitment to treatment.
• Retention: The result of quality services
Responsive Services that help maintain clients in treatment with
Organizations can sometimes have the best continued commitment.
intentions of creating culturally responsive Source: The Connecticut Department of Chil-
services but miss the mark by operating in a dren and Families, Office of Multicultural
vacuum. Initially, the vacuum approach can Affairs 2002.

80
 Chapter 4—Pursuing Organizational Cultural Competence

they provide need to be congruent with the out some means of compensating for addi-
specific populations being served; clients and tional work, perceive themselves as powerless
the community should have an opportunity to over the proposed changes, or minimize the
provide input on how services are delivered need to make any immediate changes. For
and the types of services that are needed. example, staff members may view changes as
Otherwise, services may be poorly matched to temporary or a phase and believe that the
clients, underused by the community, and organization will focus on other issues or new
detrimental to agency financial resources. For directions once the pressure or attention on
example, an agency could decide that family this specific issue subsides.
therapy is a culturally appropriate service and
proceed to create a multifamily program Task: Develop a Cultural
(treating several families together in a group Competence Plan
format) without considering that, for some To ensure the delivery of culturally responsive
cultural groups, family shame associated with services, it is important to develop a cultural
seeking help can deter the use of such services. competence plan (see the “Criteria for Devel-
Staff members are likely to have specific oping an Organizational Cultural Compe-
knowledge of client needs and to be able to tence Plan” advice box on the next page).
identify potential obstacles or challenges in Using demographic data and an organizational
how an organization attempts to implement self-assessment (including community and
culturally responsive policies and procedures. advisory board input), the organization’s cul-
A parallel process that can influence the po- tural competence committee can begin writing
tential success of staff involvement and com- an organizational plan for improving cultural
mitment to the development of cultural competence. The committee will need to
competence is the organizational culture. assign staff members to research and write
Suppose, for example, that the staff perceives each component of the plan, which should
the organization’s new commitment to cultural outline specific objectives, means of achieving
competence as another expectation of more these objectives, and recommend timelines
work without training, adequate clinical and processes for evaluating progress. The
supervision, or ongoing support. Maybe staff plan should contain at least the following
members have historically experienced fre- components:
quent announcements, mandates, or excite- • A narrative introduction that covers com-
ment generated by the administration that munity demographics and history, organi-
fade quickly. Perhaps the organization ar- zational self-assessment and other
ranges committees and meetings, purporting evaluation tools, the rationale for provid-
that they want staff input despite the fact ing culturally responsive services, and the
that decisions have already been made. organization’s strengths and needs for im-
provement in providing services that are
The organizational climate sets the stage for responsive to client cultural groups; a brief
staff responsiveness and motivation in devel- overview of current priorities, goals, and
oping cultural competence and in implement- tasks to help the organization develop and
ing culturally responsive services. Without an improve culturally responsive clinical ser-
organizational history and culture of support- vices and administrative practices is also
ing change across time, staff members will advisable.
likely resent an increase in expectations with-

81
 Improving Cultural Competence

Advice to Administrators: Criteria for Developing an Organizational Cultural

Competence Plan
Using the core elements of access, engagement, and retention as criteria in developing a cultural
competence plan, the following recommendations are offered:
• Develop a thorough knowledge and understanding of the social, cultural, and historical experi-
ences of the community of people your agency is serving.
• Identify and clearly articulate an understanding of the ethnic, cultural, linguistic, and social
groups in the area your agency serves.
• Document, track, and evaluate/assess the reasons why clients are not accepted for services.
• Know the demographics of clients within the program and their rates of program completion.
• Keep profiles of clients who do not complete services.
• Design steps for your agency to take to remove identified barriers that keep clients from using
your agency’s services.
• Establish steps your agency will implement or sustain to create a consumer-friendly environment
that reflects and respects the diversity of the clients that use your services.
• Establish internal criteria the agency will use to measure the impact of the services and programs
that it offers.

Source: The Connecticut Department of Children and Families, Office of Multicultural Affairs 2002.

• Strategies for recruiting, hiring, retaining, (e.g., training, language services, program
and promoting qualified diverse staff. development, organizational infrastructure).
• Resources and policies to support language • Guidelines for implementation that de-
services and culturally responsive services. scribe roles, responsibilities, timeframes,
• Methods to enhance professional devel- and specific activities for each step.
opment (e.g., staff education and training,
The committee must determine how to over-
peer consultation, clinical supervision) in
see the plan (e.g., by tracking accomplish-
culturally responsive treatment services.
ments, obstacles, and remediation strategies).
• Mechanisms for community involvement,
Who will develop and revise guidelines for
beginning with the development of a
treatment planning, introduce new guidelines
community advisory board and cultural
to the staff and provide counselor training, and
competence committee and including
coordinate revisions with the information
community participation in relevant
technology specialist or department?
treatment activities or in support of treat-
ment services (e.g., spiritual direction).
• Approaches to amending facility design
Task: Develop and Review Policies
and operations to present a culturally con- and Procedures To Ensure
gruent atmosphere. Culturally Responsive
• Identification of and recommendations for Organizational Practices
culturally and linguistically appropriate In essence, policies and procedures are the
program materials. backbone of an organization’s implementation
• Programmatic strategies to incorporate of culturally responsive services. By creating,
culturally congruent clinical and ancillary reviewing, and adapting clinical and adminis-
treatment services. trative policies and procedures in response to
• Fiscal planning for funding and human the ever-changing needs of client populations,
resources needed for priority activities the agency is able to provide counselors and

82
 Chapter 4—Pursuing Organizational Cultural Competence

other workers with support and the means to If an organization fails to develop culturally
respond in a consistent, yet flexible, manner. responsive policies or procedures yet claims to
Programs are likely to have the foresight to endorse or support culturally responsive ser-
develop relevant policies and procedures vices, counselors and staff members will likely
through the planning and evaluative processes carry the entire burden of implementing these
outlined in this chapter, but it is unlikely that services and will face numerous obstacles that
they will anticipate every situation. Thus, could prevent the delivery of responsive ser-
ongoing flexibility is paramount. vices. Take, for example, a counselor from a
county-funded program who was directed by
When putting together an organizational
her supervisor to complement her counseling
cultural competence plan, providers should be
approach with the client’s traditional healing
careful to follow the requirements set by state
beliefs and practices. The agency did not
licensing boards, accreditation agencies, and
provide staff support, have policies or proce-
professional organizations that oversee certifi-
dures consistent with this request, or exhibit a
cation and licensing of treatment profession-
willingness to adapt current procedures to
als. Much of the push for cultural competence
meet the client’s needs. The counselor had
throughout the healthcare field is in response
difficulty following this direction because of
to the mandates of accrediting agencies, fun-
barriers in finding an appropriate traditional
ders, and managed care organizations. These
practitioner in the local area, coordinating
entities have standards and guidelines that
services, establishing and securing confidenti-
state minimum expectations for client rights,
ality for the client and with the practitioner
program structure, and staffing, along with
(including educating the practitioner about
treatment content and conditions. Behavioral
confidentiality), arranging transportation for
health organizations, including substance
the client, obtaining a stipend for services, and
abuse treatment programs, must meet these
discerning how and when to incorporate the
standards to be accredited by national organi-
traditional practice into the treatment milieu.
zations and compensated by funders.
Counselors who feel that they have been left
Although many accrediting bodies require a
to go it alone can view implementation of
cultural competence plan that is assessed as part
culturally responsive practices as an insur-
of the accreditation process, their requirements
mountable challenge when the agency pro-
can be minimal. Consequently, organizations
vides limited support or fails to endorse
should go beyond such requirements in their
adaptive policies that are congruent with the
own thinking and planning to ensure that they
needs of the client population. Counselors
are responding adequately to the needs of the
may have high motivation to incorporate
communities they serve. Above all, are the
culturally responsive care but find themselves
policies, procedures, and systems of care suited
without appropriate agency resources, permis-
to the served populations? Do policies reflect
sion, or infrastructure to implement it. By
the organization’s commitment to cultural
developing and endorsing culturally responsive
competence in administrative practices? For
policies and procedures, an organization can
example, are strategies for professional devel-
provide carefully thought-out strategies and
opment, personnel recruitment, and retention
processes to help staff members provide real-
of culturally competent staff members reflec-
time responsive services. Well-defined policies
tive of the populations and cultures that they
and procedures reinforce commitment to and
serve?
expectations of cultural competence.

83
 Improving Cultural Competence

census data and national centers (e.g., Bureau

Evaluation and Monitoring of Labor Statistics) or through local sources,
To develop a viable cultural competence plan, including the library, city hall, or the county
information must be gathered from all levels commissioner’s office (Whealin and Ruzek
of the organization, from clients and commu- 2008). Community demographics can provide
nity, and from other stakeholders. Beginning a quick benchmark on how well an agency
with acquiring initial demographic data from serves the local community and how the
the populations that are or could be served by community is represented at all levels of the
the agency and extending to soliciting feed- organization. A demographic profile should
back from various stakeholders, gathering also summarize information about clinical,
information prior to plan development helps medical, and nonclinical staff members as well
the organization provide direction and deter- as board members. Other information can also
mine priorities. Gathering information also be helpful for specific agencies, as can hiring a
allows ongoing monitoring and feedback consultant to gather demographic information
regarding the plan’s effectiveness and areas in and conduct the organization’s self-assessment
need of improvement. Areas of evaluation and of cultural competence to limit bias; however,
monitoring can include a demographic profile lack of funding can prohibit this possibility.
of the client, community, staff, and board
constellations; community needs assessment; Task: Conduct Organizational Self-
client, family, and referral feedback; adminis- Assessment of Cultural
trative, clinical, medical, and nonclinical staff Competence
assessments; and more (American Evaluation An organization must have an awareness of
Association 2011; LaVeist et al. 2008). how it functions within the context of a multi-
cultural environment, evaluating operational
Task: Create a Demographic aspects of the agency as well as staff ability
Profile of the Community, and competence in providing culturally con-
Clientele, Staff, and Board gruent services to racially and ethnically di-
Intake, admission, and discharge data provide verse populations. Therefore, an agency should
a good starting point for determining the assess how well it currently provides culturally
demographics of current populations being responsive treatment. An honest and thorough
served. Programs would likely benefit from organizational self-assessment can serve as a
developing a demographic summary for each blueprint for the cultural competence plan
population served, consisting of age, gender, and as a benchmark to evaluate progress
race, ethnic and cultural heritage, religion, across time (National Center for Cultural
socioeconomic status, spoken and written Competence 2013). To review a sample as-
language preferences and capabilities, em- sessment guide, refer to Appendix C.
ployment rates, treatment level, and health
The importance of organizational self-
status (HHS 2003b). With adequate resources,
assessment cannot be overstated. Thorough,
the organization can generate reports dating
reliable, valid evaluations can gauge the effec-
back 5 years to determine program trends.
tiveness of an agency’s services, structure, and
Agencies should also gather demographic practices (e.g., clinical services, governing
information on groups in the agency’s local practices, policy development, staff composi-
community (Hernandez et al. 2009). This tion, and professional development) with
information can be easily obtained through culturally and racially diverse clients, staff, and

84
 Chapter 4—Pursuing Organizational Cultural Competence

communities. More and more, public and improvement regarding the function of the
private funding sources—as well as accrediting organization and the needs of its community.
bodies—use an organization’s self-assessment
Step 2: Adopt a self-assessment guideline for
as a means of measuring compliance, effec-
organizational cultural competence (see
tiveness, or quality improvement practices.
Appendix C).
A self-assessment can seem intensive in terms
Step 3: Determine the feasibility of using
of both labor and capital, but in the long run,
consultants and/or external evaluators to
it can guide an organization’s quality im-
select, analyze, and manage assessment.
provement process more efficiently by helping
it provide the most relevant services at the For many organizations, hiring outside con-
right time. Gathering feedback from many sultants is financially prohibitive. Nonetheless,
internal and external sources gives agencies the cultural competence committee could
considerable information needed to effectively recommend hiring outside evaluators and
evolve as a culturally responsive organization, consultants to help them plan, conduct, and
including data on current performance, areas assess the results of the organizational self-
needing improvement, and development evaluation. The committee should ensure that
needs. In the initial self-assessment, an or- consultants understand the population being
ganization should obtain demographic in- served by the treatment facility. This means
formation and seek feedback from key understanding the population’s cultural groups
stakeholders—including community mem- across dimensions: language and communica-
bers, clients, families, and referral sources tion, cultural beliefs and values, history, socio-
(e.g., probation and parole offices, family and economic status, education, gender roles,
child services, private practitioners)—and substance use patterns, spirituality, and other
from all levels of the organization, including distinctive aspects. Candidates should be able
administrative, managerial, clinical, medical, to articulate a clear understanding of cultural
and support staff. The following steps are competence (American Evaluation Association
recommended to help an agency gain the 2011). If consultants will train staff, they
information necessary to guide and support should have specific knowledge and profi-
the development of its cultural competence ciency in training development and delivery.
plan.
If financially feasible, it can be useful for the
Step 1: With the advisory board and cultural agency to consider using more than one con-
competence committee, identify key stake- sultant and to invite each prospective consult-
holders who can provide valuable feedback ant to present their qualifications to the board
about current strengths and areas in need of of directors and/or to a cultural competence

The Consumer Assessment of Healthcare Providers and Systems Cultural

Competence Item Set
This assessment tool evaluates provider cultural competence through client surveys. It helps identify
strengths and weaknesses of individual behavioral health service providers and organizations, aids in
provider comparisons, and assesses the extent to which client responses differ based on race,
ethnicity, or primary language. The surveys are available online through the Agency for Healthcare
Research and Quality (https://cahps.ahrq.gov/clinician_group/), as is an overview and instructions
(https://cahps.ahrq.gov/surveys-guidance/hp/instructions/index.html).

85
 Improving Cultural Competence

committee so that the best match can be backgrounds; language preferences; and com-
achieved between the agency’s needs and the munity accessibility (e.g., rural versus urban).
consultant based on his or her expertise, cost, Appendix C provides standards and lists the
and consulting style. If a consultant is hired, items that should be included in evaluating an
the organization should establish guidelines agency and its services. Additional resources
for working closely with that person, including for provider and organizational assessment of
reporting requirements to the cultural compe- cultural competence are available through the
tence committee. The organization must National Center for Cultural Competence
retain ownership of the process and provide (http://nccc.georgetown.edu/) and the Hogg
clear oversight and guidance. Foundation for Mental Health
(http://www.hogg.utexas.edu/index.php).
Step 4: Select assessment tools suitable for
each stakeholder group (e.g., clinical staff, Step 5: Determine distribution, administra-
agency referrals, clients). Several self- tion, and data collection procedures (e.g.,
assessment tools are available, including confidentiality, participant selection methods,
checklists and surveys, for use in evaluation or distribution time frames). Whatever methods
as development guides. To date, most instru- are used to gather data for the self-assessment
ments available have limited empirical support process, it is critical to explain the context of
(Delphin-Rittmon et al. 2012b; Shorkey et al. the assessment to all participants. They need
2009). to know why the assessment is being conduct-
ed and how the information they give will be
More often than not, surveys and feedback
used. Confidentiality can be a major concern
questionnaires will need to be individually
for some respondents, especially staff members
developed and tailored to the organization and
and clients, and every effort should be made to
stakeholder group depending upon setting;
address this concern. Ideally, the evaluation
available resources; racial, ethnic, and cultural

Advice to Administrators: Gathering Feedback From Clients, Community

Members, and Referrals
Agencies should incorporate a client satisfaction survey into the assessment process. This survey
should include questions to help determine whether clients believe that the organization relates well
to persons of their ethnicity or race and gives them an opportunity to pinpoint problem areas. To
review a sample assessment tool for clients, refer to the Iowa Cultural Understanding Assessment–
Client Form (White et al. 2009), available in Appendix C. The tool is also available in Spanish.

If desired, external consultants can conduct interviews with a representative sample of clients, family
members, and local community members. The key question should be “What can the treatment
provider do to be more responsive to community needs?” The survey process can be as simple as a
questionnaire, or it can involve interviews or focus groups with key people in touch with community
issues. It can also be helpful to obtain a small but representative sample of community members at
large to determine their level of awareness of the services available and their perceptions of the
treatment agency based on what they have heard. Information from people not in treatment can be
revealing and could suggest areas in which publicity is needed to counter misinformation. Likewise,
facilitators can develop, from the information gathered, a map that highlights where people go to
receive various services (Center for Substance Abuse Prevention 1995). The agency could also ask
their sources of referrals, such as faith-based organizations, community agencies, or primary care
physicians, whether they are referring clients to the agency, and if not, why. It is important to know
who is not walking through the door.

86
 Chapter 4—Pursuing Organizational Cultural Competence

instrument(s) should be administered by an changes that will be made based on the find-
objective third party, such as a consultant or a ings of and the priorities established through
member of the cultural competence commit- this assessment.
tee. Staff members should be asked about their
Step 7: Establish priorities for the organiza-
attitudes toward cultural issues with the un-
tion and incorporate these priorities into the
derstanding that their attitudes are not neces-
cultural competence plan. After obtaining the
sarily indicative of the degree to which the
results of the self-assessment process, the
staff mirrors the cultural groups served. In
organization—including boards, cultural
soliciting community feedback, the more
competence committee, community stake-
credibility the organization has in the com-
holders, and staff members—needs to estab-
munity, the higher the return rate will likely
lish realistic priorities based on the current
be. The lower the credibility, the more the
needs of clients and the community. Signifi-
organization needs to reassure respondents
cant consideration should be given to the level
that it intends to listen to, and act on, what it
of influence any given priority could have in
hears. If many survey forms are to be distrib-
effecting organizational change that will
uted, the organization could consider hiring
improve culturally responsive services. Some
students or community members on a tempo-
priorities will require more planning to im-
rary basis to make follow-up or reminder calls.
plement and can involve more financial and
Step 6: Compile and analyze the data. The staff resources, whereas other priorities will be
process of reviewing and assessing data should easier to implement from the outset (e.g.,
be overseen by the cultural competence com- hiring culturally competent counselors who
mittee. Basic data analysis procedures should are bilingual versus translating intake and
be used to ensure the accuracy of results and program forms). Therefore, long- and short-
credibility of reported information. For most range priorities should be established at the
well-designed instruments, there are relatively same time to maintain the momentum of
simple and appropriate ways to present data. change in the organization.
All available data should be assembled in a
Step 8: Develop a system to provide ongoing
report, along with interpretive comments and
monitoring and performance improvement
recommended action steps. The report should
strategies. Similar to the clinical assessment
note areas of strength and needed improve-
process with clients, the organizational self-
ment and should offer possible explanations
assessment is only valuable if it provides guid-
for any shortcomings. For example, if the
ance, determines direction and priorities, and
community is 20 percent African American,
facilitates action. Assessment is not a one-time
but only 2 percent of the agency’s clientele are
activity. It is important to continue monitoring
African American, what are some possible
to identify barriers that may impede the full
explanations for this group’s apparent un-
implementation of the cultural competence
deruse of services? It is also particularly im-
plan, to evaluate progress and performance,
portant to share results with those who
and to identify new service needs. Establishing
participated in the assessment process. Find-
a system to monitor an organization’s cultural
ings should be made available to staff, clients,
responsiveness equips it with the information
community members, boards, and managers.
necessary to formulate strategies to meet new
This increases overall sense of ownership in
demands and to continuously improve quality
the assessment and cultural competence devel-
of services.
opment process and in implementing the

87
 Improving Cultural Competence

Planning for language services is crucial, and

Language Services the need for these services must be assessed by
staff members who have initial contact with
Task: Plan for Language Services
clients, their family members, and/or other
Proactively individuals in their support systems (American
An organization must anticipate the need for Psychological Association [APA] 1990, 2002).
language services and the resources required to If frontline administrative and clinical staff
support these services, including funding, staff members are bilingual, the initial screening
composition, program materials, and transla- and assessment process can begin uninter-
tion services. Assessing the language needs of rupted. If this is not the case, receptionists or
the population to be served is essential. Upon frontline clinical staff members should at least
determination, the foremost task is letting be familiar with some rudimentary phrases in
clients with limited English proficiency know the preferred languages of their client base.
that language services are available as a basic The conversation can be scripted so that they
right for a client. Treatment providers need to can convey their limited ability to speak the
plan for the provision of linguistically appro- client’s language, obtain contact information
priate services, beginning with actively recruit- and inquire about language service needs, and
ing bicultural and bilingual clinical staff, inform the client that someone who can speak
establishing translation services and contracts, the language more fluently will be made avail-
and developing treatment materials prior to able to facilitate the initial screening process.
client contact. Although it is not realistic to Most importantly, procedures should be in
anticipate the language needs of all potential place to provide pretreatment contact and
clients, it is important to develop a list of follow-up in the client’s language to bridge the
available resources and program procedures gap between initial contact and subsequent
that staff members can follow when a client’s arrangement of language services.
language needs fall outside the organization’s
usual client demographics (The Joint Written and illustrated materials or a video
Commission 2009). about the program in the languages spoken by
the client population should be available to
How To Inform Clients About answer frequently asked questions. All materi-
Language Assistance Services als given to clients, family members, and
community members should be available in
• Use language identification or “I speak…” their primary languages. It is preferable to
cards.
develop the materials initially in those
• Post signs in regularly encountered lan-
guages at all points of entry. languages rather than simply translating mate-
• Establish uniform procedures for timely, rials from one language to another. Along
effective telephone communication be- with language, one should also consider the
tween staff members and persons with lim- level of literacy of the group in question. Some
ited English proficiency.
clients may be functionally illiterate even in
• Include statements about the services
available and the right to free language as- their native languages. Materials should
sistance services in appropriate non-English graphically reflect the population served
languages in brochures, booklets, outreach through pictures or photographs, using ethnic
materials, and other materials that are rou- themes and traditional elements familiar to
tinely distributed to the public.
the target audience. Also, materials should be
Source: OMH 2000. tested with the populations with whom they

88
 Chapter 4—Pursuing Organizational Cultural Competence

will be used, perhaps through focus groups, to to identify and disclose dual relationships to
ensure that they communicate effectively. supervisors immediately and on supervisors to
assess and determine the appropriateness of
Task: Establish Practice and using certain translator. Once a selection has
Training Guidelines for the been made, a confidentiality agreement should
Provision of Language Services be signed. Organizations need to provide
Key issues to consider in implementing and information routinely to clients about their
overseeing language services within an organi- confidentiality rights in using language ser-
zation include staff monitoring of language vices. Implementing a procedure for handling
proficiencies, selection of translators and client grievances is also recommended.
interpreters, confidentiality issues, and train- In planning for the use of language services,
ing needs. First, agencies need to assess lan- organizations should initially provide training
guage proficiencies among staff members and for staff on how to incorporate these services
encourage them to learn a language relevant to and should familiarize translators and inter-
the population served. At a minimum, staff preters with the clinical setting, terminology,
members should acquire in the given language behavioral expectations, and content related to
some basic terminology and phrases that are behavioral health (see the “Training Content
commonly used in the treatment setting. for Language Service Personnel” advice box
In recruiting and hiring translators and inter- on the next page). The language of mental
preters, administrative staff members should health and substance abuse services requires an
consider experience, motivation, skill level, additional degree of specialization. Experi-
mastery of English, and fluency in the lan- enced translators and interpreters who are
guage in need of interpretation (OMH 2000; unfamiliar with concepts of addiction, illness,
American Translators Association 2011). Be and recovery could convey information ade-
aware, however, that there can be considerable quately from a linguistic perspective but not
variation in dialects and levels of proficiency accurately convey the intent or meaning of
within the language, and these must be de- clinically oriented information or dialog.
termined in the selection process. To supple- Various training approaches can be used,
ment hiring practices, administrative policies including role-plays mirroring intakes, evalua-
should provide a means for determining the tions, and counseling sessions; indirect expo-
credentials of any language services organiza- sure to client sessions through audio or video
tions (Appendix F lists American Translators recordings of sessions or viewing from an
Association credentialing information). observation room; direct observation by sitting
in on a session, if appropriate; and consulta-
Other important hiring issues revolve around tion with other experienced language service
potential ethical dilemmas. In particular, care providers and clinical staff. Using other expe-
should be taken in using interpreters from the rienced translators and interpreters for train-
local community, which can create potential ing and/or for consultations, as well as sharing
challenges with confidentiality and dual rela- experiences in a peer support format, can be
tionships (e.g., the interpreter may also be very beneficial for new language service
client’s cousin or neighbor). Policies should providers.
place the burden on language service providers

89
 Improving Cultural Competence

Organizations must also create opportunities exactly match the words or meaning of the
for translators and interpreters to inquire client’s language or culture by becoming more
about and clarify clinical content and mean- descriptive, taking longer to deliver the mes-
ing. Language service providers often attempt sage in an effort to match the intent of a
to convey terminology or concepts that do not specific word or concept in English.

Advice to Clinical Supervisors and

Workforce and Staff
Administrators: Training Content for Development
Language Service Personnel
Translators and interpreters need additional
Task: Develop Staff Recruitment,
training to work in a clinical setting. Initial Retention, and Promotion
training should include: Strategies That Reflect the
• General mental health and substance
abuse information. Populations Served
• Introduction to behavioral health services. To determine whether it adequately reflects
• Familiarity with interviewing and assessment the population it serves, an organization has to
questions, instruments, and formats. assess its personnel, including counselors,
• Legal and ethical issues, including confi-
dentiality and professional boundaries.
administrators, and board of directors. Ac-
• Relevant programmatic policies and pro- cording to a 10-year study that collected data
cedures. on treatment admissions, racial and ethnic
• Review of program materials, forms, ques- composition of treatment populations has not
tionnaires, and other written clinical mate- significantly changed. Racially diverse groups
rials that clients receive during the course
of treatment.
(excluding non-Latino Whites) represent
• Knowledge of technical vocabulary relevant approximately 40 percent of treatment admis-
to the behavioral health field. sions (Substance Abuse and Mental Health
• Emphasis on the importance of accurate Services Administration [SAMHSA] 2011c),
interpretation and translation without addi- yet 80 percent of counselors are non-Latino
tions or omissions.
• Behavioral and professional guidelines on
Whites (Duffy et al. 2004). In striving to
how to manage potential client reactions in improve cultural responsiveness, staff compo-
and outside the session (e.g., outward dis- sition should be a major strategic planning
plays of anger or hostility; grief reactions; consideration. As much as possible, the staff
disclosing information to the translator with should mirror the client population.
a request to keep it a secret from clinical
staff; discomfort with translator’s biologi- Nevertheless, providers should avoid hiring
cal, social, and/or demographic character- “ethnic representatives,” which means hiring a
istics, such as gender orientation, age, or
socioeconomic status ). single person from an ethnic or cultural group
• Importance of cultural sensitivity in dialog and expecting him or her to serve as the cul-
between translator and client, including tural resource on that group for the entire
how questions are asked. staff. This can be burdensome, if not offensive,
• General guidelines on how to handle to that person. Belonging to a group does not
personal issues that can be elicited by par-
ticipation in the intake, assessment, and ensure cultural responsiveness toward,
treatment processes, including identifica- knowledge of, or skill in working with mem-
tion with similar clinical issues (e.g., sub- bers of that group, nor does it guarantee that
stance use patterns, family dynamics, the person culturally identifies with that cul-
traumatic events, emotional distress).
tural group or its heritage. Hiring ethnic

90
 Chapter 4—Pursuing Organizational Cultural Competence

“Improving the workforce to provide (Anderson et al. 2003; Brach and Fraser 2000;
competent services to diverse populations Lie et al. 2011). The organization should be
goes far beyond merely increasing the prepared to offer relevant professional devel-
number of individuals from each of the opment experiences consistent with counselors’
respective groups. While this is clearly an personal goals and assigned responsibilities as
important strategy, there is a need not well as the organization’s goals for culturally
only to increase the numbers but also to
responsive services. Board members, volun-
improve the quality of training for all
clinicians, regardless of their racial, ethnic, teers, and interpreters should all receive ap-
cultural, or linguistic background. This also propriate training.
includes the necessity to recruit, train, and
A professional development training plan
support interpreters.”
details the frequency, content, and schedule for
(Hoge et al. 2007, p. 192).
staff training and continuing education. Be-
cause becoming culturally competent is a
representatives undermines the expansion of process, training and support for engaging in
diversity at all organizational levels and the culturally responsive services can be more
importance of developing opportunities for all appropriate when delivered across a period of
staff members to gain awareness and improve time involving follow-up sessions rather than
their ability to effectively work with clients. through a single session. Outcome research
Some organizations struggle to find multicul- that evaluates the effectiveness of cultural
tural staff members that represent the diversity competence training materials, format, and
of their communities and clienteles. If re- content in mental health services, including
cruitment is perceived as an immediate short- treatment for substance use disorders (Bhui et
term goal, ongoing difficulties are likely in al. 2007; Lie et al. 2010), is limited. Nonethe-
hiring, promoting, and retaining a diverse staff. less, numerous resources have suggested that
Instead, recruitment strategies need to em- effective cultural training does feature certain
brace a more comprehensive and long-term qualities (Exhibit 4-5).
approach that includes internships, marketing Sometimes, staff members will express re-
to those interested in the field at an early age, sistance to participation in training activities
mentoring programs for clinical and adminis- aimed at promoting cultural competence—
trative roles, support networks, educational they may feel forced to learn about cultural
assistance, and training opportunities. competence, or they may feel unable to take
the time away from their clients to attend the
Task: Create Training Plans and
Curricula That Address Cultural “The learning objectives of a professional
Competence development program should include
The primary purpose of training is to increase awareness- and knowledge-based objec-
cultural competence in the delivery of services, tives and skills-based objectives that
beginning with outreach and extending to motivate students to explore personal
perspectives and multiple worldviews,
continuing care services that support behav-
understand and embrace culturally com-
ioral health. Training should increase staff petent health promotion strategies, and
self-awareness and cultural knowledge, review engage in self-directed competency
culturally responsive policies and procedures, development.”
and improve culturally responsive clinical skills (Perez and Luquis 2008, p. 178).

91
 Improving Cultural Competence

Exhibit 4-5: Qualities of Effective Cultural Competence Training

The qualifications of the trainer, the selection of training strategies, and the use of reputable training
curricula are extremely important in developing culturally competent staff and responsive services. The
following concepts should be considered in the development and implementation of cultural training:
• Cultural training should begin with educating new staff members about the organization’s vision,
values, and mission as related to culturally responsive services. Orientation should address the
demographic composition of clientele, policies and procedures for cultural and linguistic ser-
vices, counseling and performance expectations for assessment, treatment planning, and deliv-
ery of culturally responsive services.
• Before developing and initiating a training plan for culturally responsive services, ask staff mem-
bers about their training needs specific to the cultural groups that they serve. Receptivity will
likely increase if managers and administrators involve clinical staff in the planning process rather
than assuming that they know exactly what staff members need regarding cultural training.
• Training should occur across time, and a training plan should detail how to provide training for
new employees. Too often, trainings occur at one time, ignoring the complexity of cultural
groups and suggesting that one training session is sufficient to achieve cultural competence.
Cultural competence evolves from ongoing professional development.
• Training should incorporate diverse learning strategies, including experiential learning and
cultural immersion when appropriate (e.g., participation in community activities, role-plays, case
presentations). Training should be experientially based and process oriented, allowing self-
reflection as part of the training and assigning self-reflection activities between training sessions
(see the how-to box on self-reflection on the next page).
• Training should provide information that is practice- or research-based to ensure that partici-
pants see it as reputable and clinically sound.
• Training should create a welcoming, nonjudgmental, and professional atmosphere in which staff
members, regardless of race, ethnicity, or cultural group, have the freedom and safety to ex-
plore their own beliefs and to learn about other cultural groups. Training efforts should not
scapegoat mainstream cultural groups or make general statements about specific racial or ethnic
groups without noting that there are many cultural subgroups within a given racial or ethnic
group—often characterized by, but not limited to, geographic location, socioeconomic status, or
educational levels. Participation guidelines should be clarified for each training.
• Training should be conducted by an interdisciplinary, multicultural training team that is experi-
enced in training and well versed in cultural competence.
• Trainers should allow time for staff members to ask questions and process the presented materi-
als and experiential exercises, and they should use staff questions and exercises to explore and
correct misperceptions in a nonjudgmental manner.

Sources: Brach and Fraser 2000; Dixon and Iron 2006; Gilbert 2003; Pack-Brown and Williams 2003;
Roysircar 2006; Russell 2009.

trainings. Others might object on the grounds cess, and use this premise to introduce the
that they treat everyone equally, thus ignoring need for training centered on culturally re-
their own cultural blindness. sponsive care. Some staff members may re-
spond to incentives or predetermined
The organization’s leadership needs to address
objectives and criteria reflected in employee
staff reluctance and concerns regarding train-
performance evaluations. Others may be more
ing through initial education on the rationale
motivated by opportunities that arise from the
for cultural competence. Assume that staff
organization’s commitment to culturally re-
members are invested in creating the best
sponsive services or by other factors, such as
opportunities for their clients to achieve suc-
specialized training and supervision, the

92
 Chapter 4—Pursuing Organizational Cultural Competence

How To Engage in Self-Reflection: A Tool for Counselor Training and Supervision

Ask participants to preselect three clients whom they are currently counseling and will likely continue
to counsel prior to the next training or supervision session. Selection should be based on clients’
diversity in age, race, gender, ethnicity, socioeconomic status, education, and/or geographic loca-
tion. After each participant has selected three clients (remind participants not to disclose actual
client identity if this is an external training outside of the agency), ask them to keep a self-reflection
journal wherein the number of entries coincide with each client session until the next training. Partic-
ipants should write about their internal process, including reactions such as feelings, thoughts, or
behaviors during the session that relate to the influence of culture. For example:
• Identify racial, ethnic, and cultural similarities and differences between you and your client.
• Explain how your cultural and clinical worldviews influence your dialog, treatment planning, and
expectations of yourself and your client in the session.
• Describe assumptions that you have learned to make about your client’s specific race, ethnicity,
or culture(s).
• Even if you think these assumptions, beliefs, or biases do not play a role in your current counsel-
ing relationship and approach, discuss how they could influence your counseling. Provide a spe-
cific example.
• Describe the feelings that you have about your client. How do these feelings relate to your
client’s racial, ethnic, or cultural identity?
• Explain the differences and similarities in worldviews between you and your client.
• Discuss how your and your client’s beliefs about health, healing, disease, and addiction differ.
• Describe how your client’s experience with discrimination, oppression, and prejudice could
influence his/her current level of distress, psychological functioning, and response to treatment.
• Explore how you attend to your client’s worldview in each session.
• Describe a misunderstanding or erroneous counseling response during a counseling session that
appears related to differences in cultural identification, values, or behavior.
• Identify cultural knowledge that you must obtain to gain a better understanding of your client.
• Discuss the most important lessons that you have learned from your client.

desire to be perceived by other staff members curricula on cultural competence on their Web
as team players, or their roles as agents of sites. In addition to OMH guidelines on staff
change with other staff members. education and training (Exhibit 4-6), guide-
lines are available from psychological and
Opportunities for cultural competence train-
counseling associations (APA 2002). To re-
ing abound. National organizations, agencies
view sample training modules, see Cultural
dedicated to multicultural learning, academic
Competence for Health Administration and
institutions, government agencies, and infor-
Public Health (Rose 2011).
mation clearinghouses offer training or have
information about training opportunities and Task: Provide Culturally
Congruent Clinical Supervision
“It takes time and energy to work through
Little research is available that measures cul-
significant changes, whether in the work-
place or in our personal lives. Many times, tural competence among clinical supervisors or
resistance to change is a natural reaction evaluates the effects of supervision on cultural
of people trying to understand what is competence among counselors (Colistra and
expected of them and how the change will Brown-Rice 2011; Constantine and Sue 2005).
impact their lives.” Not much is known about the effectiveness of
(Addiction Technology Transfer Center clinical supervision in enhancing culturally
2004, p. 28) competent behavior among counselors,

93
 Improving Cultural Competence

Exhibit 4-6: OMH Staff Education and Training Guidelines

Only general agreement exists as to what constitutes an acceptable cultural competence curriculum.
OMH (2000) recommends tailoring curriculum topics to the roles and responsibilities of trainees and
the specific needs of populations served over time but suggests that training should at least address:
• The effects of cultural differences between counselors and clients/consumers on clinical and
other workforce encounters, such as the therapeutic alliance.
• The elements of effective communication among staff members and clients/consumers from
diverse cultural groups who use different languages, including how to work with interpreters and
telephone language services.
• Strategies for resolving racial, ethnic, or cultural conflicts between staff members and clients.
• The organization’s policies and procedures for written language access, including how to gain
access to interpreters and translated written materials.
• Parts of the Civil Rights Act of 1964 that address services for clients with limited English profi-
ciency.
• The organization’s complaint or grievance procedures.
• The effects of cultural differences on health promotion and disease prevention, diagnosis and
treatment, and supportive care.
• The impact of poverty and socioeconomic status, race and racism, ethnicity, and sociocultural
factors on access to care, service use, quality of care, and health outcomes.
• Differences in the clinical management of diseases and conditions indicated by differences in the
race or ethnicity of clients.
• The effects of cultural differences among clients/consumers and staff members on health out-
comes, client satisfaction, and treatment planning.

Source: OMH 2000. Adapted from material in the public domain.

although some research with a multicultural support culturally responsive services with
focus has measured counselor self-efficacy their supervisees). This can significantly im-
after receiving supervision and has examined pede organizations attempting to introduce or
the dynamics of supervisee–supervisor rela- improve culturally responsive clinical services.
tionships. Even though educational institu-
It is essential for organizations to provide
tions have developed curricula and standards
counselors with clinical supervisors who are
to reinforce the need for a multicultural per-
culturally aware, have engaged in multicultural
spective in training, many clinical supervisors
training, and model culturally competent
lack sufficient training in this area (e.g., avoid
behaviors in clinical supervision sessions (e.g.,
cultural topics in supervision, have difficulty
allowing or engaging in discussions centered
giving culturally appropriate consultations or
on race, ethnicity, and cultural groups in the
direction, fail to guide/reinforce timely im-
session). Clinical supervision is the glue that
plementation of policies or procedures that

Advice to Clinical Supervisors: Culturally Competent Clinical Supervision

Supported by a review of research on multicultural clinical supervision, Miville et al. (2005) suggest
that clinical supervisors gain awareness of and assess:
• Their own racial, ethnic, and cultural identities and attitudes and those of their supervisees.
• Their own knowledge base, strengths, and weaknesses and those of their supervisees.
• Racial, ethnic, and cultural issues that generate reactions in supervisors and in supervisees.
• Current engagement in professional development activities that support culturally responsive
practices (see the professional development advice box on the next page).

94
 Chapter 4—Pursuing Organizational Cultural Competence

How To Discuss Professional Development in Multicultural Counseling

This tool facilitates supervisee–supervisor discussions surrounding professional development activi-
ties that promote cultural competence. Supervisors can ask supervisees to review the list and check
off activities that they have engaged in recently or in the past several months. Supervisors can then
use the completed exercise as a starting point for gaining more specific information on activities
endorsed by supervisees. Even if supervisees check off no items, reviewing the list reinforces activi-
ties that build cultural competence.

Materials needed: A printed copy of the checklist and a pen or pencil.

Instructions: Mark off the activities you have engaged in during the past month and/or 6 months.
Past Past 6
month months
____ ____ I recognized a prejudice I have about certain people.
____ ____ I talked to a colleague about a cultural issue.
____ ____ I sought guidance about a cultural issue that arose in therapy.
____ ____ I attended a multicultural training seminar.
____ ____ I attended a cultural event.
____ ____ I attended an event in which most other people weren’t of my race.
____ ____ I reflected on my racial identity and how it affects my work with clients.
____ ____ I read a chapter or an article about multicultural issues.
____ ____ I read a novel about a racial group other than my own.
____ ____ I sought consultation or supervision about multicultural issues.
____ ____ I talked to a friend/associate about how our racial differences affect our
relationship.
____ ____ I challenged a racist remark—my own or someone else’s.
Source: Pack-Brown and Williams 2003, p. 136. Used with permission.

reinforces culturally competent behavior, and that cultural variables influence each aspect of
it is often the only avenue of ongoing clinical supervision: the relationship between supervi-
training and follow-up after specific workshops sors and supervisees, the supervisors’ and
or trainings are offered by the organization. supervisees’ perceptions and assessments of
clients’ presenting issues, the interactions
Clinical supervisors should adopt a multicul-
between supervisees and their clients, and the
tural framework to guide the supervision
treatment recommendations and directions
process (e.g., Sue’s [2001] multidimensional
that evolve from supervision.
model for developing cultural competence).
Endorsement of a model for developing and Task: Evaluate Staff Performance
enhancing cultural competence helps both
supervisors and supervisees understand how to
on Culturally Congruent and
address cultural issues in supervision and Complementary Attitudes,
pursue personal and professional development Knowledge, and Skills
that supports culturally responsive clinical Organizations committed to endorsing and
services. (For a specific example, see Field and implementing culturally responsive services
colleagues’ [2010] Latina–Latino multicultural need policies and procedures that reflect this
developmental supervisory model.) The model commitment in job descriptions and staff
guides supervision and reinforces the premise evaluations across all levels of the organiza-
tion. By incorporating specific goals,

95
 Improving Cultural Competence

Advice to Administrators and Clinical Supervisors: Culturally Responsive

Performance Evaluation Criteria
Cultural competence is measured by the degree to which counselors, administrators, and other staff
members engage in observable actions and attitudes that reflect cultural responsiveness. Following
are examples of descriptive evaluation criteria that address a few aspects of culturally responsive
behavior:
• Engages in ongoing self-analysis to identify and address personal and cultural biases.
• Actively seeks to view life through the eyes of others and, through doing so, develops a greater
level of sensitivity for the values and life challenges of other groups.
• Participates in hands-on training opportunities and seeks practice and feedback that build toward
mastery of responsive needs assessment techniques.
• Seeks opportunities to engage in cross-cultural activities and interactions.

expectations, and tasks into performance Task: Create an Environment That

evaluations, staff members will receive an Reflects the Populations Served
important and consistent message from the
The self-assessment process should include
organization that culturally competent behav-
an environmental review of the organization’s
ior and responsive services are valued and
physical facilities in which barriers to access
rewarded.
are examined. The plan should address iden-
tified deficits. For example, signage should be
Organizational written in all primary languages spoken by
Infrastructure the clients served; it should be written at an
appropriate level of literacy in those lan-
Task: Plan Long-Range Fiscal guages. When possible, signs should use
Support of Cultural Competence pictures and graphics to replace written in-
structions. The design of the facility, includ-
An organization’s commitment to providing
ing use of space and décor, should be inviting,
culturally responsive treatment services will
comfortable, and culturally sensitive. The
only succeed if resources are consistently
plan should establish how to make facilities
dedicated to supporting the plan. Realistical-
more accessible and culturally appropriate. In
ly, treatment program funds may be insuffi-
addition, the organization should create an
cient to initially meet the goals outlined in
environment that reflects the culture(s) of its
the organization’s self-assessment. More
clients not only within the facility, but
often than not, the committee, executive staff,
through business practices, such as using local
and board will have to prioritize the specific
and community vendors.
changes that are financially feasible. However,
this necessity does not preclude the organiza-
Task: Develop Outreach
tion from soliciting help from the communi-
ty, finding creative and inexpensive ways to Strategies To Improve Access to
make organizational changes, and using Care
strategic and financial planning to build The best-laid plans for providing culturally
resources designated for culturally responsive competent treatment are futile if clients
services. cannot access treatment. Providers should
develop outreach plans for diverse ethnic and

96
 Chapter 4—Pursuing Organizational Cultural Competence

Advice to Administrators: Improving Outreach and Access to Care

Whenever it is not feasible to provide behavioral health services in the neighborhoods or communi-
ties where they are needed, treatment providers should consider the following:
• Referring clients to community resources: Ensure that all counselors and referral sources know
where to refer individuals for culturally appropriate community services. Individuals should not
have to “bounce around” through the system seeking care that is already difficult to access.
Have culturally and linguistically appropriate brochures available that describe community ser-
vices, eligibility, and the referral process.
• Collaborating with other community services: Collaboration with other community-based
organizations is essential to compensate for the limitations faced by any single agency. Be-
havioral health service providers can reach larger numbers of underserved populations by team-
ing with others who have complementary missions and, at times, greater funding, such as other
behavioral health agencies and programs dealing with welfare-to-work services, homelessness,
or HIV/AIDS. Additional collaboration to increase use includes sending culturally competent
counselors to work at another agency or community group on at least a part-time basis, training
community members or other agency personnel to provide brief interventions or referral ser-
vices, and supporting the establishment of mutual-help groups with translated/adapted litera-
ture in neighborhood locations.
• Co-locating community services (creating a one-stop facility): Co-locating with other agencies
is often highly desirable, as it can facilitate connections among various community services that
clients need and provide an easy central location to access these services (e.g., a substance
abuse intensive outpatient treatment program, a community health service agency, and a com-
munity outpatient mental health program offered at one location). For culturally diverse people,
the process of accessing services across agencies can be complex because of the need to obtain
linguistically and culturally appropriate services and to overcome other barriers, such as eco-
nomic challenges, issues surrounding eligibility, or the cumbersome repetition of completing
forms for each agency. An effective one-stop facility ensures close coordination between each
agency that participates while also ensuring client confidentiality. Co-location with a community-
based organization that already has solid, positive visibility in the community and a culturally
competent workforce can help improve the outreach and treatment efforts of behavioral health
organizations that have had difficulty connecting with the communities that they serve.
• Eliciting support from the community and employing outreach workers: It is often easier and
more persuasive for people who abuse substances or need mental health services to receive in-
formation and be encouraged to seek treatment by persons who are ethnically similar to them
and speak the same language as they do. This is especially important for new immigrants, who
do not yet know their way around the new country and could be unsure of whom they can trust.
When possible, outreach workers should be of similar cultural origin as the population being
served and should be familiar with the community where they are working. This allows them to
explain the advantages of treatment in culturally appropriate ways, speak the appropriate lan-
guage or dialect, address the concerns of community members, and respect clients’ priorities
and issues. Outreach efforts can forge connections with important members of the community
who encourage people with mental and substance use disorders and their families to seek
treatment. These efforts are particularly important with new immigrants who may face legal and
language barriers or may have a limited understanding of contemporary medicine and treatment
possibilities. For example, lay people trained as promotores de salud (promoters of health) have
been successful in reaching Latino migrant workers (Azevedo and Bogue 2001).
• Supplying support services: Providers can use a variety of means to make treatment accessible
to culturally diverse clients. One strategy is to provide transportation from clients’ neighbor-
hoods to the provider site. In many areas, people must travel long distances to receive culturally
appropriate services. This limits the number of people able to receive treatment, especially

(Continued on the next page.)

97
 Improving Cultural Competence

Advice to Administrators: Improving Outreach and Access to Care (continued)

individuals with incomes too low to support travel. In addition, lengthy travel requirements re-
duce the chances of a person in the early stages of change with low motivation reaching a coun-
selor who can help increase motivation and move the person toward recovery. Other strategies
are the inclusion of child care and language services within the program. In addition, home-based
outpatient treatment and telemedicine strategies can work, particularly for rural populations.
• Selecting culturally appropriate strategies to provide community education: Certain forms of
outreach are more likely to be successful in some populations than in others. For example, in
Chinese and Korean communities, community fairs are often an excellent way to publicize treat-
ment services. Notices in community newspapers, on radio and television channels, on billboards,
and in stores in the languages spoken locally can reach other potential clients. The person chosen
to deliver or represent the messages in such situations should be someone familiar with the
community and likely to inspire trust. Some agencies serving American Indian people have expe-
rienced success in publishing a monthly newsletter that is sent to individual American Indians and
agencies serving the Native American community.

racial communities, particularly those whose accurate information and referral to appropri-
members may find it difficult to seek services ate mutual-help or community groups.
on their own. For example, see Community-
Regarding fiscal planning and funding op-
Defined Solutions for Latino Mental Health
portunities, some HHS initiatives support
Care Disparities (Aguilar-Gaxiola et al. 2012).
outreach through integrated care. For exam-
From the outset, effective outreach and im-
ple, the Health Resources and Services
proved access to care should include formal
Administration (HRSA) Center for Integrated
and informal contacts with community organ-
Health Solutions (CIHS) promotes the devel-
izations, spiritual leaders, and media. Providers
opment of integrated primary and behavioral
can learn from these contacts about the behav-
health services to better address the needs of
ioral health concerns in the community, spe-
individuals with mental health and substance
cial considerations for working with members
use concerns. Resources are available to help
of the community, cultural impediments to
physicians screen for behavioral health prob-
treatment, and cultural resources to aid treat-
lems and refer individuals to appropriate
ment and recovery.
treatment. SAMHSA’s Center for Substance
Unfortunately, many providers lack sufficient Abuse Treatment has a Targeted Capacity
funding to offer the level of outreach services Expansion Program that offers grants in
needed by the communities they serve. Be- support of outreach to specific populations.
cause they are overwhelmed already, the issue
The challenges outlined in this chapter are
of outreach to underserved populations is
burdensome but can be overcome. Many
often seen as a low priority, which can cause
organizations have been able to develop cul-
these providers to send people in need of
tural competence over time (for a historical
treatment away, disappointed and disheart-
perspective of one organization’s journey, see
ened. However, thoughtful and strategic use of
Exhibit 4-7). A well-defined and organized
community resources can result in more mem-
plan, coupled with a consistent organizational
bers of underserved populations receiving the
commitment, will enable organizations to
treatment they need and deserve. At mini-
initiate and accomplish the tasks necessary to
mum, outreach enables providers to offer
promote culturally responsive services.

98
 Chapter 4—Pursuing Organizational Cultural Competence

Exhibit 4-7: Cultural Competence Initiative Across Time in One Organization

Late 1980s
• The executive director and board endorse the need to pursue cultural competence and outline
agency goals.
• An agency cultural competence committee forms to help develop policies, procedures, and a
cultural competence plan. Community and client representation is established.
• A senior staff member is hired to oversee the organization’s efforts to diversify staff.

Early 1990s
• The executive director, board of directors, and advisory board endorse the need to pursue
culturally competent practices throughout the organization.
• General goals are established and senior management and staff members begin educating the
staff on cultural competence.

Mid 1990s
• Culturally competent clinical standards are developed and implemented.
• Initial vision, mission, and value statements are modified to include cultural competence.
• Training for management and clinical supervisors incorporates cultural competence in practice.
• The agency begins a community cultural assessment and introduces a client satisfaction survey
to gain feedback on current implementation of culturally responsive practices and to guide fu-
ture direction and focus.
• Ongoing clinical supervisor training on cultural competence is initiated.
• The cultural competence committee develops recommendations for job descriptions and perfor-
mance appraisals to reflect cultural competence skills and responsibilities.

Late 1990s
• Individuals and families who receive services are now involved in focus groups, orientations, and
trainings.
• Partnerships with other agencies to promote cultural competence throughout the community
are more strongly encouraged.
• A curriculum to train all staff members in the foundations of cultural competence is developed
and implemented.

2000s
• Across the organization, clinical and administrative programs engage in cultural competence
review and goal-setting.
• The mission statement is redefined to formally acknowledge the organization’s values of respect
for cultural differences, recovery, and advocacy.

99
 5 Behavioral Health
Treatment for Major
Racial and Ethnic Groups

John, 27, is an American Indian from a Northern Plains Tribe. He

IN THIS CHAPTER recently entered an outpatient treatment program in a midsized
• Introduction Midwestern city to get help with his drinking and subsequent low
• Counseling for African mood. John moved to the city 2 years ago and has mixed feelings
and Black Americans about living there, but he does not want to return to the reserva-
• Counseling for Asian tion because of its lack of job opportunities. Both John and his
Americans, Native counselor are concerned that (with the exception of his girlfriend,
Hawaiians, and Other Sandy, and a few neighbors) most of his current friends and
Pacific Islanders coworkers are “drinking buddies.” John says his friends and family
• Counseling for Hispanics on the reservation would support his recovery—including an uncle
and Latinos and a best friend from school who are both in recovery—but his
• Counseling for Native contact with them is infrequent.
Americans
John says he entered treatment mostly because his drinking was
• Counseling for White
Americans
interfering with his job as a bus mechanic and with his relationship
with his girlfriend. When the counselor asks new group members
to tell a story about what has brought them to treatment, John
explains the specific event that had motivated him. He describes
having been at a party with some friends from work and watching
one of his coworkers give a bowl of beer to his dog. The dog kept
drinking until he had a seizure, and John was disgusted when peo-
ple laughed. He says this event was “like a vision;” it showed him
that he was being treated in a similar fashion and that alcohol was
a poison. When he first began drinking, it was to deal with bore-
dom and to rebel against strict parents whose Pentecostal Christian
beliefs forbade alcohol. However, he says this vision showed him
that drinking was controlling him for the benefit of others.
Later, in a one-on-one session, John tells his counselor that he is
afraid treatment won’t help him. He knows plenty of people back

101
 Improving Cultural Competence

home who have been through treatment and healing, help-seeking behavior, and treatment
still drink or use drugs. Even though he expectations and preferences. Adopting Sue’s
doesn’t consider himself particularly tradition- (2001) multidimensional model in developing
al, he is especially concerned that there is cultural competence, this chapter identifies
nothing “Indian” about the program; he dis- cultural knowledge and its relationship to
likes that his treatment plan focuses more on treatment as a domain that requires proficien-
changing his thinking than addressing his cy in clinical skills, programmatic develop-
spiritual needs or the fact that drinking has ment, and administrative practices. This
been a poison for his whole community. chapter focuses on patterns of substance use
and co-occurring disorders (CODs), beliefs
John’s counselor recognizes the importance of
about and traditions involving substance use,
connecting John to his community and, if
beliefs and attitudes about behavioral health
possible, to a source of traditional healing.
treatment, assessment and treatment consider-
After much research, his counselor is able to
ations, and theoretical approaches and treat-
locate and contact an Indian service organiza-
ment interventions across the major racial and
tion in a larger city nearby. The agency puts
ethnic groups in the United States.
him in touch with an older woman from
John’s Tribe who resides in that city. She, in
turn, puts the counselor in touch with another Introduction
member of the Tribe who is in recovery and Culture is a primary force in the creation of a
had been staying at her house. This man person’s identity. Counselors who are culturally
agrees to be John’s sponsor at local 12-Step competent are better able to understand and
meetings. With John’s permission, the counse- respect their clients’ identities and related
lor arranges an initial family therapy session cultural ways of life. This chapter proposes
that includes his new sponsor, the woman who strategies to engage clients of diverse racial
serves as a local “clan mother,” John’s girl- and ethnic groups (who can have very differ-
friend, and, via telephone, John’s uncle in ent life experiences, values, and traditions) in
recovery, mother, and brother. With John’s treatment. The major racial and ethnic groups
permission and the assistance of his new in the United States covered in this chapter
sponsor, the counselor arranges for John and are African Americans, Asian Americans
some other members of his treatment group to (including Native Hawaiians and other Pacific
attend a sweat lodge, which proves valuable in Islanders), Latinos, Native Americans (i.e.,
helping John find some inner peace as well as Alaska Natives and American Indians), and
giving his fellow group members some insight White Americans. In addition to providing
into John and his culture. epidemiological data on each group, the chap-
To provide culturally responsive treatment, ter discusses salient aspects of treatment for
counselors and organizations must be commit- these racial/ethnic groups, drawing on clinical
ted to gaining cultural knowledge and clinical and research literature. This information is
skills that are appropriate for the specific racial only a starting point in gaining cultural
and ethnic groups they serve. Treatment pro- knowledge as it relates to behavioral health.
viders need to learn how a client’s identifica- Understanding the diversity within a specific
tion with one or more cultural groups culture, race, or ethnicity is essential; not all
influences the client’s identity, patterns of information presented in this chapter will
substance use, beliefs surrounding health and apply to all individuals. The material in this
chapter has a scientific basis, yet cultural beliefs,

102
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Multidimensional Model for Developing Cultural Competence: Cultural

Knowledge of Behavioral Health

traditions, and practices change with time and environmental context affects behavioral
are not static factors to consider in providing health. However, to provide a framework for
services for clients, families, or communities. understanding many diverse cultural groups,
some generalizations are necessary; thus, broad
Although these broad racial/ethnic categories
categories are used to organize information in
are often used to describe diverse cultural
this chapter. Counselors are encouraged to
groups, the differences between two members
learn as much as possible about the specific
of the same racial/ethnic group can be greater
populations they serve. Sources listed in
than the differences between two people from
Appendix F provide additional information.
different racial/ethnic groups (Lamont and
Small 2008; Zuckerman 1998). It is not possi-
ble to capture every aspect of diversity within Counseling for African and
each cultural group. Behavioral health workers Black Americans
should acknowledge that there will be many
individual variations in how people interact According to the 2010 U.S. Census definition,
with their environments, as well as in how African Americans or Blacks are people whose

103
 Improving Cultural Competence

origins are “in any of the black racial groups of consumption as they grow older (Center for
Africa” (Humes et al. 2011, p. 3). The term Substance Abuse Treatment [CSAT] 1999a;
includes descendants of African slaves brought Galvan and Caetano 2003). Rates of overall
to this country against their will and more substance use among African Americans vary
recent immigrants from Africa, the Caribbean, significantly by age. Several researchers have
and South or Central America (many individ- observed that despite Black youth being less
uals from these latter regions, if they come likely than White American youth to use
from Spanish-speaking cultural groups, iden- substances, as African Americans get older,
tify or are identified primarily as Latino). The they tend to use at rates comparable with
term “Black” is often used interchangeably those of White Americans (Watt 2008). This
with African American, although sometimes increase in substance use with age among
the term “African American” is used specifi- Blacks is often referred to as a crossover effect.
cally to describe people whose families have
However, Watt (2008), in her analysis of 4
been in this country since at least the 19th
years of National Survey on Drug Use and
century and thus have developed distinct
Health (NSDUH) data (1999–2002), found
African American cultural groups. “Black” can
that when controlling for factors such as drug
be a more inclusive term describing African
exposure, marriage, employment, education,
Americans as well as more recent immigrants
income, and family/social support, the cross-
with distinct cultural backgrounds.
over effect disappeared for Blacks ages 35 and
Beliefs About and Traditions older; patterns for drug and heavy alcohol use
among Black and White American adults
Involving Substance Use remained the same as for Black and White
In most African American communities, American adolescents (i.e., White Americans
significant alcohol or drug use may be socially were significantly more likely to use substanc-
unacceptable or seen as a sign of weakness es). Watt concludes that systemic issues, such
(Wright 2001), even in communities with as lower incomes and education levels, and
limited resources, where the sale of such sub- other factors, such as lower marriage rates,
stances may be more acceptable. Overall, contribute to substance use among Black
African Americans are more likely to believe adults. Additional research also suggests that
that drinking and drug use are activities for exposure to discrimination increases willing-
which one is personally responsible; thus, they ness to use substances in African American
may have difficulty accepting alcohol youth and their parents (Gibbons et al. 2010).
abuse/dependence as a disease (Durant 2005).
When comparing African Americans with
Substance Use and Substance Use other racial and ethnic groups, NSDUH data
Disorders from 2012 suggest that they are somewhat
To date, there has not been much research more likely than White Americans to use illicit
analyzing differences in patterns of substance drugs and less likely than White Americans to
use and abuse among different groups of use alcohol. They also appear to have an inci-
Blacks, but there are indications that some dence of alcohol and drug use disorders simi-
gender differences exist. For example, alcohol lar to that seen in White Americans
consumption among African American wom- (Substance Abuse and Mental Health Services
en increases as they grow older, but Caribbean Administration [SAMHSA] 2013d). Crack
Black women report consistently low alcohol cocaine use is more prevalent among Blacks

104
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

than White Americans or Latinos, whereas Some preliminary evidence suggests that
rates of abuse of methamphetamine, inhalants, African Americans are less likely to develop
most hallucinogens, and prescription drugs are drug use disorders following initiation of use
lower (SAMHSA 2011a). Phencyclidine use (Falck et al. 2008), yet more research is needed
also appears to be a more serious problem, to identify variables that influence the devel-
albeit affecting a relatively small group, among opment of drug use disorders. Even though
African Americans than among members of African Americans seem less likely than
other racial/ethnic groups. White Americans to develop alcohol use
disorders, a number of older studies have
There appear to be some other differences in
found that they more frequently experience
how African Americans use substances com-
liver cirrhosis and other alcohol-related health
pared with members of other racial/ethnic
problems (Caetano 2003; Polednak 2008). In
groups. For example, Bourgois and Schonberg
tracking 25 years of data, Polednak (2008)
(2007) observed that among people who inject-
found that the magnitude of difference has
ed heroin in San Francisco, White Americans
decreased over time; nonetheless, health dispar-
tended to administer the drug quickly whether
ities continue to exist for African Americans in
or not they could find a vein, which led them
terms of access to and quality of care, which
to inject into fat or muscle tissue and resulted
can affect a number of health problems
in a higher rate of abscesses. However, African
(Agency for Healthcare Research and Quality
Americans who injected heroin were more
2009; Smedley et al. 2003).
methodical and took the time to find a vein,
even if it took multiple attempts. This, in turn, Mental and Co-Occurring
often resulted in using syringes that were
already bloodied and increased their chances
Disorders
of contracting HIV/AIDS and other blood- A number of studies have found biases that
borne diseases. African Americans who inject- result in African Americans being overdiag-
ed heroin were significantly more likely to also nosed for some disorders and underdiagnosed
use crack cocaine than were White Americans for others. African Americans are less likely
who injected heroin (Bourgois et al. 2006). than White Americans to receive treatment
for anxiety and mood disorders, but they are
African American patterns of substance use more likely to receive treatment for drug use
have changed over time and will likely contin- disorders (Hatzenbuehler et al. 2008). In one
ue to do so. Based on treatment admission study evaluating posttraumatic stress disorder
data, admissions of African Americans who (PTSD) among African Americans in an
injected heroin declined by 44 percent during outpatient mental health clinic, only 11 per-
a 12-year period, whereas admissions declined cent of clients had documentation referring to
by only 14 percent among White Americans PTSD, even though 43 percent of the clients
(Broz and Ouellet 2008). Additionally, during showed symptoms of PTSD (Schwartz et al.
this period, the peak age for African Americans 2005). Black immigrants are less likely to be
who injected heroin increased by 10 years, yet diagnosed with mental disorders than are
it decreased by 10 years for White Americans. Blacks born in the United States (Burgess et
This suggests that the decrease in injectable al. 2008; Miranda et al. 2005b).
heroin use among African Americans was
largely due to decreased use among younger African Americans are more likely to be
individuals. diagnosed with schizophrenia and less likely
to be diagnosed with affective disorders than

105
 Improving Cultural Competence

White Americans, even though multiple African Americans are less likely than White
studies have found that rates of both disorders Americans to report lifetime CODs (Mericle
among these populations are comparable et al. 2012). However, limited research indi-
(Baker and Bell 1999; Bresnahan et al. 2000; cates that, as with other racial groups, there are
Griffith and Baker 1993; Stockdale et al. 2008; differences across African American groups in
Strakowski et al. 2003). African Americans are the screening and symptomatology of CODs.
about twice as likely to be diagnosed with a Seventy-four percent of African Americans
psychotic disorder as White Americans and who had a past-year major depressive episode
more than three times as likely to be hospital- were identified as also having both alcohol and
ized for such disorders. These differences in marijuana use disorders (Pacek et al. 2012).
diagnosis are likely the result of clinician bias Miranda et al. (2005b) found that American-
in evaluating symptoms (Bao et al. 2008; born Black women were more than twice as
Trierweiler et al. 2000; Trierweiler et al. likely to be screened as possibly having depres-
2006). Clinicians should be aware of bias in sion than African- or Caribbean-born Black
assessment with African Americans and with women, but this could reflect, in part, differ-
other racial/ethnic groups and should consid- ences in acculturation (see Chapter 1). How-
er ways to increase diagnostic accuracy by ever, research findings strongly suggest that
reducing biases. For an overview of mental cultural responses to some disorders, and
health across populations, refer to Mental possibly the rates of those disorders, do vary
Health United States, 2010 (SAMHSA among different groups of Blacks. Differences
2012a). do not appear to be simply reflections of
differences in acculturation ( Joe et al. 2006).
In some African American communities,
For a review of African American health, see
incidence and prevalence of trauma exposure
Hampton et al. (2010).
and PTSD are high, and substance use ap-
pears to increase trauma exposure even further Treatment Patterns
(Alim et al. 2006; Breslau et al. 1995; Curtis-
African Americans may be less likely to re-
Boles and Jenkins-Monroe 2000; Rich and
ceive mental health services than White
Grey 2005). Black women who abuse sub-
Americans. In the Baltimore Epidemiologic
stances report high rates of sexual abuse
Catchment Services Area study conducted
(Ross-Durow and Boyd 2000). Trauma histo-
during the 1980s, African Americans were less
ries can also have a greater effect on relapse for
likely than White Americans to receive mental
African American clients than for clients from
health services. However, at follow-up in the
other ethnic/racial groups (Farley et al. 2004).
early 1990s, African American respondents
There are few integrated approaches to trau-
were as likely as White Americans to receive
ma and substance abuse that have been evalu-
such services, but they were much more likely
ated with African American clients, and
to receive those services from general practi-
although some have been found effective at
tioners than from mental health specialists
reducing trauma symptoms and substance
(Cooper-Patrick et al. 1999). Stockdale et al.
use, the extent of that effectiveness is not
(2008) analyzed 10 years of data from the
necessarily as great as it is for White
National Ambulatory Medical Care Survey;
Americans (Amaro et al. 2007; Hien et al.
they found significant improvements in diag-
2004; SAMHSA 2006).
nosis and care for mental disorders among
African Americans in psychiatric settings

106
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

between 1995 and 2005, but they also found SAMHSA, CBHSQ 2011; Schmidt et al.
that disparities persisted in the diagnosis and 2006). Data analyzed by Perron et al. (2009)
treatment of mental disorders in primary care indicate that among African Americans with
settings. Fortuna et al. (2010) suggest that lifetime diagnoses of drug use disorders, 20.8
persistent problems exist in the delivery of percent had received some type of treatment,
behavioral health services, as evidenced by as defined broadly to include resources such as
lower retention rates for treating depression. pastoral counseling and mutual-help group
attendance. This made them more likely to
Even among people who enter substance
have received treatment than White Ameri-
abuse treatment, African Americans are less
cans (15.5 percent of whom received treat-
likely to receive services for CODs. A study of
ment) or Latinos (17.3 percent of whom
administrative records from substance abuse
received treatment). Although data indicate
and mental health treatment providers in New
that African Americans were less likely to
Jersey found that African Americans were
receive services from private providers, they
significantly more likely than White Americans
also indicate that African Americans were
to have an undetected co-occurring mental
more likely to use more informal services (e.g.,
disorder, and, if detected, they were signifi-
pastoral counseling, mutual help).
cantly less likely than White Americans or
Latinos to receive treatment for that disorder Although most major studies have found that
(Hu et al. 2006). Among persons with sub- race is not a significant factor in receiving
stance use disorders and co-occurring mood or treatment, African Americans report lengthier
anxiety disorders, African Americans are waiting periods, less initiation of treatment,
significantly less likely than White Americans more barriers to treatment participation (e.g.,
to receive services (Hatzenbuehler et al. 2008). lack of childcare, lack of insurance, lack of
African Americans who do receive services for knowledge about available services), and
CODs are more likely to obtain them through shorter lengths of stay in treatment than do
substance abuse treatment programs than White Americans (Acevedo et al. 2012;
mental health programs (Alvidrez and Brower and Carey 2003; Feidler et al. 2001;
Havassy 2005). Grant 1997; Hatzenbuehler et al. 2008; Marsh
et al. 2009; SAMHSA 2011c; Schmidt et al.
According to the Treatment Episode Data
2006). In SAMHSA’s 2010 NSDUH, 33.5
Sets (TEDS) from 2001 to 2011, African
percent of African Americans who had a need
American clients entering substance abuse
for substance abuse treatment but did not
treatment most often reported alcohol as their
receive it in the prior year reported that they
primary substance of abuse, followed by mari-
lacked money or the insurance coverage to pay
juana. However, gender differences are evident,
for it (SAMHSA, CBHSQ 2011). Economic
indicating that women report a broader range
disadvantage does leave many Africans Amer-
of substances as their primary substance of
icans uninsured; approximately 16.1 percent of
abuse than men do (SAMHSA, Center for
non-Latino Blacks had no coverage in 2004
Behavioral Health Statistics and Quality
(Schiller et al. 2005).
[CBHSQ], 2013). Most recent research sug-
gests that African Americans are about as Likewise, some researchers have found that
likely to seek and eventually receive substance African Americans are less likely than White
abuse treatment as are White Americans Americans to receive needed services or an
(Hatzenbuehler et al. 2008; Perron et al. 2009; appropriate level of service (Alegria et al.

107
 Improving Cultural Competence

2011; Bluthenthal et al. 2007; Marsh et al. value and use of specialized behavioral health
2009). For example, African Americans and services among some African Americans may
Latinos are less likely than White Americans limit service use. Hines-Martin et al. (2004)
to receive residential treatment and are more found a positive relationship between famili-
likely to receive outpatient treatment, even arity and use of mental health services among
when they present with more serious substance African Americans. Additionally, factors such
use problems (Bluthenthal et al. 2007). Other as social and familial prejudices (Ayalon and
studies have found that African Americans Alvidrez 2007; Mishra et al. 2009; Nadeem et
with severe substance use or CODs were less al. 2007) and fears relating to past abuses of
likely to enter or receive treatment than White African Americans within the mental health
Americans with equally severe disorders system ( Jackson 2003) can contribute to the
(Schmidt et al. 2006, 2007). lack of acceptance and subsequent use of these
services. An essential step in decreasing dis-
African Americans are overrepresented among
parity in behavioral health services among
people who are incarcerated in prisons and
African Americans involves conducting cul-
jails (for review, see Fellner 2009), and a sub-
turally appropriate mental health screenings
stantial number of those who are incarcerated
and using culturally sensitive instruments and
(64.1 percent of jail inmates in 2002) have
evaluation tools (Baker and Bell 1999).
substance use disorders (Karberg and James
2005) and mental health problems (SAMHSA Beliefs and Attitudes About
2012a). However, according to Karberg and
( James 2005), African Americans with sub-
Treatment
stance dependence disorders who were in jail According to 2011 NSDUH data, African
in 2002 were less likely than White Americans Americans were, next to Asian Americans,
or Latinos to participate in substance abuse the least likely of all major ethnic and racial
treatment while under correctional supervision groups to state a need for specialized sub-
(32 percent of African Americans participated stance abuse treatment (SAMHSA, CBHSQ
compared with 37 percent of Latinos and 45 2013a). Still, logistical barriers may pose a
percent of White Americans). In the 2010 greater challenge for African Americans than
TEDS survey, African Americans entering for members of other major racial and ethnic
treatment were also less likely than Asian groups. For example, 2010 NSDUH data
Americans, White Americans, Latinos, Native regarding individuals who expressed a need
Hawaiians/Pacific Islanders, or American for substance abuse treatment but did not
Indians in the same situation to be referred to receive it in the prior year indicate that
treatment through the criminal justice system African Americans were more likely than
(SAMHSA, CBHSQ 2012). Notwithstand- members of other major ethnic/racial groups
ing, African Americans are more likely to be to state that they lacked transportation to the
referred to treatment from criminal justice program or that their insurance did not cover
settings rather than self-referred or referred by the cost of such treatment (SAMHSA
other sources (Delphin-Rittmon et al. 2012) 2011a). African Americans experience several
challenges in accessing behavioral health
Beyond issues related to diagnosis and care treatment, including fears about the therapist
that can prevent African Americans from or therapeutic process and concerns about
accessing mental health services, research discrimination and costs (Holden et al. 2012;
suggests that a lack of familiarity with the

108
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Holden and Xanthos 2009; Williams et al. Most importantly, providers need to demon-
2012). strate multicultural experience. In a study
comparing outcomes among Black and White
Longstanding suspicions regarding established
clients at community mental health centers,
healthcare institutions can also affect African
the only clinician factor that predicted more
Americans’ participation in, attitudes toward,
favorable outcomes was clinicians’ general
and outcomes after treatment (for review, see
experiences and relationships with people
Pieterse et al. 2012). Historically, the mental
from racial/ethnic and cultural groups other
health system has shown bias against African
than their own (Larrison et al. 2011).
Americans, having been used in times past to
control and punish them (Boyd-Franklin and Treatment Issues and
Karger 2012; Jackson 2003). After controlling
for socioeconomic factors, African Americans
Considerations
are significantly more likely to perceive the African American clients generally respond
healthcare system as poor or fair and signifi- better to an egalitarian and authentic relation-
cantly more likely to believe that they have ship with counselors (Sue 2001). Paniagua
been discriminated against in healthcare (1998) suggests that in the initial sessions with
settings (Blendon et al. 2007). Attitudes to- African American clients, counselors should
ward psychological services appear to become develop a collaborative client–counselor rela-
more negative as psychological distress in- tionship. Counselors should request personal
creases (Obasi and Leong 2009). In many information gradually rather than attempting
African American communities, there is a to gain information as quickly as possible,
persistent belief that social and treatment avoid information-gathering methods that
services try to impose White American values, clients could perceive as an interrogation, pace
adding to their distrust of the treatment sys- the session, and not force a data-gathering
tem (Larkin 2003; Solomon 1990). agenda (Paniagua 1998; Wright 2001). Coun-
selors must also establish credibility with
African Americans, even when receiving the clients (Boyd-Franklin 2003).
same amount of services as White Americans,
are less likely to be satisfied with those services Next, counselors should establish trust. Self-
(Tonigan 2003). However, recent evidence disclosure can be very difficult for some clients
suggests that, once engaged, African American because of their histories of experiencing
clients are at least as likely to continue partici- racism and discrimination. These issues can be
pation as members of other ethnic/racial exacerbated in African American men whose
groups (Harris et al. 2006). Because distrust of experience of racism has been more severe or
the healthcare system can make it more diffi- who have had fewer positive relationships with
cult to engage African American clients ini- White Americans (Reid 2000; Sue 2001).
tially in treatment, Longshore and Grills Counselors, therefore, need to be willing to
(2000) recommend culturally congruent moti- address the issue of race and to validate African
vational enhancement strategies to address American clients’ experiences of racism and its
African American clients’ ambivalence about reality in their lives, even if it differs from
treatment services. Providers also need to craft their own experiences (Boyd-Franklin 2003;
culturally responsive health-related messages Kelly and Parsons 2008). Moreover, racism
for African Americans to improve treatment and discrimination can lead to feelings of
engagement and effectiveness (Larkin 2003). anger, anxiety, or depression. Often, these
feelings are not specific to any given event;

109
 Improving Cultural Competence

rather, they are pervasive (Boyd-Franklin et al. overview of core guiding principles in work-
2008). Counselors should explore with clients ing with African American clients.
the psychological effects of racism and develop
approaches to challenge internal negative Theoretical Approaches and
messages that have been received or generated Treatment Interventions
through discrimination and prejudice (Good- Research suggests that culturally congruent
ing 2002). interventions are effective in treating African
Additional methods that may enhance en- Americans (Longshore and Grills 2000;
gagement and promote participation include Longshore et al. 1998a; Longshore et al.
peer-supported interventions and strategies 1998b; 1999). Although there are conflicting
that promote empowerment by emphasizing results on the effectiveness of motivational
strengths rather than deficits (Paniagua 1998; interviewing among African American clients
Tondora et al. 2010; Wright 2001). It is (Montgomery et al. 2011), some motivational
important to explore with clients the interventions have been found to reduce sub-
strengths that have brought them this far. stance use among African Americans
What personal, community, or family (Bernstein et al. 2005; Longshore and Grills
strengths have helped them through difficult 2000). Longshore and Grills (2000) describe a
times? What strengths will support their culturally specific motivational intervention
recovery efforts? Exhibit 5-1 gives an for African Americans involving both peer
and professional counseling that makes use of
the core African American value of commu-
Exhibit 5-1: Core Culturally nalism by addressing the ways in which the
Responsive Principles in Counseling individual’s substance abuse affects his or her
African Americans whole community. The motivational program
According to Schiele (2000), culturally respon- affirms “the heritage, rights, and responsibili-
sive counseling for African American clients ties of African Americans…using interaction
involves adherence to six core principles: styles, symbols and values shared by members
1. Discussion of clients’ substance use should of the group” (Longshore et al. 1998b, p. 319).
be framed in a context that recognizes the
totality of life experiences faced by clients So too, African American music, artwork, and
as African Americans. food can help programs create a welcoming
2. Equality is sought in the therapeutic coun- and familiar atmosphere, as is the case for
selor–client relationship, and counselors other racial and ethnic groups when familiar
are less distant and more disclosing. cultural symbols appear in the clinical setting.
3. Emphasis is placed on the importance of
changing one’s environment—not only for Many of the interventions developed for
the good of clients themselves, but also for
substance abuse treatment services in general
the greater good of their communities.
4. Focus is placed on alternatives to sub- have been evaluated with populations that
stance use that underscore personal rituals, were at least partly composed of African
cultural traditions, and spiritual well-being. Americans; many of these interventions are as
5. Recovery is a process that involves gaining effective for African Americans as they are for
power in the forms of knowledge, spiritual
White Americans (Milligan et al. 2004; To-
insight, and community health.
6. Recovery is framed within a broader con- nigan 2003). One intervention that appears to
text of how recovery contributes to the work better for African American (and Latino)
overall healing and advancement of the clients than for White American clients—
African American community. perhaps because it focuses on improving

110
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

client–counselor communication—is node- Another therapy that has been evaluated with
link mapping (visual representation using African American clients and found effective
information diagrams, fill-in-the-blank graph- is supportive–expressive psychotherapy, which
ic tools, and client-generated diagrams or reduces substance use and improves psycho-
visual maps). This approach was associated logical functioning for individuals in metha-
with lower rates of substance use, better treat- done maintenance (Woody et al. 1987; Woody
ment attendance, and better counselor ratings et al. 1995). Medications for substance abuse
of motivation and confidence among African can also work well with African American
Americans than among White Americans clients. In one large study, African Americans
(Dansereau et al. 1996; Dansereau and were more likely than Latinos or White
Simpson 2009). Americans to indicate that they found metha-
done helpful (Gerstein et al. 1997), and in
In addition, cognitive–behavioral therapy
another study, they reported greater perceived
(CBT) has certain distinct advantages for
quality of life as a result of participation in a
African American clients; it fosters a collabo-
methadone program (Geisz 2007). Schroeder et
rative relationship and recognizes that clients
al. (2005) also reported that African Americans
are experts on their own problems (Kelly and
in a methadone program had significantly
Parsons 2008). Maude-Griffin et al. (1998)
fewer adverse medical events (e.g., infections,
compared CBT and 12-Step facilitation for a
gastrointestinal complaints) than did White
group of mostly African American (80 per-
American participants. African Americans
cent) men who were homeless and found that
who were being treated for cocaine depend-
CBT achieved significantly better abstinence
ence remained in treatment significantly
outcomes, except among those who considered
longer than did other African Americans if
themselves very religious (these individuals
they received disulfiram (Milligan et al. 2004).
had better outcomes with 12-Step facilitation).
A review of cultural adaptations of evidence-
Other interventions that use CBT principles
based practices is given by Bernal and
have also been effective with African American
Domenech Rodriguez (2012). For an over-
populations. For example, a number of studies
view of gender-specific treatment considera-
have evaluated contingency management
tions for mental and substance use disorders
approaches with predominantly African
among African American men and women,
American client populations, finding that this
see Shorter-Gooden (2009).
model was effective at reducing cocaine and
illicit opioid use, improving employment Family therapy
outcomes for clients in methadone mainte- African American clients appear more likely
nance (Silverman et al. 2002; Silverman et al. to stay connected with their families through-
2007), reducing substance use during and after out the course of their addiction. For instance,
treatment, and improving self-reported quality Bourgois et al. (2006) reported that in compar-
of life (Petry et al. 2004; Petry et al. 2005; Petry ing African American and White American
et al. 2007). The Living in the Balance inter- individuals who injected heroin, African
vention, which uses psychoeducation and CBT Americans appeared to be more likely to
techniques, has also been evaluated with a maintain contact with their extended families.
mostly African American sample and has been Some research also suggests that African
shown to improve treatment retention and Americans with substance use disorders are
reduce substance use (Hoffman et al. 1996). more likely to have family members with

111
 Improving Cultural Competence

histories of substance abuse, suggesting an

Advice to Counselors: Strengths of
even greater need to address substance abuse African American Families
within the family (Brower and Carey 2003).
African American kinship bonds have historically
Strong family bonds are important in African been sources of strength. Although substance
American cultural groups. African American abuse lessens the strength of the family and
families are embedded in a complex kinship can erode relationships, counselors can use the
inherent strengths of the family to benefit
network of biologically related and unrelated clients and their families (Boyd-Franklin and
persons. Hence, counselors should be willing Karger 2012; Larkin 2003; Reid 2000). Bell-
to expand the definition of family to a more Tolliver et al. (2009) and Hill (1972) suggest that
extended kinship system (Boyd-Franklin strengths of African American family life include:
2003; Hines and Boyd-Franklin 2005). Clients • Strong bonds and extensive kinship.
• Adaptability of family roles.
need to be asked how they define family, • A strong family hierarchy.
whom they would identify as family or “like • A strong work orientation.
family,” who resides with them in their homes, • A high achievement orientation.
and whom they rely on for help. Hines and • A strong religious orientation.
Boyd-Franklin (2005) discuss the importance
of both blood and nonblood kinship networks system. Network therapy, which involves
for African American families. To build a clients’ extended social networks, has also been
support network for African American clients, found to improve substance use outcomes for
counselors should start by asking clients to African American clients when added to
identify people (whether biological kin or not) standard treatment (Keller and Galanter
who would be willing and able to support 1999). Likewise, the family team conference
their recovery and then ask clients for permis- model can be a useful approach, given that it
sion to contact those people and include them also engages both families and communities in
in the treatment process. the helping process by attempting to stimulate
extensive mobilization of activity in the formal
Family therapy is often a productive approach and informal relationships in and around cli-
to treatment with African Americans (Boyd- ents’ families (State of New Jersey Department
Franklin 2003; Hines and Boyd-Franklin of Human Services 2004).
2005; Larkin 2003). However, the extended
family can be large and have many ties with Brief structural family therapy and strategic
other families in a community; therefore, the family therapy reduce substance use as well,
family therapist sometimes needs to take on but research has primarily focused on African
other roles to assist with case management or American youth (Santisteban et al. 1997;
other activities, including involvement in Santisteban et al. 2003; Szapocznik and
community-wide interventions (Sue 2001). In Williams 2000). Multidimensional family
reviewing specific family therapy approaches therapy has increased abstinence from sub-
for African Americans, Boyd-Franklin (2003) stance use among African American adoles-
discusses the use of a multisystem family cents and produced more lasting effects than
therapy approach, which incorporates an CBT, but it also has not been evaluated with
extended network of relationships that play a adult clients (Liddle et al. 2008). In reviewing
part in clients’ lives. Using this model, social specific family programs, Larkin (2003) reports
service and other community agencies can be promising preliminary data on a family therapy
considered a significant part of the family intervention among African Americans in
public housing that addresses substance abuse.

112
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

The program initially engages families via problems to people who are relative strangers.
psychoeducation on substance abuse and its African Americans seem less likely to self-
effects on the family, followed by a strength- disclose about the past in group settings that
based family therapy intervention. Despite the include non-Hispanic Whites ( Johnson et al.
small sample size, all 10 families admitted to 2011; Richardson and Williams 1990). Con-
the program completed treatment, and 7 of 10 sequently, groups composed only of African
family members with substance abuse prob- Americans can be more beneficial. Homoge-
lems entered recovery and continuing care. nous African American groups can also be
Participant surveys indicated that 60 percent good venues for clients to deal with systemic
of families preferred multiple-family therapy problems, such as racism and lack of economic
over single-family therapy, and 80 percent opportunities in the African American com-
preferred services delivered in the housing munity ( Jones et al. 2000).
project community center to other venues.
Mutual-help groups
Engaging Moms is another family-oriented A variety of mutual-help groups are available
program and intervention developed specifi- for African Americans entering recovery from
cally for African American mothers that has substance use and mental disorders. However,
been shown to significantly improve treatment most of the literature focuses on 12-Step
engagement (Dakof et al. 2003). The interven- groups, including Alcoholics Anonymous
tion is designed for women who have children (AA) and Narcotics Anonymous. Some find
and have been identified as cocaine users. The that the 12-Step approach warrants careful
program focuses on mobilizing family members consideration with African Americans, who
who would be likely to motivate the mothers to can find the concept of powerlessness over
enroll and remain in substance abuse treatment. substances of abuse to be too similar to experi-
Research has shown no long-term impact, yet ences of powerlessness via discrimination.
women who received the intervention were Additionally, the disease concept of addiction
significantly more likely to enter treatment (88 presented in 12-Step meetings can be difficult
percent of women involved in the program for many African Americans (Durant 2005).
versus 46 percent of the control group) and In some instances, the Black community has
remain for at least 2 weeks. changed the mutual-help model for substance
use and mental health to make it more em-
Group therapy
powering and relevant to African American
Because of the communal, cooperative values
participants. For additional information on the
held by many African Americans, group ther-
12 Steps for African Americans, visit Alcohol-
apy can be a particularly valuable component
ics Anonymous World Services (AAWS), AA
of the treatment process (Sue and Sue 2013b).
for the Black and African American Alcoholic,
A strong oral tradition is one of many forms
available online (http://www.aa.org/
of continuity with African tradition main-
pdf/products/p-51_CanAAHelpMeToo.pdf).
tained in the African American experience;
therefore, speaking in groups is generally Despite their emphasis on the concept of
acceptable to African American clients. How- powerlessness, 12-Step programs are significant
ever, Bibb and Casimer (2000) note that Black support systems for many African Americans.
Caribbean Americans can be less comfortable In AA’s 2011 membership survey, 4 percent of
with the group process, particularly the re- members identified their race as Black
quirement that they self-disclose personal (AAWS 2012). Analysis of 2006–2007

113
 Improving Cultural Competence

NSDUH data showed that African Americans express a greater degree of comfort with shar-
were less likely to use mutual-help groups in ing in meetings, and they are more likely to
the past year for substance use (about 11 engage in AA services and state that they had
percent did) than White Americans (about 67 a spiritual awakening as a result of AA partic-
percent did) or Latinos (about 16 percent did; ipation (Bibb and Casimer 2000; Kaskutas et
SAMHSA 2013d). However, the National al. 1999; Kingree 1997).
Epidemiologic Survey on Alcohol and Related
Research suggests that African Americans
Conditions (NESARC) survey did find that
who attend 12-Step programs have higher
African Americans who had a lifetime drug
levels of affiliation than White Americans in
use disorder diagnosis and had sought help
the same programs (Kingree and Sullivan
were more than three times as likely to have
2002). However, they are less likely to have a
attended mutual-help meetings as were White
sponsor or to read program materials (Kaskutas
Americans or Latinos (Perron et al. 2009).
et al. 1999), and their abstinence appears to be
Several other surveys suggest that African
less affected by meeting attendance (Timko et
Americans with alcohol-related problems are
al. 2006). Other research has found that
at least as likely to participate in AA as White
African Americans who participate in 12-Step
Americans and that greater problem severity is
groups report an increase in the number of
associated with increased likelihood of partici-
people within their social networks who sup-
pation (Kingree and Sullivan 2002). Of the
port their recovery efforts (Flynn et al. 2006).
participants who attended mutual-help group
Other mutual-help groups for African
sessions for mental health in the past year,
Americans are available, particularly faith-
approximately 10 percent were Black or Afri-
based programs to support recovery from
can American, 75 percent were White Ameri-
mental illness and substance use disorders and
can, and 11.4 percent were Latino (SAMHSA
to aid individuals in the process of transition-
2010).
ing from correctional institutions. For exam-
Durant (2005) observes that African American ple, the Nation of Islam has been involved in
12-Step participants tend to participate differ- successful substance abuse recovery efforts,
ently in meetings where participants are most- especially for incarcerated persons (Sanders
ly White Americans than in meetings where 2002; White and Sanders 2004).
most participants are African American. In
some areas, there are 12-Step meetings that Traditional healing and
are largely or entirely composed of African complementary methods
American members, and some African In general, African Americans are less likely to
American clients feel more comfortable par- make use of popular alternative or comple-
ticipating in these meetings. Mutual-help mentary healing methods than White Ameri-
groups can be particularly helpful for African cans or Latinos (Graham et al. 2005).
Americans who consider themselves religious. However, the African American culture and
Maude-Griffin et al. (1998) found that indi- history is steeped in healing traditions passed
viduals who identified as highly religious did down through generations, including herbal
significantly better when receiving 12-Step remedies, root medicines, and so forth (Lynch
facilitation than when receiving CBT, but that and Hanson 2011). The acceptance of tradi-
pattern was reversed for those who did not tional practices by African American clients
consider themselves highly religious. Other and their families does not necessarily indicate
studies have found that African Americans that they oppose or reject the use of modern

114
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

therapeutic approaches or other alternative a central role in education, politics, recreation,

approaches. They can accept and use all forms and social welfare in African American com-
of treatment selectively, depending on the munities. To date, African Americans report
perceived nature of their health problems. the highest percentage (87 percent) of reli-
That said, psychological and substance abuse gious affiliation of any major racial/ethnic
problems can be seen as having spiritual causes group (Kosmin and Keysar 2009; Pew Forum
that need to be addressed by traditional heal- on Religion and Public Life 2008). Even
ers or religious practices (Boyd-Franklin though most are committed to various
2003). Moreover, African Americans are much Christian denominations (with the Baptist and
more likely to use religion or spirituality as a African Methodist Episcopal churches ac-
response to physical or psychological problems counting for the largest percentages), a growing
(Cooper et al. 2003; Dessio et al. 2004; number of African Americans are converts to
Graham et al. 2005; Nadeem et al. 2008). Islam, and many recent immigrants from
Africa to the United States are also Muslims
African American cultural and religious insti-
(Boyd-Franklin 2003; Pew Forum on Religion
tutions (see advice box below) play an im-
and Public Life 2008).
portant role in treatment and recovery, and
African Americans who use spirituality or Relapse prevention and recovery
religion to cope with health problems are nearly African Americans appear to be responsive to
twice as likely as other African Americans to continuing care participation and recovery
also make use of complementary or alterna- activities associated with substance use and
tive medicine (Dessio et al. 2004). Likewise, mental disorders, yet research is very limited.
African American churches and mosques play According to NESARC data (Dawson et al.

Advice to Counselors: The Role of African American Religious Institutions in

Treatment and Recovery
Within African American communities, religious institutions and clergy often function as service
providers as well as counselors (Boyd-Franklin 2003; Reid 2000; Taylor et al. 2000). It is not uncom-
mon for African Americans to approach clergy first when faced with their own or family members’
mental health or substance abuse problems, but many African American clergy members believe
they are not well-prepared to address those problems (Neighbors et al. 1998; Sexton et al. 2006).
According to NESARC data, African Americans are twice as likely as Latinos and nearly three times as
likely as White Americans to receive pastoral counseling for their drug use (Perron et al. 2009).

For many African Americans in recovery, churches play a significant role in helping them maintain
abstinence (Perron et al. 2009). Beyond pastoral counseling, research suggests that other means of
engagement within the church can lead to recovery. For example, participation in religious services
has been associated with significantly better outcomes for African American men in continuing care
following court-mandated treatment (Brown et al. 2004). Stahler et al. (2007) also report successful
use of peer mentors drawn from churches for African American women in treatment, marked by
significantly fewer drug-positive urine samples in the 6 months following treatment.

Counselors working with African American clients should prepare to include churches, mosques, or
other faith communities in the therapeutic process, and they should develop a list of appropriate
spiritual resources in the community. Treatment providers may consider involving African American
clergy in treatment programs to improve clergy members’ understanding of behavioral health prob-
lems and treatments and to better engage clients and their families. Programs can conduct outreach
with local faith-based institutions and clergy to facilitate treatment referrals (Taylor et al. 2000).

115
 Improving Cultural Competence

2005), African Americans in recovery from secure resources and appropriate support when
alcohol dependence were more than twice as needed, or engage in coping behaviors condu-
likely as White Americans to maintain absti- cive to maintaining recovery. Counselors can
nence rather than just limiting alcohol con- help clients practice coping skills by role-
sumption or changing drinking patterns. In playing, even if clients are confident that they
another study analyzing the use of continuing can manage difficult or high-risk situations.
care following residential treatment in the U.S.
Department of Veterans Affairs care system, Counseling for Asian
African American men were significantly
more likely than White Americans to partici- Americans, Native
pate in continuing care (Harris et al. 2006). Hawaiians, and Other
Other research evaluating continuing care for
African American men who had been man- Pacific Islanders
dated to outpatient treatment by a parole or Asian Americans, per the U.S. Census Bureau
probation office found that participants as- definition, are people whose origins are in the
signed to a continuing care intervention were Far East, Southeast Asia, or the Indian sub-
almost three times as likely to be abstinent and continent (Humes et al. 2011). The term in-
five times less likely to be using any drugs on a cludes East Asians (e.g., Chinese, Japanese, and
weekly basis during the 6-month follow-up Korean Americans), Southeast Asians (e.g.,
period compared with those who did not Cambodian, Laotian, and Vietnamese
receive continuing care (Brown et al. 2004). Americans), Filipinos, Asian Indians, and
In evaluating appropriate relapse prevention Central Asians (e.g., Mongolian and Uzbek
strategies for African American clients, Americans). In the 2010 Census, people who
Walton et al. (2001) found that African identified solely as Asian American made up
American clients leaving substance abuse 4.8 percent of the population, and those who
treatment reported fewer cravings, greater use identified as Asian American along with one
of coping strategies, and a greater belief in or more other races made up an additional 0.9
their self-efficacy. However, they also expected percent. Census data includes specific infor-
to be involved in fewer sober leisure activities, mation on people who identify as Asian Indian,
to be exposed to greater amounts of substance Chinese, Filipino, Japanese, Korean,
use, and to have a greater need for continuing Vietnamese, and “other Asians.” The largest
care services (e.g., housing, medical care, Asian populations in the United States are
assistance with employment). Walton notes Chinese Americans, Filipino Americans,
that these findings could reflect a tendency of Asian Indian Americans, Korean Americans,
African American clients to underestimate the and Vietnamese Americans. Asian Americans
difficulties they will face after treatment; they overwhelmingly live in urban areas, and more
report a greater need for resources and greater than half (51 percent) live in just three states
exposure to substance use, but they still have a (NY, CA, and HI; Hoeffel et al. 2012).
greater belief in their ability to remain free of Not all people with origins in Asia belong to
substances. Although an individual’s belief in what is commonly conceived of as the Asian
coping can have a positive effect on initially race. Some Asian Indians, for example, self-
managing high-risk situations, it also can lead identify as White American. For this reason,
to a failure to recognize the level of risk in a among others, counselors should be careful to
given situation, anticipate the consequences, learn from their Asian American clients how

116
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

they identify themselves and which national (Iversen 2000; Martin 1975). However, some
heritages they claim. Counselors should rec- Asian Americans tend to view illicit substance
ognize that clients who appear to be Asian use and abuse as a serious breach of acceptable
may not necessarily think of themselves pri- behavior that cannot readily be discussed.
marily as persons of Asian ancestry or have a Nonetheless, there are broad differences in
deep awareness of the traditions and values of Asian cultures’ perspectives on substance use,
their countries of origin. For example, Asian thus requiring counselors to obtain more
orphans who have been adopted in the United specific information during intake and subse-
States and raised as Americans in White quent encounters.
American families may have very little con-
Acknowledging a substance abuse problem
nection with the cultural groups of their bio-
often leads to shame for Asian American
logical parents (St. Martin 2005). Counselors
clients and their families. Families may deny
should not make generalizations across Asian
the problem and inadvertently, or even inten-
cultures; each culture is quite distinct.
tionally, isolate members who abuse substances
Little literature on substance use and mental (Chang 2000). For example, some Cambodian
disorders, rates of co-occurrence, and treatment and Korean Americans perceive alcohol abuse
among Asian Americans focuses on behavioral and dependence as the result of moral weak-
health treatment for Native Hawaiians and ness, which brings shame to the family
Pacific Islanders; thus, a text box at the end (Amodeo et al. 2004; Kwon-Ahn 2001).
of this section summarizes available
information. Substance Use and Substance Use
Disorders
Beliefs About and Traditions According to the 2012 NSDUH, Asian
Involving Substance Use Americans use alcohol, cigarettes, and illicit
Within many Asian societies, the use of intox- substances less frequently and less heavily than
icants is tolerated within specific contexts. For members of any other major racial/ethnic
example, in some Asian cultural groups, alco- group (SAMHSA 2013d). However, large
hol is believed to have curative, ceremonial, or surveys may undercount Asian American
beneficial value. Among pregnant Cambodian substance use and abuse, as they are typically
women, small amounts of herbal medicines conducted in English and Spanish only
with an alcohol base are sometimes used to (Wong et al. 2007b). Despite the limitations of
ensure an easier delivery. Following childbirth, research, data suggest that although Asian
similar medicines are generally used to in- Americans use illicit substances and alcohol
crease blood circulation (Amodeo et al. 1997). less frequently than other Americans, sub-
Some Chinese people believe that alcohol stance abuse problems have been increasing
restores the flow of qi (i.e., the life force). The among Asian Americans. The longer Asian
written Chinese character for “doctor” con- Americans reside in the United States, the
tains the character for alcohol, which implies more their substance use resembles that of
the use of alcohol for medicinal purposes. other Americans. Excessive alcohol use, intox-
ication, and substance use disorders are more
Some Asian American cultural groups make
prevalent among Asians born in the United
allowances for the use of other substances.
States than among foreign-born Asians living
Marijuana, for instance, has been used medici-
in the United States (Szaflarski et al. 2011).
nally in parts of Southeast Asia for many years

117
 Improving Cultural Competence

Among Asian Americans who entered sub- to use illicit drugs, whereas Filipino Americans
stance abuse treatment between 2000 and had the highest rate of illicit drug use
2010, methamphetamine and marijuana were (Nemoto et al. 1999). In that same study,
the most commonly reported illicit drugs Filipino American immigrants were also
(SAMHSA, CBHSQ 2012). Methampheta- significantly more likely to have begun using
mine abuse among Asian Americans is partic- substances prior to immigrating than were
ularly high in Hawaii and on the West Coast Chinese or Vietnamese immigrants. Other
(OAS 2005a). As with other racial and ethnic studies have found that Filipino Americans are
groups, numerous factors—such as age, birth more likely to use illicit drugs and to inject
country, immigration history, acculturation, drugs than other Asian American populations
employment, geographic location, and in- (see review in Nemoto et al. 2002).
come—add complexity to any conclusions
To date, the largest national study to assess
about prevalence among specific Asian cultur-
substance use and mental disorders across
al groups. Asian Americans who are recent
Asian American groups is the NLAAS
immigrants, highly acculturated, unemployed,
(Takeuchi et al. 2007). This study found that
or living in Western states are generally more
Filipino American men were 2.38 times more
likely than other Asian Americans to abuse
likely to have a lifetime substance use disorder
drugs or alcohol (Makimoto 1998). For exam-
than were Chinese American men, whereas
ple, according to the National Latino and
the differences among women of diverse Asian
Asian American Study (NLAAS), Asians who
ethnicities were much smaller. Other research
are more acculturated are at greater risk for
suggests that Korean Americans are more
prescription drug abuse (Watkins and Ford
likely to have family histories of alcohol de-
2011).
pendence than are Chinese Americans
There are variations among particular groups (Ebberhart et al. 2003).
of Asians; some Asian cultural groups have
Besides the variations across different cultures,
different attitudes toward substance use than
substance use and abuse among Asian Ameri-
others, and these differences tend to be ob-
cans is also influenced by age. Substance abuse
scured in large-scale surveys. Researchers have
appears higher for young Asian Americans
found that Korean American college students
than for those who are older (possibly reflect-
drank more frequently and drank greater
ing differences in acculturation). A study
quantities than did Chinese American stu-
conducted in New York City showed that
dents at the same schools and were more likely
Asian American junior and senior high school
to consider drinking socially acceptable
students had the lowest percentage of heavy
(Chang et al. 2008). Another study in the
drinkers of any ethnic group, but those who
District of Columbia and surrounding metro-
were heavy drinkers drank twice as much daily
politan area compared substance use among
as those who did not drink heavily (Makimoto
different groups of Southeast Asians (i.e.,
1998). Asian American youth, especially im-
Cambodian, Laotian, and Vietnamese
migrants, tend to start using substances at a
Americans); Vietnamese Americans had the
later age than members of other ethnic groups,
highest rates of alcohol use, but Cambodian
which could be a factor in the lower levels of
Americans had the highest rates of illicit drug
abuse seen among Asian Americans.
use (Wong et al. 2007b). Research in San
Francisco found Chinese Americans to be less Despite rates of substance use disorders
likely than Vietnamese or Filipino Americans among Asian Americans having increased over

118
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

time, research has regularly found that, of all Americans are more likely to present with
major racial/ethnic groups in United States, somatic complaints and less likely to present
Asian Americans have the lowest rates of with symptoms of psychological distress and
alcohol use disorders (Grant et al. 2004; impairment (Hsu and Folstein 1997; Kim et
SAMHSA 2012b). This phenomenon has al. 2004; Room et al. 2001; U.S. Department
typically been explained in part by the fact of Health and Human Services [HHS] 2001;
that some Asians lack the enzyme aldehyde Zhang et al. 1998), even though mental illness
dehydrogenase, which chemically breaks down appears to be nearly as common among Asian
alcohol (McKim 2003). Thus, high levels of Americans as it is in other ethnic/racial
acetaldehyde, a byproduct of alcohol metabo- groups. In 2009, approximately 15.5 percent of
lism, accumulate and cause an unpleasant Asians reported a mental illness in the past
flushing response (Yang 2002). The alcohol year, but only 2 percent reported past-year
flushing response primarily manifests as flush- occurrence of serious mental illness (SAMHSA
ing of the neck and face but can also include 2012a). Asian Americans have a lower inci-
nausea, headaches, dizziness, and other dence of CODs than other racial/ethnic groups
symptoms. because the prevalence of substance use disor-
ders in this population is lower. In the 2012
Additional factors that could play a part in
NSDUH, 0.3 percent of Asian Americans
increasing the likelihood of substance use
indicated co-occurring serious psychological
disorders among Asian Americans include
distress and substance use disorders, and 1.1
experiences of racism and the absence of
percent had some symptoms of mental distress
ethnic identification. Compared with Asian
along with a substance use disorder—the low-
Americans who do not have alcohol use disor-
est rates of any major racial/ethnic group in the
ders, Asian Americans who have alcohol use
survey (SAMHSA 2013c).
disorders are more than five times as likely to
report unfair treatment because of their race Considerable variation in the types of mental
and are more than twice as likely to deny disorders diagnosed among diverse Asian
strong ethnic identification (Chae et al. 2008). American communities is evident, although it
Compared with other racial and ethnic is unclear to what extent this reflects diagnostic
groups, Asian Americans who drink heavily and/or self-selection biases. For example,
are more likely to have friends or peers who Barreto and Segal (2005) found that Southeast
also drink heavily (Chi et al. 1989). Asians were more likely to be treated for
major depression than other Asians or mem-
Mental and Co-Occurring bers of other ethnic/racial groups; East Asians
Disorders were the most likely of all Asian American
Overall, health and mental health are not groups to be treated for schizophrenia (nearly
seen as two distinct entities by Asian Ameri- twice as likely as White Americans). Traumat-
can cultural groups. Most Asian American ic experiences and PTSD can be particularly
views focus on the importance of virtue, difficult to uncover in some Asian American
maturity, and self-control and find full emo- clients. Although Asian Americans are as
tional expression indicative of a lack of ma- likely to experience traumatic events (e.g.,
turity and self-discipline (Cheung 2009). wars experienced by first-generation immi-
Given the potential shame they often associate grants from countries such as Vietnam and
with mental disorders and their typically Cambodia) in their lives, their cultural respons-
holistic worldview of health and illness, Asian es to trauma can conceal its psychological

119
 Improving Cultural Competence

effects. For instance, some Asian cultural year, Asian Americans were also the most
groups believe that stoic acceptance is the likely of all major racial/ethnic groups to
most appropriate response to adversity (Lee report that they could not afford or had no
and Mock 2005a,b). insurance coverage for substance abuse treat-
ment (SAMHSA, CBHSQ 2011).
Treatment Patterns
Treatment-seeking rates for mental illness are Beliefs and Attitudes About
low among most Asian populations, with rates Treatment
varying by specific ethnic/cultural heritage Compared with the general population, Asian
and, possibly, level of acculturation (Abe-Kim Americans are less likely to have confidence in
et al. 2007; Barreto and Segal 2005; Lee and their medical practitioners, feel respected by
Mock 2005a,b). Asian Americans who seek their doctors, or believe that they are involved
help for psychological problems will most in healthcare decisions. Many also believe that
likely consult family members, clergy, or tradi- their doctors do not have a sufficient under-
tional healers before mental health profession- standing of their backgrounds and values; this
als, in part because of a lack of culturally and is particularly true for Korean Americans
linguistically appropriate mental health ser- (Hughes 2002). Even so, Asian Americans,
vices available to them (HHS 2001; Spencer especially more recent immigrants, seem more
and Chen 2004). However, among those Asian likely to seek help for mental and substance
Americans who seek behavioral health treat- use disorders from general medical providers
ment, the amount of services used is relatively than from specialized treatment providers
high (Barreto and Segal 2005). (Abe-Kim et al. 2007). Many Asian American
Asian Americans tend to enter treatment with immigrants underuse healthcare services due to
less severe substance abuse problems than confusion about eligibility and fears of jeopard-
members of other ethnic/racial groups and izing their residency status (HHS 2001).
have more stable living situations and fewer As with other groups, discrimination, accul-
criminal justice problems upon leaving treat- turation stress, and immigration and genera-
ment (Niv et al. 2007). However, for Asian tional status, along with language needs, have
Americans involved in the criminal justice a large influence on behavioral health and
system, there is a more pronounced relation- treatment-seeking for Asian Americans (Meyer
ship between crime and drug abuse than for et al. 2012; Miller et al. 2011). The NLAAS
other ethnic and racial groups. In the early found that although rates of behavioral health
1990s, an estimated 95 percent of Asian service use were lower for Asian Americans
Americans in California prisons were there who immigrated recently than for the general
because of drug-related crimes (Kuramoto population, those rates increased significantly
1994). According to SAMHSA’s 2010 TEDS for U.S.-born Asian Americans; third-
data, 48.5 percent of Asian Americans in generation U.S.-born individuals’ rates of ser-
treatment were referred by the criminal justice vice use also were relatively high (Abe-Kim et
system in that year, compared with 36.4 per- al. 2007). Of those Asian Americans who had
cent of African Americans and 36.6 percent of any mental disorder diagnosis in the prior year,
White Americans (SAMHSA, CBHSQ 62.6 percent of third-generation Americans
2012). According to 2010 NSDUH data sought help for it in the prior year compared
regarding individuals who reported a need for with 30.4 percent of first-generation
treatment but did not receive it in the prior Americans.

120
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Overall, Asian Americans place less value on biopsychosocial explanations for substance use
substance abuse treatment than other popula- and mental disorders. Counselors should
tion groups and are less likely to use such promote discussions focused on clients’ under-
services (Yu and Warner 2012). Niv et al. standing of their presenting problems as well
(2007) found that Asian and Pacific Islanders as any approaches the clients have used to
entering substance abuse treatment programs address them. Subsequently, presenting prob-
in California expressed significantly more lems need to be reconceptualized in language
negative attitudes toward treatment and rated that embraces the clients’ perspectives (e.g., an
it as significantly less important than did imbalance in yin and yang, a disruption in chi;
others entering treatment. Seeking help for Lee and Mock 2005a,b). It is advisable to
substance abuse can be seen, in some Asian educate Asian American clients on the role of
American cultural groups, as an admission of the counselor/therapist, the purpose of thera-
weakness that is shameful in itself or as an peutic interventions, and how particular aspects
interference with family obligations (Masson of the treatment process (e.g., assessment) can
et al. 2013). Among 2010 NSDUH respond- help clients with their presenting problems
ents who stated a need for substance abuse (Lee and Mock 2005a,b; Sue 2001). Asian
treatment in the prior year but did not receive American clients who receive such education
it, Asian Americans were more likely than participate in treatment longer and express
members of all other major racial/ethnic greater satisfaction with it (Wong et al. 2007a).
groups to say that they could handle the prob-
As with other racial/ethnic groups, Asian
lem without treatment or that they did not
American clients are responsive to a warm and
believe treatment would help (SAMHSA
empathic approach. Counselors should realize,
2011c). Combining NSDUH data from 2003
though, that building a strong, trusting rela-
to 2011 NSDUH, Asian Americans who
tionship takes time. Among Asian American
needed but did not receive treatment in the
clients, humiliation and shame can permeate
past year were the least likely of all major
the treatment process and derail engagement
ethnic/racial groups to express a need for such
with services. Thus, it is essential to assess and
treatment (SAMHSA, CBHSQ 2013c).
discuss client beliefs about shame (see the
Treatment Issues and “Assessing Shame in Asian American Clients”
advice box on the next page). In some cases,
Considerations self-disclosure can be helpful, but the counse-
It is important for counselors to approach lor should be careful not to self-disclose in a
presenting problems through clients’ culturally way that will threaten his or her position of
based explanations of their own issues rather respect with Asian American clients.
than imposing views that could alter their
acceptance of treatment. In Asian cultural Asian American clients may look to counse-
groups, the physical and emotional aspects of lors for expertise and authority. Counselors
an individual’s life are undifferentiated (e.g., should attempt to build client confidence in
the physical rather than emotional or psycho- the first session by introducing themselves by
logical aspect of a problem can be the focus title, displaying diplomas, and mentioning his
for many Asian Americans); thus, problems as or her experience with other clients who have
well as remedies are typically handled holisti- similar problems (Kim 1985; Lee and Mock
cally. Some Asian Americans with traditional 2005a,b). Asian American clients may expect
backgrounds do not readily accept Western and be most comfortable with formalism on

121
 Improving Cultural Competence

verbal messages than on the explicit content of

Advice to Counselors: Assessing
Shame in Asian American Clients messages (Hall 1976). Asian Americans often
use indirect communication, relying on subtle
Shame and humiliation can be significant barri- gestures, expressions, or word choices to con-
ers to treatment engagement for Asian Ameri-
vey meaning without being openly confronta-
cans. Gaw (1993) suggests that the presence of
the following factors may indicate that a client tional. Counselors must not only be observant
has shame about seeking treatment: of nuances in meaning, but also learn about
• The client or a family member is extremely verbal and nonverbal communication styles
concerned about the qualifications of the specific to Asian cultural groups (for a review
counselor.
of guidelines to use when working with Asian
• The client is hesitant to involve others in
the treatment process. Americans, see Gallardo et al. 2012).
• The client is excessively worried about
confidentiality.
Asian American clients appear to respond
• The client refuses to cover expenses with more favorably to treatment in programs that
private insurance. provide services to other Asian clients.
• The client frequently misses or arrives late Takeuchi et al. (1995) found that Asian
for treatment. Americans were much more likely to return to
• Family members refuse to support treat-
ment.
mental health clinics where most clients were
• The client insists on having a White Ameri- Asian American than to programs where that
can counselor to avoid opening up to an- was not the case (98 percent and 64 percent
other Asian. returned, respectively). When demographic
• The client refuses treatment even when differences were controlled for, those who
severe problems are evident.
attended programs that had predominantly
Asian clients were 15 times more likely to
the part of counselors, especially at the begin-
return after the initial visit. Asian Americans
ning of treatment and prior to assessment of
were also more likely to stay in treatment
clients’ needs (Paniagua 1998). Many Asian
when matched with an Asian American coun-
American clients expect counselors to be
selor regardless of the type of program they
directive (Leong and Lee 2008). Passivity on
attended. Sue et al. (1991) also found that
the part of the counselor can be misinterpret-
Asian American clients attended significantly
ed as a lack of concern or confidence.
more treatment sessions if matched with an
Counselors who are unaccustomed to working Asian American counselor.
with Asian populations will likely encounter
Among Asian American women, crucial
conflict between their theoretical worldview of
strategies include reducing the shame of sub-
counseling and the deference to authority and
stance abuse and focusing on the promotion of
avoidance of confrontation that is common
overall health rather than just addressing
among more traditional Asian American
substance abuse. Such strategies reduce the
clients. Some clients can be hesitant to con-
chance of a woman and her family seeing
tradict the counselor or even to voice their
substance abuse as an individual flaw. Home
own opinions. Confrontation can be seen as
visits, when agreed in advance with the client,
something to avoid whenever possible. Fur-
can be appropriate in some cases as a way to
thermore, many Asian cultural groups have
gain the trust of, and show respect for, Asian
high-context styles of communication, mean-
American women. Asian American women
ing that members often place greater im-
may not be as successful in mixed-gender
portance on nonverbal cues and the context of

122
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Advice to Administrators: Culturally Responsive Program Development

Behavioral health service program administrators can improve engagement and retention of Asian
clients by making culturally appropriate accommodations in their programs. The accommodations
required will vary according to the specific cultural groups, language preferences, and levels of
acculturation in question. The following culturally responsive program suggestions were initially
identified for Cambodian clients but can be adapted to match the unique needs of other Asian
clients from different ethnic and cultural backgrounds:
• Create an advisory committee using representatives from the community.
• Incorporate cultural knowledge and maintain flexible attitudes as a counselor.
• Use cotherapist teams in which one member is Asian and bilingual.
• Provide services in the clients’ primary language.
• Develop culturally specific questionnaires for intake to capture information that may be missed
by standard questionnaires.
• Conduct culturally appropriate assessments of trauma that ask about the traumatic experiences
common to the population in question.
• Visit client homes to improve family involvement in treatment.
• Provide support to families during transitions from and to professional care.
• Emphasize traditional values.
• Explore client coping mechanisms that draw upon cultural strengths.
• Use acupuncture or other traditional practices for detoxification.
• Integrate Buddhist ideas, values, and practices into treatment when appropriate.
• Emphasize relationship-building; help clients with life problems beyond behavioral health concerns.
• Provide concrete services, such as housing assistance and legal help.

Sources: Amodeo et al. 2004; Park et al. 2011.

groups if strict gender roles exist whereby be more effective if providers avoid approaches
communication is constricted within and out- that target emotional responses and instead
side the family; women will likely remain silent use strategies that are more indirect in discuss-
or defer to the men in the group (Chang 2000). ing feelings (e.g., saying “that might make
For more information on treating women, see some people feel angry” rather than asking
Treatment Improvement Protocol (TIP) 51, directly what the client is feeling; Sue 2001).
Substance Abuse Treatment: Addressing the
Asian Americans often prefer a solution-
Specific Needs of Women (CSAT 2009c).
focused approach to treatment that provides
Theoretical Approaches and them with concrete strategies for addressing
specific problems (Sue 2001). Even though
Treatment Interventions little research is available in evaluating specific
Some Asian cultural groups emphasize cogni- interventions with Asian Americans, clinicians
tions. For instance, Asian cultural groups that tend to recommend cognitive–behavioral,
have a Buddhist tradition, such as the Chinese, solution-focused, family, and acceptance
view behavior as controlled by thought. Thus, commitment therapies (Chang 2000; Hall et
they accept that addressing cognitive patterns al. 2011; Iwamasa et al. 2006; Rastogi and
will affect behaviors (Chen 1995). Some Asian Wadhwa 2006; Sue 2001). Asian American
cultural groups encourage a stoic attitude clients are likely to expect that their counselors
toward problems, teaching emotional suppres- take an active role in structuring the therapy
sion as a coping response to strong feelings session and provide clear guidelines about
(Amodeo et al. 2004; Castro et al. 1999b; Lee what they expect from clients. CBT has the
and Mock 2005a,b; Sue 2001). Treatment can

123
 Improving Cultural Competence

advantages of being problem focused and time For most Asian Americans, particularly those
limited, which will likely increase its appeal for who are less acculturated, successful treatment
many Asian Americans who might see other involves the client’s family (Chang 2000; Kim
types of therapy as failing to achieve real goals et al. 2004; Rastogi and Wadhwa 2006). Even
(Iwamasa et al. 2006). Although specific data in individual treatment, it is important to
on the effectiveness of CBT among Asian understand the client’s family and his or her
Americans is not available, there is some relationship with its members, the dynamics
research indicating that CBT is effective for and style of the family, and the family’s role in
treating depressive symptoms in Asians (Dai the client’s substance abuse (Meyer et al.
et al. 1999; Fujisawa et al. 2010). In China, a 2012). Particularly among Asian American
Chinese Taoist version of CBT has been women, family involvement can be essential
developed to treat anxiety disorders and was due to the client’s concern about being re-
found to be effective, especially in conjunction sponsive to her family’s needs. Nonetheless,
with medication (Zhang et al. 2002). involving the family can be quite difficult, as
both male and female clients may wish to
Family therapy conceal their substance abuse from their fami-
Some Asian Americans, particularly those lies because of the shame that it brings.
who are less acculturated, prefer individual
therapy to group or family interventions be- Advice to Counselors: Culturally
cause it better enables them to save face and Responsive Family Therapy
keep their privacy (Kuramoto 1994). Some Guidelines for Asian Families
clients may wish to enter treatment secretly so
Kim et al. (2004) reviewed references that
that they can keep their families and friends provide guidelines for family therapy with
from knowing about their problems. Once Korean Americans. They established 11 essen-
treatment is initiated, counselors should tial ingredients applicable to Korean and other
strongly reinforce the wisdom of seeking help Asian American groups and families. To pro-
through statements such as “you show concern vide culturally responsive therapy to Asian
Americans, counselors should:
for your husband by seeking help” or “you are • Assess support from community and ex-
obviously a caring father to seek this help.” tended family systems.
• Assess immigration history, if appropriate.
The norm in Asian families is that “all prob- • Establish credibility as a professional in the
lems (including physical and mental problems) initial meeting with the family.
must be shared only among family members”; • Explain the key principles and expectations
sharing with others can cause shame and guilt, of family therapy and the family roles (es-
pecially elders/decisionmakers) in the pro-
exacerbating problems (Paniagua 1998, pp.
cess.
59–60). Counselors should expect to take • Enable clients, particularly male elders or
more time than usual to learn about clients’ decisionmakers, to save face.
situations, anticipate client needs for reassur- • Validate and address somatic complaints.
ance in divulging sensitive information, and • Be both problem focused and present
focused.
frame discussions in a culturally competent
• Be directive in guiding therapy.
way. For example, counselors can assure cli- • Respect the family’s hierarchy.
ents that discussing problems is a step toward • Avoid being confrontational and facilitate
resuming their full share of responsibility in interactions that are nonconfrontational.
their families and removing some of the stress • Reframe problems in positive terms.
their families have been feeling. Source: Kim et al. 2004.

124
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

To engage family members in the client’s group goals in this framework can garner
treatment, the counselor first needs to be active participation. Still, in group settings and
familiar with the way the family functions. in other instances, Asian American clients
Different acculturation levels among individu- may expect a fair amount of direction from the
al family members and across generations can group leader. Chen (1995) described leader-
affect how the family functions, producing ship of a culturally specific therapy group for
significant stress and internal conflict. Also, Chinese Americans, noting that clients expect
the counselor must be aware of how gender a group leader to act with authority and give
roles and generational status influence the more credence to his or her expertise than to
communication patterns and rules within each other group members. If members of the
family (e.g., expectations of how a child ad- group belong to the same Asian American
dresses a parent, the potential relegation of community, the issue of confidentiality will
authority among female family members). loom large, because the community is often
Even more than for other clients, it is critical small. Asian cultural groups generally appreci-
for Asian Americans to “avoid embarrassing ate education in more formal settings, so
the family members in front of each other. psychoeducation groups can work well for
The counselor should always protect the Asian Americans. It is possible for a psy-
dignity and self-respect of the client and his or choeducational group with Asian American
her family” (Paniagua 1998, p. 71). participants to evolve comfortably into group
therapy.
Group therapy
Group therapy may not be a good choice for Mutual-help groups
Asian Americans, as many prefer individual According to 2012 NSDUH data, Asian
therapy (Lai 2001; Sandhu and Malik 2001). Americans were less likely than other racial
Paniagua (1998, p. 73) suggests that “group and ethnic groups to report the use of mutual-
therapy…would be appropriate in those cases help groups in the past year (SAMHSA
in which the client’s support system (relatives 2013d). Mutual-help groups can be challeng-
and close friends) is not available and an ing for Asian Americans who find it difficult
alternative support system is quickly needed.” and shaming to self-disclose publicly. The
Some Asian Americans participating in group degree of emotion and candor within these
therapy will find it difficult to be assertive in a groups can further alienate traditional Asian
group setting, preferring to let others talk. American clients. Furthermore, linguistically
They can also abide by more traditional roles appropriate mutual-help groups are not always
in this context; men might not want to divulge available for people who do not speak English.
their problems in front of women, women can Highly acculturated Asian Americans may
feel uncomfortable speaking in front of men, perceive participation in mutual-help groups
and both men and women might avoid con- as less of a problem, but nevertheless, Asian
tradicting another person in group (especially Americans can benefit from culture-specific
an older person). It may not make sense to mutual-help groups where norms of interper-
Asian American clients to hear about the sonal interaction are shared. Asian American
problems of strangers who are not part of their 12-Step groups are available in some locales.
community. It is important for counselors to assess client
attitudes toward mutual-help participation
Asian Americans are likely to be motivated to
and find alternative strategies and resources,
work for the good of the group; presenting

125
 Improving Cultural Competence

including encouragement to attend without through a variety of culture-specific interven-

sharing (Sandhu and Malik 2001). tions. For example, some Southeast Asian
cultural groups practice cao gio—massaging
Although they are not mutual-help groups in
the skin with ointment and hot coins (Chan
the traditional sense, mutual aid societies and
and Chen 2011). The Chinese have developed
associations are important in some Asian
enormously complex systems of medical
American communities. Some mutual aid
treatment over centuries of pragmatic experi-
societies have long histories and have provided
mentation. Traditional herbal medicine com-
assistance ranging from financial loans to help
bines plant substances according to precise
with childcare and funerals. The Chinese have
formulas to have the desired influence on the
family associations for people with the same
affected organs of the body. Acupuncture
last name who share celebrations and offer
techniques involve regulating the flow of
each other help. Japanese, Chinese, and South
energy (qi) through the body by inserting
Asians have specific associations for people
needles at precise locations called acupuncture
from the same province or village. For some
points. In traditional Chinese medicine, which
Asian American groups, such as Koreans,
has influenced traditional medical practices in
churches are the primary organizational vehi-
other Asian cultural groups, illness is seen as
cles for assistance. These social support groups
an imbalance of yin and yang; a return to
can be important resources for Asian American
physical wellness can require introducing
clients, their families, and the behavioral
elements such as herbs to increase yin or yang
health agencies that provide services to them.
as needed (Torsch and Ma 2000).
Traditional healing and Among less acculturated Asian Americans,
complementary methods Western medicine, including Western behav-
Asian Americans are twice as likely as other ioral health services, can be insufficient to deal
Americans to report making use of acupunc- with a problem such as substance abuse and its
ture and traditional healers. Even though there effects on clients and their families. For exam-
is considerable variation in their use of com- ple, all health problems for the Hmong
plementary and traditional medicine (Hughes (whether physical or psychological) are con-
2002), many Asian Americans highly regard sidered spiritual in nature; if providers ignore
traditional healers, herbal preparations, and the clients’ understanding of their problems as
other culturally specific interventions as a spiritual maladies, they are unlikely to effect
means of restoring harmony and balance. positive change (Fadiman 1997). Even for
However, Asian American clients do not more acculturated Asian Americans, the use of
always readily disclose the use of traditional traditional healing methods and spirituality
medicine to Western treatment providers. Ahn can be a very important aspect of treatment
et al. (2006) found that about two-thirds of (see Chan and Chen 2011 for an overview of
Chinese and Vietnamese Americans who health beliefs and practices). Such use can
spoke no or limited English had used tradi- provide a spiritual connection that helps man-
tional medicine, but only 7.6 percent had age feelings that are especially difficult to
discussed the use of these therapies with their express to others. Many practices associated
Western medical providers. with meditation, yoga, and Eastern religious
traditions can help disperse the stress and
Traditional treatment to restore physical and
anxiety experienced during treatment and
emotional balance for Asian Americans occurs
recovery. In the United States, there are few

126
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Behavioral Health Counseling for Native Hawaiians and Other Pacific Islanders
The ancestors of Native Hawaiians and other Pacific Islanders were the original inhabitants of Hawaii,
Guam, Samoa, and other Pacific islands. The population of Native Hawaiians and other Pacific
Islanders grew more than three times faster than the total U.S. population from 2000 to 2010. More
than half of Native Hawaiian and other Pacific Islanders live in Hawaii and California. The largest
Pacific Islander populations in the United States comprise Hawaiians, Samoans, and Chamorros—the
indigenous people of the Mariana Islands, of which Guam is the largest (Hixson et al. 2012).

Native Hawaiians and other Pacific Islanders make up a relatively small proportion of the total United
States population. In the 2010 Census, 540,000 people, or 0.2 percent of the population, reported
their race as Native Hawaiian or other Pacific Islander, and another 685,000 people (0.2 percent of
the population) stated that they were Native Hawaiian or other Pacific Islander in addition to one or
more other races (Hixson et al. 2012). The largest concentration of Native Hawaiians and other
Pacific Islanders is in Hawaii, where individuals with at least some of this ancestry made up 23.3
percent of the population.

In 2012, according to NSDUH data, 5.4 percent of Native Hawaiians and other Pacific Islanders
interviewed had a substance use disorder in the prior year, and 7.8 percent engaged in current illicit
drug use (SAMHSA 2013d). Binge and heavy drinking appear to be relatively high, especially among
Native Hawaiian/Pacific Islander women. Data from the 2001–2011 TEDS surveys indicate that the
most common primary substances of abuse among Native Hawaiians and other Pacific Islanders
entering substance abuse treatment are alcohol, cannabis, and methamphetamine (SAMHSA 2013c).
Because of its relatively small size, many studies have either ignored or been unable to make conclu-
sions about substance use and abuse in this population; other research has grouped Native
Hawaiians and other Pacific Islanders together with Asians (more for the sake of convenience than
for underlying cultural similarities).

According to NSDUH data, 1.8 percent of adult Native Hawaiians and other Pacific Islanders report-
ed serious mental illness. Insufficient data were available to analyze past-year mental illness rates
(SAMHSA 2013c). Similar to substance use data, specific mental health data are limited across
national studies, primarily because the population has been grouped with Asians. However, the
evidence that is available suggests that Native Hawaiians are less likely than other racial/ethnic
groups in Hawaii to access treatment services even though they experience higher rates of mental
health problems (for a review of health beliefs and practices, see Mokuau and Tauili’ili 2011).

A few examples of culturally specific interventions for Native Hawaiians have been presented in the
literature. For example, the Rural Hawai’i Behavioral Health Program, which provides substance
abuse and mental health services to Native Hawaiians living in rural areas, incorporates Native
Hawaiian beliefs and practices into all areas of the program, emphasizing the value of ‘ohana (family)
relations, including the importance of respecting and honoring ancestors and elders and passing on
cultural ways to the next generation. Program staff members are trained in Native Hawaiian culture
and beliefs, including spirituality and the essential value of graciousness, the honoring of mana (life
energy), healing rituals such as pule (prayer), the use of healing herbs, and Native Hawaiian beliefs
about the causes of illness, such as wrongdoing and physical disruption (Oliveira et al. 2006).

Ho’oponopono is a form of group therapy used by Native Hawaiians; it involves family members and
is facilitated by a Küpuna (elder). A qualitative study by Morelli and Fong (2000) of Ho’oponopono
with pregnant or postpartum women with substance use disorders (primarily methamphetamine
abuse) reported high client satisfaction and positive outcomes (80 percent were abstinent 2 years
after treatment). The Na Wahine Makalapua Project, sponsored by the Hawaii Department of
Health’s Alcohol and Drug Abuse Division and SAMHSA’s Center for Substance Abuse Prevention,
uses elements of Hawaiian culture to treat women with substance use disorders, such as by having
Küpuna counsel younger generations.

127
 Improving Cultural Competence

examples of culturally specific treatment pro- abstinence difficult for Asian clients. Counse-
grams that focus on Asian religious or spiritual lors should take this into account and address
treatment; however, there are programs over- difficulties that can arise for clients with fami-
seas, such as the Thai Buddhist treatment lies who have shame about mental illness or
center described by Barrett (1997). substance use disorders. To date, there are no
indications that standard approaches are un-
Asian Americans are much more likely than
suitable for Asian American clients. For more
members of other racial/ethnic groups to label
information on these approaches, see the
themselves as secular, agnostic, or atheist
planned TIP, Relapse Prevention and Recovery
(Kosmin and Keysar 2009; Pew Forum on
Promotion in Behavioral Health Services
Religion and Public Life 2008). That said, a
(SAMHSA planned e).
substantial number of Asian Americans still
have religious affiliations. About 45 percent
are Protestant; 17 percent, Catholic; 14 per- Counseling for Hispanics
cent, Hindu; 9 percent, Buddhist; and 4 per- and Latinos
cent, Muslim (Pew Forum on Religion and
Public Life 2008). More acculturated Asian The terms “Hispanic” and “Latino” refer to
Americans are likely to enter treatment people whose cultural origins are in Spain and
through medical settings and to be comforta- Portugal or the countries of the Western
ble with a medical model for treatment, but Hemisphere whose culture is significantly
those who are less acculturated or are foreign- influenced by Spanish or Portuguese coloniza-
born can prefer the use of traditional healing tion. Technically, a distinction can be drawn
and/or religious traditions and beliefs as part between Hispanic (literally meaning people
of their treatment ( Ja and Yuen 1997). Reli- from Spain or its former colonies) and Latino
gious institutions can play an important part (which refers to persons from countries ranging
in the treatment of some groups of Asian from Mexico to Central and South America
Americans. For example, Kwon-Ahn (2001) and the Caribbean that were colonized by
notes that many Korean Americans, particu- Spain, and also including Portugal and its
larly more recent immigrants, turn to Chris- former colonies); this TIP uses the more
tian clergy or church groups for assistance inclusive term (Latino), except when research
with family and personal problems, such as specifically indicates the other. The term
substance abuse, before seeking professional “Latina” refers to a woman of Latino descent.
help. Amodeo et al. (2004) suggest that, in Latinos are an ethnic rather than a racial
working with Cambodian immigrants, provid- group; Latinos can be of any race. According
ers integrate Buddhist philosophy and practic- to 2010 Census data, Latinos made up 16
es into treatment, and, if possible, partner with percent of the total United States population;
Buddhist temples to facilitate treatment entry they are its fastest growing ethnic group (Ennis
or to provide services for clients who choose et al. 2011). Latinos include more than 30
to reside in Buddhist temples. national and cultural subgroups that vary by
Relapse prevention and recovery national origin, race, generational status in the
United States, and socioeconomic status
Little research has evaluated relapse preven-
(Padilla and Salgado de Snyder 1992;
tion and recovery promotion strategies specifi-
Rodriguez-Andrew 1998). According to Ennis
cally for Asian Americans. However, issues
et al. (2011), of Latinos currently living in the
involving shame can make the adjustment to
United States (excluding Puerto Rico and

128
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

other territories), Mexican Americans are the and Glassman 1999). The authors concluded
largest group (63 percent), followed by Central that “losing control” has a different cultural
and South Americans (13.4 percent), Puerto meaning for these two groups, which in turn
Ricans (9.2 percent), and Cubans (3.5 percent). affects how they use alcohol.

Beliefs About and Traditions For many Latino men, drinking alcohol is a
part of social occasions and celebrations. By
Involving Substance Use contrast, solitary drinking is discouraged and
Attitudes toward substance use vary among seen as deviant. Social norms for Latinas are
Latino cultural groups, but Latinos are more often quite different, and those who have
likely to see substance use in negative terms substance abuse problems are judged much
than are White Americans. Marin (1998) more harshly than men. Women can be per-
found that Mexican Americans were signifi- ceived as promiscuous or delinquent in meet-
cantly more likely to expect negative conse- ing their family duties because of their
quences and less likely to expect positive substance use (Hernandez 2000). Amaro and
outcomes as a result of drinking than were Aguiar (1995) note that the heavy emphasis
White Americans. Similarly, Hadjicostandi on the idealization of motherhood contributes
and Cheurprakobkit (2002) note that most to the level of denial about the prevalence of
Latinos believe that prescription drug abuse substance use among Latinas. Women who
could have dangerous effects (85.7 percent), use injection drugs feel the need to maintain
that individuals who abuse substances cause their roles as daughters, mothers, partners, and
their whole families to suffer (81.4 percent), community members by separating their drug
and that people who use illicit drugs will use from the rest of their lives (Andrade and
participate in violent crime (74.9 percent) and Estrada 2003), yet research suggests that
act violently toward family members (78.9 substance abuse among women does not go
percent). Driving under the influence of alco- unrecognized within the Latino community
hol is one of the most serious substance use (Hadjicostandi and Cheurprakobkit 2002).
problems in the Latino community.
Among families, Latino adults generally show
Other research suggests that some Latinos strong disapproval of alcohol use in adoles-
hold different alcohol expectancies. When cents of either gender (Flores-Ortiz 1994).
comparing drinking patterns and alcohol Adults of both genders generally disapprove of
expectancies among college students, Velez- the initiation of alcohol use for youth 16 years
Blasini (1997) found that Puerto Rican partic- of age and under (Rodriguez-Andrew 1998).
ipants were more likely than other students to Long (1990) also found that even among
see increased sociability as a positive expectan- Latino families in which there has been multi-
cy related to drinking and sexual impairment generational drug abuse, young people were
as a negative expectancy. Puerto Rican partici- rarely initiated into drug abuse by family
pants were also significantly more likely to members. However, evidence regarding paren-
report abstinence from alcohol. In another tal substance use and its influence on youth
study comparing Puerto Ricans and Irish has been mixed; most studies show some
Americans, Puerto Rican participants who correlation between parental attitudes toward
expected a loss of control when drinking had alcohol use and youth drinking (Rodriguez-
fewer alcohol-related problems, whereas Irish Andrew 1998). For instance, research with
Americans who expected a loss of control had college students found that family influences
a greater number of such problems ( Johnson

129
 Improving Cultural Competence

had a significant effect on drinking in Latinos Although data are available from a number of
but not White Americans; the magnitude of studies regarding Latino drinking and drug
this effect was greater for Latinas than for use patterns, more targeted research efforts are
Latino men (Corbin et al. 2008). needed to unravel the complexities of sub-
stance use and the many factors that affect use,
Substance Use and Substance Use abuse, and dependence among subgroups of
Disorders Latino origin (Rodriguez-Andrew 1998). For
According to 2012 NSDUH data, rates of example, some studies show that Latino men
past-month illicit substance use, heavy drink- are more likely to have an alcohol use disorder
ing, and binge drinking among Latinos were than are White American men (Caetano
lower than for White Americans, Blacks, and 2003), whereas others have found the reverse
Native Americans, but not significantly so to be true (Schmidt et al. 2007). Disparities
(SAMHSA 2013d). The same data showed in survey results may reflect varying efforts to
that 8.3 percent of Latinos reported past- develop culturally responsive criteria (Carle
month illicit drug use compared with 9.2 2009; Hasin et al. 2007). The table in Exhibit
percent of White Americans and 11.3 percent 5-2 shows lifetime prevalence of substance
of African Americans. use disorders among Latinos based on

Exhibit 5-2: Lifetime Prevalence of Substance Use Disorders According to Ethnic

Subgroup and Immigration Status
Any Alcohol Drug
Ethnic Substance Use Alcohol Dependence, Drug Dependence,
Subgroup Disorder, % Abuse, % % Abuse, % %
Puerto Ricans
(born in the U.S. 15.9 7.7 5.6 4.6 4.3
mainland)
Puerto Ricans
(born in 11.1 4.6 5.3 4.3 3.6
Puerto Rico)
Cuban
Americans (born in 20.9 6.5 8.2 3.6 5.7
the U.S.)
Cuban
Americans 6.4 3.4 2.2 2.2 1.9
(foreign-born)
Mexican Ameri-
cans (born in the 21.4 9.4 7.7 5.8 5.3
U.S.)
Mexican Ameri-
7 3.5 2.8 2.0 1.7
cans (foreign-born)
Other Latino (born
20.4 10.4 5.3 8.4 5.2
in the U.S.)
Other Latino
5.7 3.2 2.2 2.1 1.0
(foreign-born)

Source: Alegria et al. 2008a.

130
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

immigration status and ethnic subgroup than men in the same age group across other
(Alegria et al. 2008a). racial/ethnic populations.
Among diverse Latino cultural groups, differ- Latino youth appear to start using illicit drugs
ent patterns of alcohol use exist. For example, at an earlier age than do members of other
some older research suggests that Mexican major ethnic/racial groups. Cumulative data
American men are more likely to engage in from 28 years of the Monitoring the Future
binge drinking (having five or more drinks at Study show Latino eighth graders as having
one time; drinking less frequently, but in higher rates of heavy drinking, marijuana use,
higher quantities) than other Latinos but use cocaine use, and heroin use than African or
alcohol less frequently (Caetano and Clark White Americans in the same grade. Among
1998). There are also differences regarding the youth in grade 12, the rates of use among
abuse of other substances. Among Latinos Latino and White American students are
entering substance abuse treatment in 2006, more similar, but Latinos still had the highest
heroin and methamphetamine use were espe- rates of crack cocaine and injected heroin use
cially high among Puerto Ricans and Mexican ( Johnston et al. 2003).
Americans, respectively. Other research has
Patterns of substance use and abuse vary based
found that Puerto Ricans are more likely to
on Latinos’ specific cultural backgrounds.
inject drugs and tend to inject more often
Among Latinos, rates of past-year alcohol
during the course of a day than do other
dependence were higher among Puerto Rican
Latinos (Singer 1999).
and Mexican American men (15.3 percent and
Patterns of substance use are also linked to 15.1 percent, respectively) than among
gender, age, socioeconomic status, and accul- South/Central American or Cuban American
turation in complex ways (Castro et al. 1999a; men (9 percent and 5.3 percent, respectively).
Wahl and Eitle 2010). For instance, increased Among Latinas, past-year alcohol dependence
frequency of drinking is associated with great- rates were significantly higher for Puerto
er acculturation for Latino men and women, Rican women (6.4 percent) than for Mexican
yet the drinking patterns of Latinas are affect- American (2.1 percent), Cuban American (1.6
ed significantly more than those of Latino percent), or South/Central American (0.8
men (Markides et al. 2012; Zemore 2005). percent) women (Caetano et al. 2008).
Age appears to influence Latino drinking Mental and Co-Occurring
patterns somewhat differently than it does for
other racial/ethnic groups. Research indicates
Disorders
that White Americans often “age out” of As with other populations, it is important to
heavy drinking after frequent and heavy alco- address CODs in Latino clients, as CODs
hol use in their 20s, but for many Latinos, have been associated with higher rates of
drinking peaks between the ages 30 and 39. treatment dropout (Amodeo et al. 2008).
Latinos in this age range have the lowest There are also reports of diagnostic bias, sug-
abstention rates and the highest proportions gesting that some disorders are underreported
of frequent and heavy drinkers of any age and others are overreported. Minsky et al.
group (Caetano and Clark 1998). In the same (2003) found that, at one large mental health
study, Latino men between 40 and 60 years of treatment site in New Jersey, major depression
age had higher rates of substance use disorders was overdiagnosed among Latinos, especially
Latinas, whereas psychotic symptoms were

131
 Improving Cultural Competence

sometimes ignored. Among Latinos with linguistically and/or culturally appropriate

CODs, other mental disorders preceded the services (SAMHSA 2011c). They were about
development of a substance use disorder 70 twice as likely to state the former and four
percent of the time (Vega et al. 2009). times as likely to state the latter as members of
the group that was the next most likely to
Overall, research indicates fewer mental disor-
make such statements.
ders and CODs among Latinos than among
White Americans (Alegria et al. 2008a; Vega A significant problem prohibiting participa-
et al. 2009). However, data from the 2012 tion in substance abuse treatment among
NSDUH indicate that the magnitude of the Latinos is the lack of insurance coverage to
difference may be decreasing; 1.2 percent of pay for treatment. In SAMHSA’s 2010
Latinos had both serious mental illness and NSDUH, 32 percent of Latinos who needed
substance use disorders in the prior year, as did but did not receive substance abuse treatment
White Americans, similar to the rate seen in the past year reported that they lacked mon-
among African Americans (0.9 percent; ey or insurance coverage to pay for it compared
SAMHSA 2013c). When any mental disorder with 29.5 percent of White Americans and
symptoms co-occurring with a substance use 33.5 percent of African Americans
disorder diagnosis were evaluated, Latinos had (SAMHSA 2011c). Other national surveys
a slightly higher rate of co-occurrence (3.4 also found that Latinos with self-identified
percent) than did African Americans (3.3 drinking problems were significantly more
percent; SAMHSA 2013c). Rates of mental likely than either White Americans or African
disorders and CODs also vary by Latino Americans to indicate that they did not seek
subgroup (Alegria et al. 2008a), and accultura- treatment because of logistical barriers, such as
tion can play a confounding, but inconsistent, a lack of funds or being unable to obtain
role in the identification and development of childcare (Schmidt et al. 2007).
CODs in Latino populations (Alegria et al.
Latinos with substance use disorders are about
2008a; Vega et al. 2009).
as likely to enter substance abuse treatment
Treatment Patterns programs as White Americans (Hser et al.
1998; Perron et al. 2009; Schmidt et al. 2006).
Barriers to treatment entry for Latinos in-
Latinos tend to enter treatment at a younger
clude, but are not limited to, lack of Spanish-
age than either African Americans or White
speaking service providers, limited English
Americans (Marsh et al. 2009). There are also
proficiency, financial constraints, lack of cul-
significant differences in treatment-seeking
turally responsive services, fears about immi-
patterns among Latino cultural groups. For
gration status and losing custody of children
example, Puerto Ricans who inject heroin are
while in treatment, negative attitudes toward
much more likely to participate in methadone
providers, and discrimination (Alegria et al.
main-tenance and less likely to enter other
2012; Mora 2002). Among all ethnic/racial
less-effective detoxification programs than
groups included in the 2010 NSDUH, Lati-
are Dominicans, Central Americans, and
nos were the most likely to report that they
other Latinos (Reynoso-Vallejo et al. 2008).
had a need for treatment but did not receive it
The researchers note, however, that this could
because they could not find a program with
be due partially to the fact that Puerto Ricans,
the appropriate type of treatment or because
compared with other Latinos, have a greater
there were no openings in programs that they
awareness of treatment options.
wished to attend, which may reflect a lack of

132
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Beliefs and Attitudes About 1998; Perron et al. 2009; Schmidt et al. 2006).
Treatment Latinos who receive substance abuse treatment
also report less satisfaction with the services
In general, Latino attitudes toward health care
they receive than White or African Americans
are shaped by a lack of access to regular quality
(Wells et al. 2001). Even when receiving a
care, including inability to afford it (see review
level of substance abuse treatment services
of health beliefs and help-seeking behaviors
comparable to those received by White and
among Mexican Americans and Mexicans
African Americans, Latinos are more likely to
dwelling in the United States in Rogers 2010).
be dissatisfied with treatment (Tonigan 2003).
DeNavas-Walt et al. (2006) found that Lati-
nos are less likely to have health insurance
Treatment Issues and
(32.7 percent were uninsured in 2005) than
either non-Latino White Americans (11.3 Considerations
percent were uninsured) or African Americans Latino clients’ responsiveness to therapy is
(19.6 percent were uninsured). They are also influenced not only by counselor and program
less likely to have had a regular place to go for characteristics, but also by individual charac-
conventional medical care (Schiller et al. teristics, including worldview, degree of accul-
2005). Lack of knowledge about available turation, gender orientation, religious beliefs,
services can be a major obstacle to seeking and personality traits. As with other cultural
services (Vega et al. 2001). In their review, groups, efforts to establish clear communica-
Murguia et al. (2000) identified several factors tion and a strong therapeutic alliance are
that influence the use of medical services, essential to positive treatment outcomes
including cultural health beliefs, demographic among Latino clients. Foremost, counselors
barriers, level of acculturation, English profi- should recognize the importance of—and
ciency, accessibility of service providers, and integrate into their counseling style and ap-
flexibility of intake procedures; they found proach—expressions of concern, interest in
that many Latinos only seek medical care for clients’ families, and personal warmth (person-
serious illnesses. alismo; Ishikawa et al. 2010).

Research on substance abuse indicates that Counselors and clinical supervisors need to be
Latinos who use illicit drugs appear to have educated about culturally specific attributes
relatively unfavorable attitudes toward treat- that can influence participation and clinical
ment and perceive less need for treatment than interpretation of client behavior in treatment.
do illicit drug users among every other major For instance, some Latino cultural groups view
ethnic and racial group but Native Americans time as more flexible and less structured; thus,
(Brower and Carey 2003). However, in the rather than negatively interpreting the client’s
2011 NSDUH, Latinos were more likely than behavior regarding the keeping of strict
White Americans, African Americans, or schedules or appointment times, counselors
Asian Americans to indicate that they had a should adopt scheduling strategies that pro-
need for substance abuse treatment in the vide more flexibility (Alvarez and Ruiz 2001;
prior year but did not receive it (SAMHSA Sue 2001). However, counselors should also
2012b). Other studies have found that Latinos advise Latino clients of the need to take rele-
with substance use disorders are about as likely vant actions with the aim of arriving on time
to enter substance abuse treatment programs for each appointment or group session. Coun-
as other racial and ethnic groups (Hser et al. selors should try to avoid framing noncompli-
ance in Latino clients as resistance or anger. It

133
 Improving Cultural Competence

is often, instead, a pelea nonga (relaxed fight) (Field and Caetano 2010). Available literature
showing both a sense of being misunderstood and research highlight four main themes sur-
and respeto (respect that also encompasses a rounding general counseling issues and pro-
sense of duty) for the counselor’s authority grammatic strategies for Latinos, as follows.
(Barón 2000; Medina 2001).
Socializing the client to treatment: Latino
Unfortunately, many providers who work with clients are likely to benefit from orientation
Latino cultural groups continue to have mis- sessions that review treatment and counseling
perceptions and can even see culture as a processes, treatment goals and expectations,
hindrance to effective treatment rather than as and other components of services (Organista
a source of potential strength (Quintero et al. 2006).
2007). For instance, in treating the alcohol
Reassurance of confidentiality: Regardless of
problems of Latinas, many counselors believe
the particular mode of therapy, counselors
that they should not incorporate endorsement
should explain confidentiality. Many Latinos,
of traditional and possibly harmful cultural
especially undocumented workers or recent
patterns into the services they provide (Mora
immigrants, are fearful of being discovered by
2002). However, other counselors note that
authorities like the United States Citizenship
the transformative value of the most positive
and Immigration Services and subsequently
aspects of Latino cultural groups can be em-
deported back to their countries of origin
phasized: strength, perseverance, flexibility,
(Ramos-Sanchez 2009).
and an ability to survive (Gloria and Peregoy
1996). Respecting women’s choices can mean Client–counselor matching based on gen-
supporting empowerment to pursue new roles der: To date, research does not provide con-
and make new choices free of alcohol, guilt, sistent findings on client–counselor matching
and discrimination (Mora 2002). For others, it based on similarity of Latino ethnicity. How-
can mean reinvigorating the positivity of ever, client–counselor matching based on
Latina culture to promote abstinence while gender alone appears to have a greater effect
respecting and maintaining traditional family on improving engagement and abstinence
roles for women (Gloria and Peregoy 1996). among Latinos than it does for clients of other
ethnicities (Fiorentine and Hillhouse 1999).
Because some research has found that Latinos
have higher rates of treatment dropout than Client–program matching: Matching clients
other populations (Amaro et al. 2006), pro- to ethnicity-specific programs appears to
grams working with this population should improve outcomes for Latinos. Takeuchi et al.
consider ways to improve retention and out- (1995) found that only 68 percent of Mexican
comes. Treatment retention issues for Latinos American clients in programs that had a
can be similar to those found for other popu- majority of White American clients returned
lations (Amodeo et al. 2008), but culturally after the first session compared with 97 per-
specific treatment has been associated with cent in those programs where the majority of
better retention for Latinos (Hohman and clients were Mexican American.
Galt 2001). Research evaluating ethnic match-
ing with brief motivational interventions also Theoretical Approaches and
found more favorable substance abuse treat- Treatment Interventions
ment outcomes at 12-month follow-up when Overall, research evaluating cultural adoption
clients and providers were ethnically matched of promising or evidence-based practices in

134
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

treatment specifically for Latinos is scarce Family therapy

(Carvajal and Young 2009). For instance, Family therapy is often recommended for
empirical literature evaluating CBT specifical- treating Latinos with substance use disorders
ly for substance abuse and substance use dis- (Amaro et al. 2006; Barón 2000; Hernandez
orders in Latinos is quite limited. Still, a 2000). Although there is little research evalu-
number of authors recommend CBT for ating the effectiveness of family therapy for
Latinos in mental health and substance abuse adults, both multidimensional family therapy
treatment settings because it is action oriented, (Liddle 2010) and brief strategic family thera-
problem focused, and didactic (Alvarez and py (Santisteban et al. 1997; Santisteban et al.
Ruiz 2001; Organista 2006; Organista and 2003; Szapocznik and Williams 2000) have
Muñoz 1998). CBT’s didactic component can been found to reduce substance use and im-
educate Latinos about disorders and frame prove psychological functioning among Latino
therapy as an educational (and hence less youth. The term familismo refers to the cen-
shameful) experience. However, Organista’s trality of the family in Latino culture and can
(2006) review of available research on CBT include valuing and protecting children, re-
for mental disorders among Latinos suggests specting the elderly, preserving the family
that this approach is not always as effective name, and consulting with one another before
with Latinos as it is with other populations. making important decisions. As highlighted in
Other effective interventions include contin- the case study of a Puerto Rican client on the
gency management and motivational inter- next page, counselors must consider the poten-
viewing; see the review by Amaro et al. (2006) tially pivotal roles families can play in support-
for more on these interventions. Methadone ing treatment and recovery. Latino families are
maintenance, too, has been associated with likely to have a strong sense of obligation and
long-term reductions in the use of alcohol as commitment to helping their members, in-
well as heroin and other illicit drugs among cluding those who have substance use disor-
Mexican Americans with opioid use disorders, ders. Even so, the level of family support for
although 33 percent of the original cohort people who have substance use or mental
died before the 22-year longitudinal study disorders varies among Latinos depending on
concluded (Goldstein and Herrera 1995). country of origin, level of acculturation, degree
Another therapeutic intervention that can of family cohesion, socioeconomic status, and
improve outcomes for Latino clients is node- factors related to substance use (Alegria et al.
link mapping (visual representation using 2012). For example, Reynoso-Vallejo et al.
information diagrams, fill-in-the blank graph- (2008) concluded that significantly higher
ic tools, and client-generated diagrams or rates of homelessness found among people
visual maps), which has been associated with from Central American countries who inject-
lower levels of opioid and cocaine use, better ed heroin compared with other Latinos could
treatment attendance, and higher counselor stem from lower levels of tolerance for injec-
ratings of motivation and confidence for tion drug use among their families.
Latinos in methadone maintenance treatment For counselors who lack cultural understand-
(Dansereau et al. 1996; Dansereau and Simp- ing, it can be easy to simply label and judge
son 2009). For a review of Latino outcome families’ behavior as enabling or codependent.
studies in health, substance abuse, and mental Instead, counselors should move away from
health in social work, refer to Jani and col- labeling the behavior and focus more on help-
leagues (2009). ing families recognize how their behavior can

135
 Improving Cultural Competence

Case Study: A Puerto Rican Client

Anna is a 27-year-old woman who was born in New York and self-identifies as Puerto Rican. She has
a 12th-grade education, is unemployed, and lives with her parents, her 4-year-old daughter, and a
nephew. Anna is separated from her partner, who is also her daughter’s father. She entered treat-
ment as a result of feeling depressed ever since her partner physically assaulted her because she
refused to use heroin (the event that sparked their separation). She states, “I want to be clean and
take care of my family.” At intake, she had just undergone detoxification and had stopped using
alcohol, crack cocaine, and heroin.

Anna states that she feels guilty about her drug use and the way it caused her to neglect her family.
She has been having serious problems with her mother, who is critical of her substance use, but
believes that her mother is important in her recovery because of the structure she provides at home.
She describes her father as a very important figure with whom she enjoys spending time. Her father
had stopped drinking 9 years before and is very supportive of her abstinence. He is willing to help in
any way he can but has been very sick lately and was diagnosed with prostate cancer. Her father had
never received treatment for his drinking problem, and her mother believes that Anna should be
able to stop just like her father did. As she describes her situation in treatment, Anna’s vergüenza
(shame) and sense of hopelessness is very evident. She fears her father’s death and her mother’s
subsequent rejection of her for not helping out.

Anna’s treatment includes family therapy to restructure communication patterns, rules, expecta-
tions, and roles. For family sessions, either her mother or both parents participate, depending on her
father’s physical condition. Initially, her parents displayed a tendency to focus on the problems of the
past, but the counselor directed them to focus on changes needed to help Anna’s recovery. The
counselor has also worked with other family members to rally support and use their strengths while
also clarifying perceptions, feelings, and behaviors that will help them function as a family unit.
Anna’s counselor recognizes that, within the context of her culture, her reliance on her family can be
used to aid her recovery and that her family, as defined by Anna, can be used as a support system.
Source: Medina 2001. Adapted with permission.

affect one member’s substance abuse and how of the rules of the system. Otherwise, mem-
best to handle it. The advice box on the next bers could see group therapy as oppressive.
page provides general therapeutic guidelines Facilitators in groups consisting mostly of
for working with Latino families. Latino clients must establish trust, responsibil-
ity, and loyalty among members. In addition,
Group therapy acculturation levels and language preferences
Little information is available concerning should be assessed when forming groups so
Latinos’ preferences in behavioral health that culturally specific or Spanish-speaking
services, but a study evaluating mental health groups can be made available if needed.
treatment preferences for women in the Unit-
ed States found that Latinas were significantly Mutual-help groups
more likely to prefer group treatment Findings on the usefulness of 12-Step groups
(Nadeem et al. 2008). According to Paniagua for Latino clients are inconsistent. Member-
(1998), the use of group therapy with Latino ship surveys of AA indicate that Latinos
clients should emphasize a problem-focused comprise about 5 percent of AA membership
approach. Group leaders should allow mem- (AAWS 2012). Latinos who received inpatient
bers to learn from each other and resist func- treatment were less likely to attend AA than
tioning as a content expert or a representative White Americans (Arroyo et al. 1998). Rates

136
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

of engagement than for White American

Advice to Counselors: Family Therapy
Guidelines for Latino Families participants (Hoffman 1994; Tonigan et al.
1998). For some Latinos, 12-Step groups can
• Provide bilingual services. appeal to religious and spiritual beliefs. Her-
• Use family therapy as a primary method of
nandez (2000) suggests that mutual-help
treatment.
• Assess cultural identity and acculturation groups composed solely of Latinos make it
level for each family member. easier for participants to address the cultural
• Determine the family’s level of belief in context of substance abuse. Some Latino 12-
traditional and complementary healing Step groups do not hold that substance abuse
practices; integrate these as appropriate.
is a biopsychosocial problem, instead concep-
• Discuss the family’s beliefs, history, and
experiences with standard American be- tualizing the disorder as a weakness of charac-
havioral health services. ter that must be corrected. Hoffman (1994)
• Explore migration and immigration experi- studied Latino 12-Step groups in Los Angeles
ences, if appropriate. and observed that, in addition to a more
• Provide additional respect to the father or
traditional form of AA, there were groups that
father figure in the family.
• Interview family members or groups of practiced terapia dura (i.e., rough therapy),
family members (e.g., children) separately which often uses a confrontational approach
to allow them to voice concerns. and endorses family values related to machismo
• Generate solutions with the family. Do not (e.g., by reinforcing that overcoming substance
force changes in family relationships.
abuse rather than drinking is manly). Howev-
• Provide specific, concrete suggestions for
change that can be quickly implemented. er, these groups were not overly welcoming of
• Focus on engaging the family in the first female members and gay men. In such cases,
session using warmth and personalismo. gay Latino men and Latinas can benefit from
Sources: Bean et al. 2001; Hernandez 2005; attending 12-Step groups that are not cultur-
Lynch and Hanson 2011. ally specific or that do not use terapia dura.

of mutual-help participation among people Traditional healing and

with drug use disorders are also lower for complementary methods
Latinos (Perron et al. 2009). Language can In a study of the use of alternative and com-
present a barrier to mutual-help group partici- plementary medical therapies, Latinos were
pation for Spanish-speaking Latinos; however, less likely to use medical alternatives than
Spanish-language meetings are held in some were White Americans (Graham et al. 2005).
locations. Counselors should consider the However, those who did use such approaches
appropriateness of 12-Step participation on a were more likely to do so because they could
case-by-case basis (Alvarez and Ruiz 2001). not afford standard medical care (Alegria et al.
For example, Mexican American men who 2012). As in other areas, the use of comple-
identify with attitudes of machismo can feel mentary and traditional medicine likely varies
uncomfortable with the 12-Step approach. according to acculturation level and country of
Concern about divulging family issues in public origin. For instance, the use of faith and reli-
can cause hesitation to address substance- gious practices to cope with mental and emo-
related problems in public meetings. tional problems is significantly more common
among foreign-born Latinos than among
For Latinos who do participate in 12-Step those born in the United States (Nadeem et al.
programs, findings suggest higher rates of 2008; Vega et al. 2001).
abstinence, degree of commitment, and level

137
 Improving Cultural Competence

Many Latinos place great importance on the Data are lacking on long-term recovery for
practice of Roman Catholicism. Yamamoto Latinos. Given the many obstacles that block
and Acosta (1982) describe the central tenets accessibility to treatment for Latinos, continu-
of Latino Catholicism as sacrifice, charity, and ing care planning can benefit from greater use
forgiveness. These beliefs can hinder assertive- of informal or peer supports. For example,
ness in some Latinos, but they can also be a White and Sanders (2004) recommend the
source of strength and recovery. Traditionally, use of a recovery management approach with
Latinos have been Catholic, although several Latinos. They point to an early example of the
Protestant and evangelical groups have con- East Harlem Protestant Parish’s work, which
verted millions of Latinos to their religions helped Puerto Rican individuals recovering
since the 1970s. Some Latinos also believe in from heroin dependence connect to social
syncretistic religions (e.g., Santería or clubs and religious communities that sup-
Curanderismo) or practices derived from them ported recovery. Latinos use community and
and make use of a variety of traditional heal- family support in addition to spirituality to
ing practices and rituals to heal mental and address mental disorders (Lynch and Hanson
spiritual ailments (Lefley et al. 1998; Sandoval 2011; Molina 2001). Castro et al. (2007) also
1979). Among Puerto Ricans, espiritismo note that family support systems can be espe-
(spiritualism) is a popular traditional healing cially important for Latinos in recovery.
system successfully used to address mental
health issues (Lynch and Hanson 2011; Moli- Counseling for Native
na 2001). Some Mexican Americans rely on
curanderos, folk healers who address problems Americans
that might be framed as psychological (Falicov There are 566 federally recognized American
2005, 2012). For a review of culturally respon- Indian Tribes, and their members speak more
sive interventions with Latinos, refer to than 150 languages (U.S. Department of the
Gallardo and Curry (2009). Interior, Indian Affairs 2013a); there are
Relapse prevention and recovery numerous other Tribes recognized only by
states and others that still go unrecognized by
There are no substantial studies evaluating the
government agencies of any sort. According to
use of relapse prevention and recovery promo-
the 2010 U.S. Census (Norris et al. 2012), the
tion with Latinos, yet literature suggests that
majority (78 percent) of people who identified
they would be appropriate and effective for
as American Indian or Alaska Native, either
this population (Blume et al. 2005; Castro et
alone or in combination with one or more
al. 2007). Overall, Latinos can face somewhat
other races, lived outside of American Indian
different triggers for relapse relating to accul-
and Alaska Native areas. Approximately 60
turative stress or the need to uphold particular
percent of the 5.2 million people who identi-
cultural values (e.g., personalismo, machismo;
fied as American Indian or Alaska Native,
Castro et al. 2007), which can lead to higher
alone or in combination with one or more
rates of relapse among some Latino clients.
other races, reside in urban areas (Norris et al.
For example, in a study of relapse patterns
2012). The category of Alaska Natives in-
among White American and Latino individu-
cludes four recognized Tribal groups—
als who used methamphetamine, Brecht et al.
Alaskan Athabascan, Aleut, Eskimo, and
(2000) found that Latino participants relapsed
Tingit-Haida—along with many other inde-
more quickly than White American
pendent communities (Ogunwole 2006).
participants.

138
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Native Americans who belong to federally among Native Americans, see the planned TIP,
recognized Tribes and communities are mem- Behavioral Health Services for American Indians
bers of sovereign Indian nations that exist and Alaska Natives (SAMHSA planned a).
within the United States. On lands belonging
to these Tribes and communities, Native Beliefs About and Traditions
Americans are able to govern themselves to a Involving Substance Use
large extent and are not subject to most state Few American Indian Tribes and no Alaska
laws—only to federal legislation that is specif- Natives consumed alcoholic beverages prior to
ically designated as applying to them (Henson contact with non-Native people, and those
2008). Although health care (including sub- who did used alcohol primarily for special
stance abuse treatment) is provided to many occasions and ceremonies. Most Tribes first
Native Americans by Indian Health Services encountered the use of alcohol when they
(IHS), Tribal governments do have the option encountered European settlers and traders.
of taking over those services. Counselors Because of this lack of experience with alco-
working with these populations should re- hol, few Native Americans had a context for
member that Native Americans, by virtue of drinking besides what they learned from these
their membership in sovereign Tribal entities, non-Natives, who at the time drank in large
have rights that are different from those of quantities and often engaged in binge drink-
other Americans; this distinguishes them from ing. Although patterns of alcohol consump-
members of other ethnic/racial groups. tion in the mainstream population of the
American Indians live in all 50 states; the United States changed over time, they re-
states with the largest populations of Ameri- mained relatively the same in the more isolat-
can Indians are Oklahoma, California, and ed Native American communities. According
Arizona. The 2000 Census allowed people to to an NSDUH report on American Indian
identify, for the first time, as a member of and Alaska Native adults, binge drinking
more than one race. Of persons who checked continues to be a significant problem for these
two or more races, nearly one in five indicated populations. Both binge drinking and illicit
that they were part American Indian or Alaska drug use is higher among Native Americans
Native (U.S. Census Bureau 2001a,b). than the national average (30.2 percent versus
23 percent and 12.7 percent versus 9.2 percent,
Behavioral health service providers should respectively; SAMHSA 2013d).
recognize that Native American Tribes repre-
sent a wide variety of cultural groups that American Indian drinking patterns vary a
differ from one another in many ways (Duran great deal by Tribe. Tribal attitudes toward
et al. 2007). Alaska Natives who live in coastal alcohol influence consumption in complicated
areas have very different customs from those ways. For example, in Navajo communities,
inhabiting interior areas (Attneave 1982). The excessive drinking was acceptable if done in a
diversity of Native American Tribes notwith- group or during a social activity. However,
standing, they also share a common bond of solitary drinking (even in lesser amounts) was
respect for their cultural heritages, histories, considered to be deviant (Kunitz et al. 1994).
and spiritual beliefs, which are different from Kunitz et al. (1994) observed that during the
those of mainstream American culture. For 1960s, binge drinking was acceptable among
more information on the treatment and pre- the Navajo during public celebrations, whereas
vention of substance abuse and mental illness any drinking was considered unacceptable
among the neighboring Hopi population,

139
 Improving Cultural Competence

wherein regular drinkers were shunned or, in show that Alaska Natives are significantly
some cases, expelled from the community. more likely to abstain than are other Alaskans
Hopi individuals who did drink tended to do (Wells 2004).
so alone or moved off the reservation to bor-
The most common pattern of abusive drink-
der towns where heavy alcohol use was com-
ing among American Indians appears to be
mon. The ostracism of Hopi drinkers seemed
binge drinking followed by long periods of
to lead to even greater levels of abuse, given
abstinence (French 2000; May and Gossage
that there were much higher death rates from
2001). A similar pattern is seen among Alaska
alcoholic cirrhosis among the Hopi than
Natives (Seale et al. 2006; Wells 2004). As an
among the Navajo.
example, the Urban Indian Health Institute
Native American recovery movements have (2008) found that binge drinking was signifi-
often viewed substance abuse as a result of cantly more common among the Native
cultural conflict between Native and Western American population (with 21.3 percent
cultures, seeing substances of abuse as weapons engaging in binge drinking in the prior 30
that have caused further loss of traditions days compared with 15.8 percent of non-
(Coyhis and White 2006). To best treat this Native Americans) and that, among those who
population, substance abuse treatment provid- drank, 40.7 percent of Native American par-
ers need to expand their perspectives regarding ticipants engaged in binge drinking compared
substance abuse and dependence and must with 26.9 percent of non-Natives.
embrace a broader view that explores the
There are a number of historical reasons for
spiritual, cultural, and social ramifications of
the development of binge drinking among
substance abuse (Brady 1995; Duran 2006;
Native Americans. The existence of dry reser-
Jilek 1994).
vations (which can limit the times when indi-
Substance Use and Substance Use viduals are able to get alcohol), high levels of
poverty, lack of availability (e.g., in remote
Disorders Alaska Native villages), a history of trauma,
According to 2012 NSDUH data, American and the loss of cultural traditions can all con-
Indian and Alaska Native peoples have the tribute to the development and continuation
highest rates of substance use disorders and of this pattern of drinking. Native Americans
binge drinking (SAMHSA 2013d). Although are also more likely than members of other
rates of substance abuse are high among major racial/ethnic groups to have had their
Native Americans, so too are rates of absti- first drink before the age of 21 or before the
nence. American Indians and Alaska Natives age of 16, which also may shape drinking
are more likely to report no alcohol use in the patterns (SAMHSA 2011c).
past year than are members of all other major
racial and ethnic groups (OAS 2007). The However, data on heavy and binge drinking do
American Indian Services Utilization and not reflect the same pattern of alcohol con-
Psychiatric Epidemiology Risk and Protective sumption for all Native American Tribes. One
Factors Project (AI-SUPER PFP) also found analysis of alcohol dependence among mem-
that rates of lifetime abstinence from alcohol bers of seven different Tribes found rates of
for American Indians in the study were signif- dependence varying from 56 percent of men
icantly higher than lifetime abstinence rates and 30 percent of women in one Tribe to 1
among the general population (Beals et al. percent of men and 2 percent of women in
2003). Data on alcohol consumption also another (Koss et al. 2003). Other research

140
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

confirms significant differences in alcohol use diagnosis of an alcohol use disorder (Gilman
among diverse Native American communities et al. 2008). Illicit drug use is also more com-
(O’Connell et al. 2005; Whitesell et al. 2006). mon for Native Americans than for members
of other major racial/ethnic groups.
In addition to alcohol, methamphetamine and
inhalant abuse are major concerns for a num- Among Native Americans entering treatment
ber of Native American communities. None- in 2010, alcohol use disorders alone or in
theless, there are considerable regional conjunction with drug use disorders were the
differences in patterns and prevalence of drug most pressing substance-related problem, with
use (Miller et al. 2012). According to the cannabis and opioids other than heroin being
National Congress of American Indians the next most common primary substances of
(2006), 74 percent of Tribal police forces abuse. One of the largest studies on American
ranked methamphetamine as the drug causing Indian substance use and abuse to date, the
the most problems in their communities. AI-SUPER PFP, found that 31.2 percent of
Methamphetamine abuse can be even more American Indians met criteria for a lifetime
serious for Native Americans living in rural diagnosis of a substance use disorder, and 13.4
areas than for those in urban areas, but it is percent met criteria for a past-year diagnosis
also a serious problem for growing numbers of (Beals et al. 2003). The study found that rates
American Indians, especially women, entering of alcohol use disorders were high among men
treatment in urban areas (Spear et al. 2007). from the three Tribes represented but varied
to a greater degree among women across
American Indians and Alaska Natives are
Tribes (Mitchell et al. 2003).
more likely to report having used inhalants at
some time during their lives, but use tends to American Indians have high rates of certain
peak in 8th grade and then decrease (Miller et diseases and conditions. In particular, the
al. 2012). In some Native American communi- incidence of diabetes is increasing among
ties (e.g., on the Kickapoo reservation in Tex- Native Americans, and approximately 38
as), inhalants have been a major drug of abuse percent of elder Native Americans have diabe-
for adults as well as youth. During the early tes (Moulton et al 2005). Diabetes is also
1990s, about 46 percent of the adult popula- associated with both substance use disorders
tion on that reservation were thought to abuse and depression in this population (Tann et al.
inhalants (Fredlund 1994). Although more 2007). Other health problems associated with
recent data are not available, reports from the alcohol use include fetal alcohol syndrome,
area suggest that inhalant abuse remains a cirrhosis, and depression.
significant problem (Morning Star 2005).
Mental and Co-Occurring
Rates of substance use disorders appear to be
higher in individuals who consider themselves
Disorders
exclusively Native American than for those According to the 2012 NSDUH, 28.3 percent
who identify as more than one race/ethnicity, of American Indians and Alaska Natives
but even when surveys ask whether people are report having a mental illness, with approxi-
of mixed race, those who report themselves to mately 8.5 percent indicating serious mental
be partially Native American still have high illness in the past year (SAMHSA 2013c).
rates of substance use disorders (OAS 2007). Native Americans were nearly twice as likely
Native Americans are about 1.4 times more to have serious thoughts of suicide as members
likely than White Americans to have a lifetime of other racial/ethnic populations, and more

141
 Improving Cultural Competence

than 10 percent reported a major depressive Treatment Patterns

episode in the past year. Common disorders Despite a number of potential barriers to
include depression, anxiety, and substance use. treatment (Venner et al. 2012), Native Ameri-
As with other groups, substance use disorders cans are about as likely as members of other
among Native Americans have been associated racial/ethnic groups to enter behavioral health
with increased rates of a variety of different programs. According to data from the 2003
mental disorders (Beals et al. 2002; Tann et al. and 2011 NSDUH (SAMHSA, CBHSQ
2007; Westermeyer 2001). The 2012 NSDUH 2012), Native Americans were more likely to
revealed that 14 percent of Native Americans have received substance use treatment in the
reported both past-year substance use disor- past year than persons from other racial/ethnic
ders and mental illness. Among those who groups (15.0 percent versus 10.2 percent).
reported mental illness, nearly 5 percent re- Other studies indicate that about one-third of
ported several mental illnesses co-occurring Native Americans with a current substance use
with substance use disorders (SAMHSA disorder had received treatment in the prior
2013c). year (Beals et al. 2006; Herman-Stahl and
Chong 2002). The 2012 NSDUH reported
Native American communities have experi- that approximately 15 percent of Native
enced severe historical trauma and discrimina- Americans received mental health treatment
tion (Brave Heart and DeBruyn 1998; Burgess (SAMHSA 2013c).
et al. 2008). Studies suggest that many Native
Americans suffer from elevated exposure to Native Americans were least likely of all major
specific traumas (Beals et al. 2005; Ehlers et al. ethnic/racial groups to state that they could not
2006; Manson 1996; Manson et al. 2005), and find the type of program they needed and were
they may be more likely to develop PTSD as a the next least likely after Native Hawaiians and
result of this exposure than members of other other Pacific Islanders to state that they did not
ethnic/racial groups. PTSD comparison rates know where to go or that their insurance did
taken from the AI-SUPER PFP study and not cover needed treatment. Among Native
the National Comorbidity Study show that Americans who identified a need for treat-
12.8 percent of the Southwest Tribe sample ment in the prior year but did not enter treat-
and 11.5 percent of the Northern Plains Tribe ment, the most commonly cited reasons for
sample met criteria for a lifetime diagnosis of not attending were lack of transportation, lack
PTSD compared with 4.3 percent of the of time, and concerns about what one’s neigh-
general population (Beals et al. 2005). Trauma bors might think (SAMHSA 2011c).
histories and PTSD are so prevalent among Many Native Americans, especially those
Native Americans in substance abuse treat- residing on reservations or other Tribal lands,
ment that Edwards (2003) recommends that seek mental health and substance abuse treat-
assessment and treatment of trauma should be ment through Tribal service providers or IHS
a standard procedure for behavioral health (Jones-Saumty 2002; McFarland et al. 2006).
programs serving this population. For exam- However, an analysis using multiple sources
ple, Native American veterans with substance found that 67 percent of Native Americans
use disorders are significantly more likely to entering substance abuse treatment over the
have co-occurring PTSD than the general course of a year did so in urban areas, and the
population of veterans with substance use majority of those urban-based programs were
disorders (Friedman et al. 1997). not operated by IHS (McFarland et al. 2006).

142
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

The same research also found that Native beliefs about treatment providers that can
Americans were somewhat more likely than influence not only willingness to participate in
the general treatment-seeking population to treatment services, but also the level of trust
enter residential programs. clients have for providers. Counselors and
other behavioral health workers must develop
Native Americans were more likely to enter
ongoing relationships within local Native
treatment as a result of criminal justice refer-
American communities to gain knowledge of
rals than were White Americans or African
the unique attributes of each community, to
Americans: 47.9 percent of American Indians
show investment in the community, and to
and Alaska Natives entering public treatment
learn about community resources (Exhibit 5-
programs in 2010 were court-ordered to
3). Identifying and developing resources with-
treatment compared with 36.6 percent of
in Native communities can help promote
White Americans and 36.4 percent of African
culturally congruent relationships.
Americans (SAMHSA, CBHSQ 2012). The
lack of recognition of special needs and Exhibit 5-3: Native Americans and
knowledge of Native American cultures within Community
behavioral health programs may be the main
reasons for low treatment retention and un- Many Native Americans believe that recovery
cannot happen for individuals alone and that
deruse of help-seeking behaviors among their entire community has become sick.
Native Americans (LaFromboise 1993; Sue Coyhis calls this the “healing forest” model:
and Sue 2013e). one cannot take a sick tree from a sick forest,
heal it, and put it back in the same environ-
Beliefs and Attitudes About ment expecting that it will thrive. Instead, the
community must embrace recovery.
Treatment
Duran et al. (2005) evaluated obstacles to Today, community development models are
being implemented in American Indian and
treatment entry among American Indians on
Alaska Native communities to address preven-
three different reservations; most frequently tion and treatment issues for mental and sub-
mentioned were the perception that good- stance use disorders as well as related issues,
quality or suitable services were unavailable such as suicide prevention (Edwards and
and the perceived need for individuals to be Egbert-Edwards 1998; HHS 2010; May et al.
2005). Using these models, communities move
self-reliant. They also found social relation-
toward greater commitment to social problem-
ships to be extremely important in overcoming solving and the development of effective,
these barriers. Jumper-Thurman and Plested culturally congruent strategies relevant to their
(1998) reported that focus groups of American Tribes or villages. According to Edwards et al.
Indian women listed mistrust as one of the (1995), community approaches often lead to:
• A reduction of substance use.
primary barriers for seeking treatment. This is
• Breaking intergenerational cycles of alco-
due, in part, to the women’s belief that they hol abuse.
would encounter people they knew among • Increased community support.
treatment agency staff; they also doubted the • The strengthening of individual and group
confidentiality of the treatment program. cultural identity.
• Leadership development.
• Increased interpersonal and inter-Tribal
Treatment Issues and problem-solving skills and solidarity.
Considerations
For an example, see Jumper-Thurman et al.
Each Tribe and community will likely have (2001).
different customs, healing traditions, and

143
 Improving Cultural Competence

To provide culturally responsive treatment, They also, for the most part, have a holistic
providers need to understand the Native view of health that incorporates physical,
American client’s Tribe; its history, traditions, emotional, and spiritual elements (Calabrese
worldview, and beliefs; the dimensions of its 2008), individual and community healing
substance abuse problem and other communi- (Duran 2006; McDonald and Gonzalez 2006),
ty problems; the incidence of trauma and and prevention and treatment activities
abuse among its members; its traditional (Johnston 2002). For many, culture is the path
healing practices; and its intrinsic strengths. to prevention and treatment.
Providers who work with Native Americans
However, not all Native Americans have a
but do not have an understanding of their
need to develop stronger connections to their
cultural identity and acculturation patterns are
communities and cultural groups. As Brady
at a distinct disadvantage (Ponterotto et al.
(1995) cautions, culture is complex and chang-
2000). Before beginning any treatment, pro-
ing, and a return to the values of a traditional
viders should routinely seek consultation with
culture is not always desired. An initial inquiry
knowledgeable professionals who are experi-
into each client’s connection with his or her
enced in working with the specific Tribal
culture, cultural identity, and desire to incor-
group in question (Duran 2006; Edwards and
porate cultural beliefs and practices into
Egbert-Edwards 1998; Straits et al. 2012) and
treatment is an essential step in culturally
should conduct thorough client assessments
competent practice. When appropriate, pro-
that evaluate cultural identity (see Appendix F
viders can help facilitate the client’s reconnec-
and Chapter 2 for resources). Some Native
tion with his or her community and cultural
American persons have a strong connection to
values as an integral part of the treatment
their cultures and others do not; some identify
plan. In addition, treatment providers need to
with a blend of American Indian cultural
adapt services to be culturally responsive. In
groups called pan-Indianism or inter-Tribal
doing so, outcomes are likely to improve not
identity. Still others are comfortable with a
only for Native American clients, but for all
dual identity that embraces both Native and
clients within the program. Fisher et al. (1996)
non-Native cultural groups.
modified a therapeutic community in Alaska
Native Americans often approach the begin- to incorporate Alaska Native spiritual and
ning of a relationship in a calm, unhurried cultural practices and found that retention
manner, and they may need more time to rates improved for White and African Ameri-
develop trust with providers. Concerns about can clients as well as Alaska Native clients
confidentiality can be an important issue to participating in the program.
address with Native American clients, espe-
In working with Native American clients,
cially for those in small, tightly-knit commu-
providers should be prepared to address spirit-
nities. For providers, it is very important to
uality and to help clients access traditional
make clear to clients that what they say to the
healing practices. Culturally responsive treat-
counselor will be held in confidence, except
ment should involve community events, group
when there is an ethical duty to report.
activities, and the ability to participate in
Native American cultural groups generally ceremonies to help clients achieve balance and
believe that health is nurtured through balance find new insight (Calabrese 2008). Stronger
and living in harmony with nature and the attachment to Native American cultural
community (Duran 2006; Garrett et al. 2012). groups protects against substance use and

144
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

abuse; therefore, strengthening this connection client strengths and empowerment, recognize
is important in substance abuse treatment the need to accept personal responsibility for
(Duran 2006; Moss et al. 2003; Spicer 2001; change, and make use of learning styles that
Stone et al. 2006). many Native Americans find culturally ap-
propriate (Heilbron and Guttman 2000;
Theoretical Approaches and McDonald and Gonzalez 2006). Motivational
Treatment Interventions interviewing is also recommended for Native
Some clinicians caution that a model of coun- American clients. In a small study, Villanueva
seling that requires self-disclosure to relative et al. (2007) found that all treatment modali-
strangers can be counterproductive with Native ties resulted in improvements at 15-month
American clients. Other authors recommend follow-up, but clients who received motiva-
CBT and social learning approaches for tional enhancement therapy reported signifi-
Native American clients, as such approaches cantly fewer drinks per drinking day during
typically have less cultural bias, focus on prob- the 10- to 15-month posttreatment follow-up
lem-solving and skill development, emphasize period. Venner et al. (2006) wrote a manual for
motivational interviewing with Native
American clients.
Advice to Counselors: Counseling
Native Americans Family therapy
When working with Native American clients, Family involvement in treatment leads to
providers should: better outcomes for Native Americans at the
• Use active listening and reflective re-
time of discharge from treatment (Chong and
sponses.
• Avoid interrupting the client. Lopez 2005). Research also suggests that
• Refrain from asking about family or per- family and community support can have a
sonal matters unrelated to substance abuse significant effect on recovery from substance
without first asking the client’s permission use disorders for this population ( Jones-
to inquire about these areas.
Saumty 2002; Paniagua 1998). Family therapy
• Avoid extensive note-taking or excessive
questioning. can be quite helpful and perhaps even essential
• Pay attention to the client’s stories, experi- for American Indian clients (Coyhis 2000),
ences, dreams, and rituals and their rele- especially when other social supports are
vance to the client. lacking ( Jones-Saumty 2002).
• Recognize the importance of listening and
focus on this skill during sessions. American Indians place high value on family
• Accept extended periods of silence during and extended family networks; restoring or
sessions.
• Allow time during sessions for the client to
healing family bonds can be therapeutic for
process information. clients with substance use disorders. Moreo-
• Greet the client with a gentle (rather than ver, Native American clients are sometimes
firm) handshake and show hospitality (e.g., less motivated to engage in “talk therapy” and
by offering food and/or beverages). more willing to participate in therapeutic
• Give the client ample time to adjust to the
setting at the beginning of each session.
activities that involve social and family rela-
• Keep promises. tionships ( Joe and Malach 2011). Treatment
• Offer suggestions instead of directions approaches should remain flexible and in-
(preferably more than one to allow for cli- clude clients’ families when appropriate.
ent choice). Counselors should be able to recognize what
Sources: Aragon 2006; Trimble et al. 2012. constitutes family, family constellations, and

145
 Improving Cultural Competence

family characteristics. The Native American adapted, group therapy can be very beneficial
concept of family can include elders, others and culturally congruent. It is important,
from the same clan, or individuals who are not however, to determine Native American clients’
biologically related. In many Tribes, all mem- level of acculturation before recommending
bers are considered relatives. Families can be Western models of group therapy, as less
matrilineal (i.e., kinship is traced through the acculturated Native clients are likely to be less
female line) and/or matrilocal (i.e., married comfortable with group talk therapy (Mail and
couples live with wife’s parents). Shelton 2002). Group therapy for Alaska
Natives should also be nonconfrontational and
When families do enter treatment, they may
focus on clients’ strengths.
initially prefer to focus on a concrete problem,
but not necessarily on the most significant Group therapy can incorporate Native
family issue. Discussion of a clearly defined American traditions and rituals to make it
presenting problem enables families to assess more culturally suitable. For example, the
the therapeutic process and better understand talking circle is a Native tradition easily
what is expected of them in treatment. Provid- adapted for behavioral health treatment. In
ers should be aware that the entire clan and/or this tradition, the members of the group sit in
Tribe could know about a given client’s treat- a circle. An eagle feather, stone, or other sym-
ment and progress. Family therapy models bolic item is passed around, and each person
such as network therapy, which makes use of speaks when he or she is handed the item.
support structures outside the immediate Based on a review of the literature, Paniagua
family and which were originally developed (1998) recommends that providers using
for Native American families living in urban group therapy with Native American clients:
communities, can be particularly effective with • Earn support or permission from Tribal
Native clients, especially when they have been authorities before organizing group therapy.
cut off from their home communities because • Consult with Native professionals.
of substance abuse or other issues. For more • If group members consent, invite respected
information on network therapy and similar Tribal members (e.g., traditional healers or
approaches, see TIP 39, Substance Abuse elders) to participate in sessions.
Treatment and Family Therapy (CSAT 2004b).
Mutual-help groups
Group therapy Native American peoples have a long history
Although researchers and providers once of involvement in mutual-help activities that
viewed group therapy as ineffective for Ameri- predates the 12-Step movement (Coyhis and
can Indian clients (Paniagua 1998), opinion White 2006). Depending on acculturation,
has shifted to recognize that, when appropri- availability of a community support network,
ately structured, group therapy can be a pow- and the nature of their presenting problems,
erful treatment component (Garrett 2004; Native American clients may be more likely to
Garrett et al. 2001; Trimble and Jumper- solicit help from significant others, extended
Thurman 2002). Garrett (2004) notes that family members, and community members.
many Native American Tribes have traditional Contemporary manifestations of Native
healing practices that involve groups; for many American mutual-help efforts include adapta-
of these cultural groups, healing needs to occur tions of the 12 Steps (Exhibit 5-4) and of 12-
within the context of the group or community Step meeting rituals and practices (Coyhis and
(e.g., in talking circles). Thus, if properly White 2006). Another modified element of

146
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Exhibit 5-4: The Lakota Version of the 12 Steps

The Lakota Tribe has adapted the 12 Steps to suit its particular belief system as follows:
1. I admit that because of my dependence on alcohol, I have been unable to care for myself and my
family.
2. I believe that the Great Spirit can help me to regain my responsibilities and model the life of my
forefathers (ancestors).
3. I rely totally on the ability of the Great Spirit to watch over me.
4. I strive every day to get to know myself and my position within the nature of things.
5. I admit to the Great Spirit and to my Indian brothers and sisters the weaknesses of my life.
6. I am willing to let the Great Spirit help me correct my weaknesses.
7. I pray daily to the Great Spirit to help me correct my weaknesses.
8. I make an effort to remember all those that I have caused harm to and, with the help of the Great
Spirit, achieve the strength to try to make amends.
9. I do make amends to all those Indian brothers and sisters that I have caused harm to whenever
possible through the guidance of the Great Spirit.
10. I do admit when I have done wrong to myself, those around me, and the Great Spirit.
11. I seek through purification, prayer, and meditation to communicate with the Great Spirit as a
child to a father in the Indian way.
12. Having addressed those steps, I carry this brotherhood and steps to sobriety to all my Indian
brothers and sisters with alcohol problems and together we share all these principles in all our
daily lives.

Source: CSAT 1999b, p. 56. Reprinted from material in the public domain.

the 12 Steps is use of a circular, rather than a considerable number also continue to partici-
linear, path to healing. The circle is important pate in traditional 12-Step groups. In the AI-
to American Indian philosophy, which sees the SUPER-PFP, 47 percent of Northern Plains
great forces of life and nature as circular Tribe respondents and 28.8 percent of South-
(Coyhis 2000). In addition, staff members of west Tribe respondents with a past-year sub-
the White Bison program have also rewritten stance use disorder reported 12-Step group
the AA “Big Book” from a Native American attendance in the prior year (Beals et al. 2006).
perspective (Coyhis and Simonelli 2005). The Mohatt et al. (2008b) found that more Alaska
principles of the 12 Steps, which involve using Natives in recovery reported participation in
the group or community to provide support 12-Step groups than in substance abuse treat-
and motivation while emphasizing spiritual ment. In Venner and Feldstein’s (2006) re-
reconnection, appeal to many Native Ameri- search with American Indians in recovery, 84
cans who see treatment as social in nature and percent of respondents had attended some
who view addiction as a spiritual problem. mutual-help meetings.
The Native American Wellbriety movement is Traditional healing and
a modern, indigenous mutual-help program complementary methods
that has its roots in 12-Step groups but incor- Native American peoples have a range of be-
porates Native American spiritual beliefs and liefs about health care—from traditional beliefs
cultural practices (Coyhis and Simonelli 2005; to strong support for modern science—and
Coyhis and White 2006; White Bison, Inc. may use a number of strategies when address-
2002; also see http://www.whitebison.org). ing health problems. Traditional healing prac-
Although the Wellbriety movement is popular tices are often used in conjunction with modern
with many Native Americans in recovery, a medicine. For example, American Indians

147
 Improving Cultural Competence

traditionally view all things as deeply inter- 2002; White 2000). The sweat lodge, in par-
connected. Disruption of the physical, mental, ticular, is frequently used in substance abuse
spiritual, or emotional sides of a person can treatment settings (Bezdek and Spicer 2006;
result in illness. A Native American client may Schiff and Moore 2006).
consult a medical doctor to address part of the
Alaskan behavioral health programs have
problem and a traditional healer to help regain
developed recovery camps to provide a treat-
balance and harmony.
ment setting that incorporates Native beliefs
The use of traditional healing for substance and seasonal practices (e.g., Old Minto Family
abuse and mental health problems is fairly Recovery Camp:
common among Native Americans (Herman- http://www.tananachiefs.org/ health-
Stahl and Chong 2002; Herman-Stahl et al. services/old-minto-family-recovery-camp-
2003). For example, among Native American new/). Recovery camps are based on the mod-
individuals who reported a substance use el of traditional Native Alaskan fishing camps
disorder in the past year, 57.4 percent of those and provide a context in which clients can
from a Southwest Tribe and 31.7 percent from learn about traditional practices, such as suste-
a Northern Plains Tribe used traditional heal- nance activities. Another program, the Village
ers or healing practices (Beals et al. 2006). In a Sobriety Project, incorporates traditional
survey of American Indians from three differ- Yup’ik and Cup’ik Eskimo traditions of hunt-
ent Arizona Tribes, 27.4 percent stated that ing, chopping wood, berry picking, and taking
they had used traditional healers and/or heal- tundra walks (Mills 2003). See Niven (2010)
ing practices to help with mental health prob- for a review of client-centered, culturally
lems (Herman-Stahl and Chong 2002). responsive behavioral health techniques for
Overall, many Native Americans believe that use with Alaska Natives.
culture is the primary avenue of healing and
It is difficult to measure the effectiveness of
that connecting with one’s culture is not only a
Native American healing practices using
means of prevention, but also a healing treat-
ment (Bassett et al. 2012) There are a number of potential pitfalls
that can occur when trying to integrate
Each Native American culture has its own Native spiritual and cultural practices into
specific healing practices, and not all of those treatment. Cultural groups are complex
practices are necessarily appropriate to adapt systems; removing pieces of them for
to behavioral health treatment settings. How- implementation as part of a treatment
ever, many traditional healing activities and program can be a disservice to the culture
ceremonies have been made accessible during as well as the clients (Kunitz et al. 1994;
treatment or effectively integrated into treat- Moss et al. 2003); a breach of customs
ment settings (Castro et al. 1999b; Coyhis and traditions; and a sign of disrespect for
the community and Tribe, Tribal lead-
2000; Coyhis and White 2006; Mail and
ership, and Native American practices. It
Shelton 2002; Sue 2001; White 2000). These is important to take the time to build
practices include sacred dances (such as the relationships and seek consultation with
Plains Indians’ sun dance and the Kiowa’s Tribal elders, and other Tribal leaders to
gourd dance), the four circles (a model for ensure that the best and most appropriate
conceptualizing a harmonious life), the talking steps are taken in creating a culturally
circle, sweat lodges, and other purification relevant and responsive treatment
practices (Cohen 2003; Mail and Shelton model and program.

148
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Western standards and practices. Limited or (Garrity 2000). In 2001, roughly 20 percent of
inconsistent funding, migration patterns, American Indians identified as Baptist, 17
culturally incompetent or incongruent evalua- percent as Catholic, 17 percent as having no
tion practices, and abuses incurred during or religious preference, and 3 percent as following
after data collection are major confounding a Tribal religion (Kosmin et al. 2001).
variables that have limited knowledge on the
The relative importance of religion can also
effectiveness of incorporating traditional
vary among diverse Native American commu-
practices into Western approaches to the
nities. Before pursuing traditional methods,
treatment of substance abuse and mental
assessment of clients’ spiritual orientation is
illness. Nonetheless, Mail and Shelton (2002)
important. Spirituality is a personal issue that
reviewed earlier literature on the use of “indig-
treatment providers must respect; clients
enous therapeutic interventions” for alcohol
should choose which spiritual and cultural
abuse and dependence and suggest that a
methods to incorporate into treatment. Pro-
number of these interventions have been of
viders should also be wary of an obsession
value to Native Americans with substance use
with their clients’ cultural activities, which may
disorders. Other authors have concurred
be considered intrusive (LaFromboise et al.
(Coyhis and White 2006; Sabin et al. 2004).
1993). Checking with community resources
Regardless of whether a program adapts spe- on the subject and asking the client “What
cific Native American healing practices, pro- feels right for you?” are appropriate steps to
viders working with this population should take in identifying whether traditional healing
recognize that spirituality is central to its practices will have therapeutic value. Providers
values and is perceived as an integral part of should consult with Native healers or Tribal
life itself. It is through spiritual experiences leaders about the appropriateness of using a
that Native Americans believe they will find particular practice as part of behavioral health
meaning in life. Some Native languages have services. Rather than using traditional healing
words that refer to spirituality as “walking methods themselves, counselors may wish to
around” or “living the path.” In many cases, the refer clients to a Native American healer in
spiritual traditions of Native Americans are the community or in the treatment program.
not (and have never been) conceived of as a
religion, but rather as a set of beliefs and Relapse prevention and recovery
practices that pervades every aspect of daily Despite limited data on long-term recovery
life (Deloria 1973). for Native Americans who have substance use
disorders, a few studies have found high rates
Despite religion and spirituality often playing of relapse following substance abuse treatment
important roles in recovery from mental and (see review in Chong and Herman-Stahl
substance use disorders for Native Americans, 2003). White and Sanders (2004) recommend
providers should not assume that only indige- that long-term recovery plans for Native
nous spirituality is relevant. The majority of Americans make use of a recovery manage-
Native Americans do not practice their tradi- ment rather than a traditional continuing care
tional spirituality exclusively, and Christian approach. Such an approach emphasizes the
religious institutions like the Native American use of informal recovery communities and
Church and Pentecostal churches have been traditional healing approaches to provide
instrumental in helping many Native Ameri- extended monitoring and support for Native
cans overcome substance use disorders Americans leaving treatment.

149
 Improving Cultural Competence

Researchers have conducted interviews with of the population in the 2010 Census; Mather
both American Indians (Bezdek and Spicer et al. 2011).
2006) and Alaska Natives (Hazel and Mohatt
White Americans, like other large ethnic and
2001; Mohatt et al. 2008; People Awakening
cultural groups, are extremely heterogeneous
Project 2004) who have achieved extended
in historical, social, economic, and personal
periods of recovery. Bezdek and Spicer (2006)
features, with many (often subtle) distinctions
identified two key tasks for American Indians
among subgroups. Perhaps because White
entering recovery. First, they need to learn how
Americans have been the majority in the
to respond to family and friends who drank
United States, it is sometimes forgotten how
with them and to those who supported their
historically important certain distinctions
recovery. Next, they have to find new ways to
between diverse White American ethnic
deal with boredom and negative feelings. By
heritages have been (and continue to be, for
accomplishing these tasks, Native clients can
some). Conversely, many White American
build new social support systems, develop
people prefer not to see themselves as such
effective coping strategies for negative feelings,
and instead identify according to their specific
and achieve long-term recovery. The People
ethnic background (e.g., as Irish American).
Awakening Project found that, among Alaska
For similar reasons, certain cross-cutting
Natives who had a substantial period of recov-
cultural issues (see Chapter 1) like geographic
ery, the development of active, culturally ap-
location, sexual orientation, and religious
propriate coping strategies was essential (e.g.,
affiliation are important in defining the cul-
distancing themselves from friends or family
tural orientations of many White Americans.
who drank heavily, getting involved in church,
doing community service, praying; Hazel and
Beliefs About and Traditions
Mohatt 2001; Mohatt et al. 2008; People
Awakening Project 2004). Involving Substance Use
Historically, use of alcohol was accepted
among White/European cultural groups
Counseling for White because it provided an easy way to preserve
Americans fruit and grains and did not contain bacteria
that might be found in water. Over time, the
According to the 2010 U.S. Census definition, production and consumption of alcohol be-
White Americans are people whose ancestors came an often-integral part of cultural activi-
are among those ethnic groups believed to be ties, which can be seen in the way some White
the original peoples of Europe, the Middle cultural groups take particular pride in nation-
East, or North Africa (Humes et al. 2011). al brands of alcoholic beverages (e.g., Scotch
The racial category of White Americans whisky, French wine; Abbott 2001; Hudak
includes people of various ethnicities, such as 2000). A number of European cultural groups
Arab Americans, Italian Americans, Polish (e.g., French, Italian) traditionally believed
Americans, and Anglo Americans (i.e., people that daily alcohol use was healthy for both
with origins in England), among others. Many mind and body (Abbott 2001; Marinangeli
Latinos will also identify racially (if not ethni- 2001), and for others (e.g., English, Irish), the
cally) as White American. Non-Latino White bar or pub was the traditional center of com-
Americans constitute the largest racial group munity life (O’Dwyer 2001). Despite some
in the United States (making up 63.7 percent variations in cultural attitudes toward appro-
priate drinking practices, alcohol has been and

150
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

remains the primary recreational substance for often more accepting of prescription medica-
Whites in the United States. Predominant tion abuse and less likely to perceive prescrip-
attitudes toward drinking in the United States tion medications as potentially harmful
more closely reflect those of Northern Europe; (Hadjicostandi and Cheurprakobkit 2002).
alcohol use is generally accepted during cele-
Despite illicit drug use now being as common
brations and recreational events, and, at such
among White Americans as people of color,
times, excessive consumption is more likely to
White Americans still tend to perceive drug
be acceptable.
use as an activity that occurs outside their
Typically, White European cultural groups families and communities. In a 2001 survey,
accept alcohol use as long as it does not inter- only 54 percent of White Americans ex-
fere with responsibilities, such as work or pressed concern that someone in their family
family, or result in public drunkenness (Hamid might develop a drug abuse problem compared
1998). However, among certain groups of with 81 percent of African Americans (Pew
White Americans (usually defined by religious Research Center for the People and the Press
beliefs), the use of alcohol or any other intoxi- 2001). In the same survey, White Americans
cant is considered immoral (van Wormer expressed less concern about drug abuse in
2001). These religious beliefs, combined with their neighborhoods than did other racial and
concerns about the effects of problematic ethnic groups. However, in terms of seeing
drinking patterns (especially among men in drugs as a national problem, White Americans
the frontier; White 1998), became the impetus and other racial and ethnic groups are in closer
for the early 19th-century creation of the agreement. Perhaps as a result of this misper-
Temperance Movement and culminated in the ception about the prevalence of drug use in
passing of the 18th Amendment to the United their homes and communities, White
States Constitution, which enacted Prohibition. American parents are less likely to convey
Although the Temperance Movement is no disapproval of drug use to their children than
longer a major political force, belief in the African American parents (National Center
moral and social value of abstinence continues on Addiction and Substance Abuse 2005) and
to be strong among some segments of the much more likely than Latino or African
White American population. American parents to think that their children
have enough information about drugs (Pew
Illicit drug use, on the other hand, has histori-
Research Center for the People and the Press
cally been demonized by White American
2001).
cultural groups and seen as an activity engaged
in by people of color or undesirable subcul- There are also differences in how White Amer-
tures (Bonnie and Whitebread 1970; Hamid icans, Latinos, and African Americans perceive
1998; Whitebread 1995). For example, White drug and alcohol addictions. White Americans
Americans typically link drug use to per- are less likely than African Americans, but
ceived threat of crime—particularly crimes more likely than Latinos, to state that they
perpetrated by people of color (Hamid 1998; believe a person can recover fully from addic-
Whitebread 1995). Attitudes have changed tion (Office of Communications 2008). How-
over time, but White American cultural ever, White Americans are more likely than
groups continue to enforce strong cultural African Americans to indicate that substance
prohibitions against most types of illicit drug use disorders should be treated as diseases
use. At the same time, White Americans are (Durant 2005).

151
 Improving Cultural Competence

Substance Use and Substance Use White Americans who use heroin are less likely
Disorders than people who use heroin from all other
major racial/ethnic groups except African
According to 2012 NSDUH data, rates of
Americans to have injected the drug
past-year substance use disorders were higher
(SAMHSA 2011c). White Americans are also
for White Americans than for Native
more likely than members of other major
Hawaiians, other Pacific Islanders, and Asian
racial/ethnic groups, except Native Hawaiians
Americans; rates of current alcohol use were
and other Pacific Islanders (for whom esti-
higher than for every other major ethnic/racial
mates may not be accurate), to have tried
group (SAMHSA 2013d). Alcohol has tradi-
ecstasy. Except for Native Americans (some of
tionally been the drug of choice among White
whom may use the hallucinogen peyote for
Americans of European descent; however, not
religious purposes), they are also more likely
all European cultural groups have the same
than other racial/ethnic groups to have tried
drinking patterns. Researchers typically con-
hallucinogens (SAMHSA 2011c). Research
trast a Northern/Eastern European pattern, in
confirms that prescription drug misuse is
which alcohol is consumed mostly on week-
more common among White Americans than
ends or during celebrations, with that of
African Americans or Latinos (Ford and
Southern Europe, in which alcohol is con-
Arrastia 2008; SAMHSA 2011c), and they are
sumed daily or almost daily but in smaller
more likely to have used prescription opioids
quantities and almost always with food. The
in the past year and to use them on a regular
Southern European pattern involves more
basis.
regular use of alcohol, but it is also associated
with less alcohol-related harm overall (after Comparative studies indicate that White
controlling for total consumption; Room et al. Americans are more likely than all other major
2003). The pattern of White Americans typi- racial/ethnic groups except Native Americans
cally follows that of Northern and Eastern to have an alcohol use disorder (Hasin et al.
Europe, but individuals from some ethnic 2007; Perron et al. 2009; Schmidt et al. 2007).
groups maintain the Southern European White Americans are at a greater risk of having
pattern. severe alcohol withdrawal symptoms (such as
delirium tremens) than are African Americans
White Americans, on average, begin drinking
or Latinos with alcohol use disorders (Chan et
and develop alcohol use disorders at a younger
al. 2009). So too, White Americans are more
age than African Americans and Latinos
likely than African Americans or Latinos to
(Reardon and Buka 2002). White Americans
meet diagnostic criteria for a drug use disorder
are more likely to have their first drink before
at some point during their lives (Perron et al.
the age of 21 and to have their first drink
2009). Overall, substance use disorders vary
before the age of 16 than members of any
considerably across and within non-European
other major racial/ethnic group except Native
White American cultural groups. For example,
Americans (SAMHSA 2011c). Some data
rates of substance abuse treatment admissions
suggest that White Americans begin using
in Michigan from 2005 suggest that substance
illicit drugs at an earlier age than African
use disorders may be considerably lower for
Americans (Watt 2008) and that the mean age
Arab Americans than other White Americans
for White Americans who inject heroin has
(Arfken et al. 2007).
decreased (Broz and Ouellet 2008).

152
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Mental and Co-Occurring Americans and about 60 percent lower for

Disorders Asian Americans (Grant et al. 2005). A simi-
lar pattern exists for major depressive disorder
About 20 percent of White Americans report-
(Hasin et al. 2005).
ed some form of mental illness in the past year,
and they were more likely to have past-year
Treatment Patterns
serious psychological distress than other popu-
White Americans are more likely to receive
lation groups excluding Native Americans
mental health treatment or counseling than
(SAMHSA 2012a).
other racial/ethnic groups (SAMHSA 2012b).
White Americans appear to be more likely White Americans are more likely than African
than Latinos or Asian Americans to have Americans to receive substance abuse treat-
CODs (Alegria et al. 2008a; Vega et al. 2009) ment services from a private physician or
and more likely to have concurrent serious other behavioral health or primary care profes-
psychological distress and substance use disor- sional (Perron et al. 2009). Among White
ders (SAMHSA 2011c). White Americans American clients entering substance abuse
with CODs are also more likely to receive treatment programs in 2010, alcohol (alone or
treatment for both their substance use and in conjunction with illicit drugs) was most
mental disorders than are African Americans often the primary substance of abuse, followed
with CODs (Alvidrez and Havassy 2005; by heroin and cannabis. However, findings are
Hatzenbuehler et al. 2008), but they are per- inconsistent concerning the relative frequency
haps less likely to receive treatment for their with which White Americans enter substance
substance use disorder alone (Alvidrez and abuse treatment. Some studies have found that
Havassy 2005). White Americans are more White Americans are more likely to receive
likely to receive family counseling and mental needed behavioral health services than both
health services while in substance abuse treat- African Americans and Latinos (Marsh et al.
ment and less likely to have unmet treatment 2009; Wells et al. 2001). In contrast, other
needs (Marsh et al. 2009; Wells et al. 2001). In studies have found that African Americans
addition, White Americans are significantly with an identified need are somewhat more
less likely than Latinos or African Americans likely to enter treatment for drug use disorders
to believe that antidepressants are addictive and about as likely to receive treatment for
(Cooper et al. 2003). alcohol use disorders when compared with
White Americans (Hatzenbuehler et al. 2008;
The most common mental disorders among
Perron et al. 2009; SAMHSA, CBHSQ 2012;
White Americans are mood disorders (par-
Schmidt et al. 2006).
ticularly major depression and bipolar I disor-
der) and anxiety disorders (specifically Beliefs and Attitudes About
phobias, including social phobia, and general-
ized anxiety disorder; Grant et al. 2004b).
Treatment
Among White Americans, these disorders are White Americans appear to be generally
more prevalent than in any other ethnic/racial accepting of behavioral health services. They
groups save Native Americans (Grant et al. have better access to health care and are more
2005; Hasin et al. 2005). For example, rates of a likely to use services than people of color, but
lifetime diagnosis of generalized anxiety disor- this varies widely based on socioeconomic
der are about 40 percent lower for African status and cultural affiliation. Most treatment
Americans and Latinos than for White services have historically been developed for

153
 Improving Cultural Competence

White American populations, so it is not opposed to being in partial remission or drink-

surprising that White Americans are more ing without symptoms of alcohol dependence
likely than other racial/ethnic groups to be (Dawson et al. 2005).
satisfied with treatment services (Tonigan
2003). Treatment Issues and
Still, attitudes differ among certain cultural
Considerations
subgroups of White Americans. For example, Most major treatment interventions have been
Russian immigrants from the former Soviet evaluated with a population that is largely or
Union have a longstanding distrust of mental entirely White American, although the role of
health systems and hence may avoid substance White American cultural groups is rarely
abuse treatment (Kagan and Shafer 2001). considered in evaluating those interventions.
Other groups who have a strong family orien- For example, as Straussner (2001) notes, “the
tation, such as Italian Americans or Scotch- paradox of writing about substance abusers of
Irish Americans, might avoid treatment that European background is that they are a group
asks them to reveal family secrets (Giordano that is believed to be the group for whom the
and McGoldrick 2005; Hudak 2000). traditional alcohol and other drug treatment
models have been developed, and yet they are
According to 2010 NSDUH data regarding a group whose unique treatment needs and
people who recognized a need for substance treatment approaches have rarely been ex-
abuse treatment in the prior year but did not plored” (p. 165). Very few evaluations of
receive it, White Americans were more likely treatment strategies and interventions (wheth-
than members of other major racial/ethnic er based on research or clinical observation)
groups to state that it was because they had no have taken into account ethnic and cultural
time for treatment, that they were concerned differences among White American clients,
what their neighbors might think, that they and therefore it is generally not possible to
did not want others to know, and/or that they make culturally responsive recommendations
were concerned about how it might affect for specific subgroups of White Americans.
their jobs (SAMHSA 2011c). Other research
confirms that White Americans are significant- Culturally responsive treatment for many
ly more likely to avoid treatment due to fear of White Americans will involve helping them
what others might think or because they are in rediscover their cultural backgrounds, which
denial (Grant 1997). White Americans may sometimes have been lost through acculturation
also have different attitudes toward recovery, at and can be an important part of their long-
least regarding alcohol use disorders, than do term recovery. Giordano and McGoldrick
members of other ethnic/racial groups. Ac- (2005) note that ethnic identity and culture
cording to NESARC data on people who can be more important for some White
met criteria for a diagnosis of alcohol de- Americans “in times of stress or personal
pendence at some point during their lives, crisis,” when they may want to “return to
White Americans were more likely than familiar sources of comfort and help, which
African Americans, Latinos, or other non- may differ from the dominant society’s norms”
Latinos to have achieved remission from that (p. 503). Appendix B provides information on
disorder but were also less likely than African instruments for assessing cultural identifica-
Americans or other non-Latinos (but not tion. For an overview of challenges in main-
Latinos) to currently abstain from drinking, as taining mental health, access to health care,

154
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

and help-seeking among White Americans, ethnic heritages, and there is no approach that
see Downey and D’Andrea (2012). is effective for all White Americans in family
therapy (Hanson 2011). Hierarchical families,
Theoretical Approaches and such as German American families, may
Treatment Interventions expect the counselor to be authoritative, at
Overall, the optimum treatment approach least in the initial sessions (Winawer and
with White Americans is a comprehensive Wetzel 2005), although a more egalitarian
one; the more tools in the toolkit, the greater German American family might not respond
the chance of success (McCaul et al. 2001). well to such imperatives. In the same vein, one
Within-group differences arise regarding client of French background could readily
education level, socioeconomic status, gender, accept direct and clear therapeutic assign-
and other factors, which must be considered. ments that contain measurable goals (Abbot
Providers can, however, assume that most 2001), whereas another French American
well-accepted treatment approaches and inter- client may value counseling that is more pro-
ventions (e.g., CBT, motivational interviewing, cess oriented. Thus, it is imperative to assess
12-Step facilitation, contingency management, the cultural identification of clients and their
pharmacotherapies) have been tested and families, along with the treatment needs that
evaluated with White American clients. best match their cultural worldviews.

Still, treatment is not uniformly appropriate In some White American families, there is a
even for White Americans. Approaches may longstanding culture of drinking. Attempts at
need modification to suit class, ethnic, reli- abstinence can be perceived by family mem-
gious, and other client traits. Providers should bers as culturally inappropriate. In other fami-
establish not only the client’s ethnic back- lies, there is deep denial about alcohol abuse or
ground, but also how strongly the person dependence, especially when talking about
identifies with that background. Few clinicians substance use to those outside the family. For
have made observations on best therapeutic example, some Polish American families can
approaches for members of particular White be resistant to the idea that drinking is the
American cultural/ethnic subgroups. cause of family problems (Folwarski and
Smolinski 2005) and sometimes believe that
Family therapy to admit an alcohol problem, especially to
In White American families, individuals are someone outside the family, signals weakness.
generally expected to be independent and self-
reliant; as a result, families in therapy can have Group therapy
trouble adjusting to work that focuses more on Standard group therapies developed for men-
communication processes than specific prob- tal health and substance abuse treatment
lems or content (McGill and Pearce 2005). programs have generally been used and evalu-
Van Wormer (2001) notes that many White ated with White American populations. For
Americans need help addressing communica- details on group therapy in substance abuse
tion issues. In family therapy, useful approach- treatment, see TIP 41, Substance Abuse Treat-
es include those that encourage open, direct, ment: Group Therapy (CSAT 2005c).
and nonthreatening communication.
Mutual-help groups
There is no singular description that fits Mutual-help groups, of which AA is the most
White American families within or across prevalent, have a largely White American

155
 Improving Cultural Competence

membership (AAWS 2008; Atkins and Traditional healing and

Hawdon 2007). In a 2011 survey, 87 percent complementary methods
of AA members indicated their race as White Only 12 percent of White Americans consider
(AAWS 2012). In research with largely White themselves atheist, agnostic, or secular without
populations, AA participation has been found a religious affiliation, meaning that, as a group,
to be an effective strategy for promoting White Americans are more religious than
recovery from alcohol use disorders (Dawson Asian Americans but less so than Latinos or
et al. 2006; McCrady et al. 2004; Moos and African Americans (Pew Forum on Religion
Moos 2006; Ritsher et al. 2002; Weisner et al. and Public Life 2008). As with other groups,
2003). Other mutual-help groups, such as White Americans belong to many different
Self-Management and Recovery Training, religions, although the vast majority belong to
Secular Organizations for Sobriety/Save Our various Christian denominations, with approx-
Selves, and Women for Sobriety, also have imately 57 percent identifying as Protestant
predominately White American membership and 25.9 percent as Catholic (National Center
and are based on Western ideas drawn from on Addiction and Substance Abuse, 2001).
psychology (Atkins and Hawdon 2007; White White Americans also make up 91 percent of
1998). practitioners of Judaism in the United States,
The appeal of mutual-help groups among 14 percent of followers of Islam, and 32 per-
White Americans rests on the historical ori- cent of the American Buddhist population
gins of this model. The 12-Step model was (Kosmin et al. 2001). For more religious
originally developed by White Americans White Americans, pastoral counseling or
based on European ideas of spirituality, faith, prayer can be useful aids in the treatment of
and group interaction. Although the model substance use disorders. However, White
has been adopted worldwide by different Americans are significantly less likely to use
cultural groups (White 1998), the 12-Step prayer as a method of coping (Graham et al.
model works especially well for White ethnic 2005). White Americans are more likely than
groups, including Irish Americans, Polish members of other major racial/ethnic groups
Americans, French Americans, and Scotch- to use complementary or alternative medical
Irish Americans, because it incorporates therapies, such as herbal medicine, acupunc-
Western cultural traditions involving spiritual ture, chiropractors, massage therapy, yoga, and
practice, public confession, and the use of special diets (Graham et al. 2005).
anonymity to protect against humiliation
(Abbott 2001; Gilbert and Langrod 2001; Relapse prevention and recovery
Hudak 2000; McGoldrick et al. 2005; Taggart Factors that promote recovery for White
2005). Americans include the learning and use of
coping skills (Litt et al. 2003; Litt et al. 2005;
In addition to mutual-help groups for sub- Maisto et al. 2006). Even though some research
stance abuse, numerous recovery support suggests that White Americans are less likely
groups, Internet resources, Web-based com- to use coping skills than African Americans
munities, and peer support programs are (Walton 2001) and have lower levels of self-
available to promote mental health recovery. efficacy upon leaving treatment (Warren et al.
Many resources are available through the 2007), the development of these skills and of
National Alliance on Mental Illness self-efficacy is important in managing relapse
(http://www.nami.org). risks and in maintaining recovery. Counselors

156
 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

may offer psychoeducation on the value of 2002; McIntosh and McKeganey 2000;
coping strategies, specific skills to manage Rumpf et al. 2002). Other important factors
stressful situations or environments, and op- include continuing care, the development of
portunities to practice these skills during substitute behaviors (i.e., reliance on healthy
treatment. Some coping skills or strategies or positive activities in lieu of substance use),
may be more important than others in manag- the creation of new caring relationships that
ing high-risk situations, but research suggests do not involve substance use, and increased
that greater use of a variety of coping strate- spirituality (Valliant 1983). Valliant (1983)
gies is more important than the use of any one and others (e.g., Laudet et al. 2002; McCrady
specific skill (Gossop et al. 2002). et al. 2004; Moos and Moos 2006) conclude,
based on research with mostly White partici-
Social and family supports are also important
pants, that mutual-help groups often play an
in maintaining recovery and preventing re-
important role in maintaining recovery.
lapse among White Americans (Laudet et al.

TIPs That Provide Supplemental Information on Topics in This Chapter

TIP 34: Brief Interventions and Brief Therapies for Substance Abuse (CSAT 1999a)

TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment (CSAT 1999c)

TIP 39: Substance Abuse Treatment and Family Therapy (CSAT 2004b)

TIP 41: Substance Abuse Treatment: Group Therapy (CSAT 2005c)

TIP 42: Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005d)

TIP 44: Substance Abuse Treatment for Adults in the Criminal Justice System (CSAT 2005b)
TIP 47: Substance Abuse: Clinical Issues in Intensive Outpatient Treatment (CSAT 2006c)

TIP 51: Substance Abuse Treatment: Addressing the Specific Needs of Women (CSAT 2009c)

TIP 57: Trauma-Informed Care in Behavioral Health Services (SAMHSA 2014)

Planned TIP: Relapse Prevention and Recovery Promotion in Behavioral Health Services (SAMHSA
planned e)

157
 6 Drug Cultures and the
Culture of Recovery

Lisa is a 19-year-old White college student living in San Diego,

IN THIS CHAPTER CA, who was sent to treatment by her parents after failing her
• What Are Drug Cultures? college classes and being placed on academic probation. While
• The Role of Drug Cultures home on break earlier that year, her parents found pills in her room
in Substance Abuse but let her return to school after she promised to stop using. The
Treatment academic probation is only part of the reason her parents sent her
to treatment. They were also concerned about her recent weight
loss, as her older sister had previously struggled with bulimia.
Lisa began using marijuana at age 15 with a cousin. In her first year
of high school, she had difficulty fitting in. However, the next year,
she became friendly with an electronic dance music clique that
helped her define an identity for herself and introduced her to ecsta-
sy (3,4-methylenedioxymethamphetamine, or MDMA), metham-
phetamine, and various hallucinogens, along with new ideas about
politics, music, and art. She has since found similar friends at college
and keeps in touch with several members of her high school clique.
In treatment, Lisa tells her counselor that she has long felt neglect-
ed by her parents, who are too interested in material things. She
sees her drug use and that of her friends as a rebellion against the
materialistic attitudes of their parents. She also dismisses her fami-
ly’s cultural heritage, insisting that her parents only identify as
Americans even though they are first-generation Americans with
European backgrounds. She talks at length about ways to acquire
and prepare relatively unknown hallucinogens, the best music to
listen to while using, and how to evaluate the quality of marijuana.
Lisa says that she doesn’t believe she has a problem. She thinks that
her failing grades reflect her lack of interest in college, which she
says she is attending only because people expect it of her. When
asked what she would rather be doing, she says she does not have
any clearly defined goals and just wants to do “something with art

159
 Improving Cultural Competence

which she notes “isn’t even illegal,” and take

This Treatment Improvement Protocol
(TIP) emphasizes the concept that many other botanical hallucinogens. She is adamant
subcultures exist within and across diverse about keeping her friends, who she says have
ethnic and racial populations and cultures. been supportive of her and are not materialis-
Drug cultures are a formidable example— tic “sellouts” like her parents.
these are cultures that can influence the
presentation of mental, substance use, Her counselor places a priority on connecting
and co-occurring disorders as well as Lisa with other people her age who are in
prevention and treatment strategies recovery. She asks a client who graduated from
and outcomes. the program and is only a year older than Lisa
to accompany her to Narcotics Anonymous
(NA) meetings attended mostly by younger
people in recovery. The counselor also encour-
or music.” Lisa points out that, unlike most of ages Lisa’s friendships with other young peo-
her classmates, she doesn’t drink and has ple in the program. When Lisa complains
stopped doing addictive drugs like ecstasy and about her parents’ materialism and the materi-
methamphetamine, which were responsible for alism of mainstream culture, her counselor
her weight loss. She is convinced that she can brings up the spiritual elements of mutual-
continue to smoke pot and Salvia divinorum, help recovery groups and how they provide an

Multidimensional Model for Developing Cultural Competence: Drug Cultures

160
 Chapter 6—Drug Cultures and the Culture of Recovery

alternative model for interacting with others.

The counselor begins to help Lisa explore how
What Are Drug Cultures?
her drug use may be an attempt to fill her Up to this point, this TIP has focused on
unmet emotional and social needs and may cultures based on ethnicity, race, language, and
hinder the development of her own interests, national origin. The TIP looks primarily at
identity, and goals. those cultural groups because they are the
major cultural forces that shape an individual’s
Treatment providers should consider how
life and worldview. However, there are other
cultural aspects of substance use reinforce
types of cultural groups (sometimes referred to
substance use, substance use disorders, and
as subcultures) that are also organized around
relapses. Factors to note include clients’ possi-
shared values, beliefs, customs, and traditions;
ble self-medication of psychological distress or
these cultural groups can have, as their core
mental disorders. Beyond specific biopsycho-
organizing theme, such factors as sexuality,
social issues that contribute to the risk of
musical styles, political ideologies, and so on.
substance-related disorders and the initiation
For most clients in treatment for substance use
and progression of use, counselors and treat-
disorders (including those who have a co-
ment organizations must continually acquire
occurring mental disorder), the drug subcul-
knowledge about the ever-changing, diverse
ture will likely have affected their substance
drug cultures in which client populations may
use and can affect their recovery; that is the
participate and which reinforce the use of
primary rationale for the development of this
drugs and alcohol. Moreover, behavioral health
unique chapter. Research literature in this
service providers and program administrators
topic area is considerably limited.
need to translate this knowledge into clinical
and administrative practices that address and Some people question whether a given drug
counter the influence of these cultures within culture is in fact a subculture, but many seem
the treatment environment (e.g., by instituting to have all the elements ascribed to a culture
policies that ban styles of dress that indicate (see Chapter 1). A drug culture has its own
affiliation with a particular drug culture). history (pertaining to drug use) that is usually
orally transmitted. It has certain shared values,
Adopting Sue’s multidimensional model (2001)
beliefs, customs, and traditions, and it has its
for developing cultural competence, this chap-
own rituals and behaviors that evolve over
ter identifies drug cultures as a domain that
time. Members of a drug culture often share
requires proficiency in clinical skills, program-
similar ways of dressing, socialization patterns,
matic development, and administrative practic-
language, and style of communication. Some
es. It explores the concept of drug cultures, the
even develop a social hierarchy that gives
relationship between drug cultures and main-
different status to different members of the
stream culture, the values and rituals of drug
culture based on their roles within that culture
cultures, and how and why people value their
( Jenkot 2008). As with other cultures, drug
participation in drug cultures. This chapter
cultures are localized to some extent. For exam-
describes how counselors can determine a
ple, people who use methamphetamines in
client’s level of involvement in a drug culture,
Hawaii and Missouri could share certain atti-
how they can help clients identify and develop
tudes, but they will also exhibit regional differ-
alternatives to the drug cultures in which they
ences. The text boxes in this chapter offer
participate, and the importance of assisting
examples of the distinct values, languages,
clients in developing a culture of recovery.

161
 Improving Cultural Competence

rituals, and types of artistic expression associ-

Exhibit 6-1: How Drug Cultures Differ
ated with particular drug cultures.
• There is overlap among members, but drug
Many subcultures exist outside mainstream cultures differ based on substance used—
society and thus are prone to fragmentation. A even among people from similar ethnic and
single subculture can split into three or four socioeconomic backgrounds. The drug cul-
related subcultures over time. This is especially ture of heroin use (McCoy et al. 2005;
Pierce 1999; Spunt 2003) differs from the
true of drug cultures, in which people use drug culture of ecstasy use (Reynolds 1998).
different substances, are from different locales, • Drug cultures differ according to geo-
or have different socioeconomic statuses; they graphic area; people who use heroin in the
may also have very different cultural attitudes Northeast United States are more likely to
related to the use of substances. Bourgois and inhale than inject the drug, whereas the
opposite is true among people in the
Schonberg (2007) described how ethnic and Western United States who use heroin
racial differences can affect the drug cultures (Office of Applied Studies [OAS] 2004).
of users of the same drugs to the point that • Drug cultures can differ according to other
even such things as injection practices can social factors, such as socioeconomic status.
differ between Black and White heroin users The drug culture of young, affluent people
who use heroin can occasionally mirror the
in the same city. Exhibit 6-1 lists of some of drug culture of the street user, but it will al-
the ways in which drug cultures can differ so have notable differences (McCoy et al.
from one another. 2005; Pierce 1999; Spunt 2003).
• Drug cultures (even involving the same
Differences in the physiological and psycho- drugs and the same locales) change over
logical effects of drugs account for some dif- time; older people from New York who use
ferences among drug cultures. For example, heroin and who entered the drug culture in
the 1950s or 1960s feel marginalized within
the drug culture of people who use heroin is
the current drug scene, which they see as
typically less frenetic than the drug culture promoting a different set of values
involving methamphetamine use. However, (Anderson and Levy 2003).
other differences seem to be more clearly
related to the historical development of the change factors are quite different. In Missouri,
culture itself or to the effects of larger social the low cost and easy production of the drug
forces. Cultural and socioeconomic compo- influenced development of a methampheta-
nents contributed to the rise in methamphet- mine drug culture. Missouri leads the nation
amine use among gay men on the West Coast in the number of methamphetamine labs seized
(Reback 1997) and among Whites of lower by police; a disproportionately large number of
socioeconomic status in rural Missouri seizures occur in rural areas (Carbone-Lopez et
(Topolski and Anderson-Harper 2004). How- al. 2012; Topolski and Anderson-Harper
ever, in these two cases, the details of those 2004). The popularity of the drug among

How To Identify Key Characteristics of a Drug Culture

Counselors and clinical supervisors must acquire knowledge about drug cultures represented within
the client population. Drug cultures can change rapidly and vary across racial and ethnic groups,
geographic areas, socioeconomic levels, and generations, so staying informed is challenging. Besides
needing an understanding of current drug cultures (to help prevent infiltration of related behaviors
and attitudes within the treatment environment), counselors also need to help clients understand how
such cultures support use and pose dynamic relapse risks.

(Continued on the next page.)

162
 Chapter 6—Drug Cultures and the Culture of Recovery

How To Identify and Discuss Key Characteristics of a Drug Culture (continued)

Counselors can use this exercise to begin to educate clients about the influence of drug cultures and
help them identify the specific behaviors, values, and attitudes that constitute their experience of using
alcohol and drugs. It can be a helpful tool in improving clients’ understanding of the reinforcing as-
pects of alcohol and drug use beyond physiological effects. In addition, this exercise can be used as a
training tool in clinical supervision to help counselors understand the influence and potential reinforc-
ing qualities of a drug culture among clients and within the treatment milieu.
Materials needed: Diagram handout and pencils.
Instructions:
• Determine whether this exercise is more appropriate as an individual or group exercise. Assess
the newness and variability of recovery within the group constellation. If several group members
support recovery-related behavior, conducting this exercise may be a beneficial educational tool
and means of intervention with clients who continue to identify mainly with their drug culture.
Conversely, if most group members are new or have had difficulty accepting treatment or
treatment guidelines, this exercise may be more aptly used as an individual tool.
• Attention: In group settings, strict parameters need to be established at the beginning of the
session to ensure that the discussion remains centered on attitudes, values, and behaviors sur-
rounding drug and alcohol use—not on specific techniques or procedures for using drugs or rit-
uals surrounding intake or injection.
• Start the discussion by first presenting the idea that drug cultures exist—describing the main
elements that constitute culture (refer to Chapter 1 or the categories identified in the “Drug
Culture” diagram below). Next, provide examples of how drug culture can support continued
use and relapse. Keep in mind that not all clients are engaged in a drug culture.
• Following the general introduction, review each block in the diagram and ask clients to provide
examples related to their own use and involvement with drugs and alcohol. After discussing
their examples, ask them to identify the most significant behaviors, attitudes, and values that re-
inforce their use (e.g., a feeling of acceptance or camaraderie).
• Counselors can redirect this general discussion to related topics—for example, by identifying
behaviors, values, and attitudes likely to support recovery or by shifting from discussion to role-
plays that will help clients address relapse risks associated with their drug culture and practice
coping skills (e.g., assertiveness or refusal skills to counter the influence of others once they are
discharged from the program or to address situations that arise during the course of treatment).

Drug Culture
Establishing Trust and
Socialization Values
Credibility
How were you introduced to the What values are upheld or
How do you go about
culture? devalued in the group?
establishing credibility?
Gender Roles and
Status Rules
Relationships
In what ways can you obtain Are there spoken and unspoken
What gender expectations
status or be seen as a success? rules or norms?
exist surrounding drug use?
Concepts of Sanction, Dress
Symbols and Images
Punishment, and Conflict Are there specific ways to
Are there symbols that represent
Mediation dress that show allegiance
a particular association with a
How does the group deal with to a specific substance or
group or substance?
in-group conflicts? group?
Language & Communication
View of Past, Present, Attitudes
Are there special verbal or
and Future What are common attitudes
nonverbal ways to communicate
Are there specific beliefs about toward others (nonusers,
about substance-
the past, present, and/or future? police, etc.)?
related activities?

163
 Improving Cultural Competence

Whites could be linked to the historical de- shops” from multiple doctors and procures
velopment of the methamphetamine trade by drugs for misuse from pharmacies. Although
White motorcycle gangs (Morgan and Beck drug cultures typically play a greater role in
1997). On the other hand, most gay men who the lives of people who use illicit drugs, people
use the drug report having first used it at who use legal substances—such as alcohol—
parties with the expectation of involvement in are also likely to participate in such a culture
sexual activity (Hunt et al. 2006). In studies of (Gordon et al. 2012). Drinking cultures can
gay men who used methamphetamine, the develop among heavy drinkers at a bar or a
main reason for use was to heighten sexual college fraternity or sorority house that works
experience (Halkitis et al. 2005; Kurtz 2005; to encourage new people to use, supports high
Reback 1997). Morgan and Beck (1997) levels of continued or binge use, reinforces
found that increased sexual activity was one denial, and develops rituals and customary
reason why certain women and heterosexual behaviors surrounding drinking. In this chap-
men used methamphetamine, but it was not as ter, drug culture refers to cultures that evolve
important a reason as it was for gay men. from drug and alcohol use.
This chapter aims to explain that people who The Relationship Between Drug
use drugs participate in a drug culture, and
further, that they value this participation.
Cultures and Mainstream Culture
However, not all people who abuse substances To some extent, subcultures define themselves
are part of a drug culture. White (1996) draws in opposition to the mainstream culture. Sub-
attention to a set of individuals whom he calls cultures may reject some, if not all, of the values
“acultural addicts.” These people initiate and and beliefs of the mainstream culture in favor
sustain their substance use in relative isolation of their own, and they will often adapt some
from other people who use drugs. Examples of elements of that culture in ways quite different
acultural addicts include the medical profes- from those originally intended (Hebdige 1991;
sional who does not have to use illegal drug Issitt 2009; Exhibit 6-2). Individuals often
networks to abuse prescription medication, or identify with subcultures—such as drug cul-
the older, middle-class individual who “pill tures—because they feel excluded from or

Exhibit 6-2: The Language of a Drug Culture

One of the defining features of any culture is the language it uses; this need not be an entire lan-
guage, and may simply comprise certain jargon or slang and a particular style of communication. The
use of slang regarding drugs and drug activity is a well-recognized aspect of drug culture. Not as
well-known is the diversity of that language and how it varies across time and place. Rather than
coining new words, the language of drug culture often borrows words from mainstream culture and
adapts them to new purposes.

For example, Williams (1992) examined the use of Star Trek terminology among people who used
crack cocaine in New York during the 1980s. They adopted the persona of members of the Star Trek
Enterprise crew in their use of language—such as “going on a mission” when they went looking for
cocaine; “beam me up, Scotty” when they wanted to get high; and referring to crack cocaine itself as
“Scotty.” Crack cocaine users even created an imaginary book entitled The Book of Tech that they
referred to as if it contained important information for people who use and sell crack cocaine (e.g.,
how to cook freebase cocaine from cocaine hydrochloride). This language (and other terms derived
from other sources) helped members of this drug culture recognize other members. People who did
not understand the terms used were typically taken advantage of during drug transactions.

164
 Chapter 6—Drug Cultures and the Culture of Recovery

unable to participate in mainstream society. chances of any attempt to change behavior

The subculture provides an alternative source (Cohen 1992). The drug culture enables its
of social support and cultural activities, but members to view substance use disorders as
those activities can run counter to the best normal or even as status symbols. The disorder
interests of the individual. Many subcultures becomes a source of pride, and people may
are neither harmful nor antisocial, but their celebrate their drug-related identity with other
focus is on the substance(s) of abuse, not on members of the culture (Pearson and Bourgois
the people who participate in the culture or 1995; White 1996). Social stigma also aids in
their well-being. the formation of oppositional values and
beliefs that can promote unity among mem-
Mainstream culture in the United States has
bers of the drug culture (Exhibit 6-3).
historically frowned on most substance use
and certainly substance abuse (Corrigan et al. When people with substance use disorders
2009; White 1979, 1998). This can extend to experience discrimination, they are likely to
legal substances such as alcohol or tobacco delay entering treatment and can have less
(including, in recent years, the increased pro- positive treatment outcomes (Fortney et al.
hibition against cigarette smoking in public 2004; Link et al. 1997; Semple et al. 2005).
spaces and its growing social unacceptability Discrimination can also increase denial and
in private spaces). As a result, mainstream step up the individual’s attempts to hide sub-
culture does not—for the most part—have an stance use (Mateu-Gelabert et al. 2005). The
accepted role for most types of substance use, immorality that mainstream society attaches
unlike many older cultures, which may accept to substance use and abuse can unintentionally
use, for example, as part of specific religious serve to strengthen individuals’ ties with the
rituals. Thus, people who experiment with drug culture and decrease the likelihood that
drugs in the United States usually do so in they will seek treatment.
highly marginalized social settings, which can
The relationship between the drug and main-
contribute to the development of substance
stream cultures is not unidirectional. Since the
use disorders (Wilcox 1998). Individuals who
beginning of a definable drug culture, that
are curious about substance use, particularly
culture has had an effect on mainstream cul-
young people, are therefore more likely to
tural institutions, particularly through music
become involved in a drug culture that en-
(Exhibit 6-4), art, and literature. These con-
courages excessive use and experimentation
nections can add significantly to the attraction
with other, often stronger, substances (for a
a drug culture holds for some individuals
review of intervention strategies to reduce
(especially the young and those who pride
discrimination related to substance use disor-
themselves on being nonconformists) and
ders, see Livingston et al. 2012).
create a greater risk for substance use escalat-
When people who abuse substances are mar- ing to abuse and relapse.
ginalized, they tend not to seek access to
mainstream institutions that typically provide Understanding Why People Are
sociocultural support (Myers et al. 2009). This Attracted to Drug Cultures
can result in even stronger bonding with the To understand what an individual gains from
drug culture. A marginalized person’s behavior participating in a drug culture, it is important
is seen as abnormal even if he or she attempts first to examine some of the factors involved
to act differently, thus further reducing the

165
 Improving Cultural Competence

Exhibit 6-3: The Values and Beliefs of a Heroin Culture

Many core values of illicit drug cultures involve rejecting mainstream society and its cultural values.
Stephens (1991) analyzed value statements from people addicted to heroin and extracted the core
tenets of this drug culture’s value system. They are:
• Antisocial viewpoint—Members of this drug culture share a viewpoint that sees all people as
basically dishonest and egocentric; they are especially distrustful of those who do not use heroin.
• Rejection of middle-class values—Members denigrate values such as the need for hard work,
security, and honesty.
• Excitement/hedonism—Members value immediate gratification and the intense pursuit of pleas-
ure over more stable and lasting values.
• Importance of outward appearances—As much as members of the drug culture may complain
about the mainstream culture’s shallowness, they strongly believe in conspicuous consumption
and the importance of owning things that give an image of prosperity.
• Valence of street addict subcultures—Members of this drug culture value the continued partici-
pation of others in the culture, even to the point of expecting individuals who have stopped us-
ing to continue to participate in the culture.
• Emotional detachment—People involved in this drug culture value emotional aloofness and see
emotional involvement with others as a weakness.

These core values (initially examined by Stephens et al. 1976) were taken from a specific drug culture
(heroin), but they can be found in many other drug cultures that center on the use of illicit drugs.
However, these same values will not be upheld in every drug culture. For instance, the drug culture
of people who use MDMA does not appear to value emotional aloofness, but rather to appreciate
the drug’s ability to create a feeling of emotional intimacy among those who use it (Gourley 2004;
Reynolds 1998). Drug cultures involving legal substances (notably alcohol) are less likely to reject the
core values of mainstream society and are less likely to be rejected by that society. They will, howev-
er, still value excitement/hedonism and the participation of others in the subculture.

Exhibit 6-4: Music and Drug Cultures

Since the 1920s, when marijuana use became associated with jazz musicians, there has been a con-
nection between certain music subcultures and particular types of substance use (Blake 2007;
Gahlinger 2001). As Blackman (1996) notes, “Before the emergence of post-war youth culture, there
was a direct connection between the development of the popular music—jazz—and the use of illicit
drugs in terms of musicians who used drugs, including heroin, cocaine, and cannabis and their narra-
tives about these drugs through songs” (p. 137). Early Federal legislation criminalizing marijuana was
motivated, in part, by use of the drug by jazz musicians and fear that their example would influence
youth (Whitebread 1995).

In recent years, the link between drug culture and music has been exemplified by the importance of
MDMA in the rave music scene (Kotarba 2007; Murguia et al. 2007). Reynolds (1998) credits the
development of rave music to MDMA’s ability to create a feeling of intimacy among relative
strangers and the way in which people who use it respond to repetitive, up-tempo music. Con-
versely, Adlaf and Smart (1997) found that adolescents in Canada typically became involved in the
rave music scene after starting to use MDMA and other drugs. Regardless of how the relationship
developed, MDMA and rave music are so closely linked that it is hard to tell where the music culture
ends and the drug culture begins.

Blackman (1996) states that drug use has become an essential element of youth culture mainly
through its association with musical artists. Similarly, Knutagard (1996) observes how different youth
cultures, each defined in part by its members’ choices in music and substance use, have made some
types of substance use acceptable to many young people. Esan (2007) notes that urban music and
drug

166
 Chapter 6—Drug Cultures and the Culture of Recovery

Exhibit 6-4: Music and Drug Cultures (continued)

culture have a shared appeal to young people based on their apparently antagonistic relationship to
mainstream culture. Since the 1990s, rock group confessional memoirs have become increasingly
popular, often depicting a lifestyle and culture of excess and providing explicit details of drug use
and methods; consumption-driven, high-risk, or excessive behaviors; tragic consequences of use;
and, sometimes, the author’s participation in rehabilitation (Oksanen 2012).

Certain drugs and the drug-dealing lifestyle are featured prominently in different types of music,
including hip hop (Esan 2007; Schensul et al. 2000) or narcocorridos (a popular form of Mexican and
Mexican American border music that tells of the lives of drug traffickers [Edberg 2004]). However,
even music that is not overtly concerned with drug use can become connected to a drug culture or to
substance use in an individual’s mind. According to White (1996), links between particular songs and
the recall of euphoric drug experiences are especially common and may need to be addressed ex-
plicitly in treatment. Hearing these songs can act as a trigger for drug use and can, therefore, be a
potential cause of relapse.

in substance use and the development of Drug cultures serve as an initiating force as
substance use disorders. Despite having differ- well as a sustaining force for substance use and
ing theories about the root causes of substance abuse (White 1996). As an initiating force, the
use disorders, most researchers would agree culture provides a way for people new to drug
that substance abuse is, to some extent, a use to learn what to expect and how to appre-
learned behavior. Beginning with Becker’s ciate the experience of getting high. As White
(1953) seminal work, research has shown that (1996) notes, the drug culture teaches the new
many commonly abused substances are not user “how to recognize and enjoy drug effects”
automatically experienced as pleasurable by (p. 46). There are also practical matters involved
people who use them for the first time in using substances (e.g., how much to take,
(Fekjaer 1994). For instance, many people find how to ingest the substance for strongest effect)
the taste of alcoholic beverages disagreeable that people new to drug use may not know
during their first experience with them, and when they first begin to experiment with drugs.
they only learn to experience these effects as The skills needed to use some drugs can be
pleasurable over time. Expectations can also be quite complicated, as shown in Exhibit 6-6.
important among people who use drugs; those
The drug culture has an appeal all its own that
who have greater expectancies of pleasure
promotes initiation into drug use. Stephens
typically have a more intense and pleasurable
(1991) uses examples from a number of ethno-
experience. These expectancies may play a part
graphic studies to show how people can be as
in the development of substance use disorders
taken by the excitement of the drug culture as
(Fekjaer 1994; Leventhal and Schmitz 2006).
they are by the drug itself. Media portrayals,
Additionally, drug-seeking and other behav- along with singer or music group autobiog-
iors associated with substance use have a raphies, that glamorize the drug lifestyle may
reinforcing effect beyond that of the actual increase its lure (Manning 2007; Oksanen
drugs. Activities such as rituals of use (Exhibit 2012). In buying (and perhaps selling) drugs,
6-5), which make up part of the drug culture, individuals can find excitement that is missing
provide a focus for those who use drugs when in their lives. They can likewise find a sense of
the drugs themselves are unavailable and help purpose they otherwise lack in the daily need to
them shift attention away from problems they seek out and acquire drugs. In successfully
might otherwise need to face (Lende 2005). navigating the difficulties of living as a person

167
 Improving Cultural Competence

Exhibit 6-5: The Rituals of Drug Cultures

Several authors have noted that illicit drug use and alcohol use typically involve ritualized behaviors
(Alverson 2005; Carlson 2006; Carnes et al. 2004; Grund 1993; White 1996). The rituals of substance
use affect where, when, and how substances are used. Substance-related rituals serve both instru-
mental and social functions. Instrumental functions include maximizing drug effects, minimizing
negative effects of drug use, and preventing secondary problems. Socially, the rituals display one’s
affiliation with the drug culture to other people and help create a sense of community within the
culture. Obviously, the social function is more central to group activities than to solitary rituals.

Most drug-related social rituals involve sharing substances or sharing the experience of intoxication.
Some drug cultures (e.g., marijuana) encourage the sharing of substances, but even when they are
not shared, drugs are often used with other people who use, such as in crack houses and shooting
galleries (Bourgois 1998; Grund 1993; Williams 1992). Rituals involving shared substance use and
public substance use strengthen the bonds between members of a drug culture and sustain the drug
culture. Some social rituals are so important to members of the drug culture that they participate in
them even when they have no drugs, such as when marijuana smokers smoke an inert substance
(e.g., horse manure, banana peels) together when they have no marijuana (White 1996). Drug use
can also be incorporated into other ritualized behaviors, such as sexual activity (Carnes et al. 2004).

Individuals develop their own drug-related rituals through the influence of other members of the
culture and also through trial and error. This allows them to determine what works best for them to
maximize the drug’s effect and minimize related problems. For example, Grund (1993) found,
through observing the rituals surrounding the injection of cocaine and heroin among people in the
Netherlands, that specific rituals governed the timing and administration of the drugs so that heroin
lessened the unpleasant side effects of the cocaine. Other recent examples are the combination of
energy drinks with alcohol to delay the normal onset of sleepiness (Howland and Rohsenow 2013;
Substance Abuse and Mental Health Services Administration [SAMHSA] 2013c) and the combination
of methylphenidate with alcohol to intensify euphoric effects (for review of central nervous system
stimulant use and emergency room information, see SAMHSA 2013b).

Exhibit 6-6: Questions Regarding Knowledge and Skill Demands of Heroin Use
• If first use is by snorting, how is it done (assuming the person has never taken a drug intranasal-
ly)? Is there a special technique for using heroin this way?
• If first use is by injection, is it best to inject the drug under the skin (skin-popping) or into a vein?
• What equipment is required? If one doesn’t have a hypodermic syringe, what other equipment
can be substituted to make up a set of “works” or an “outfit”?
• How is heroin prepared (cooked) for injection?
• What techniques or procedures are used to inject the drug?
• What does one do if the needle clogs?
• Is there any way to test the purity of the drug?
• How much of the drug constitutes a desirable dose?
• If more than one person is using and an outfit is being shared, who uses it first?
• If sharing, how can the works be cleaned to prevent the transmission of disease?
• How does one know if he or she has injected too much?
• Are there any unpleasant side effects one should anticipate?
• How long will the effects of the drug last?
• Is there any way to maximize the drug’s effects?
• Is there anything one should not do while high on the drug?
• How much time must pass before the drug can be used again?
• If a bruise or an abscess develops at the injection site, how can it be hidden and treated (without
seeing a physician)?

Source: White 1996.

168
 Chapter 6—Drug Cultures and the Culture of Recovery

who uses drugs, they can gain approval from acceptance is a major reason many young
peers who use drugs and a feeling that they are people begin to use drugs, as social acceptance
successful at something. can be found with less effort within the drug
culture.
In some communities, participation in the
drug trade—an aspect of a drug culture—is In addition to helping initiate drug use, drug
simply one of the few economic opportunities cultures serve as sustaining forces. They sup-
available and is a means of gaining the admi- port continued use and reinforce denial that a
ration and respect of peers (Bourgois 2003; problem with alcohol or drugs exists. The
Simon and Burns 1997). However, drug deal- importance of the drug culture to the person
ing as a source of status is not limited to eco- using drugs often increases with time as the
nomically deprived communities. In studying person’s association with it deepens (Moshier
drug dealing among relatively affluent college et al. 2012). White (1996) notes that as a
students at a private college, Mohamed and person progresses from experimentation to
Fritsvold (2006) found that the most im- abuse and/or dependence, he or she develops a
portant motives for dealing were ego gratifica- more intense need to “seek for supports to
tion, status, and the desire to assume an outlaw sustain the drug relationship” (p. 9). In addi-
image. tion to gaining social sanction for their sub-
stance use, participants in the drug culture
Marginalized adolescents and young adults
learn many skills that can help them avoid the
find drug cultures particularly appealing.
pitfalls of the substance-abusing lifestyle and
Many individual, family, and social risk factors
thus continue their use. They learn how to
associated with adolescent substance abuse are
avoid arrest, how to get money to support
also risk factors for youth involvement with a
their habit, and how to find a new supplier
drug culture. Individual factors—such as
when necessary.
feelings of alienation from society and a strong
rejection of authority—can cause youth to The more an individual’s needs are met within
look outside the traditional cultural institu- a drug culture, the harder it will be to leave
tions available to them (family, church, school, that culture behind. White (1996) gives an
etc.) and instead seek acceptance in a subcul- example of a person who was initially attracted
ture, such as a drug culture (Hebdige 1991; in youth to a drug culture because of a desire
Moshier et al. 2012). Individual traits like for social acceptance and then grew up within
sensation-seeking and poor impulse control, that culture. Through involvement in the drug
which can interfere with functioning in main- culture, he was able to gain a measure of self-
stream society, are often tolerated or can be esteem, change his family dynamic, explore his
freely expressed in a drug culture. Family sexuality, develop lasting friendships, and find
involvement with drugs is a significant risk a career path (albeit a criminal one). For this
factor due to additional exposure to the drug individual, who had so much of his life invest-
lifestyle, as well as early learning of the values ed in the drug culture, it was as difficult to
and behaviors (e.g., lying to cover for parents’ conceive of leaving that culture as it was to
illicit activities) associated with it (Haight et conceive of stopping his substance use.
al. 2005). Social risk factors (e.g., rejection by
peers, poverty, failure in school) can also in- Online Drug Cultures
crease young people’s alienation from tradi- One major change that has occurred in drug
tional cultural institutions. The need for social cultures in recent years is the development of

169
 Improving Cultural Competence

How To Lead an Exercise Examining Benefits, Losses, and the Future

Counselors and clinical supervisors can help clients identify reinforcing aspects (besides physiologi-
cal effects) of their drug and alcohol use and the losses associated with use, including unmet goals
and dreams. The physiological, social, and emotional gains and losses that have transpired during
their use (whether or not they associate these losses with their use) can serve as risks for relapse.
This exercise works well as an interactive psychoeducational lecture for clients, as a training tool for
counselors, and as a group counseling exercise. It can also be adapted for individual sessions.

Materials needed: Group room with sufficient space to move around.

Instructions:
• Select an amenable client aware of the losses and consequences associated with his/her use.
Later in the exercise, select other clients to give other group members a more direct experience.
• Divide the group in two. For large groups, select only 6 to 8 people for each side. Have each
subgroup stand on opposite sides of the room facing each other. One group will represent the
benefits of use; the other, losses associated with use (see diagram for room set-up).
• Rather than using the client’s personal benefits and losses (at least initially), ask group members
to brainstorm about their experiences that represent each side. Begin with the side of the room
that represents “benefits of use” and ask everyone in the room to name some benefits. Then,
assign a specific benefit to each person in the “benefits of use” group and create a one-line
message for each (a first-person statement describing the benefit), asking the representative cli-
ent to remember the line. For example, if the group named a benefit of use as immediate ac-
ceptance from others who use, assign this benefit to one person and create a message to
capture it: “I make you feel like you belong,” or “We are family now.” Continue brainstorming
until you have assigned six or more benefits.
• Next, go to the opposite group that represents the losses associated with use and begin to
solicit losses from everyone in the room. Assign a loss to each person in the “loss” group, create
a one-line message that coincides with each loss, and then ask an individual to remember each
loss message (e.g., “I am the loss of your children,” “I am the loss of your self-respect,” “I am
the loss of your health”). In addition, ask the group to name future goals and plans that were
curtailed because of use. Assign these losses as well, following the same format (e.g., “I am the
loss of a college degree,” “I am the loss of intimate relationships,” “I am the loss of belief in the
future”). Note: If you run out of people, you can assign two roles to one person.
• At this point, the exercise can already be a powerful experience for many clients. Now, have the
person who was originally selected as the client stand facing the “benefits of use” group. Have
the client process what it is like to see the benefits of use. You can also have each person in the
“benefits of use” group state his or her one-line message to help facilitate this process. Stand
with the client as he or she moves to the “loss” group. Again, have the client stand and face this
group while asking him or her what it is like to see the losses, including the losses related to
goals and the future. Note: It is not important as an exercise to have benefits or losses specific
only to this client. It is far better to gain a sample from the entire group so that everyone is in-
volved and to maximize the exercise’s effectiveness as a psychoeducational tool.
• After the client has stood in front of both groups, ask him or her to move back and forth be-
tween each group several times to see what emotional changes occur in experiencing each
group. It is important to process this experience as a group. You can invite other members to
switch out of their roles and stand in as clients to experience this exercise more directly. Clients
are likely to see how seductive the “benefits of use” group can be and how this attraction can
lead back to relapse. This exercise may also help clients connect with the losses associated with
their use. At times, clients may gain awareness that the very losses associated with their use can
also serve as a trigger for use as a means of self-medicating feelings.

(Continued on the next page.)

170
 Chapter 6—Drug Cultures and the Culture of Recovery

How To Lead an Exercise Examining Benefits, Losses, and the Future (continued)
• Allot sufficient time for this psychoeducational lecture—not only to demonstrate the benefits and
losses associated with use, but also to enable the group to process their thoughts and feelings.

Group Room Setup

Internet communities organized around drug of whom were from the United States. Re-
use (Gatson 2007a; Murguia et al. 2007) and spondents were likely to be young (90 percent
drug use facilitation, including information on were under 30), male (76 percent), White (92
use, production, and sales (Bowker 2011; U.S. percent), relatively affluent (58 percent had
Department of Justice 2002). Such communi- household incomes of $45,000 or more),
ties develop around Web sites or discussion employed (41 percent were employed full
boards where individuals can describe their time; another 28 percent, part time), and/or in
drug-related experiences, find information on school (57 percent were attending school full
acquiring and using drugs, and discuss related or part time). According to the 2011 National
issues ranging from musical interests to legal Survey on Drug Use and Health, approxi-
problems. Many of the Web sites where these mately 0.3 percent of individuals 12 years of
online communities develop are originally age or older purchase prescription drugs
created to lessen the negative consequences of through the Internet (SAMHSA, 2012b).
substance use by informing people about vari-
ous related legal and medical issues (Gatson The Role of Drug Cultures
2007b; Murguia et al. 2007). As in other drug
cultures, users of these Web sites and discus- in Substance Abuse
sion boards develop their own language and Treatment
values relating to drug use. Club drugs and
hallucinogenics are the most often-discussed Most people seek some kind of social affilia-
types of drugs, but online communities involve tion; it is one aspect of life that gives meaning
the discussion of all types of licit and illicit to day-to-day existence. Behavioral health
substances, including stimulants and opioids service providers can better understand and
(Gatson 2007a; Murguia et al. 2007; Tackett- help their clients if they have an understand-
Gibson 2007). ing of the culture(s) with which they identify.
This understanding can be even more im-
Murguia et al. (2007) reported on a survey of portant when addressing the role of drug
adult (ages 18 and older) participants in one culture in a client’s life because, of all cultural
online community. The self-selected survey affiliations, it is likely to be the one most
sample included 1,038 respondents, 80 percent intimately connected with his or her substance

171
 Improving Cultural Competence

abuse. The drug culture is likely to have had a clients about their relationships, daily activities
considerable influence on the client’s behav- and habits relating to substance use, values,
iors related to substance use. and views of other people and the world can
allow providers to develop a good sense of the
Drug Cultures in Assessment and meanings drug cultures hold for clients.
Engagement To engage a client in treatment, understanding
The first step in understanding the role a drug his or her relationship with a drug culture may
culture plays in a client’s life is to assess which be as important as understanding elements of
drug culture(s) the client has been involved that client’s racial or ethnic identity. Clients
with and his or her level of involvement. There are unlikely to self-identify as members of the
are no textbooks that can inform providers drug culture in the same way that they would
about the drug cultures in their areas, but identify as an African American or Asian
counselors probably know quite a bit about American, for example, but they can still be
them already, as they learn much about drug offended or distrustful if they think the provid-
cultures through talking with their clients. er or program does not understand how their
Counselors who are themselves in recovery lifestyle relates to their substance use. Affilia-
may be familiar with some clients’ substance- tion with a drug culture is a source of client
using lifestyles and social environments or will identity; the client’s place in the drug culture
have insight into how to explore the issue with can be important to his or her self-esteem.
clients. They can also educate their colleagues.
After the assessment and engagement stage,
Providers who have never personally abused the provider’s attitude toward the client’s
substances can learn from recovered counse- participation in a drug culture will be signifi-
lors as well as from their clients. However, cantly different from his or her attitude to-
asking a client point-blank about his or her ward the client’s other cultural affiliations. As
involvement in a drug culture is likely to be most providers already know (even if they do
answered with a blank stare. Instead, talking to not use the term drug culture), if a client

How To Learn About Clients’ Daily Routines and Rituals

One way to gain an understanding of a client’s involvement in a specific drug culture is to learn about
his or her daily routines and rituals. Keep in mind that there can be different routines on weekends or
specific days of the week; ask about exceptions to the typical daily schedule.

Materials needed: Weekly calendar.

Instructions:
• To elicit information about the client’s daily activities, use a cue or anchor to initiate this explora-
tion, such as a calendar highlighting each day of a week—Monday through Sunday.
• Placing the calendar in front of the client, ask him or her to describe a typical day, beginning with
the time that he or she generally wakes up and building on the morning routines (e.g., “What
does an average morning look like for you?”).
• Encourage the client to provide a specific account of his or her routine rather than a general
response. Important information can be obtained by asking the client about feelings or reactions
to daily activities as they unfold in the session.
• After completing an example of an entire day, ask the client if there are exceptions to this schedule
that routinely occur on another day of the week or during the weekend. Once these are processed,
it can be beneficial to ask what it was like for him or her to talk about these daily routines.

172
 Chapter 6—Drug Cultures and the Culture of Recovery

(e.g., style of dress, music, language, or com-

“The culture of recovery is an informal munication patterns). This can occur through
social network in which group norms (pre- two basic processes: replacing the element
scribed patterns of perceiving, thinking,
with something new that is positively associat-
feeling, and behaving) reinforce sobriety
and long-term recovery from addiction.”
ed with a culture of recovery (e.g., replacing a
marijuana leaf keychain with an NA key-
(White 1996, p. 222) chain), and reframing something so that it is
no longer associated with drug use or the drug
continues to be closely affiliated with the culture (e.g., listening to music that was asso-
drug-using life, then he or she is more likely to ciated with the drug culture at a sober dance
relapse. The people, places, things, thoughts, with others in recovery; White 1996). The
and attitudes related to drug and/or alcohol process will depend on the nature of the cul-
use act as triggers to resume use of substances. tural element.
Behavioral health service providers need to
help their clients weaken and eventually elim- Developing a Culture of Recovery
inate their connections to the drug culture. Just as people who are actively using or abus-
White (1996) identifies an important issue to ing substances bond over that common experi-
address during transition from engagement to ence to create a drug culture that supports
treatment—in the process of engaging clients, their continued substance use, people in recov-
providers help them identify how their con- ery can participate in activities with others
nections to the drug culture prevent them who are having similar experiences to build a
from reaching their goals and how the loss of culture of recovery. There is no single drug
these connections would affect them if they culture; likewise, there is no single culture of
chose to cut ties with the drug culture. recovery. However, large international mutual-
help organizations like Alcoholics Anonymous
Finding Alternatives to Drug (AA) do represent the culture of recovery for
Cultures many individuals (Exhibit 6-7). Even within
A client can meet the psychosocial needs previ- such organizations, though, there is some
ously satisfied by the drug culture in a number cultural diversity; regional differences exist, for
of ways. Strengthening cultural identity can be example, in meeting-related rituals or attitudes
a positive action for the client; in some cases, toward certain issues (e.g., use of prescribed
the client’s family or cultural peers can serve as psychotropic medication, approaches to
a replacement for involvement in the drug spirituality).
culture. This option is particularly helpful when
the client’s connection to a drug culture is The planned TIP, Relapse Prevention and
relatively weak and his or her traditional culture Recovery Promotion in Behavioral Health
is relatively strong. However, when this option Services (SAMHSA planned e), provides more
is unavailable or insufficient, clinicians must information on using mutual-help groups in
focus on replacing the client’s ties with the drug
culture (or the culture of addiction) with new Recovery from mental and substance use
disorders is a process of change through
ties to a culture of recovery.
which people improve their health and
To help clients break ties with drug cultures, wellness, live in a self-directed manner, and
programs need to challenge clients’ continued work toward achieving their full potential.
involvement with elements of those cultures (SAMHSA 2011b)

173
 Improving Cultural Competence

treatment settings and in long-term recovery. replace the activities, beliefs, people, places, and
It contains detailed information about poten- things associated with substance abuse with
tial recovery supports that behavioral health new recovery-related associations—the central
programs can use to foster cultures of recovery purpose of creating a culture of recovery.
among clients and program graduates.
Even programs that already recognize the
Most treatment programs try to foster a culture need to create a culture of recovery for their
of recovery for their clients. Some modalities, clients can make doing so more of a focus in
with therapeutic communities being the lead treatment. White (1996) explores ways to do
example, focus on this issue as a primary treat- this, including:
ment strategy. Even one-on-one outpatient • Teaching clients about the existence of
treatment programs typically encourage attend- drug cultures and their potential influence
ance at mutual-help groups, such as AA, to in clients’ lives.
meet sociocultural recovery needs. Most pro- • Teaching clients about cultures of recovery
viders also recognize that clients need to and discussing how elements of the drug

Exhibit 6-7: 12-Step Group Values and the Culture of Recovery

For historical reasons, cultures of recovery (like the recovery process in general) in the United States
have been greatly influenced by 12-Step groups such as AA and NA (White 1998). These groups
provide a clearly defined culture of recovery for a great many people. They provide members with a
set of rituals, daily activities, customs, traditions, values, and beliefs.

The 12 Steps and 12 Traditions represent the core principles, values, and beliefs of such groups.
Wilcox (1998) defines these values as surrender; faith; acceptance, tolerance, and patience; honesty,
openness, and willingness; humility; willingness to examine character defects; taking life one day at a
time; and keeping things simple. As seen by comparing these values with those common to the
heroin culture described in the “The Values and Beliefs of a Heroin Culture” box earlier in this chap-
ter, one of the ways in which 12-Step groups work is by instilling a set of values contrary to those
found in drug cultures. However, they also provide members with a new set of values that are in
some ways distinct from the values of the mainstream culture that were rejected when the individual
began his or her involvement in the drug culture (Wilcox 1998).

Many of the values of AA and other 12-Step groups are embodied in rituals that take place in meet-
ings and in members’ daily lives. White (1998) lists four ritual categories:
• Centering rituals help members stay focused on recovery by reading recovery literature, han-
dling recovery tokens or symbols, and taking regular self-assessments or personal inventories
each day.
• Mirroring rituals keep members in contact with one another and help them practice sober living
together. Attending meetings, telling one’s story, speaking regularly by phone, and using slo-
gans (e.g., “keep it simple,” “pass it on”), among others, are mirroring activities.
• Acts of personal responsibility include being honest and becoming time-conscious and punctu-
al. Activities include the creation of new rituals of daily living related to sleeping, hygiene, and
other areas of self-care while also being reliable and courteous.
• Acts of service involve performing rituals to help others in recovery. These acts are related to
the Twelfth Step, which directs members to carry the message of their spiritual awakening to
others who abuse alcohol or are dependent on it, thereby encouraging them to practice the 12
Steps. Acts of service recognize that people in recovery have something of value to offer those
still abusing alcohol.

These rituals aid the processes of personal transformation and integration into a new cultural group.

174
 Chapter 6—Drug Cultures and the Culture of Recovery

culture can be replaced by elements of a of recovery involves connecting individuals

culture of recovery. back to the larger community and to their
• Establishing clear boundaries for appro- cultures of origin (Davidson et al. 2008). This
priate behavior (e.g., behavior that does can require efforts to educate the community
not reflect drug cultures) in the program about recovery as well (e.g., by promoting a
and consistently correcting behaviors that recovery month in the community, hosting
violate boundaries (e.g., wearing shirts de- recovery walks or similar events, or offering
picting pot leaves; displaying gang- outreach to community groups, such as
affiliated symbols, gestures, and tattoos). churches or fraternal/benevolent societies).
• Working to shape a peer culture within the
Programs that do not have a plan for creating
program so that longer-term clients and
a culture of recovery among clients risk their
staff members can socialize new clients to
clients returning to the drug culture or hold-
a culture of recovery.
ing on to elements of that culture because it
• Having regular assessments of clients and
meets their basic and social needs. In the worst
the entire program in which staff members
case scenario, clients will recreate a drug cul-
and clients determine areas where work is
ture among themselves within the program. In
needed to minimize cultural attitudes that
the best case, staff members will have a plan
can undermine treatment.
for creating a culture of recovery within their
• Involving clients’ families (when appropri-
treatment population.
ate) in the treatment process so they can
support clients’ recovery as well as partici-
pate in their own healing process. SAMHSA’s Guiding Principles of
Recovery
White (1996) suggests that programs build
• Recovery emerges from hope.
linkages with mutual-help groups; include
• Recovery is person driven.
mutual-help meetings in their programs or • Recovery occurs via many pathways.
provide access to community mutual-help • Recovery is holistic.
meetings; and include mutual-help rituals, • Recovery is supported by peers and allies.
symbols, language, and values in treatment • Recovery is supported through relationship
and social networks.
processes.
• Recovery is culturally based and influenced.
Other activities that can improve integration • Recovery is supported by addressing
trauma.
into a recovery culture include SAMHSA’s • Recovery involves individual, family, and
Recovery Community Services Program community strengths and responsibility.
(http://www.samhsa.gov/grants/2011/ti_11_0 • Recovery is based on respect.
04.aspx), which was developed to provide and
More information on the Guiding Principles of
evaluate peer-based recovery support services, Recovery is available at the SAMHSA Store
and Recovery Community Centers, which (http://store.samhsa.gov/shin/content//PEP12-
provide space for recovering people to social- RECDEF/PEP12-RECDEF.pdf).
ize, organize, and develop a recovery culture Source: SAMHSA 2012c.
(White and Kurtz 2006). Developing a culture

175
Appendix A—Bibliography

Abbott, A.A. Substance abuse treatment with clients of French background. In: Straussner,
S.L.A., ed. Ethnocultural Factors in Substance Abuse Treatment (pp. 180–198). New York: Guil-
ford Press, 2001.
Abbott, P.J. Traditional and western healing practices for alcoholism in American Indians and
Alaska Natives. Substance Use & Misuse 33(13):2605–2646, 1998.
Abe, J. A community ecology approach to cultural competence in mental health service delivery:
The case of Asian Americans. Asian American Journal of Psychology 3(3):168–180, 2012.
Abe-Kim, J., Takeuchi, D.T., Hong, S., Zane, N., Sue, S., Spencer, M.S., Appel, H., Nicdao, E.,
and Alegria, M. Use of mental health-related services among immigrant and US-born Asian
Americans: Results from the National Latino and Asian American study. American Journal of
Public Health 97(1):91–98, 2007.
Abdel-Khalek, A.M. Internal consistency of an Arabic adaptation of the Beck Depression Inven-
tory in four Arab countries. Psychological Reports 82:264–266, 1998.
Abudabbeh, N., and Hamid, A. Substance use among Arabs and Arab Americans. In: Straussner,
S.L.A., ed. Ethnocultural Factors in Substance Abuse Treatment (pp. 275–290). New York: Guil-
ford Press, 2001.
Abueg, F.R., and Chun, K.M. Traumatization stress among Asians and Asian Americans. In:
Organista, P.B., Chun, K.M., and Marin, G., eds. Readings in Ethnic Psychology (pp. 283–294).
New York: Routledge, 1998.
Acevedo, A., Garnick, D.W., Lee, M.T., Horgan, C.M., Ritter, G., Panas, L., Davis, S., Leeper, T.,
Moore, R., and Reynolds, M. Racial and ethnic differences in substance abuse treatment ini-
tiation and engagement. Journal of Ethnicity in Substance Abuse 11(1):1–21, 2012.
Acevedo-Polakovich, I.D., Reynaga-Abiko, G., Garriott, P.O., Derefinko, K.J., Wimsatt, M.K.,
Gudonis, L.C., and Brown, T.L. Beyond instrument selection: Cultural considerations in the
psychological assessment of U.S. Latinas/os. Professional Psychology: Research and Practice
38(4):375–384, 2007.
Ackerman, S.J., and Hilsenroth, M.J. A review of therapist characteristics and techniques posi-
tively impacting the therapeutic alliance. Clinical Psychology Review 23(1):1–33, 2003.
Adewuya, A.O. Validation of the Alcohol Use Disorders Identification Test (AUDIT) as a
screening tool for alcohol-related problems among Nigerian university students. Alcohol and
Alcoholism 40:575–577, 2005.

177
 Improving Cultural Competence

Addiction Technology Transfer Center. The Change Book: A Blueprint for Technology Transfer. 2nd
ed. Kansas City, MO: Addiction Technology Transfer Center, 2004.
Adlaf, E.M., and Smart, R.G. Party subculture or dens of doom? An epidemiological study of
rave attendance and drug use patterns among adolescent students. Journal of Psychoactive
Drugs 29(2):193–198, 1997.
African immigrants in the United States are the nation’s most highly educated group. Journal of
Blacks in Higher Education 26:60–61, 2000.
Agency for Healthcare Research and Quality. National Healthcare Disparities Report 2008. Rock-
ville, MD: Agency for Healthcare Research and Quality, 2009.
Agency for Healthcare Research and Quality. National Healthcare Disparities Report 2011. Rock-
ville, MD: Agency for Healthcare Research and Quality, 2012.
Aguilar-Gaxiola, S., Loera, G., Mendez, L., Sala, M., Latino Mental Health Concilio, and
Nakamoto, J. Community-Defined Solutions for Latino Mental Health Care Disparities: Califor-
nia Reducing Disparities Project, Latino Strategic Planning Workgroup Population Report. Sac-
ramento, CA: UC Davis, 2012.
Ahmad, S., and Bhugra, D. Sex and culture. In: Bhattacharya, R., Cross, S., and Bhugra, D., eds.
Clinical Topics in Cultural Psychiatry (pp. 196–208). London: Royal College of Psychiatrists,
2010.
Ahn, A.C., Ngo-Metzger, Q., Legedza, A.T.R., Massagli, M.P., Clarridge, B.R., and Phillips,
R.S. Complementary and alternative medical therapy use among Chinese and Vietnamese
Americans: Prevalence, associated factors, and effects of patient-clinician communication.
American Journal of Public Health 96(4):647–653, 2006.
Akbar, N. Cultural expressions of the African-American child. Black Child Journal 2(2):6–16,
1981.
Alansari, B.M. Gender differences in depression among undergraduates from seventeen Islamic
countries. Social Behavior and Personality 34:729–738. 2006.
Al-Ansari, E.A., and Negrete, J.C. Screening for alcoholism among alcohol users in a traditional
Arab Muslim society. Acta Psychiatrica Scandinavica 83(3):217–222, 1990.
Alarcon, R.D. Culture, cultural factors and psychiatric diagnosis: Review and projections. World
Psychiatry 8(3):131–139, 2009.
Alcoholics Anonymous World Services, Inc. A.A. for the Black and African American Alcoholic.
New York: Alcoholics Anonymous World Services, 2001.
Alcoholic Anonymous World Services, Inc. Alcoholics Anonymous 2007 Membership Survey. New
York: Alcoholics Anonymous World Services, 2008.
Alcoholics Anonymous World Services, Inc. Alcoholics Anonymous 2011 Membership Survey. New
York: Alcoholics Anonymous World Services, 2012.
Alderete, E., Vega, W. A., Kolody, B., and Aguilar-Gaxiola, S. Lifetime prevalence of and risk
factors for psychiatric disorders among Mexican migrant farmworkers in California. American
Journal of Public Health 90(4):608–614, 2000.

178
 Appendix A—Bibliography

Alegria, M., Canino, G., Shrout, P.E., Woo, M., Duan, N., Vila, D., Torres, M., Chen, C.N., and
Meng, X.L. Prevalence of mental illness in immigrant and non-immigrant U.S. Latino
groups. The American Journal of Psychiatry 165(3):359–369, 2008a.
Alegria, M., Canino, G., Stinson, F.S., and Grant, B.F. Nativity and DSM-IV psychiatric disor-
ders among Puerto Ricans, Cuban Americans, and Non-Latino Whites in the United States:
Results from the National Epidemiologic Survey on Alcohol and Related Conditions. The
Journal of Clinical Psychiatry 67(1):56–65, 2006.
Alegria, M., Carson, N.J., Goncalves, M., and Keefe, K. Disparities in treatment for substance use
disorders and co-occurring disorders for ethnic/racial minority youth. Journal of the American
Academy of Child and Adolescent Psychiatry 50(1):22–31, 2011.
Alegria, M., Chatterji, P., Wells, K., Cao, Z., Chen, C.N., Takeuchi, D., Jackson, J., and Meng,
X.L. Disparity in depression treatment among racial and ethnic minority populations in the
United States. Psychiatric Services 59(11):1264–1272, 2008b.
Alegria, M., Mulvaney-Day, N., Woo, M., and Viruell-Fuentes, E.A. Psychology of Latino
adults: Challenges and an agenda for action. In: Chang, E.C., ed. Handbook of Race and De-
velopment in Mental Health (pp. 279–306). New York: Springer Science + Business Media,
2012.
Alim, T.N., Graves, E., Mellman, T.A., Aigbogun, N., Gray, E., Lawson, W., and Charney, D.S.
Trauma exposure, posttraumatic stress disorder and depression in an African-American pri-
mary care population. Journal of the National Medical Association 98(10):1630–1636, 2006.
Allen, J.P., Litten, R.Z., Fertig, J.B., and Babor, T. A review of research on the Alcohol Use Dis-
orders Identification Test (AUDIT). Alcoholism: Clinical and Experimental Research 21:613–
619, 1997.
Almeida, R. Asian Indian families: An overview. In: McGoldrick, M., Giordano, J., and Garcia-
Preto, N., eds. Ethnicity and Family Therapy. 3rd ed. (pp. 377–394). New York: Guilford Press,
2005.
Aloud, N. Factors Affecting Attitudes Toward Seeking and Using Formal Mental Health and Psycho-
logical Services Among Arab-Muslims Population [Doctoral dissertation]. Columbus, OH: Ohio
State University, 2004.
Alvarez, L.R., and Ruiz, P. Substance abuse in the Mexican American population. In: Straussner,
S.L.A., ed. Ethnocultural Factors in Substance Abuse Treatment (pp. 111–136). New York: Guil-
ford Press, 2001.
Alverson, H. Students’ Social Life at Dartmouth College: Reflections in Their Looking Glass. Dart-
mouth, NH: Dartmouth College, 2005.
Alvidrez, J., and Havassy, B.E. Racial distribution of dual-diagnosis clients in public sector men-
tal health and drug treatment settings. Journal of Health Care for the Poor and Underserved
16(1):53–62, 2005.

179
 Improving Cultural Competence

Amaro, H., and Aguiar, M. Programa Mama/Mom’s Project: A community-based outreach

model for addicted women. In: Szapocznik, J., Orlandi, M.A., and Epstein, L.G., eds. A His-
panic/Latino Family Approach to Substance Abuse Prevention (pp. 125–153). CSAP Cultural
Competence Series 2. HHS Publication No. (SMA) 95-3034. Rockville, MD: Center for
Substance Abuse Prevention, 1995.
Amaro, H., Arévalo, S., Gonzalez, G., Szapocznik, J., and Iguchi, M.Y. Needs and scientific
opportunities for research on substance abuse treatment among Hispanic adults. Drug and
Alcohol Dependence 84(Suppl 1):S64–S75, 2006.
Amaro, H., Dai, J., Arévalo, S., Acevedo, A., Matsumoto, A., Nieves, R., and Prado, G. Effects of
integrated trauma treatment on outcomes in a racially/ethnically diverse sample of women in
urban community-based substance abuse treatment. Journal of Urban Health 84(4):508–522,
2007.
American Evaluation Association. Public Statement on Cultural Competence in Evaluation. Fairha-
ven, MA: American Evaluation Association, 2011.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Text
Revision ed. Washington, DC: American Psychiatric Association, 2000.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed.
Washington, DC: American Psychiatric Association, 2013.
American Psychological Association. APA Guidelines for Providers of Psychological Services to Eth-
nic, Linguistic, and Culturally Diverse Populations. Washington, DC: American Psychological
Association, 1990.
American Psychological Association. Guidelines on Multicultural Education, Training, Research,
Practice, and Organizational Change for Psychologists. Washington, DC: American Psychologi-
cal Association, 2002.
American Psychological Association. Resilience and Recovery After War: Refugee Children and
Families in the United States. Washington, DC: American Psychological Association, 2010.
American Psychological Association. Crossroads: The Psychology of Immigration in the New Centu-
ry. Washington, DC: American Psychological Association, 2012.
American Translators Association. Interpreting: Getting it Right: A Guide to Buying Interpreting
Services. Alexandria, VA: American Translators Association, 2011.
Amodeo, M., Chassler, D., Oettinger, C., Labiosa, W., and Lundgren, L.M. Client retention in
residential drug treatment for Latinos. Evaluation and Program Planning 31(1):102–112,
2008.
Amodeo, M., and Jones, L.K. Viewing alcohol and other drug use cross culturally: A cultural
framework for clinical practice. Families in Society 78(3):240–254, 1997.
Amodeo, M., Peou, S., Grigg-Saito, D., Berke, H., Pin-Riebe, S., and Jones, L.K. Providing
culturally specific substance abuse services in refugee and immigrant communities: Lessons
from a Cambodian treatment and demonstration project. Journal of Social Work Practice in the
Addictions 4(3):23–46, 2004.

180
 Appendix A—Bibliography

Amodeo, M., Robb, N., Peou, S., and Tran, H. Alcohol and other drug problems among South-
east Asians: Patterns of use and approaches to assessment and intervention. Alcoholism Treat-
ment Quarterly 15(3):63–77, 1997.
Amorim, P., Lecrubier, Y., Weiller, E., Hergueta, T., and Sheehan, D. DSM-III-R psychotic
disorders: Procedural validity of the Mini International Neuropsychiatric Interview (MINI):
Concordance and causes for discordance with the CIDI. European Psychiatry 13:26–34, 1998.
Anderson, J., Moeschberger, M., Chen, M.S. Jr., Kunn, P., Wewers, M.E., and Guthrie, R. An
acculturation scale for Southeast Asians. Social Psychiatry and Psychiatric Epidemiology
28:134–141, 1993.
Anderson, L.M., Scrimshaw, S.C., Fullilove, M.T., Fielding, J.E., and Normand, J. Culturally
competent healthcare systems. A systematic review. American Journal of Preventive Medicine
24(3 Suppl):68–79, 2003.
Anderson, T.L., and Levy, J.A. Marginality among older injectors in today’s illicit drug culture:
Assessing the impact of aging. Addiction 98(6):761–770, 2003.
Andrade, R., and Estrada, A.L. Are Hispana IDUs tecatas?: Reconsidering gender and culture in
Hispana injection drug use. Substance Use & Misuse 38(8):1133–1158, 2003.
Aragon, A.M. A clinical understanding of urban American Indians. In: Witko, T.M., ed. Mental
Health Care for Urban Indians: Clinical Insights From Native Practitioners (pp. 19–31). Wash-
ington, DC: American Psychological Association, 2006.
Arciniega, G.M., Anderson, T.C., Tovar-Blank, Z.G., and Tracey, T.J.G. Toward a fuller concep-
tion of Machismo: Development of a traditional Machismo and Caballerismo Scale. Journal
of Counseling Psychology 55(1):19–33, 2008.
Arfken, C.L., Kubiak, S.P., and Koch, A.L. Health issues in the Arab American community:
Arab Americans in publicly financed substance abuse treatment. Ethnicity and Disease 17(2
Suppl 3):S3, 2007.
Arfken, C.L., Said, M., and Owens, D. Racial and ethnic differences in reported criminal justice
referral at treatment admission. Journal of Psychoactive Drugs 44(5):428–433, 2012.
Arias, E. United States life tables by Hispanic origin. Vital and Health Statistics 2(152). National
Center for Health Statistics, 2010.
Arndt, S., Acion, L., and White, K. How the states stack up: Disparities in substance abuse out-
patient treatment completion rates for minorities. Drug and Alcohol Dependence 132(3):547–
554, 2013.
Arroyo, J.A., Westerberg, V.S., and Tonigan, J.S. Comparison of treatment utilization and out-
come for Hispanics and non-Hispanic Whites. Journal of Studies on Alcohol 59(3):286–291,
1998.
Assanangkornchai, S., Conigrave, K.M., and Saunders, J.B. Religious beliefs and practice, and
alcohol use in Thai men. Alcohol and Alcoholism 37(2):193–197, 2002.
Association for Assessment in Counseling and Education. Standards for Multicultural Assessment.
4th ed. Alexandria, VA: Association for Assessment in Counseling and Education, 2012.

181
 Improving Cultural Competence

Atkins, R.G. Jr., and Hawdon, J.E. Religiosity and participation in mutual-aid support groups for
addiction. Journal of Substance Abuse Treatment 33(3):321–331, 2007.
Attneave, C. American Indians and Alaska Native families: Emigrants in their own homeland.
In: McGoldrick, M., Pearce, J.K., and Giordano, J., eds. Ethnicity and Family Therapy (pp. 55–
83). New York: Guilford Press, 1982.
Ayalon, L., and Alvidrez, J. The experience of Black consumers in the mental health system—
Identifying barriers to and facilitators of mental health treatment using the consumers’ per-
spective. Issues in Mental Health Nursing 28(12):1323–1340, 2007.
Ayalon, L. and Young, M.A. Using the SCL-90-R to Assess distress in African Americans and
Caucasian Americans. Journal of Black Studies 39:420–433, 2009.
Azevedo, K., and Bogue, H.O. Health and occupational risks of Latinos living in rural America.
In: Aguirre-Molina, M., Molina, C., and Zambrana, R.E., eds. Health Issues in the Latino
Community (pp. 359–380). San Francisco: Jossey-Bass, 2001.
Azocar, F., Areán, P., Miranda, J., and Muñoz, R.F. Differential item functioning in a Spanish
translation of the Beck Depression Inventory. Journal of Clinical Psychology 57:355–365, 2001.
Babor, T.F., de la Fuente, J.R., Saunders, J., and Grant, M. AUDIT: The Alcohol Use Disorders
Identification Test. Guidelines for Use in Primary Health Care. Geneva: World Health Organi-
zation, 1992.
Baicker, K., Chandra, A., and Skinner, J.S. Geographic variation in health care and the problem
of measuring racial disparities. Perspectives in Biology and Medicine, 48:S42–S53, 2005.
Bail, K.M., Foster, J., Dalmida, S.G., Kelly, U., Howett, M., Ferranti, E.P., and Wald, J. The im-
pact of invisibility on the health of migrant farmworkers in the southeastern United States: A
case study from Georgia. Nursing Research and Practice, 2012.
Bainwol, S., and Gressard, C.F. The incidence of Jewish alcoholism: A review of the literature.
Journal of Drug Education 15(3):217–224, 1985.
Baker, F.M., and Bell, C.C. Issues in the psychiatric treatment of African Americans. Psychiatric
Services 50(3):362–368, 1999.
Baldwin, J.A., and Bell, Y.R. The African self-consciousness scale: An Africentric personality
questionnaire. The Western Journal of Black Studies 9(2):61–68, 1985.
Balsam, K.F., Huang, B., Fieland, K.C., Simoni, J.M., and Walters, K.L. Culture, trauma, and
wellness: A comparison of heterosexual and lesbian, gay, bisexual, and two-spirit Native
Americans. Cultural Diversity & Ethnic Minority Psychology 10(3):287–301, 2004.
Bao, Y., Fisher, J., and Studnicki, J. Racial differences in behavioral inpatient diagnosis: Examin-
ing the mechanisms using the 2004 Florida inpatient discharge data. The Journal of Behavior
Health Services Research 35(3):347–357, 2008.
Barbujani, G., Magagni, A., Minch, E., and Cavalli-Sforza, L.L. An apportionment of human
DNA diversity. Proceedings of the National Academy of Sciences of the United States of America
94(9):4516–4519, 1997.

182
 Appendix A—Bibliography

Bardwell, W.A., and Dimsdale, J.E. The impact of ethnicity and response bias on the self-report
of negative affect. Journal of Applied Biobehavioral Research 6:27–38, 2001.
Barón, M. Addiction treatment for Mexican American families. In: Krestan, J.A., ed. Bridges to
Recovery: Addiction, Family Therapy, and Multicultural Treatment (pp. 219–252). New York:
The Free Press, 2000.
Barr, D.A. Health Disparities in the United States: Social Class, Race, Ethnicity, and Health. Balti-
more: Johns Hopkins University Press, 2008.
Barreto, R.M., and Segal, S.P. Use of mental health services by Asian Americans. Psychiatric
Services 56(6):746–748, 2005.
Barrett, M.E. Wat Thamkrabok: A Buddhist drug rehabilitation program in Thailand. Substance
Use & Misuse 32(4):435–459, 1997.
Barry, D.T. Development of a new scale for measuring acculturation: The East Asian Accultura-
tion Measure (EAAM). Journal of Immigrant Health 3:193–197, 2001.
Bassett, D., Tsosie, U., and Nannauck, S. “Our culture is medicine”: Perspectives of Native healers
on posttrauma recovery among American Indian and Alaska Native patients. The Permanente
Journal, 16(1):19–27, 2012.
Batistoni, S.S., Neri, A.L., and Cupertino, A.P. Validity of the Center for Epidemiological Stud-
ies Depression Scale among Brazilian elderly. Revista de Saude Publica 41:598–605, 2007.
Bazron, B., and Scallet, L. The Impact of Culturally and Linguistically Appropriate Services on Access
To Care in a Managed Behavioral Health Care Environment. Working Draft. Falls Church,
VA: The Lewin Group, 1998.
Beach, M.C., Gary, T.L., Price, E.G., Robinson, K., Gozu, A., Palacio, A., Smarth, C., Jenckes,
M., Feuerstein, C., Bass, E.B., Powe, N.R., and Cooper, L.A. Improving health care quality
for racial/ethnic minorities: A systematic review of the best evidence regarding provider and
organization interventions. BMC Public Health 6:104, 2006.
Beals, J., Manson, S.M., Shore, J.H., Friedman, M.J., Ashcraft, M., Fairbank, J.A., and Schlenger,
W.E. The prevalence of posttraumatic stress disorder among American Indian Vietnam vet-
erans: Disparities and context. Journal of Traumatic Stress 15(2):89–97, 2002.
Beals, J., Manson, S.M., Whitesell, N.R., Spicer, P., Novins, D.K., and Mitchell, C.M. Prevalence
of DSM-IV disorders and attendant help-seeking in two American Indian reservation popu-
lations. Archives of General Psychiatry 62(1):99–108, 2005.
Beals, J., Novins, D.K., Spicer, P., Whitesell, N.R., Mitchell, C.M., and Manson, S.M. Help
seeking for substance use problems in two American Indian reservation populations. Psychiat-
ric Services 57(4):512–520, 2006.

183
 Improving Cultural Competence

Beals, J., Spicer, P., Mitchell, C.M., Novins, D.K., Manson, S.M., and the American Indian Ser-
vice Utilization Psychiatric Epidemiology Risk and Protective Factors Project Team: Big
Crow, C.K., Buchwald, D., Chambers, B., Christensen, M.L., Dillard, D.A., DuBray, K., Es-
pinoza, P.A., Fleming, C.M., Frederick, A.W., Gurley, D., Jervis L.L., Jim, S.M., Kaufman,
C.E., Keane, E.M., Klein, S.A., Lee, D., McNulty, M.C., Middlebrook, D.L., Moore, L.A.,
Nez, T.D., Norton, I.M., Orton, H.D., Randall, C.J., Sam, A., Shore, J.H., Simpson, S.G.,
and Yazzie, L.L. Racial disparities in alcohol use: Comparison of two American Indian reser-
vation populations with national data. American Journal of Public Health 93(10):1683–1685,
2003.
Bean, R.A., Perry, B.J., and Bedell, T.M. Developing culturally competent marriage and family
therapists: Guidelines for working with Hispanic families. Journal of Marital & Family Thera-
py 27(1):43–54, 2001.
Beauvais, F., Wayman, J.C., Jumper-Thurman, P., Plested, B., and Helm, H. Inhalant abuse
among American Indian, Mexican American, and non-Latino white adolescents. The Ameri-
can Journal of Drug and Alcohol Abuse 28(1):171–187, 2002.
Beck, A.T., and Steer, R.A. BAI, Beck Anxiety Inventory Manual. San Antonio, TX: The Psycho-
logical Corporation, 1990.
Beck, A.T., Steer, R.A., and Brown, G.K. Beck Depression Inventory - II Manual. San Antonio,
TX: The Psychological Corporation, 1996.
Becker, H.S. Becoming a marihuana user. American Journal of Sociology 59(3):235, 1953.
Bedregal, L.E., Sobell, L.C., Sobell, M.B., and Simco, E. Psychometric characteristics of a Span-
ish version of the DAST-10 and the RAGS. Addictive Behaviors 31:309–319, 2006.
Bell-Tolliver, L., Burgess, R., and Brock, L.J. African American therapists working with African
American families: An exploration of the strengths perspective in treatment. Journal of Mari-
tal and Family Therapy 35(3):293–307, 2009.
Bennett, L.A., and Cook, P.W. Alcohol and drug studies. In: Sargent, C.F., and Johnson, T.M.,
eds. Handbook of Medical Anthropology: Contemporary Theory and Method. Revised ed. (pp.
235–251). Portsmouth, NH: Greenwood Publishing Group, 1996.
Benuto, L.T. Guide to Psychological Assessment With Hispanics. New York: Springer, 2012.
Berger, L. K., Zane, N., and Hwang, W-C. Therapist ethnicity and treatment orientation differ-
ences in multicultural counseling competencies. Asian American Journal of Psychology 5(1):
53–65, 2014.
Bergmark, K.H., and Kuendig, H. Pleasures of drinking: A cross-cultural perspective. Journal of
Ethnicity in Substance Abuse 7(2):131–153, 2008.
Berlin, E.A., and Fowkes, W.C., Jr. A teaching framework for cross-cultural health care. Applica-
tion in family practice. The Western Journal of Medicine 139(6):934–938, 1983.
Bernal, G., and Domenech Rodriguez, M.M. Cultural Adaptations: Tools for Evidence-Based Prac-
tice with Diverse Populations. Washington, D.C: American Psychological Association, 2012.

184
 Appendix A—Bibliography

Bernstein, J., Bernstein, E., Tassiopoulos, K., Heeren, T., Levenson, S., and Hingson, R. Brief
motivational intervention at a clinic visit reduces cocaine and heroin use. Drug and Alcohol
Dependence 77(1):49–59, 2005.
Berry, J.W. Acculturative stress. In: Organista, P.B., Chun, K.M., and Marin, G., eds. Readings in
Ethnic Psychology (pp. 117–122). New York: Routledge, 1998.
Bezdek, M., and Spicer, P. Maintaining abstinence in a northern plains tribe. Medical Anthropolo-
gy Quarterly 20(2):160–181, 2006.
Bhugra, D., and Becker, M.A. Migration, cultural bereavement and cultural identity. World Psy-
chiatry 4(1):18–24, 2005.
Bhugra, D., and Gupta, S. Culture and its influence on diagnosis and management. In: Morgan,
C., ed. Principles of Social Psychiatry. 2nd ed. (pp. 117–131). Hoboken, NJ: Wiley-Blackwell,
2010.
Bhui, K., Warfa, N., Edonya, P., McKenzie, K., and Bhugra, D. Cultural competence in mental
health care: A review of model evaluations. BMC Health Services Research 7:15, 2007.
Bibb, A., and Casimer, G.J. Addiction recovery among West Indians. In: Krestan, J.A., ed. Bridges
to Recovery: Addiction, Family Therapy, and Multicultural Treatment (pp. 173–191). New York:
The Free Press, 2000.
Bigby, J., and American College of Physicians. Cross-Cultural Medicine. Philadelphia: American
College of Physicians, 2003.
Black, D.W., Arndt, S., Hale, N., and Rogerson, R. Use of the Mini International Neuropsychiat-
ric Interview (MINI) as a screening tool in prisons: Results of a preliminary study. Journal of
the American Academy of Psychiatry and the Law 32:158–162, 2004.
Blackman, S.J. Has drug culture become an inevitable part of youth culture? A critical assessment
of drug education. Educational Review 48(2):131–142, 1996.
Blake, A. Drugs and popular music in the modern age. In: Manning, P., ed. Drugs and Popular
Culture: Drugs, Media and Identity in Contemporary Society (pp. 103–116). Devon, United
Kingdom: Willan Publishing, 2007.
Bland, I.J., and Kraft, I. The therapeutic alliance across cultures. In: Okpaku, S.O., ed. Clinical
Methods in Transcultural Psychiatry (pp. 266–278). Washington, DC: American Psychiatric
Press, 1998.
Blendon, R.J., Buhr, T., Cassidy, E.F., Perez, D.J., Hunt, K.A., Fleischfresser, C., Benson, J.M.,
and Herrmann, M.J. Disparities in health: Perspectives of a multi-ethnic, multi-racial Ameri-
ca. Health Affairs (Project Hope) 26(5):1437–1447, 2007.
Bloomfield, K., Gmel, G., and Wilsnack, S. Introduction to special issue: Gender, culture and
alcohol problems: A multi-national study. Alcohol and Alcoholism Supplement 41(1):i3–i7, 2006.
Blume, A.W., Morera, O.F., and de la Cruz, B.G. Assessment of addictive behaviors in ethnic-
minority cultures. In: Donovan, D.M., and Marlatt, G.A., eds. Assessment of Addictive Behav-
iors. 2nd ed. (pp. 49–70). New York: Guilford Press, 2005.

185
 Improving Cultural Competence

Bluthenthal, R.N., Jacobson, J.O., and Robinson, P.L. Are racial disparities in alcohol treatment
completion associated with racial differences in treatment modality entry? Comparison of
outpatient treatment and residential treatment in Los Angeles County, 1998 to 2000. Alcohol-
ism: Clinical & Experimental Research 31(11):1920–1926, 2007.
Bonilla, J., Bernal, G., Santos, A., and Santos, D. A revised Spanish version of the Beck Depres-
sion Inventory: Psychometric properties with a Puerto Rican sample of college students.
Journal of Clinical Psychology 60:119–130, 2004.
Bonnie, R.J., and Whitebread, C.H. The forbidden fruit and the tree of knowledge: An inquiry
into the legal history of American marijuana prohibition. Virginia Law Review 56(6):971,
1970.
Borges, G., and Cherpitel, C. J. Selection of screening items for alcohol abuse and alcohol de-
pendence among Mexicans and Mexican Americans in the emergency department. Journal of
Studies on Alcohol 62:277–285, 2001.
Bourgois, P. In Search of Respect: Selling Crack in El Barrio. 2nd ed. New York: Cambridge Univer-
sity Press, 2003.
Bourgois, P. Just another night in a shooting gallery. Theory, Culture & Society 15(2):37–66, 1998.
Bourgois, P., and Schonberg, J. Intimate apartheid: Ethnic dimensions of habitus among home-
less heroin injectors. Ethnography 8(1):7–31, 2007.
Bourgois, P., Martinez, A., Kral, A., Edlin, B.R., Schonberg, J., and Ciccarone, D. Reinterpreting
ethnic patterns among White and African American men who inject heroin: A social science
of medicine approach. PLoS Medicine 3:0001–0011, 2006.
Bowker, A. The 21st Century substance abuser: Cyberspace intersecting with the drug culture.
Scituate, MA: Corrections Connection, 2011.
Boyd-Franklin, N. Black Families in Therapy: Understanding the African American Experience. 2nd
ed. New York: Guilford Press, 2003.
Boyd-Franklin, N., and Karger, M. Intersections of race, class, and poverty: Challenges and resili-
ence in African American families. In: Normal Family Processes: Growing Diversity and Com-
plexity. 4th ed. (pp. 273–296). New York: Guilford Press, 2012.
Boyd-Franklin, N., Kelly, S., and Durham, J. African-American couples in therapy. In: Gurman,
A.S., ed. Clinical Handbook of Couple Therapy (pp. 681–697). New York: Guilford Press, 2008.
Brach, C., and Fraser, I. Can cultural competency reduce racial and ethnic health disparities? A
review and conceptual model. Medical Care Research and Review 57(Suppl 1):181–217, 2000.
Brady, M. Culture in treatment, culture as treatment: A critical appraisal of developments in
addictions programs for indigenous North Americans and Australians. Social Science & Medi-
cine 41(11):1487–1498, 1995.
Brave Heart, M.Y.H. Gender differences in the historical trauma response among the Lakota.
Journal of Health & Social Policy 10(4):1–20, 1999.

186
 Appendix A—Bibliography

Brave Heart, M.Y.H. Culturally and historically congruent clinical social work assessment with
native clients. In Fong, R., and Furuto, S. eds. Cultural Competent Practice: Skills, Interventions,
and Evaluation (pp. 163–177). Reading, MA: Longman Publishers, 2001.
Brave Heart, M.Y.H., Chase, J., Elkins, J., and Altschul, D.B. Historical trauma among Indige-
nous peoples of the Americas: Concepts, research, and clinical considerations. Journal of Psy-
choactive Drugs 43(4):282–290, 2011.
Brave Heart, M.Y.H., and Debruyn, L.M. The American Indian Holocaust: Healing historical
unresolved grief. American Indian and Alaska Native Mental Health Research, 8(2):56–78,
1998.
Brecht, M.L., von Mayrhauser, C., and Anglin, M.D. Predictors of relapse after treatment for
methamphetamine use. Journal of Psychoactive Drugs 32(2):211–220, 2000.
Breslau, N., Davis, G.C., and Andreski, P. Risk factors for PTSD-related traumatic events: A
prospective analysis. The American Journal of Psychiatry 152(4):529–535, 1995.
Bresnahan, M., Begg, M.D., Brown, A., Schaefer, C., Sohler, N., Insel, B., Vella, L., and Susser, E.
Race and risk of schizophrenia in a US birth cohort: Another example of health disparity?
International Journal of Epidemiology 36:751–758, 2000.
Brisbane, F.L. Introduction: Diversity among African Americans. In: Brisbane, F.L., Epstein,
L.G., Pacheco, G., and Quinlan, J.W., eds. Cultural Competence for Health Care Professionals
Working With African-American Communities: Theory and Practice. CSAP Cultural Compe-
tence Series 7 (pp. 1–8). Rockville, MD: Center for Substance Abuse Prevention, 1998.
Broekman, B.F.P., Nyunt, S.Z., Niti, M., Jin, A.Z., Ko, S. M., Kumar, R. Fones C.S, and Ng, T.P.
Differential item functioning of the Geriatric Depression Scale in an Asian population. Jour-
nal of Affective Disorders 108:285–290, 2008.
Brower, K.J., and Carey, T.L. Racially related health disparities and alcoholism treatment out-
comes. Alcoholism: Clinical & Experimental Research 27(8):1365–1367, 2003.
Brown, B.S., O’Grady, K., Battjes, R.J., and Farrell, E.V. Factors associated with treatment out-
comes in an aftercare population. The American Journal of Addiction 13(5):447–460, 2004.
Broz, D., and Ouellet, L.J. Racial and ethnic changes in heroin injection in the United States:
Implications for the HIV/AIDS epidemic. Drug and Alcohol Dependence 94(1-3):221–233,
2008.
Burgess, D.J., Ding, Y., Hargreaves, M., van Ryn, M., and Phelan, S. The association between
perceived discrimination and underutilization of needed medical and mental health care in a
multi-ethnic community sample. Journal of Health Care for the Poor and Underserved
19(3):894–911, 2008.
Butcher, J.N., Dahlstrom, W.G., Graham, J.R., Tellegen, A., and Kaemmer, B. The Minnesota
Multiphasic Personality Inventory-2 (MMPI-2): Manual for Administration and Scoring. Min-
neapolis, MN: University of Minnesota Press, 1989.
Butler, S.F., Redondo, J.P., Fernandez, K.C., and Villapiano, A. (2009). Validation of the Spanish
Addiction Severity Index Multimedia Version (S-ASI-MV). Drug and Alcohol Dependence
99:18–27, 2009.

187
 Improving Cultural Competence

Caetano, R. Alcohol-related health disparities and treatment-related epidemiological findings

among Whites, Blacks, and Hispanics in the United States. Alcoholism: Clinical & Experi-
mental Research 27(8):1337–1339, 2003.
Caetano, R., and Clark, C.L. Trends in alcohol-related problems among Whites, Blacks, and
Hispanics: 1984–1995. Alcoholism: Clinical and Experimental Research 22(2):534–538, 1998.
Caetano, R., Ramisetty-Mikler, S., and Rodriguez, L.A. The Hispanic Americans baseline alco-
hol survey (HABLAS): Rates and predictors of alcohol abuse and dependence across His-
panic national groups. Journal of Studies on Alcohol and Drugs 69(3):441–448, 2008.
Caetano, R., and Schafer, J. DSM-IV alcohol dependence in a treatment sample of White, Black,
and Mexican-American men. Alcoholism: Clinical and Experimental Research 20(2):384–390,
1996.
Calabrese, J.D. Clinical paradigm clashes: Ethnocentric and political barriers to Native American
efforts at self-healing. ETHOS 36(3):334–353, 2008.
Calsyn, D.A., Saxon, A.J., and Daisy, F. Validity of the MCMI Drug Abuse Scale varies as a
function of drug choice, race, and Axis II subtypes. American Journal of Drug and Alcohol Abuse
17:153–159, 1991.
Campinha-Bacote, J., Claymore-Cuny, D., Cora-Bramble, D., Gilbert, J., Husbands, R.M., Like,
R.C., Llerena-Quinn, R., Lu, F.G., Soto-Greene, M.L., Stubblefield-Tave, B., and Tang, G.
Transforming the Face of Health Professions Through Cultural and Linguistic Competence Educa-
tion: The Role of the HRSA Centers of Excellence. Washington, DC: Health Resources and Ser-
vices Administration, 2005.
Canady, R.B., Stommel, M., and Holzman, C. Measurement properties of the centers for epide-
miological studies depression scale (CES-D) in a sample of African American and non-
Hispanic White pregnant women. Journal of Nursing Measurement 17:91–104, 2009.
Canino, G. Alcohol use and misuse among Hispanic women: Selected factors, processes, and
studies. The International Journal of the Addictions 29(9):1083–1100, 1994.
Canino, G., Bravo, M., Ramirez, R., Febo, V.E., Rubio-Stipec, M., Fernández, R.L., and Hasin,
D. The Spanish Alcohol Use Disorder and Associated Disabilities Interview Schedule
(AUDADIS): Reliability and concordance with clinical diagnoses in a Hispanic population.
Journal of Studies on Alcohol 60:790–799, 1999.
Canino, G., Vega, W.A., Sribney, W.M., Warner, L.A., and Alegria, M. Social relationships, social
assimilation, and substance use disorders among adult Latinos in the United States. Journal of
Drug Issues 38(1):69–101, 2008.
Carbone-Lopez, K., Owens, J.G., and Miller, J. Women’s “storylines” of methamphetamine ini-
tiation in the Midwest. Journal of Drug Issues 42(3):226–246, 2012.
Cardemil, E.V., Moreno, O., and Sanchez, M. One size does not fit all: Cultural considerations in
evidence-based practice for depression. In: Springer, D.W., Rubin, A., and Beevers, C.G., eds.
Treatment of Depression in Adolescents and Adults (pp. 221–243). Hoboken, NJ: John Wiley &
Sons, 2011.

188
 Appendix A—Bibliography

Carise, D., and McLellan, A.T. Increasing Cultural Sensitivity of the Addiction Severity Index (ASI):
An example With Native Americans in North Dakota. Special Report. Rockville, MD: Center for
Substance Abuse Treatment, 1999.
Carle, A. Assessing the adequacy of self-reported alcohol abuse measurement across time and
ethnicity: Cross-cultural equivalence across Hispanics and Caucasians in 1992, non-
equivalence in 2001–2002. BMC Public Health 9(1):60, 2009.
Carlson, R.G. Ethnography and applied substance misuse research: Anthropological and cross-
cultural factors. In: Miller, W.R., and Carroll, K.M., eds. Rethinking Substance Abuse: What the
Science Shows and What We Should Do About It (pp. 201–219). New York: Guilford Press, 2006.
Carmody, D.P. Psychometric characteristics of the Beck Depression Inventory-II with college
students of diverse ethnicity. International Journal of Psychiatry in Clinical Practice 9:22–28,
2005.
Carnes, P.J., Murray, R.E., and Charpentier, L. Addiction interaction disorder. In: Coombs, R.H.,
ed. Handbook of Addictive Disorders: A Practical Guide to Diagnosis and Treatment (pp. 31–60).
Hoboken, NJ: John Wiley & Sons, 2004.
Carpenter-Song, E., Whitley, R., Lawson, W., Quimby, E., and Drake, R.E. Reducing disparities
in mental health care: Suggestions from the Dartmouth-Howard collaboration. Community
Mental Health Journal 47(1):1–13, 2011.
Carvajal, S.C., and Young, R.S. Culturally based substance abuse treatment for American Indi-
ans/Alaska natives and Latinos. Journal of Ethnicity in Substance Abuse 8(3):207–222, 2009.
Case Management Society of America. Standards of Practice for Case Management. Little Rock,
AR: Case Management Society of America, 2010.
Casswell, S., Pledger, M., and Hooper, R. Socioeconomic status and drinking patterns in young
adults. Addiction 98(5):601–610, 2003.
Castro, F.G. Cultural competence training in clinical psychology: Assessment, clinical interven-
tion, and research. In: Bellack, A.S., and Hersen, M., eds. Comprehensive Clinical Psychology:
Sociocultural and Individual Differences, Vol. 10 (pp. 127–140). Oxford: Pergamon, 1998.
Castro, F.G., Cota, M.K., and Vega, S. Health promotion in Latino populations: Program plan-
ning, development, and evaluation. In: Huff, R.M., and Kline, M.V., eds. Promoting Health in
Multicultural Populations: A Handbook for Practitioners (pp. 137–168). Thousand Oaks, CA:
Sage Publications, 1999a.
Castro, F.G., and Gutierres, S. (1997). Drug and alcohol use among rural Mexican Americans. In:
Robertson, E.B., and National Institute on Drug Abuse, eds. Rural Substance Abuse: State Of
Knowledge and Issues (pp. 498-530). Rockville, MD: U.S. Department of Health and Human
Services, National Institutes of Health, National Institute on Drug Abuse, 1997.
Castro, F.G., and Murray, K.E. Cultural adaptation and resilience: Controversies, issues, and
emerging models. In: Reich, J.W., Zautra, A.J., and Hall, J.S., eds. Handbook of Adult Resilience
(pp. 375–403). New York: Guilford Press, 2010.

189
 Improving Cultural Competence

Castro, F.G., Nichols, E., and Kater, K. Relapse prevention with Hispanic and other racial/ethnic
populations: Can cultural resilience promote relapse prevention? In: Witkiewitz, K.A., and
Marlatt, G.A., eds. Therapist’s Guide to Evidence-Based Relapse Prevention: Practical Resources
for the Mental Health Professional (pp. 259–292). Boston: Elsevier Academic Press, 2007.
Castro, F.G., Proescholdbell, R.J., Abeita, L., and Rodriguez, D. Ethnic and cultural minority
groups. In: McCrady, B.S., and Epstein, E.E., eds. Addictions: A Comprehensive Guidebook (pp.
499–526). New York: Oxford University Press, 1999b.
Castro, Y., Gordon, K.H., Brown, J.S., Anestis, J. C., and Joiner, J. Examination of racial differ-
ences on the MMPI-2 clinical and restructured clinical scales in an outpatient sample. As-
sessment 15:277–286, 2008.
Celenk, O., and Van de Vijver, F. Assessment of acculturation: Issues and overview of measures.
Online Readings in Psychology and Culture 8(1), 2011.
Center for Substance Abuse Prevention. Following Specific Guidelines Will Help You Assess Cultural
Competence in Program Design, Application, and Management. Technical Assistance Bulletin:1–
4. Rockville, MD: Center for Substance Abuse Prevention, 1994.
Center for Substance Abuse Prevention. CSAP Implementation Guide: Hispanic/Latino Natural
Support Systems. HHS publication No. (SMA) 95-3033. Washington, DC: Substance Abuse
and Mental Health Services Administration, U.S. Department of Health and Human Ser-
vices, 1995.
Center for Substance Abuse Treatment. Improving Treatment for Drug-Exposed Infants. Treat-
ment Improvement Protocol (TIP) Series 5. HHS Publication No. (SMA) 95-3057. Rock-
ville, MD: Substance Abuse and Mental Health Services Administration, 1993a.
Center for Substance Abuse Treatment. Pregnant, Substance-Using Women. Treatment Improve-
ment Protocol (TIP) Series 2. HHS Publication No. (SMA) 93-1998. Rockville, MD: Sub-
stance Abuse and Mental Health Services Administration, 1993b.
Center for Substance Abuse Treatment. Screening for Infectious Diseases Among Substance Abusers.
Treatment Improvement Protocol (TIP) Series 6. HHS Publication No. (SMA) 95-3060.
Rockville, MD: Substance Abuse and Mental Health Services Administration, 1993c.
Center for Substance Abuse Treatment. Practical Approaches in the Treatment of Women Who Abuse
Alcohol and Other Drugs. HHS Publication No. (SMA) 94-3006. Washington, DC: U.S. Gov-
ernment Printing Office, 1994a.
Center for Substance Abuse Treatment. Simple Screening Instruments for Outreach for Alcohol and
Other Drug Abuse and Infectious Diseases. Treatment Improvement Protocol (TIP) Series 11.
HHS Publication No. (SMA) 94-2094. Rockville, MD: Substance Abuse and Mental Health
Services Administration, 1994b.
Center for Substance Abuse Treatment. Alcohol and Other Drug Screening of Hospitalized Trauma
Patients. Treatment Improvement Protocol (TIP) Series 16. HHS Publication No. (SMA)
95-3041. Rockville, MD: Substance Abuse and Mental Health Services Administration,
1995a.

190
 Appendix A—Bibliography

Center for Substance Abuse Treatment. Combining Alcohol and Other Drug Treatment with Diver-
sion for Juveniles in the Justice System. Treatment Improvement Protocol (TIP) Series 21. HHS
Publication No. (SMA) 95-3051. Rockville, MD: Substance Abuse and Mental Health Ser-
vices Administration, 1995b.
Center for Substance Abuse Treatment. Developing State Outcomes Monitoring Systems for Alcohol
and Other Drug Abuse Treatment. Treatment Improvement Protocol (TIP) Series 14. HHS
Publication No. (SMA) 95-3031. Rockville, MD: Substance Abuse and Mental Health Ser-
vices Administration, 1995c.
Center for Substance Abuse Treatment. The Role and Current Status of Patient Placement Criteria
in the Treatment of Substance Use Disorders. Treatment Improvement Protocol (TIP) Series 13.
HHS Publication No. (SMA) 95-3021. Rockville, MD: Substance Abuse and Mental Health
Services Administration, 1995d.
Center for Substance Abuse Treatment. The Tuberculosis Epidemic: Legal and Ethical Issues for
Alcohol and Other Drug Abuse Treatment Providers. Treatment Improvement Protocol (TIP)
Series 18. HHS Publication No. (SMA) 95-3047. Rockville, MD: Substance Abuse and
Mental Health Services Administration, 1995e.
Center for Substance Abuse Treatment. Treatment Drug Courts: Integrating Substance Abuse
Treatment With Legal Case Processing. Treatment Improvement Protocol (TIP) Series 23.
HHS Publication No. (SMA) 96-3113. Rockville, MD: Substance Abuse and Mental Health
Services Administration, 1996.
Center for Substance Abuse Treatment. A Guide to Substance Abuse Services for Primary Care
Clinicians. Treatment Improvement Protocol (TIP) Series 24. HHS Publication No. (SMA)
97-3139. Rockville, MD: Substance Abuse and Mental Health Services Administration,
1997a.
Center for Substance Abuse Treatment. Substance Abuse Treatment and Domestic Violence. Treat-
ment Improvement Protocol (TIP) Series 25. HHS Publication No. (SMA) 97-3163. Rock-
ville, MD: Substance Abuse and Mental Health Services Administration, 1997b.
Center for Substance Abuse Treatment. Comprehensive Case Management for Substance Abuse
Treatment. Treatment Improvement Protocol (TIP) Series 27. HHS Publication No. (SMA)
98-3222. Rockville, MD: Substance Abuse and Mental Health Services Administration,
1998a.
Center for Substance Abuse Treatment. Continuity of Offender Treatment for Substance Use Disor-
ders From Institution to Community. Treatment Improvement Protocol (TIP) Series 30. HHS
Publication No. (SMA) 98-3245. Rockville, MD: Substance Abuse and Mental Health Ser-
vices Administration, 1998b.
Center for Substance Abuse Treatment. Naltrexone and Alcoholism Treatment. Treatment Im-
provement Protocol (TIP) Series 28. HHS Publication No. (SMA) 98-3206. Rockville, MD:
Substance Abuse and Mental Health Services Administration, 1998c.
Center for Substance Abuse Treatment. Substance Abuse Among Older Adults. Treatment Im-
provement Protocol (TIP) Series 26. HHS Publication No. (SMA) 98-3179. Rockville, MD:
Substance Abuse and Mental Health Services Administration, 1998d.

191
 Improving Cultural Competence

Center for Substance Abuse Treatment. Substance Use Disorder Treatment for People With Physical
and Cognitive Disabilities. Treatment Improvement Protocol (TIP) Series 29. HHS Publica-
tion No. (SMA) 98-3249. Rockville, MD: Substance Abuse and Mental Health Services
Administration, 1998e.
Center for Substance Abuse Treatment. Brief Interventions and Brief Therapies for Substance Abuse.
Treatment Improvement Protocol (TIP) Series 34. HHS Publication No. (SMA) 99-3353.
Rockville, MD: Substance Abuse and Mental Health Services Administration, 1999a.
Center for Substance Abuse Treatment. Cultural Issues in Substance Abuse Treatment. HHS Publi-
cation No. (SMA) 99-3278. Rockville, MD: Center for Substance Abuse Treatment, 1999b.
Center for Substance Abuse Treatment. Enhancing Motivation for Change in Substance Abuse
Treatment. Treatment Improvement Protocol (TIP) Series 35. HHS Publication No. (SMA)
99-3354. Rockville, MD: Substance Abuse and Mental Health Services Administration,
1999c.
Center for Substance Abuse Treatment. Screening and Assessing Adolescents for Substance Use Disor-
ders. Treatment Improvement Protocol (TIP) Series 31. HHS Publication No. (SMA) 99-
3282. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1999d.
Center for Substance Abuse Treatment. Treatment of Adolescents With Substance Use Disorders.
Treatment Improvement Protocol (TIP) Series 32. HHS Publication No. (SMA) 99-3283.
Rockville, MD: Substance Abuse and Mental Health Services Administration, 1999e.
Center for Substance Abuse Treatment. Treatment for Stimulant Use Disorders. Treatment Im-
provement Protocol (TIP) Series 33. HHS Publication No. (SMA) 99-3296. Rockville, MD:
Substance Abuse and Mental Health Services Administration, 1999f.
Center for Substance Abuse Treatment. Integrating Substance Abuse Treatment and Vocational
Services. Treatment Improvement Protocol (TIP) Series 38. HHS Publication No. (SMA)
00-3470. Rockville, MD: Substance Abuse and Mental Health Services Administration,
2000a.
Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons With Child Abuse
and Neglect Issues. Treatment Improvement Protocol (TIP) Series 36. HHS Publication No.
(SMA) 00-3357. Rockville, MD: Substance Abuse and Mental Health Services Administra-
tion, 2000b.
Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons With HIV/AIDS.
Treatment Improvement Protocol (TIP) Series 37. HHS Publication No. (SMA) 00-3459.
Rockville, MD: Substance Abuse and Mental Health Services Administration, 2000c.
Center for Substance Abuse Treatment. A Provider’s Introduction to Substance Abuse Treatment for
Lesbian, Gay, Bisexual, And Transgender Individuals. HHS Publication No. (SMA) 01-3498.
Rockville, MD: Substance Abuse and Mental Health Services Administration, 2001.
Center for Substance Abuse Treatment. Patterns of Substance Use Among Minority Youth and
Adults in the United States: An Overview and Synthesis of National Survey Findings. NEDS
Analytic Summary Series #29, February 2002.

192
 Appendix A—Bibliography

Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the
Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. HHS Pub-
lication No. (SMA) 04-3939. Rockville, MD: Substance Abuse and Mental Health Services
Administration, 2004a.
Center for Substance Abuse Treatment. Substance Abuse Treatment and Family Therapy. Treat-
ment Improvement Protocol (TIP) Series 39. HHS Publication No. (SMA) 04-3957. Rock-
ville, MD: Substance Abuse and Mental Health Services Administration, 2004b.
Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in
Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. HHS Publi-
cation No. SMA 05-4048. Rockville, MD: Substance Abuse and Mental Health Services
Administration, 2005a.
Center for Substance Abuse Treatment. Substance Abuse Treatment for Adults in the Criminal
Justice System. Treatment Improvement Protocol (TIP) Series 44. HHS Publication No.
(SMA) 05-4056. Rockville, MD: Substance Abuse and Mental Health Services Administra-
tion, 2005b.
Center for Substance Abuse Treatment. Substance Abuse Treatment: Group Therapy. Treatment
Improvement Protocol (TIP) Series 41. HHS Publication No. SMA 05-4056. Rockville,
MD: Substance Abuse and Mental Health Services Administration, 2005c.
Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons with Co-Occurring
Disorders. Treatment Improvement Protocol (TIP) Series 42. HHS Publication No. SMA
05-3992. Rockville, MD: Substance Abuse and Mental Health Services Administration,
2005d.
Center for Substance Abuse Treatment. Detoxification and Substance Abuse Treatment. Treatment
Improvement Protocol (TIP) Series 45. HHS Publication No. SMA 06-4131. Rockville,
MD: Substance Abuse and Mental Health Services Administration, 2006a.
Center for Substance Abuse Treatment. Substance Abuse: Administrative Issues in Intensive Outpa-
tient Treatment. Treatment Improvement Protocol (TIP) Series 46. HHS Publication No.
SMA 06-4151. Rockville, MD: Substance Abuse and Mental Health Services Administra-
tion, 2006b.
Center for Substance Abuse Treatment. Substance Abuse: Clinical Issues in Intensive Outpatient
Treatment. Treatment Improvement Protocol (TIP) Series 47. HHS Publication No. 06-
4182. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2006c.
Center for Substance Abuse Treatment. Managing Depressive Symptoms in Substance Abuse Clients
During Early Recovery. Treatment Improvement Protocol (TIP) Series 48. HHS Publication
No. SMA 08-4353 Rockville, MD: Substance Abuse and Mental Health Services Admin-
istration, 2008.
Center for Substance Abuse Treatment. Addressing Suicidal Thoughts and Behaviors With Clients in
Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series 50. HHS Publica-
tion No. SMA 09-4381. Rockville, MD: Substance Abuse and Mental Health Services Ad-
ministration, 2009a.

193
 Improving Cultural Competence

Center for Substance Abuse Treatment. Incorporating Alcohol Pharmacotherapies Into Medical
Practice. Treatment Improvement Protocol (TIP) Series 49. HHS Publication No. SMA 09-
4380. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009b.
Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of
Women. Treatment Improvement Protocol (TIP) Series 51. HHS Publication No. SMA 09-
4426 Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009c.
Center for Substance Abuse Treatment. Supervision and the Professional Development of the Sub-
stance Abuse Counselor. Treatment Improvement Protocol (TIP) Series 52. HHS Publication
No. SMA 09-4435. Rockville, MD: Substance Abuse and Mental Health Services Admin-
istration, 2009d.
Centers for Disease Control and Prevention. CDC Health Disparities and Inequalities Report—
United States, 2011. Morbidity and Mortality Weekly Report 60(Suppl):1–109, 2011.
Chae, D.H., Takeuchi, D.T., Barbeau, E.M., Bennett, G.G., Lindsey, J.C., Stoddard, A.M., and
Krieger, N. Alcohol disorders among Asian Americans: Associations with unfair treatment,
racial/ethnic discrimination, and ethnic identification (the National Latino and Asian Ameri-
cans study, 2002–2003). Journal of Epidemiology and Community Health 62(11):973–979,
2008.
Chan, G.M., Hoffman, R.S., Gold, J.A., Whiteman, P.J., Goldfrank, L.R., and Nelson, L.S.
Racial variations in the incidence of severe alcohol withdrawal. Journal of Medical Toxicology
5(1):8–14, 2009.
Chan, S., and Chen, D. Families with Asian roots. In: Lynch, E.W., and Hanson, M.J., eds. De-
veloping Cross-Cultural Competence: A Guide for Working With Children and Their Families. 4th
ed. (pp. 234–318). Baltimore: Paul H. Brookes Publishing, 2011.
Chang, J., Shrake, E., and Rhee, S. Patterns of alcohol use and attitudes toward drinking among
Chinese and Korean American college students. Journal of Ethnicity in Substance Abuse
7(3):341–356, 2008.
Chang, P. Treating Asian/Pacific American addicts and their families. In: Krestan, J.A., ed. Bridg-
es to Recovery: Addiction, Family Therapy, and Multicultural Treatment (pp. 192–218). New
York: Free Press, 2000.
Chao, P.J., Steffen, J.J., and Heiby, E.M. The effects of working alliance and client-clinician
ethnic match on recovery status. Community Mental Health Journal 48(1):91–97, 2012.
Chapleski, E.E., Lamphere, J.K., Kaczynski, R., Lichtenberg, P.A., and Dwyer, J.W. Structure of
a depression measure among American Indian elders: Confirmatory factor analysis of the
CES-D Scale. Research on Aging 19:462–485, 1997.
Chapman, L.K., Williams, S. R., Mast, B.T., and Woodruff-Borden, J. A confirmatory factor
analysis of the Beck Anxiety Inventory in African American and European American young
adults. Journal of Anxiety Disorders 23:387–392, 2009.
Chappel, J.N. Spiritual components of the recovery process. In: Graham, A.W., and Wilford,
B.B., eds. Principles of Addiction Medicine. 2nd ed. (pp. 725–728). Chevy Chase, MD: Ameri-
can Society of Addiction Medicine, 1998.

194
 Appendix A—Bibliography

Charon, J.M. Ten Questions: A Sociological Perspective. 5th ed. Belmont, CA: Wadsworth, 2004.
Chatterji, S., Saunders, J.B., Vrasti, R., Grant, B.F., Hasin, D., and Mager, D. Reliability of the
alcohol and drug modules of the Alcohol Use Disorder and Associated Disabilities Interview
Schedule–Alcohol/Drug-Revised (AUDADIS-ADR): An international comparison. Drug
and Alcohol Dependence 47:171–185, 1997.
Chavez, A.F., and Guido-DiBrito, F. Racial and ethnic identity and development. New Directions
for Adult and Continuing Education 84:39–47, 1999.
Chen, C.P. Group counseling in a different cultural context: Several primary issues in dealing
with Chinese clients. Group 19(1):45–55, 1995.
Cheng, T.C., and Robinson, M.A. Factors leading African Americans and Black Caribbeans to
use social work services for treating mental and substance use disorders. Health & Social
Work 38(2):99–109, 2013.
Cheng, A.T., Tien, A.Y., Chang, C.J., Brugha, T.S., Cooper, J. E., Lee, C.S. Compton, W., Liu,
C.Y., Yu, W.Y., and Chen, H.M. Cross-cultural implementation of a Chinese version of the
Schedules for Clinical Assessment in Neuropsychiatry (SCAN) in Taiwan. British Journal of
Psychiatry 178:567–572, 2001.
Cherpitel, C.J. Screening for alcohol problems in the emergency department. Annals of Emergency
Medicine 26:158–166, 1995.
Cherpitel, C. J. Comparison of screening instruments for alcohol problems between Black and
White emergency room patients from two regions of the country. Alcoholism: Clinical and Ex-
perimental Research 21:1391–1397. 1997.
Cherpitel, C.J. Emergency room and primary care services utilization and associated alcohol and
drug use in the United States general population. Alcohol and Alcoholism 34:581–589, 1999.
Cherpitel, C.J. A brief screening instrument for problem drinking in the emergency room: The
RAPS4. Journal of Studies on Alcohol 61:447–449, 2000.
Cherpitel, C.J. Screening for alcohol problems in the U.S. general population: Comparison of the
CAGE, RAPS4, and RAPS4-QF by gender, ethnicity, and service utilization. Alcoholism:
Clinical and Experimental Research 26:1686–1691, 2002.
Cherpitel, C.J., and Bazargan, S. Screening for alcohol problems: Comparison of the audit,
RAPS4 and RAPS4-QF among African American and Hispanic patients in an inner city
emergency department. Drug and Alcohol Dependence 71:275–280, 2003.
Cherpitel, C.J., and Borges, G. Performance of screening instruments for alcohol problems in the
ER: A comparison of Mexican-Americans and Mexicans in Mexico. American Journal of
Drug and Alcohol Abuse 26:683–702, 2000.
Cherpitel, C.J., Robertson, M., Ye, Y., Borges, G., Bautista, C.F., Lown, A., Greenfield, T., and
Bond, J. Comorbidity for alcohol use disorders and drug use in Mexican-origin groups:
Comparison of data from national alcohol surveys in the U.S. and Mexico. Substance Use &
Misuse 42(11):1685–1703, 2007.

195
 Improving Cultural Competence

Cherpitel, C.J., Ye, Y., Moskalewicz, J., and Swiatkiewicz, G. Screening for alcohol problems in
two emergency service samples in Poland: Comparison of the RAPS4, CAGE and AUDIT.
Drug and Alcohol Dependence 80:201–207, 2005.
Cheung, S. Asian American immigrant mental health: Current status and future directions. In:
Chin. J.L., ed. Diversity in Mind and in Action, Vol 1: Multiple Faces of Identity (pp. 87–104).
Santa Barbara, CA: Praeger/ABC-CLIO, 2009.
Chi, I., Lubben, J.E., and Kitano, H.H. Differences in drinking behavior among three Asian-
American groups. Journal of Studies on Alcohol 50(1):15–23, 1989.
Choney, S.K., Berryhill-Paapke, E., and Robbins, R.R. The acculturation of American Indians:
Developing frameworks for research and practice. In: Ponterotto, J.G., Casas, J.M., Suzuki,
L.A., and Alexander, C.M., eds. Handbook of Multicultural Counseling (pp. 73–92). Thousand
Oaks, CA: Sage Publications, 1995.
Chong, J., and Herman-Stahl, M. Substance abuse treatment outcomes among American Indians
in the telephone aftercare project. Journal of Psychoactive Drugs 35(1):71–77, 2003.
Chong, J., and Lopez, D. Social networks, support, and psychosocial functioning among Ameri-
can Indian women in treatment. American Indian and Alaska Native Mental Health Research
12(1):62–85, 2005.
Chow, J.C., Jaffee, K., and Snowden, L. Racial/ethnic disparities in the use of mental health
services in poverty areas. American Journal of Public Health 93(5):792–797, 2003.
Cochrane, R., and Bal, S. The drinking habits of Sikh, Hindu, Muslim and White men in the
West Midlands: A community survey. British Journal of Addiction 85(6):759–769, 1990.
Cohen, K. Honoring the Medicine: The Essential Guide to Native American Healing. New York:
Ballantine Books, 2003.
Cohen, P. Junky elend: Some ways of explaining it and dealing with it. Wiener Zeitschrift Fur
Suchtforschung 14, 1991(3-4):59–64, 1992.
Cokley, K., and Williams, W. A psychometric examination of the Africentric Scale: Challenges in
measuring Afrocentric values. Journal of Black Studies 35(6):827–843, 2005.
Cole, S.R., Kawachi, I., Maller, S.J., and Berkman, L.F. Test of item-response bias in the CES-D
scale: Experience from the New Haven EPESE Study. Journal of Clinical Epidemiology
53:285–289, 2000.
Colistra, A., and Brown-Rice, K. When the Rubber Hits the Road: Applying Multicultural Compe-
tencies in Cross-Cultural Supervision. Alexandria, VA: American Counseling Association,
2011.
Comas-Diaz, L. Multicultural Care: A Clinician’s Guide to Cultural Competence (pp. 33–56). Wash-
ington, DC: American Psychological Association, 2012.
Congress, E.P. The use of culturagrams to assess and empower culturally diverse families. Fami-
lies in Society 75(9):531–540, 1994.

196
 Appendix A—Bibliography

Congress, E.P. Cultural and ethical issues in working with culturally diverse patients and their
families: The use of the culturagram to promote cultural competent practice in health care
settings. Social Work in Health Care 39(3-4):249–262, 2004.
Congress, E.P., and Kung, W.W. Using the culturagram to assess and empower culturally diverse
families. In: Congress, E.P., and González, M.J., eds. Multicultural Perspectives in Working
With Families. 2nd ed. (pp. 3–21). New York: Springer, 2005.
Constantine, M.G., and Sue, D.W. Strategies for Building Multicultural Competence in Mental
Health and Educational Settings. Hoboken, NJ: John Wiley & Sons, 2005.
Cook, C.C.H. Addiction and spirituality. Addiction 99(5):539–551, 2004.
Cooper, L.A., Brown, C., Vu, H.T., Ford, D.E., and Powe, N.R. How important is intrinsic spir-
ituality in depression care? A comparison of White and African-American primary care pa-
tients. Journal of General Internal Medicine 16(9):634–638, 2001.
Cooper, L.A., Gonzales, J.J., Gallo, J.J., Rost, K.M., Meredith, L.S., Rubenstein, L.V., Wang,
N.Y., and Ford, D.E. The acceptability of treatment for depression among African-
American, Hispanic, and White primary care patients. Medical Care 41(4):479–489, 2003.
Cooper-Patrick, L., Gallo, J.J., Powe, N.R., Steinwachs, D.S., Eaton, W.W., and Ford, D.E. Men-
tal health service utilization by African Americans and Whites: The Baltimore epidemiologic
catchment area follow-up. Medical Care 37(10):1034–1045, 1999.
Corbett, K., Mora, J., and Ames, G. Drinking patterns and drinking-related problems of Mexi-
can-American husbands and wives. Journal of Studies on Alcohol 52(3):215–223, 1991.
Corbin, W.R., Vaughan, E.L., and Fromme, K. Ethnic differences and the closing of the sex gap
in alcohol use among college-bound students. Psychology of Addictive Behaviors 22(2):240–
248, 2008.
Cormier, L.S., Nurius, P., and Osborn, C.J. Interviewing and Change Strategies for Helpers: Fun-
damental Skills and Cognitive Behavioral Interventions. 6th ed. Belmont, CA: Brooks/Cole,
Cengage Learning, 2009.
Cornell, S., and Kalt, J.P. American Indian Self-Determination: The Political Economy of a Successful
Policy. Cambridge, MA: Harvard University, 2010.
Corrigan, P.W., Kuwabara, S.A., and O’Shaughnessy, J. The public stigma of mental illness and
drug addiction: Findings from a stratified random sample. Journal of Social Work 9(2):139–
147, 2009.
Cortes, D.E., and Rogler, L.H. Biculturality among Puerto Rican adults in the United States.
American Journal of Community Psychology 22:707–722, 1994.
Cottler, L.B. Composite International Diagnostic Interview - Substance Abuse Module (SAM). St.
Louis, MO: Washington University School of Medicine, Department of Psychiatry, 2000.
Council of National Psychological Associations for the Advancement of Ethnic Minority Inter-
ests. Psychology Education and Training from Culture-Specific and Multiracial Perspectives:
Critical Issues and Recommendations. Washington, DC: American Psychological Association,
2009.

197
 Improving Cultural Competence

Coyhis, D. Culturally specific addiction recovery for Native Americans. In: Krestan, J., ed. Bridges
to Recovery: Addiction, Family Therapy, and Multicultural Treatment (pp. 77–114). New York:
The Free Press, 2000.
Coyhis, D., and Simonelli, R. Rebuilding Native American communities. Child Welfare
84(2):323–336, 2005.
Coyhis, D.L., and White, W.L. Alcohol Problems in Native America: The Untold Story of Resistance
and Recovery —”The Truth About the Lie.” Colorado Springs, CO: White Bison, Inc., 2006.
Craig, R.J., and Olson, R. Stability of the MCMI-III in a substance-abusing inpatient sample.
Psychological Reports 83(3, Pt 2):1273–1274, 1998.
Cremonte, M., and Cherpitel, C.J. Performance of screening instruments for alcohol use disor-
ders in emergency department patients in Argentina. Substance Use and Misuse 43:125–138
2008.
Crissey, S.R. Educational attainment in the United States: 2007. In: Current Population Reports:
U.S. Census Bureau. Washington, DC: U.S. Census Bureau, 2009.
Crocker, J., Luhtanen, R., Blaine, B., and Broadnax, S. Collective self-esteem and psychological
well-being among White, Black, and Asian college students. Personality and Social Psychology
Bulletin 20:503–513, 1994.
Cross, T.L., Bazron, B.J., Dennis, K.W., and Isaacs, M.R. Towards a Culturally Competent System
of Care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally
Disturbed, Vol. 1. Washington, DC: Georgetown University Child Development Center,
1989.
Cross, W.E. The psychology of nigrescence: Revising the Cross model. In: Ponterotto, J.G.,
Casas, J.M., Suzuki, L.A., and Alexander, C.M., eds. Handbook of Multicultural Counseling
(pp. 93–122). Thousand Oaks, CA: Sage, 1995.
Crum, R.M. The epidemiology of addictive disorders. In: Graham, A.W., Schultz, T.K., Mayo-
Smith, M.F., Ries, R.K., and Wilford, B.B., eds. Principles of Addiction Medicine (pp. 17–31).
Chevy Chase, MD: American Society of Addiction Medicine, 2003.
Cuellar, I., Arnold, B., and Maldonado, R. Acculturation Rating Scale for Mexican Americans II:
A revision of the original ARSMA scale. Hispanic Journal of Behavioral Sciences 17:275–304,
1995.
Cuellar, I., Harris, L.C., and Jasso, R. An acculturation scale for Mexican American normal and
clinical populations. Hispanic Journal of Behavioral Sciences 2:199–217, 1980.
Curtis-Boles, H., and Jenkins-Monroe, V. Substance abuse in African American women. Journal
of Black Psychology 26(4):450–469, 2000.
Daeppen, J.B., Burnand, B., Schnyder, C., and Bonjour, M. Validation of the addiction severity
index in French-speaking alcoholic patients. Journal of Studies on Alcohol 57:585–590, 1996.
Dai, Y., Zhang, S., Yamamoto, J., Ao, M., Belin, T.R., Cheung, F., and Hifumi, S.S. Cognitive
behavioral therapy of minor depressive symptoms in elderly Chinese Americans: A pilot
study. Community Mental Health Journal 35(6):537–542, 1999.

198
 Appendix A—Bibliography

Dakof, G.A., Quille, T.J., Tejeda, M.J., Alberga, L.R., Bandstra, E., and Szapocznik, J. Enrolling
and retaining mothers of substance-exposed infants in drug abuse treatment. Journal of Con-
sulting & Clinical Psychology 71(4):764–772, 2003.
Damashek, A., Bard, D., and Hecht, D. Provider cultural competency, client satisfaction, and
engagement in home-based programs to treat child abuse and neglect. Child Maltreatment
17(1):56–66, 2012.
Dana, R.H. Understanding Cultural Identity in Intervention and Assessment. Thousand Oaks, CA:
Sage Publications, 1998.
D’Andrea, W. Psychology of European American adults: Challenges, advantages, and the push
for further growth. In: Downey, C.A., ed. Handbook of Race and Development in Mental Health
(pp. 223–241). New York: Springer Science + Business Media, 2012.
Dansereau, D.F., and Simpson, D.D. A picture is worth a thousand words: The case for graphic
representations. Professional Psychology: Research and Practice 40(1):104–110, 2009.
Dansereau, D.F., Joe, G.W., Dees, S.M., and Simpson, D.D. Ethnicity and the effects of map-
ping-enhanced drug abuse counseling. Addictive Behaviors 21(3):363–376, 1996.
D’Avanzo, C.E., Frye, B., and Froman, R. Culture, stress and substance use in Cambodian refu-
gee women. Journal of Studies on Alcohol 55(4):420–426, 1994.
Davidson, L., Andres-Hyman, R., Bedregal, L., Tondora, J., Fry, J., and Kirk, T.A. From double
trouble to dual recovery: Integrating models of recovery in addiction and mental health. Jour-
nal of Dual Diagnosis 9(1):273–290, 2008.
Dawson, D.A., Grant, B.F., Stinson, F.S., and Chou, P.S. Estimating the effect of help-seeking on
achieving recovery from alcohol dependence. Addiction 101(6):824–834, 2006.
Dawson, D.A., Grant, B.F., Stinson, F.S., Chou, P.S., Huang, B., and Ruan, W.J. Recovery from
DSM-IV alcohol dependence: United States, 2001–2002. Addiction 100(3):281–292, 2005.
de Korin, E.C., and Petry, S.S.d.C. Brazilian families. In: Ethnicity and Family Therapy. 3rd ed.
(pp. 166–177). New York: Guilford Press, 2005.
De La Rosa, M. Acculturation and Latino adolescents substance use: A research agenda for the
future. Substance Use & Misuse 37(4):429–456, 2002.
De La Rosa, M., Vega, R., and Radisch, M.A. The role of acculturation in the substance abuse
behavior of African-American and Latino adolescents: Advances, issues, and recommenda-
tions. Journal of Psychoactive Drugs 32(1):33–42, 2000.
Deloria, V. God Is Red: A Native View of Religion. New York: Dell Publishing, 1973.
Delphin-Rittmon, M.E., Andres-Hyman, R., Flanagan, E.H., and Davidson, L. Seven essential
strategies for promoting and sustaining systemic cultural competence. Psychiatric Quarterly
84(1):53–64, 2012a.
Delphin-Rittmon, M., Andres-Hyman, R., Flanagan, E.H., Ortiz, J., Amer, M.M., and Da-
vidson, L. Racial-ethnic differences in referral source, diagnosis, and length of stay in inpa-
tient substance abuse treatment. Psychiatric Services 63(6):612–615, 2012b.

199
 Improving Cultural Competence

DeNavas-Walt, C., Proctor, B.D., and Lee, C.H. Income, Poverty, and Health Insurance Coverage
in the United States: 2005. (pp. 60–229). Washington, DC: U.S. Government Printing Office,
2006.
Dessio, W., Wade, C., Chao, M., Kronenberg, F., Cushman, L.E., and Kalmuss, D. Religion,
spirituality, and healthcare choices of African-American women: Results of a national survey.
Ethnicity and Disease 14(2):189–197, 2004.
de Torres, L.A., Rebollo, E.M., Ruiz-Moral, R., Fernandez-Garcia, J.A., Vega, R.A., and Palomi-
no, M.M. Diagnostic usefulness of the Alcohol Use Disorders Identification Test (AUDIT)
questionnaire for the detection of hazardous drinking and dependence on alcohol among
Spanish patients. European Journal of General Practice 15:15–21, 2009.
Diwan, S., Jonnalagadda, S. S., and Gupta, R. Differences in the structure of depression among
older Asian Indian immigrants in the United States. Journal of Applied Gerontology 23:370–
384, 2004.
Dixon, M., and Iron, P.E. Strategies for Cultural Competency in Indian Health Care. Washington,
DC: American Public Health Association, 2006.
Dixon, L., Lewis-Fernandez, R., Goldman, H., Interian, A., Michaels, A., and Kiley, M.C. Ad-
herence disparities in mental health: Opportunities and challenges. Journal of Nervous and
Mental Disease 199(10):815–820, 2011.
Dogra, N., and Karim, K. Diversity training for psychiatrists. In: Bhattacharya, R. Cross, S., and
Bhugra, D., eds. Clinical Topics in Cultural Psychiatry (pp. 348–365). London: Royal College
of Psychiatrists, 2010.
Donisi, V.,Tedeschi, F.,Percudani, M., Fiorillo, A., Confalonieri, L., De Rosa, C., Salazzari, D.,
Tansella, M., Thornicroft, G., and Amaddeo, F. Prediction of community mental health ser-
vice utilization by individual and ecological level socio-economic factors. Psychiatry Research
209(3): 691–698, 2013.
Downey, C.A., and D’Andrea, W. Psychology of European American adults: Challenges, ad-
vantages, and the push for further growth. In: Chang, E.C., and Downey, C.A., eds. Handbook
of Race and Development in Mental Health (pp. 223–241). New York: Springer Science, 2012.
Drake, R. E., McHugo, G. J., and Biesanz, J. C. The test-retest reliability of standardized instru-
ments among homeless persons with substance use disorders. Journal of Studies on Alcohol
56:161–167, 1995.
Dreachslin, J.L., Gilbert, M.J., and Malone, B. Diversity and Cultural Competence in Health Care:
A Systems Approach. 1st ed. San Francisco: Jossey-Bass, 2013.

200
 Appendix A—Bibliography

Duffy, F.F., West, J.C. Wilk, J. Narrow, W.E., Hales, D., Thompson, J., Regier, D.A., Kohout, J.,
Pion, G.M., Wicherski, M.M., Bateman, N., Whitaker, T., Merwin, E.I., Lyon, D., Fox, J.C.,
Delaney, K.R., Hanrahan, N., Stockton, R., Garbelman, J., Kaladow, J., Clawson, T.W., Smith,
S.C., Bergman, D.M., Northey, W.F., Blankertz, L., Thomas, A., Sullivan, L.D., Dwyer, K.P.,
Fleischer, M.S., Woodruff, C.R., Goldsmith, H.F., Henderson, M.J., Atay, J.J., and Mander-
scheid, R.W. Mental health practitioners and trainees. In: Manderscheid, R.W., and Hender-
son, M.J., eds. Mental Health, United States, 2002 (pp. 327–368). HHS Publication No.
(SMA) 3938. Rockville, MD: Substance Abuse and Mental Health Services Administration,
2004.
Dugger, K. Social location and gender-role attitudes: A comparison of Black and White women.
In: Lorber, J., and Farrell, S.A., eds. The Social Construction of Gender (pp. 38–59). Newbury
Park, CA:Sage Publications, 1991.
Duran, B., Duran, E., and Brave Heart, M.Y.H. Native Americans and trauma of history. In:
Thornton, R., ed. Studying Native America: Problems and Prospects (pp. 60–76). Madison, WI:
University of Wisconsin Press, 1998.
Duran, B.G., Oetzel, J., Lucero, J., Jiang, Y., Novins, D.K., Manson, S., and Beals, J. Obstacles for
rural American Indians seeking alcohol, drug, or mental health treatment. Journal of Consult-
ing and Clinical Psychology 73(5):819–829, 2005.
Duran, B.G., Wallerstein, N., and Miller, W.R. New approaches to alcohol interventions among
American Indian and Latino communities: The experience of the Southwest Addictions Re-
search Group. Alcoholism Treatment Quarterly 25(4):1–10, 2007.
Duran, E. Healing the Soul Wound: Counseling With American Indians and Other Native Peoples
(Multicultural Foundations of Psychology and Counseling). New York: Teachers College Press,
2006.
Durant, A. African-American alcoholics: An interpretive/constructivist model of affiliation with
Alcoholics Anonymous (AA). Journal of Ethnicity in Substance Abuse 4(1):5–21, 2005.
Dutton, G. R., Grothe, K. B., Jones, G. N., Whitehead, D., Kendra, K., and Brantley, P.J. Use of
the Beck Depression Inventory-II with African American primary care patients. General
Hospital Psychiatry 26:437–442, 2004.
Ebberhart, N.C., Luczak, S.E., Avanecy, N., and Wall, T.L. Family history of alcohol dependence
in Asian Americans. Journal of Psychoactive Drugs 35(3):375–377, 2003.
Edberg, M.C. El Narcotraficante: Narcocorridos and the Construction of a Cultural Persona on the
U.S. Mexican Border. Austin, TX: University of Texas Press, 2004.
Edwards, E.D., and Egbert-Edwards, M. Community development with American Indians and
Alaska Natives. In: Rivera, F.G., and Erlich, J.L., eds. Community Organizing in a Diverse So-
ciety. 3rd ed. (pp. 25–42). Boston: Allyn & Bacon, 1998.
Edwards, E.D., Seaman, J.R., Drews, J., and Edwards, M.E. A community approach for Native
American drug and alcohol prevention programs: A logic model framework. Alcoholism
Treatment Quarterly 13(2):43–62, 1995.
Edwards, Y. Cultural connection and transformation: substance abuse treatment at Friendship
House. Journal of Psychoactive Drugs 35(1):53–58, 2003.

201
 Improving Cultural Competence

Ehlers, C.L., Hurst, S., Phillips, E., Gilder, D.A., Dixon, M., Gross, A., Lau, P., and Yehuda, R.
Electrophysiological responses to affective stimuli in American Indians experiencing trauma
with and without PTSD. Annals of the New York Academy of Sciences 1071:125–136, 2006.
Ennis, S.R., Rios-Vargas, M., and Albert, N.G. The Hispanic Population: 2010. Census 2010
Brief. Washington, DC: U.S. Census Bureau, 2011.
Esan, O. Echoes of drug culture in urban music. In: Manning, P., ed. Drugs and Popular Culture:
Drugs, Media and Identity in Contemporary Society (pp. 196–210). Devon, United Kingdom:
Willan Publishing, 2007.
Escobar, J.I., and Vega, W.A. Mental health and immigration’s AAAs: where are we and where
do we go from here? Journal of Nervous and Mental Disease 188(11):736–740, 2000.
Evans, E., Pierce, J., Li, L., Rawson, R., and Hser, Y.I. More alike than different: Health needs,
services utilization, and outcomes of Asian American and Pacific Islander (AAPI) popula-
tions treated for substance use disorders. Journal of Ethnicity in Substance Abuse 11(4):318–
338, 2012.
Evans-Campbell, T. Historical trauma in American Indian/Native Alaska communities: A multi-
level framework for exploring impacts on individuals, families, and communities. Journal of
Interpersonal Violence 23(3):316–338, 2008.
Ewing, J.A. Detecting alcoholism. The CAGE questionnaire. Journal of the American Medical
Association 252:1905–1907, 1984.
Eytan, A., Durieux-Paillard, S., Whitaker-Clinch, B., Loutan, L., and Bovier, P. A. Transcultural
validity of a structured diagnostic interview to screen for major depression and posttraumatic
stress disorder among refugees. Journal of Nervous and Mental Disease 195:723–728, 2007.
Fadiman, A. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and
the Collision of Two Cultures. 1st ed. New York: Farrar, Straus, and Giroux, 1997.
Falck, R.S., Wang, J., and Carlson, R.G. Among long-term crack smokers, who avoids and who
succumbs to cocaine addiction? Drug and Alcohol Dependence 98(1-2):24–29, 2008.
Falicov, C.J. Mexican Families. In: McGoldrick, M., Giordano, J., and Garcia-Preto, N., eds.
Ethnicity and Family Therapy. 3rd ed. (pp. 229–241). New York: Guilford Press, 2005.
Falicov, C.J. Immigrant family processes: A multidimensional framework. In: Walsh, F., ed. Nor-
mal Family Processes: Growing Diversity and Complexity. 4th ed. (pp. 297–323). New York:
Guilford Press, 2012.
Farley, M., Golding, J.M., Young, G., Mulligan, M., and Minkoff, J.R. Trauma history and relapse
probability among patients seeking substance abuse treatment. Journal of Substance Abuse
Treatment 27(2):161–167, 2004.
Farver, J.A., Narang, S.K., and Bhadha, B.R. East meets West: Ethnic identity, acculturation, and
conflict in Asian Indian families. Journal of Family Psychology 16(3):338–350, 2002.
Feidler, K., Screen, A., Greenfield, L., and Fountain, D. Analysis of Three Outcome Proxies for Post-
Treatment Substance Use in NTIES. Rockville, MD: Substance Abuse and Mental Health
Services Administration, 2001.

202
 Appendix A—Bibliography

Fekjaer, H.O. The Psychology of “Getting High.” Colombo, Sri Lanka: ADIC, 1994.
Felix-Ortiz, M., Newcomb, M.D., and Myers, H. A multidimensional measure of cultural identi-
ty for Latino and Latina adolescents. Hispanic Journal of Behavioral Sciences 16:99–115, 1994.
Fellner, J. Race, drugs and law enforcement in the United States. Stanford Law and Policy Review
20(2):257–292, 2009.
Fernandez-Montalvo, J., Landa, N., Lopez-Goni, J. J., and Lorea, I. Personality disorders in
alcoholics: A comparative pilot study between the IPDE and the MCMI-II. Addictive Behav-
iors 31:1442–1448, 2006.
Field, C., and Caetano, R. The role of ethnic matching between patient and provider on the
effectiveness of brief alcohol interventions with Hispanics. Alcoholism: Clinical & Experi-
mental Research 34(2):262–271, 2010.
Field, L. D., Chavez-Korell, S., and Domenech Rodriguez, M.M. No hay rosas sin espinas: Con-
ceptualizing Latina-Latina supervision from a multicultural developmental supervisory mod-
el. Training and Education in Professional Psychology 4(1):47–54, 2010.
Fiorentine, R., and Hillhouse, M.P. Drug treatment effectiveness and client-counselor empathy:
Exploring the effects of gender and ethnic congruency. Journal of Drug Issues 29(1):59–74,
1999.
Fisher, D.G., Lankford, B.A., and Galea, R.P. Therapeutic community retention among Alaska
Natives: Akeela house. Journal of Substance Abuse Treatment 13(3):265–271, 1996.
Flores-Ortiz, Y.G. The role of cultural and gender values in alcohol use patterns among Chica-
na/Latina high school and university students: Implications for AIDS prevention. The Inter-
national Journal of the Addictions 29(9):1149–1171, 1994.
Flynn, A.M., Alvarez, J., Jason, L.A., Olson, B.D., Ferrari, J.R., and Davis, M.I. African Ameri-
can Oxford House residents: Sources of abstinent social networks. Journal of Prevention & In-
tervention in the Community 31(1-2):111–119, 2006.
Folwarski, J., and Smolinski, J. Polish Families. In: McGoldrick, M., Giordano, J., and Garcia-
Preto, N., eds. Ethnicity and Family Therapy. 3rd ed. (pp. 741–755). New York: Guilford Press,
2005.
Fontes, L.A. Interviewing Clients Across Cultures: A Practitioner’s Guide. New York: Guilford Press,
2008.
Ford, J.A., and Arrastia, M.C. Pill-poppers and dopers: A comparison of non-medical prescrip-
tion drug use and illicit/street drug use among college students. Addictive Behaviors
33(7):934–941, 2008.
Fortney, J., Mukherjee, S., Curran, G., Fortney, S., Han, X., and Booth, B.M. Factors associated
with perceived stigma for alcohol use and treatment among at-risk drinkers. The Journal of
Behavior Health Services & Research 31(4):418–429, 2004.
Fortuna, L.R., Alegria, M., and Gao, S. Retention in depression treatment among ethnic and
racial minority groups in the United States. Depression and Anxiety 27(5):485–494, 2010.

203
 Improving Cultural Competence

Fowler, D.M., Glenwright, B.J., Bhatia, M., and Drapeau, M. Counselling expectations of a
sample of East Asian and Caucasian Canadian undergraduates in Canada. Canadian Journal
of Counselling and Psychotherapy/Revue Canadienne de Counseling et de Psychotherapie
45(2):151–167, 2011.
Fragoso, J. M. and Kashubeck, S. Machismo, gender role conflict, and mental health in Mexican
American men. Psychology of Men and Masculinity 1:87–97, 2000.
Frake, C.O. The diagnosis of disease among the Subanun of Mindanao. American Anthropologist
63(1):113–132, 1961.
Frank, D., DeBenedetti, A.F., Volk, R.J., Williams, E.C., Kivlahan, D.R., and Bradley, K.A.
Effectiveness of the AUDIT-C as a screening test for alcohol misuse in three race/ethnic
groups. Journal of General Internal Medicine 23:781–787, 2008.
Frank, J.W., Moore, R.S., and Ames, G.M. Historical and cultural roots of drinking problems
among American Indians. American Journal of Public Health 90(3):344–351, 2000.
Franks, P.H. Silence/Listening and Intercultural Differences. Presented at the Twenty-First Annual
International Listening Association Convention. March 8, 2000. Virginia Beach, VA, 2000.
Fredlund, E.V. Volatile Substance Abuse Among the Kickapoo People in the Eagle Pass, Texas Area,
1993. Research Briefs. Austin, TX: Texas Commission on Alcohol and Drug Abuse
(TCADA), 1994.
French, L.A. Addictions and Native Americans. Westport, CT: Praeger, 2000.
Friedman, M.J., Ashcraft, M.L., Beals, J.L., Keane, T.M., Manson, S.M., and Marsella, A.J.
Matsunaga Vietnam Veterans Project, Vols. 1 and 2. White River Junction, VT: National Cen-
ter for Posttraumatic Stress Disorder and National Center for American Indian and Alaska
Native Mental Health Research, 1997.
Fujisawa, D., Nakagawa, A., Tajima, M., Sado, M., Kikuchi, T., Hanaoka, M., and Ono, Y. Cogni-
tive behavioral therapy for depression among adults in Japanese clinical settings: A single-
group study. BMC Research Notes 3:160, 2010.
Fung, K., Lo, H.T., Srivastava, R., and Andermann, L. Organizational cultural competence con-
sultation to a mental health institution. Transcultural Psychiatry 49(2):165–184, 2012.
Gache, P., Michaud, P., Landry, U., Accietto, C., Arfaoul, S., Wenger, O., and Daeppen, J.B. The
Alcohol Use Disorders Identification Test (AUDIT) as a screening tool for excessive drink-
ing in primary Care: Reliability and validity of a French version. Alcoholism: Clinical and Ex-
perimental Research 29:2001–2007, 2005.
Gahlinger, P.M. The Sagebrush Medical Guide to Illegal Drugs. 1st ed. Las Vegas, NV: Sagebrush
Press, 2001.
Gallardo, M.E., and Curry, S.J. Shifting perspectives: Culturally responsive interventions with
Latino substance abusers. Journal of Ethnicity in Substance Abuse 8(3):314–329, 2009.
Gallardo, M.E., Yeh, C.J., Trimble, J.E., and Parham, T.A. Culturally Adaptive Counseling Skills:
Demonstrations of Evidence-Based Practices. Thousand Oaks, CA: Sage Publications, 2012.

204
 Appendix A—Bibliography

Galvan F.H., and Caetano R. Alcohol use and related problems among ethnic minorities in the
United States. Alcohol Research & Health 27(1):87–94, 2003.
Garcia, M. and Marks, G. Depressive symptomatology among Mexican-American adults: An
examination with the CES-D Scale. Psychiatry Research 27:137–148, 1989.
Garrett, M.T. Sound of the drum: Group counseling with Native Americans. In: DeLucia-
Waack, J.L., Gerrity, D.A., Kalodner, C.R., and Riva, M.T., eds. Handbook of Group Counsel-
ing and Psychotherapy (pp. 169–182). Thousand Oaks, CA: Sage Publications, 2004.
Garrett, M.T., Garrett, J., and Brotherton, D. Inner circle/outer circle: A group technique based
on Native American healing circles. Journal for Specialists in Group Work 26:17–30, 2001.
Garrett, M. T. and Pichette, E. F. Red as an apple: Native American acculturation and counseling
with or without reservation. Journal of Counseling and Development 78:3–13, 2000.
Garrett, M.T., Portman, T. A.A., Williams, C., Grayshield, L., Rivera, E.T., and Parrish, M.
Native American adult lifespan perspectives: Where power moves. In: Chang, E.C., ed.
Handbook of Race and Development in Mental Health (pp. 107–126). New York: Springer Sci-
ence + Business Media, 2012.
Garrett, M.T., and Wilbur, M.P. Does the worm live in the ground? Reflections on Native Amer-
ican spirituality. Journal of Multicultural Counseling and Development 27:193–206, 1999.
Garrity, J.F. Jesus, peyote, and the holy people: Alcohol abuse and the ethos of power in Navajo
healing. Medical Anthropology Quarterly 14(4):521–542, 2000.
Gaston-Johansson, F., Hill-Briggs, F., Oguntomilade, L., Bradley, V., and Mason, P. Patient
perspectives on disparities in healthcare from African-American, Asian, Hispanic, and Native
American samples including a secondary analysis of the Institute of Medicine focus group
data. Journal of the National Black Nurses Association 18(2):43–52, 2007.
Gatewood-Colwell, G., Kaczmarek, M., and Ames, M.H. Reliability and validity of the Beck
Depression Inventory for a White and Mexican-American gerontic population. Psychological
Reports 65:1163–1166, 1989.
Gatson, S.N. Assessing the likelihood of internet information-seeking leading to offline drug use
by youth. In: Murguâia, E., Tackett-Gibson, M., and Lessem, A., eds. Real Drugs in a Virtual
World: Drug Discourse and Community Online (pp. 99–120.) Lanham, MD: Lexington Books,
2007a.
Gatson, S.N. The body or the body politic? Risk, harm, moral panic and drug use discourse
online. In: Murguâia, E., Tackett-Gibson, M., and Lessem, A., eds. Real Drugs in a Virtual
World: Drug Discourse and Community Online (pp. 23–44). Lanham, MD: Lexington Books,
2007b.
Gaw, A.C. Culture, Ethnicity and Mental Illness. Washington,, DC: American Psychiatric Press,
1993.
Geisz, M.B. Rand Researchers Study Racial Disparities in Substance Abuse Treatment Programs.
Princeton, NJ: Robert Wood Johnson Foundation, 2007.
Gensheimer, L. Learning from the experiences of Hmong mental health providers. Hmong Stud-
ies Journal 7:1–31, 2006.

205
 Improving Cultural Competence

Georges, C.A. Advancing diversity in nursing: An interview with Dr. Catherine Alicia Georges,
by Theodore Richardeanea. Policy Politics & Nursing Practice 9(1):22–26, 2008.
Gerson, K. Moral dilemmas, moral strategies, and the transformation of gender: Lessons from
two generations of work and family change. Gender & Society 16(1):8–28, 2002.
Gerstein, D.R., Datta, A.R., Ingels, J.S., Johnson, R.A., Rasinski, K.A., Schildhaus, S., Talley, K.,
Jordan, K., Phillips, D.B., Anderson, D.W., Condelli, W.G., and Collins, J.S. The National
Treatment Improvement Evaluation Study: Final Report. Rockville, MD: Substance Abuse and
Mental Health Services Administration, 1997.
Ghassemzadeh, H., Mojtabai, R., Karamghadiri, N., and Ebrahimkhani, N. Psychometric prop-
erties of a Persian-language version of The Beck Depression Inventory-Second Edition:
BDI-II-Persian. Depression and Anxiety 21:185–192, 2005.
Giang, K.B., Spak, F., Dzung, T.V., and Allebeck, P. The use of audit to assess level of alcohol
problems in rural Vietnam. Alcohol and Alcoholism 40:578–583, 2005.
Gibbons, F. X., Etcheverry, P. E., Stock, M. L., Gerrard, M., Weng, C. Y., Kiviniemi, M., and
O’Hara, R.E. Exploring the link between racial discrimination and substance use: What me-
diates? What buffers? Journal of Personality and Social Psychology 99(5):785–801, 2010.
Gil, R.M., and Vazquez, C.I. The Maria Paradox: How Latinas Can Merge Old World Traditions
With New World Self-Esteem. New York: G.P. Putnam’s Sons, 1996.
Gilbert, J., and Langrod, J. Polish identity and substance abuse. In: Straussner, S.L.A., ed. Eth-
nocultural Factors in Substance Abuse Treatment (pp. 234–249). New York: Guilford Press,
2001.
Gilbert, M.J. Alcohol consumption patterns in immigrant and later generation Mexican Ameri-
can women. Hispanic Journal of Behavioral Sciences 9(3):299–313, 1987.
Gilbert, M.J. Acculturation and changes in drinking patterns among Mexican-American women:
Implications for prevention. Alcohol Health and Research World 15(3):234–238, 1991.
Gilbert, M.J. A Manager’s Guide to Cultural Competence Education for Health Care Professionals.
Woodland Hills, CA: The California Endowment, 2003.
Gilman, S.E., Breslau, J., Conron, K.J., Koenen, K.C., Subramanian, S.V., and Zaslavsky, A.M.
Education and race-ethnicity differences in the lifetime risk of alcohol dependence. Journal of
Epidemiology and Community Health 62(3):224–230, 2008.
Gim Chung, R.H., Kim, B.S.K., and Abreu, J.M. (2004). Asian American Multidimensional
Acculturation Scale: Development, factor analysis, reliability, and validity. Cultural Diversity
and Ethnic Minority Psychology 10:66–80, 2004.
Giordano, J., and McGoldrick, M. Families of European origin: An overview. In: McGoldrick,
M., Giordano, J., and Garcia-Preto, N., eds. Ethnicity and Family Therapy. 3rd ed. (pp. 501–
519). New York: Guilford Press, 2005.
Giordano, J., and McGoldrick, M. Italian families. In: McGoldrick, M., Giordano, J., and Pearce,
J.K., eds. Ethnicity and Family Therapy. 2nd ed. (pp. 567–582). New York: Guilford Press,
1996.

206
 Appendix A—Bibliography

Gloria, A.M., and Peregoy, J.J. Counseling Latino alcohol and other substance users/abusers:
Cultural considerations for counselors. Journal of Substance Abuse Treatment 13(2):119–126,
1996.
Goldstein, A., and Herrera, J. Heroin addicts and methadone treatment in Albuquerque: A 22-
year follow-up. Drug and Alcohol Dependence 40(2):139–150, 1995.
Gone, J.P., and Trimble, J.E. American Indian and Alaska Native mental health: Diverse perspec-
tives on enduring disparities. Annual Review of Clinical Psychology 8:131–160, 2012.
Goode, T. Policy Brief 4: Engaging Communities to Realize the Vision of One Hundred Percent Access
and Zero Health Disparities: A Culturally Competent Approach. Washington, DC: National
Center for Cultural Competence, Georgetown University Child Development Center. 2001.
Goode, T.D., Dunne, M.C., and Bronheim, S.M. The Evidence Base for Cultural and Linguistic
Competency in Health Care. New York: The Commonwealth Fund, 2006.
Gooding, V.A. Managing Multi-Generational Anger in African American Males. Jenkintown, PA:
Family and Corrections Network, 2002.
Gordon, R., Heim, D., and MacAskill, S. Rethinking drinking cultures: A review of drinking
cultures and a reconstructed dimensional approach. Public Health 126(1):3–11, 2012.
Gossop, M., Stewart, D., Browne, N., and Marsden, J. Factors associated with abstinence, lapse or
relapse to heroin use after residential treatment: Protective effect of coping responses. Addic-
tion 97(10):1259–1267, 2002.
Gourley, M. A subcultural study of recreational ecstasy use. Journal of Sociology 40(1):59–73, 2004.
Graham, R.E., Ahn, A.C., Davis, R.B., O’Connor, B.B., Eisenberg, D.M., and Phillips, R.S. Use
of complementary and alternative medical therapies among racial and ethnic minority adults:
Results from the 2002 National Health Interview Survey. Journal of the National Medical As-
sociation 97(4):535–545, 2005.
Grant, B.F. Barriers to alcoholism treatment: Reasons for not seeking treatment in a general
population sample. Journal of Studies on Alcohol 58(4):365–371, 1997.
Grant, B.F., Dawson, D.A., Stinson, F.S., Chou, S.P., Dufour, M.C., and Pickering, R.P. The 12-
month prevalence and trends in DSM-IV alcohol abuse and dependence: United States,
1991-1992 and 2001-2002. Drug and Alcohol Dependence 74(3):223–234, 2004a.
Grant, B.F., Harford, T.C., Dawson, D.A., Chou, P.S., and Pickering, R.P. The Alcohol Use
Disorder and Associated Disabilities Interview schedule (AUDADIS): Reliability of alcohol
and drug modules in a general population sample. Drug and Alcohol Dependence 39:37–44,
1995.
Grant B.F., and Hasin, D.S. (1990). The Alcohol Use Disorders and Associated Disabilities Interview
Schedule (AUDADIS). Rockville, MD: National Institute on Alcohol Abuse and Alcoholism,
1990.
Grant, B.F., Hasin, D.S., Stinson, F.S., Dawson, D.A., June, R.W., Goldstein, R.B., Smith, S.M.,
Saha, T.D., and Huang, B. Prevalence, correlates, co-morbidity, and comparative disability of
DSM-IV generalized anxiety disorder in the USA: Results from the National Epidemiologic
Survey on alcohol and related conditions. Psychological Medicine 35(12):1747–1759, 2005.

207
 Improving Cultural Competence

Grant, B.F., Stinson, F.S., Dawson, D.A., Chou, S.P., Dufour, M.C., Compton, W., Pickering, R
P., and Kaplan, K. Prevalence and co-occurrence of substance use disorders and independent
mood and anxiety disorders: Results from the National Epidemiologic Survey on Alcohol
and Related Conditions. Archives of General Psychiatry 61(8):807–816, 2004b.
Grant, B.F., Stinson, F.S., Hasin, D.S., Dawson, D.A., Chou, S.P., and Anderson, K. Immigration
and lifetime prevalence of DSM-IV psychiatric disorders among Mexican Americans and
non-Hispanic Whites in the United States: Results from the national epidemiologic survey
on alcohol and related conditions. Archives of General Psychiatry 61(12):1226–1233, 2004c.
Greene, B. Ethnic minority lesbians and gay men: Mental health and treatment issues. In:
Greene, B., ed. Ethnic and Cultural Diversity Among Lesbians and Gay Men (pp. 216–
239).Thousand Oaks, CA: Sage Publications, 1997.
Griffith, E.E.H., and Baker, F.M. Psychiatric care of African Americans. In: Gaw, A.C., ed.
Culture, Ethnicity, and Mental Illness (pp. 147–173). Washington, DC: American Psychiatric
Press, 1993.
Griffith, J.D., Joe, G.W., Chatham, L.R., and Simpson, D.D. The development and validation of
a simpatia scale for Hispanics entering drug treatment. Hispanic Journal of Behavioral Sciences
20:468–482, 1998.
Griner, D., and Smith, T.B. Culturally adapted mental health intervention: A meta-analytic
review. Psychotherapy: Theory, Research, Practice, Training 43(4):531–548, 2006.
Grothe, K.B., Dutton, G.R., Jones, G.N., Bodenlos, J., Ancona, M., and Brantley, P.J. Validation
of the Beck Depression Inventory-II in a low-income African American sample of medical
outpatients. Psychological Assessment 17:110–114, 2005.
Grund, J.P.C. Drug Use as a Social Ritual: Functionality, Symbolism and Determinants of Self-
Regulation. Rotterdam, Netherlands: Instituut voor Verslavingsonderzoek, 1993.
Grzywacz, J.G., Quandt, S.A., Early, J., Tapia, J., Graham, C.N., and Arcury, T.A. Leaving family
for work: Ambivalence and mental health among Mexican migrant farmworker men. Journal
of Immigrant and Minority Health 8(1):85–97, 2006.
Guerrero, E.G. Organizational characteristics that foster early adoption of cultural and linguistic
competence in outpatient substance abuse treatment in the United States. Evaluation and
Program Planning 35(1):9–15, 2012.
Guerrero, E.G., and Kim, A. Organizational structure, leadership and readiness for change and
the implementation of organizational cultural competence in addiction health services. Eval-
uation and Program Planning 40:74–81, 2013.
Guerrero, E.G., Marsh, J.C., Duan, L., Oh, C., Perron, B, and Lee, B. Disparities in completion
of substance abuse treatment between and within racial and ethnic groups. Health Services
Research 48(4):1450–1467, 2013.
Guindon, M.H., and Sobhany, M.S. Toward cultural competency in diagnosis. International
Journal for the Advancement of Counselling 23(4):269–282, 2001.
Gupta, R., Punetha, D., and Diwan, S. The revised CES-D scale for caregivers of the elderly in
India. International Journal of Aging and Human Development 62:61–78, 2006.

208
 Appendix A—Bibliography

Hadjicostandi, J., and Cheurprakobkit, S. Drugs and substances: Views from a Latino communi-
ty. American Journal of Drug & Alcohol Abuse 28(4):693–710, 2002.
Haight, W., Jacobsen, T., Black, J., Kingery, L., Sheridan, K., and Mulder, C. “In these bleak
days”: Parent methamphetamine abuse and child welfare in the rural Midwest. Children and
Youth Services Review 27:949–971, 2005.
Halkitis, P.N., Fischgrund, B.N., and Parsons, J.T. Explanations for methamphetamine use
among gay and bisexual men in New York City. Substance Use & Misuse 40(9-10):1331–1345,
2005.
Hall, E.T. Beyond Culture. Garden City, NY: Anchor Press, 1976.
Hall, G.C.N., Hong, J.J., Zane, N.W.S., and Meyer, O.L. Culturally competent treatments for
Asian Americans: The relevance of mindfulness and acceptance-based psychotherapies.
Clinical Psychology: Science and Practice 18(3):215–231, 2011.
Hambleton, R.K., Merenda, P.F., and Spielberger, C.D. Adapting Educational and Psychological
Tests for Cross-Cultural Assessment. Mahwah, N.J: L. Erlbaum Associates, 2005.
Hamid, A. Drugs in America: Sociology, Economics, and Politics. Gaithersburg, MD: Aspen Pub-
lishers, 1998.
Hampton, R.L., Gullotta, T.P., and Crowel, R.L. Handbook of African American Health. New
York: Guilford Press, 2010.
Hands Across Cultures. Culture is the Cure: La Cultura Cura. Retrieved on March 28, 2014, from
http://handsacrosscultures.org
Hanson, M.J. Families with Anglo-European roots. In: Lynch, E.W., and Hanson, M.J., eds.
Developing Cross-Cultural Competence: A Guide for Working With Children and Their Families.
4th ed. (pp. 80–102). Baltimore: Paul H. Brookes Publishing, 2011.
Haraguchi, A., Ogai, Y., Senoo, E., Saito, S., Suzuki, Y., Yoshino, A., Ino, A., Yanbe, K., Hasega-
wa, M., Murakami, M., Murayama, M., Ishikawa, T., Higuchi, S., and Ikeda, K. Verification
of the Addiction Severity Index Japanese version (ASI-J) as a treatment-customization, pre-
diction, and comparison tool for alcohol-dependent individuals. International Journal of Envi-
ronmental Research and Public Health 6:2205–2225, 2009.
Harris, A.H., McKellar, J.D., Moos, R.H., Schaefer, J.A., and Cronkite, R.C. Predictors of en-
gagement in continuing care following residential substance use disorder treatment. Drug and
Alcohol Dependence 84(1):93–101, 2006.
Hasin, D., Aharonovich, E., Liu, X., Mamman, Z., Matseoane, K., Carr, L.G., and Li, T.K. Alco-
hol dependence symptoms and alcohol dehydrogenase 2 polymorphism: Israeli Ashkenazis,
Sephardics, and recent Russian immigrants. Alcoholism: Clinical & Experimental Research
26(9):1315–1321, 2002.
Hasin, D.S., Goodwin, R.D., Stinson, F.S., and Grant, B.F. Epidemiology of major depressive
disorder: Results from the national epidemiologic survey on alcoholism and related condi-
tions. Archives of General Psychiatry 62(10):1097–1106, 2005.

209
 Improving Cultural Competence

Hasin, D.S., Stinson, F.S., Ogburn, E., and Grant, B.F. Prevalence, correlates, disability, and
comorbidity of DSM-IV alcohol abuse and dependence in the United States: Results from
the national epidemiologic survey on alcohol and related conditions. Archives of General Psy-
chiatry 64(7):830–842, 2007.
Hathaway, S.R., and McKinley, J.C. Minnesota Multiphasic Personality Inventory-2. Minneapolis,
MN: National Computer Systems, 1989.
Hatzenbuehler, M.L., Keyes, K.M., Narrow, W.E., Grant, B.F., and Hasin, D.S. Racial/ethnic
disparities in service utilization for individuals with co-occurring mental health and substance
use disorders in the general population: Results from the national epidemiologic survey on al-
cohol and related conditions. The Journal of Clinical Psychiatry 69(7):1112–1121, 2008.
Haynes, F.E. Gender and family ideals: An exploratory study of Black middle-class Americans.
Journal of Family Issues 21(7):811–837, 2000.
Hays, P.A. Sorting things out: Culturally responsive assessment. In: Addressing Cultural Complexi-
ties in Practice: Assessment, Diagnosis, and Therapy. 2nd ed. (pp. 105–127). Washington, DC:
American Psychological Association, 2008.
Hazel, K.L., and Mohatt, G.V. Cultural and spiritual coping in sobriety: Informing substance
abuse prevention for Alaska Native communities. Journal of Community Psychology 29(5):541–
562, 2001.
Hebdige, D. Subculture: The Meaning of Style. New York: Routledge, 1991.
Heilbron, C.L., and Guttman, M.A.J. Traditional healing methods with First Nations women in
group counselling. Canadian Journal of Counselling 34(1):3–13, 2000.
Helms, J.E. Black and White Racial Identity: Theory, Research, and Practice. Westport, CT: Praeger,
1990.
Helms, J.E. An update of Helms’s White and people of color racial identity models. In: Ponterot-
to, J.G., Casas, J.M., Suzuki, L.A., and Alexander, C.M., eds. Handbook of Multicultural Coun-
seling (pp. 181–198). Thousand Oaks, CA: Sage Publications, 1995.
Helms, J.E. Racial identity in the social environment. In: Pedersen, P.B., ed. Multicultural Coun-
seling in Schools: A Practical Handbook. 2nd ed. (pp. 44–58). Needham Heights, MA: Allyn &
Bacon, 2003.
Helms, J.E., and Carter, R.T. Development of the White racial identity inventory. In: Helms,
J.E., ed. Black and White Racial Identity: Theory, Research, and Practice (pp. 67–80). Westport,
CT: Praeger, 1990.
Helms, J.E., and Carter, R.T. Relationships of White and Black racial identity attitudes and
demographic similarity to counselor preferences. Journal of Counseling Psychology 38(4):446–
457, 1991.
Henson, E.C. The State of the Native Nations Conditions Under U.S. Policies of Self-Determination:
The Harvard Project on American Indian Economic Development. New York: Oxford University
Press, 2008.

210
 Appendix A—Bibliography

Herbeck, D.M., Brecht, M.L., and Pham, A.Z. Racial/ethnic differences in health status and
morbidity among adults who use methamphetamine. Psychology, Health, & Medicine
18(3):262–274, 2013.
Herman-Stahl, M., and Chong, J. Substance abuse prevalence and treatment utilization among
American Indians residing on-reservation. American Indian and Alaska Native Mental Health
Research 10(3):1–23, 2002.
Herman-Stahl, M., Spencer, D.L., and Duncan, J.E. The implications of cultural orientation for
substance use among American Indians. American Indian and Alaska Native Mental Health
Research 11(1):46–66, 2003.
Hernandez, M. Puerto Rican families and substance abuse. In: Krestan, J.A., ed. Bridges to Recov-
ery: Addiction, Family Therapy, and Multicultural Treatment (pp. 253–283). New York: The
Free Press, 2000.
Hernandez, M. Central American families. In: McGoldrick, M., Giordano, J., and Garcia-Preto,
N., eds. Ethnicity and Family Therapy. 3rd ed. (pp. 178–191.) New York: Guilford Press, 2005.
Hernandez, M., Nesman, T., Mowery, D., Acevedo-Polakovich, I.D., and Callejas, L.M. Cultural
competence: A literature review and conceptual model for mental health services. Psychiatric
Services 60(8):1046–1050, 2009.
Hien, D.A., Cohen, L.R., Miele, G.M., Litt, L.C., and Capstick, C. Promising treatments for
women with comorbid PTSD and substance use disorders. The American Journal of Psychiatry
161(8):1426–1432, 2004.
Hill, R.B. The Strengths of Black Families. New York: Emerson Hall Publishers, 1972.
Hines, P.M., and Boyd-Franklin, N. African American families. In: McGoldrick, M., Giordano,
J., and Garcia-Preto, N., eds. Ethnicity and Family Therapy. 3rd ed. (pp. 87–100). New York:
Guilford Press, 2005.
Hines-Martin, V.P., Usui, W., Kim, S., and Furr, A. A comparison of influences on attitudes
towards mental health service use in an African-American and White community. Journal of
the National Black Nurses Association 15(2):17–22, 2004.
Hixson, L., Hepler, B.B., and Kim, M.O. The Native Hawaiian and Other Pacific Islander Popula-
tion: 2010. Census 2010 Brief. Washington, DC: U.S. Census Bureau, 2012.
Ho, M.K. Use of Ethnic Sensitive Inventory (ESI) to enhance practitioner skills with minorities.
Journal of Multicultural Social Work 1:57–67, 1991.
Hoeffel, E.M., Rastogi, S., Kim, M.O., and Shahid, H. The Asian Population: 2010. Census 2010
Brief. Washington, DC: U.S. Census Bureau, 2012.
Hoffman, F. Cultural adaptations of Alcoholics Anonymous to serve Hispanic populations.
International Journal of Addictions 29(4):445–460, 1994.
Hoffman, J.A., Caudill, B.D., Koman, J.J., III, Luckey, J.W., Flynn, P.M., and Mayo, D.W. Psy-
chosocial treatments for cocaine abuse: 12-month treatment outcomes. Journal of Substance
Abuse Treatment 13(1):3–11, 1996.

211
 Improving Cultural Competence

Hoffmann, T., Dana, R.H., and Bolton, B. Measured acculturation and MMPI-168 performance
of Native American adults. Journal of Cross-Cultural Psychology 16(2):243–256, 1985.
Hoge, M.A., Morris, J.A., Daniels, A.S., Stuart, G.W., Huey, L.Y., and Adams, N. An Action Plan
on Behavioral Health Workforce Development. Rockville, MD: Substance Abuse and Mental
Health Services Administration, 2007.
Hohman, M.M., and Galt, D.H. Latinas in treatment: Comparisons of residents in a culturally
specific recovery home with residents in non-specific recovery homes. Journal of Ethnic &
Cultural Diversity in Social Work 9(3-4):93–109, 2001.
Holden, K.B., and Xanthos, C. Disadvantages in mental health care among African Americans.
Journal of Health Care for the Poor and Underserved 20(2 Suppl):17–23, 2009.
Holden, K.B., McGregor, B.S., Blanks, S.H., and Mahaffey, C. Psychosocial, socio-cultural, and
environmental influences on mental health help-seeking among African-American men.
Journal of Men’s Health 9(2):63–69, 2012.
Horton, J., Compton, W., and Cottler, L.B. Reliability of substance use disorder diagnoses among
African-Americans and Caucasians. Drug and Alcohol Dependence 57:203–209, 2000.
Hovey, J.D. Migrant Health Issues: Mental Health and Substance Abuse. Monograph Series. Buda,
TX: National Center for Farmworker Health, 2001.
Howard, D.L. Are the treatment goals of culturally competent outpatient substance abuse treat-
ment units congruent with their client profile? Journal of Substance Abuse Treatment
24(2):103–113, 2003.
Howard, M.O., Walker, R.D., Suchinsky, R.T., and Anderson, B. Substance-use and psychiatric
disorders among American Indian veterans. Substance Use & Misuse 31(5):581–598, 1996.
Howland, J., and Rohsenow, D.J. Risks of energy drinks mixed with alcohol. JAMA: The Journal of
the American Medical Association 309(3):245–246, 2013.
Hser, Y.I., Maglione, M., Polinsky, M.L., and Anglin, M.D. Predicting drug treatment entry
among treatment-seeking individuals. Journal of Substance Abuse Treatment 15(3):213–220,
1998.
Hsu, L.K.G., and Folstein, M.F. Somatoform disorders in Caucasian and Chinese Americans.
Journal of Nervous and Mental Disease 185(6):382–387, 1997.
Hu, H.M., Kline, A., Huang, F.Y., and Ziedonis, D.M. Detection of co-occurring mental illness
among adult patients in the New Jersey substance abuse treatment system. American Journal of
Public Health 96(10):1785–1793, 2006.
Hudak, J. Addiction and groups of European origin. In: Krestan, J.A., ed. Bridges to Recovery:
Addiction, Family Therapy, and Multicultural Treatment (pp. 284–315). New York: Free Press,
2000.
Hughes, D.L. Quality of Health Care for Asian Americans: A Fact Sheet. New York: The Common-
wealth Fund, 2002.
Humes, K.R., Jones, N.A., and Ramirez, R.R. Overview of Race and Hispanic Origin: 2010. Cen-
sus 2010 Brief. Washington, DC: U.S. Census Bureau, 2011.

212
 Appendix A—Bibliography

Humeniuk, R., Henry-Edwards, S., Ali, R., Poznyak, V., and Monteiro, M.G. The Alcohol, Smok-
ing and Substance Involvement Screening Test (ASSIST): Manual for Use in Primary Care. Ge-
neva, Switzerland: World Health Organization, 2010.
Hunt, D., Kuck, S., and Truitt, L. Methamphetamine Use: Lessons Learned. Rockville, MD: Nation-
al Institute of Justice/NCJRS, 2006.
Imel, Z.E., Baldwin, S., Atkins, D. C., Owen, J., Baardseth, T., and Wampold, B.E. Racial/ethnic
disparities in therapist effectiveness: A conceptualization and initial study of cultural compe-
tence. Journal of Counseling Psychology 58(3):290–298, 2011.
Interian, A., Martinez, I., Rios, L.I., Krejci, J., and Guarnaccia, P.J. Adaptation of a motivational
interviewing intervention to improve antidepressant adherence among Latinos. Cultural Di-
versity & Ethnic Minority Psychology 16(2):215-225, 2010.
Ishikawa, R.Z., Cardemil, E.V., and Falmagne, R.J. Help seeking and help receiving for emotion-
al distress among Latino men and women. Qualitative Health Research 20(11):1558–1572,
2010.
Issitt, M.L. Hippies: A Guide to an American Subculture. Santa Barbara, CA: Greenwood
Press/ABC-CLIO, 2009.
Iversen, L.L. The Science of Marijuana. New York: Oxford University Press, 2000.
Iwamasa, G.Y., Hsia, C., and Hinton, D. Cognitive behavior therapy with Asian Americans. In:
Hays, P.A., and Iwamasa, G., eds. Culturally Responsive Cognitive–Behavioral Therapy: Assess-
ment, Practice, and Supervision. 1st ed. Washington, DC: American Psychological Association,
2006.
Ja, D.Y., and Aoki, B. Substance abuse treatment: Cultural barriers in the Asian American com-
munity. In: Organista, P.B., Chun, K.M., and Marin, G., eds. Readings in Ethnic Psychology
(pp. 386–401). New York: Routledge, 1998.
Ja, D., and Yuen, F.K. Substance abuse treatment among Asian Americans. In: Lee, E., ed. Work-
ing with Asian Americans: A Guide for Clinicians (pp. 295–308). New York: Guilford Press,
1997.
Jackson, V. In Our Own Voice: African-American Stories of Oppression, Survival and Recovery in
Mental Health Systems (Part 3 of the “It’s About Time: Discovering, Recovering and Cele-
brating Psychiatric Consumer/Survivor History” series.) Rockville, MD: Center for Mental
Health Studies, 2003.
Jani, J.S., Ortiz, L., and Aranda, M.P. Latino outcome studies in social work: A review of the
literature. Research on Social Work Practice 19(2):179–194, 2009.
Jenkot, R. Cooks are like gods: Hierarchies in methamphetamine-producing groups. Deviant
Behavior 29:667–689, 2008.
Jilek, W.G. Traditional healing in the prevention and treatment of alcohol and drug abuse. Trans-
cultural Psychiatric Research Review 31(3):219–258, 1994.
Joe, J. R., and Malach, R. S. Families with American Indian roots. In: Lynch, E.W., and Hanson,
M.J., eds. Developing Cross-Cultural Competence: A Guide for Working With Children and Their
Families. 4th ed. (pp. 110–139). Baltimore: Paul H. Brookes Publishing, 2011.

213
 Improving Cultural Competence

Joe, S., Baser, R.E., Breeden, G., Neighbors, H.W., and Jackson, J.S. Prevalence of and risk factors
for lifetime suicide attempts among Blacks in the United States. JAMA: The Journal of the
American Medical Association 296(17):2112–2123, 2006.
Joe, S., Woolley, M.E., Brown, G. K., Ghahramanlou-Holloway, M., and Beck, A.T. Psychomet-
ric properties of the Beck Depression Inventory-II in low-income, African American suicide
attempters. Journal of Personality Assessment 90:521–523, 2008.
Johnson, J.E., Connolly Gibbons, M.B., and Crits-Christoph, P. Gender, race, and group behav-
ior in group drug treatment. Drug and Alcohol Dependence 119(3):e39–e45, 2011.
Johnson, P.B., and Glassman, M. The moderating effects of gender and ethnicity on the relation-
ship between effect expectancies and alcohol problems. Journal of Studies on Alcohol 60(1):64–
69, 1999.
Johnson, R.C., and Nagoshi, C.T. Asians, Asian-Americans and Alcohol. Medford, OR: CNS
Productions, 2012.
Johnston, L.D., O’Malley, P.M., Bachman, J.G., and Schulenberg, J.E. Monitoring the Future:
National Survey Results on Drug Use, 1975–2003. Volume I: Secondary School Students. NIH
Publication No. 04-5507. Bethesda, MD: National Institute on Drug Abuse, 2003.
Johnston, S.L. Native American traditional and alternative medicine. Annals of the American
Academy of Political and Social Science 583(1):195–213, 2002.
Jome, L.M., and Moody, M.J. How to develop cultural competence as a White clinician. In:
VandeCreek, L., and Jackson, T.L., eds. Innovations in Clinical Practice: A Source Book, Vol. 20
(pp. 355–371). Sarasota, FL: Professional Resource Press/Professional Resource Exchange,
2002.
Jones, L., Brazel, D., Peskind, E.R., Morelli, T., and Raskind, M.A. Group therapy program for
African-American veterans with posttraumatic stress disorder. Psychiatric Services
51(9):1177–1179, 2000.
Jones-Saumty, D. Substance abuse treatment for Native Americans. In: Xueqin Ma, G., and
Henderson, G., eds. Ethnicity and Substance Abuse: Prevention and Intervention (pp. 270–283).
Springfield, IL: Charles C. Thomas Publisher, 2002.
Jones-Webb, R.J., Hsiao, C.Y., and Hannan, P. Relationships between socioeconomic status and
drinking problems among black and white men. Alcoholism: Clinical and Experimental Re-
search 19(3):623–627, 1995.
Journey Mental Health Center. Celebrating Fifty-Five Years: Vision & Values. Madison, WI: Jour-
ney Mental Health Center, 2004.
Journey Mental Health Center. Values for Culturally Competent Services. Madison, WI: Journey
Mental Health Center, 2013.
Juang, L.P., Syed, M., Cookston, J.T., Wang, Y., and Kim, S.Y. Acculturation-based and everyday
family conflict in Chinese American families. New Directions for Child and Adolescent Devel-
opment 2012(135):13–34, 2012.
Jumper-Thurman, P., and Plested, B. Health Needs of American Indian Women. Bethesda, MD:
National Institute on Drug Abuse, 1998.

214
 Appendix A—Bibliography

Jumper-Thurman, P., Plested, B.A., Edwards, R.W., Helm, H.M., and Oetting, E.R. Using the
Community Readiness Model in Native communities. In: Trimble, J.E., Beauvais, F., Epstein,
L.G., Pacheco, G., and Johnson, S., eds. Health Promotion and Substance Abuse Prevention
Among American Indian and Alaska Native Communities: Issues in Cultural Competence. Cultur-
al Competence Series No. 9. HHS Publication No. (SMA) 99-3440. (pp. 129–158). Rock-
ville, MD: Substance Abuse Mental Health Services Administration, 2001.
Kaczorowski, J.A., Williams, A.S., Smith, T.F., Fallah, N., Mendez, J.L., and Nelson-Gray, R.
Adapting clinical services to accommodate needs of refugee populations. Professional Psycholo-
gy: Research and Practice 42(5):361–367, 2011.
Kagan, H., and Shafer, K.C. Russian-speaking substance abusers in transition: New country, old
problems. In: Straussner, S.L.A., ed. Ethnocultural Factors in Substance Abuse Treatment (pp.
250–271). New York: Guilford Press, 2001.
Karberg, J.C., and James, D.J. Substance Dependence, Abuse, and Treatment of Jail Inmates, 2002.
Bureau of Justice Statistics: Special Report. Washington, DC: U.S. Department of Justice,
2005.
Karriker-Jaffe, K.J., and Zemore, S.E. Associations between acculturation and alcohol consump-
tion of Latino men in the United States. Journal of Studies on Alcohol 70(1):27–31, 2009.
Kaskutas, L.A., Weisner, C., Lee, M., and Humphreys, K. Alcoholics anonymous affiliation at
treatment intake among White and Black Americans. Journal of Studies on Alcohol 60(6):810–
816, 1999.
Keller, D.S., and Galanter, M. Technology transfer of network therapy to community-based
addictions counselors. Journal of Substance Abuse Treatment 16(2):183–189, 1999.
Kelly, B.C., and Parsons, J.T. Predictors and comparisons of polydrug and non-polydrug cocaine
use in club subcultures. The American Journal of Drug and Alcohol Abuse 34(6):774–781, 2008.
Kerr, W.C. Categorizing US state drinking practices and consumption trends. International
Journal of Environmental Research and Public Health 7(1):269–283, 2010.
Kim, B.L., and Ryu, E. Korean families. In: Ethnicity and Family Therapy. 3rd ed. (pp. 349–362).
New York: Guilford Press, 2005.
Kim, E.Y., Bean, R.A., and Harper, J.M. Do general treatment guidelines for Asian American
families have applications to specific ethnic groups? The case of culturally-competent therapy
with Korean Americans. Journal of Marital and Family Therapy 30(3):359–372, 2004.
Kim, S.C. Family therapy for Asian Americans: A strategic-structural framework. Psychotherapy
22(2):342–348, 1985.
Kim, Y.A., Morales, K.H., and Bogner, H.R. Patient ethnicity and the identification of anxiety in
elderly primary care patients. Journal of the American Geriatrics Society 56:1626–1630, 2008.
Kingree, J.B. Measuring affiliation with 12-Step groups. Substance Use & Misuse 32(2):181–194,
1997.
Kingree, J.B., and Sullivan, B.F. Participation in Alcoholics Anonymous among African-
Americans. Alcoholism Treatment Quarterly 20(3/4):175–186, 2002.

215
 Improving Cultural Competence

Klonoff, E.A., and Landrine, H. Revising and improving the African American acculturation
scale. Journal of Black Psychology 26(2):235–261, 2000.
Knutagard, H. New trends in European youth & drug cultures. Youth Studies Australia 15(2):37–
42, 1996.
Koltko-Rivera, M.E. The psychology of worldviews. Review of General Psychology 8(1):3–58,
2004.
Kopelowicz, A., Zarate, R., Wallace, C.J., Liberman, R.P., Lopez, S.R., and Mintz, J. The ability
of multifamily groups to improve treatment adherence in Mexican Americans with schizo-
phrenia. Archives of General Psychiatry 69(3):265–273, 2012.
Kosmin, B.A., and Keysar, A. American Religious Identification Survey (ARIS 2008) Summary
Report. Hartford, CT: Trinity College, 2009.
Kosmin, B.A., Mayer, E., and Keysar, A. American Religious Identification Survey. New York: The
Graduate Center of the City University of New York, 2001.
Koss, M.P., Yuan, N.P., Dightman, D., Prince, R.J., Polacca, M., Sanderson, B., and Goldman, D.
Adverse childhood exposures and alcohol dependence among seven Native American tribes.
American Journal of Preventive Medicine 25(3):238–244, 2003.
Kotarba, J.A. Music as a feature of the on-line discussion of illegal drugs. In: Murguâia, E., Tack-
ett-Gibson, M., and Lessem, A., eds. Real Drugs in a Virtual World: Drug Discourse and Com-
munity Online (pp. 161–179). Lanham, MD: Lexington Books, 2007.
Krenz, S., Dieckmann, S., Favrat, B., Spagnoli, J., Leutwyler, J.l., Schnyder, C. Daeppen, J.B., and
Besson, J. French version of the Addiction Severity Index (5th Edition): Validity and reliabil-
ity among Swiss opiate-dependent patients. European Addiction Research 10:173–179, 2004.
Kress, V.E.W., Eriksen, K.P., Rayle, A.D., and Ford, S.J.W. The DSM-IV-TR and culture: Con-
siderations for counselors. Journal of Counseling & Development, 83(1):97–104, 2005.
Kunitz, S.J., Levy, J.E., Andrews, T., DuPuy, C., Gabriel, K.R., and Russell, S. Drinking Careers: A
Twenty-Five-Year Study of Three Navajo Populations. New Haven, CT: Yale University Press,
1994.
Kuntsche, S., Gmel, G., Knibbe, R.A., Kuendig, H., Bloomfield, K., Kramer, S., and Grittner, U.
Gender and cultural differences in the association between family roles, social stratification,
and alcohol use: A European cross-cultural analysis. Alcohol and Alcoholism. Supplement
41(1):i37–i46, 2006.
Kuramoto, F.H. Drug abuse prevention research concerns in Asian and Pacific Islander popula-
tions. In: Cazares, A., and Beatty, L.A., eds. Scientific Methods for Prevention Intervention Re-
search (pp. 249–272). NIDA Research Monograph 139. Rockville, MD: U.S. Department of
Health and Human Services, 1994.
Kurtz, S.P. Post-circuit blues: Motivations and consequences of crystal meth use among gay men
in Miami. AIDS and Behavior 9(1):63–72, 2005.
Kusnir, D. Salvadoran families. In: Ethnicity and Family Therapy. 3rd ed. (pp. 256–265). New
York: Guilford Press, 2005.

216
 Appendix A—Bibliography

Kwan, K.-L.K., and Sodowsky, G.R. Internal and external ethnic identity and their correlates: A
study of Chinese American immigrants. Journal of Multicultural Counseling and Development
25:51–57, 1997.
Kwon-Ahn, Y.H. Substance abuse among Korean Americans: A sociocultural perspective and
framework for intervention. In: Straussner, S.L.A., ed. Ethnocultural Factors in Substance Abuse
Treatment (418–435). New York: Guilford Press, 2001.
LaFromboise, T. American Indian mental health policy. In: Atkinson, D.R., Morten, G., and Sue,
D.W., eds. Counseling American Minorities: A Cross-Cultural Perspective (pp. 123–143). Madi-
son, WI: Brown and Benchmark, 1993.
LaFromboise, T., Coleman, H.L.K., and Gerton, J. Psychological impact of biculturalism: Evi-
dence and theory. Psychological Bulletin 114(3):395–412, 1993.
Lai, T.F.M. Ethnocultural background and substance abuse treatment of Chinese Americans. In:
Straussner, S.L.A., ed. Ethnocultural Factors in Substance Abuse Treatment (pp. 345–367). New
York: The Guilford Press, 2001.
Lamont, M., and Small, M.L. How culture matters: Enriching our understanding of poverty. In:
Lin, A.C., and Harris, D.R., eds. The Colors of Poverty: Why Racial and Ethnic Disparities Exist
(pp. 76–102). New York: Russell Sage Foundation, 2008.
Larkin, R. African-Americans in public housing: a traditional social work approach to substance
abuse treatment. Journal of Health and Social Policy 17(2):67–82, 2003.
Larrison, C.R., Schoppelrey, S.L., Hack-Ritzo, S., and Korr, W.S. Clinician factors related to
outcome differences between black and white patients at CMHCs. Psychiatric Services
62(5):525–531, 2011.
Larsen, L.J. The Foreign-Born Population in the United States: 2003. Washington, DC: U.S. Census
Bureau, 2004.
Laudet, A.B., Morgen, K., and White, W.L. The role of social supports, spirituality, religiousness,
life meaning and affiliation with 12-Step fellowships in quality of life satisfaction among in-
dividuals in recovery from alcohol and drug problems. Alcohol Treatment Quarterly 24(1-
2):33–73, 2006.
Laudet, A.B., Savage, R., and Mahmood, D. Pathways to long-term recovery: A preliminary
investigation. Journal of Psychoactive Drugs 34(3):305–311, 2002.
LaVeist, T.A., Relosa, R., and Sawaya, N. The COA360: A tool for assessing the cultural compe-
tency of healthcare organizations. Journal of Healthcare Management 53(4):257–266, 2008.
Leavitt, R.L. Cultural Competence: A Lifelong Journey to Cultural Proficiency. Thorofare, NJ:
SLACK Inc., 2010.
Le Cook, B., and Alegria, M. Racial-ethnic disparities in substance abuse treatment: The role of
criminal history and socioeconomic status. Psychiatric Services 62(11):1273–1281, 2011.
Lecrubier, Y., Sheehan, D.V., Weiller, E., Amorim, P., Bonora, I., Sheehan, K.H. Janavs, J., and
Dunbar, G.C. The Mini International Neuropsychiatric Interview (MINI): A short diagnos-
tic structured interview: Reliability and validity according to the CIDI. European Psychiatry
12:224–231, 1997.

217
 Improving Cultural Competence

Lee, E. Asian American families: An overview. In: McGoldrick, M., Giordano, J., and Pearce,
J.K., eds. Ethnicity and Family Therapy. 2nd ed. (pp. 227–248). New York: Guilford Press,
1996.
Lee, E., and Mock, M.R. Asian families: An overview. In: McGoldrick, M., Giordano, J., and
Garcia-Preto, N., eds. Ethnicity and Family Therapy. 3rd ed. (pp. 269–289). New York: Guil-
ford Press, 2005a.
Lee, E., and Mock, M.R. Chinese families. In: McGoldrick, M., Giordano, J., and Garcia-Preto, N.,
eds. Ethnicity and Family Therapy. 3rd ed. (pp. 302–318). New York: Guilford Press, 2005b.
Lee, J., and Bean, F.D. America’s changing color lines: Immigration, race/ethnicity, and multira-
cial identification. Annual Review of Sociology 30(1):221–242, 2004.
Lefley, H.P., Sandoval, M.C., and Charles, C. Traditional healing systems in a multicultural
setting. In: Okpaku, S.O., ed. Clinical Methods in Transcultural Psychiatry (pp. 88–110). Wash-
ington, DC: American Psychiatric Association, 1998.
Lende, D.H. Wanting and drug use: A biocultural approach to the analysis of addiction. ETHOS
33(1):100–124, 2005.
Leong, F.T.L., and Lee, S.H. Chinese Americans: Guidelines for disaster mental health workers.
In: Marsella, A.J., Johnson, J.L., Watson, P., and Gryczynski, J., eds. Ethnocultural Perspectives
on Disaster and Trauma: Foundations, Issues, and Applications (pp. 241–269). New York:
Springer Science + Business Media, 2008.
Leonhard, C., Mulvey, K., Gastfriend, D.R., and Shwartz, M. The Addiction Severity Index: A
field study of internal consistency and validity. Journal of Substance Abuse Treatment 18:129–
135, 2000.
Leung, S.F. and Arthur, D. Alcohol use disorders identification test (AUDIT): Validation of an
instrument for enhancing nursing practice in Hong Kong. International Journal of Nursing
Studies 37:57–64, 2000.
Leventhal, A.M., and Schmitz, J.M. The role of drug use outcome expectancies in substance
abuse risk: An interactional-transformational model. Addictive Behavior 31(11):2038–2062,
2006.
Lewis, E.W., Duran, E., and Woodis, W. Psychotherapy in the American Indian population.
Psychiatric Annals 29(8):477–479, 1999.
Liang, T., Liu, E.W., Zhong, H., Wang, B., Shen, L.M., and Wu, Z.L. Reliability and validity of
addiction severity index in drug users with methadone maintenance treatment in Guizhou
province, China. Biomedical and Environmental Sciences 21:308–313, 2008.
Libby, A.M., Orton, H.D., Beals, J., Buchwald, D., and Manson, S.M. Childhood abuse and later
parenting outcomes in two American Indian tribes. Child Abuse & Neglect 32(2):195–211, 2008.
Liddle, H.A. Multidimensional family therapy: A science-based treatment system. The Australian
and New Zealand Journal of Family Therapy 31(2):133–148, 2010.
Liddle, H.A., Dakof, G.A., Turner, R.M., Henderson, C.E., and Greenbaum, P.E. Treating ado-
lescent drug abuse: A randomized trial comparing multidimensional family therapy and cog-
nitive behavior therapy. Addiction 103(10):1660–1670, 2008.

218
 Appendix A—Bibliography

Lie, D. A., Lee-Rey, E., Gomez, A., Bereknyei, S., and Braddock, C.H., 3rd. Does cultural competen-
cy training of health professionals improve patient outcomes? A systematic review and proposed
algorithm for future research. Journal of General Internal Medicine 26(3):317–325, 2011.
Lie, D., Shapiro, J., Cohn, F., and Najm, W. Reflective practice enriches clerkship students’ cross-
cultural experiences. Journal of General Internal Medicine 25(Suppl 2):S119–S125, 2010.
Lima, C.T., Freire, A.C., Silva, A.P., Teixeira, R.M., Farrell, M., and Prince, M. Concurrent and
construct validity of the audit in an urban Brazilian sample. Alcohol and Alcoholism 40:584–
589, 2005.
Lin, N. Measuring depressive symptomatology in China. Journal of Nervous and Mental Disease
177:121–131, 1989.
Link, B.G., Struening, E.L., Rahav, M., Phelan, J.C., and Nuttbrock, L. On stigma and its conse-
quences: Evidence from a longitudinal study on men and dual diagnosis of mental illness and
substance abuse. Journal of Health and Social Behavior 38(2):177–190, 1997.
Linkins, K.W., McIntosh, S., Bell, J., and Chong, U. Indicators of Cultural Competence in Health
Care Delivery Organizations: An Organizational Cultural Competence Assessment Profile.
Health Resources and Services Administration, U.S. Department of Health and Human Ser-
vices, 2002.
Litt, M.D., Kadden, R.M., Cooney, N.L., and Kabela, E. Coping skills and treatment outcomes
in cognitive–behavioral and interactional group therapy for alcoholism. Journal of Consulting
and Clinical Psychology 71(1):118–128, 2003.
Litt, M.D., Kadden, R.M., and Stephens, R.S. Coping and self-efficacy in marijuana treatment:
Results from the marijuana treatment project. Journal of Consulting and Clinical Psychology
73(6):1015–1025, 2005.
Livingston, J.D., Milne, T., Fang, M.L., and Amari, E. The effectiveness of interventions for reducing
stigma related to substance use disorders: A systematic review. Addiction 107(1):39–50, 2012.
Lobo, S. American Indian Urban Mobility in the San Francisco Bay Area: Final Report for Bureau of
the Census. Washington, DC: U.S. Census Bureau, 2001.
Lobo, S. Urban clan mothers: Key households in cities. American Indian Quarterly 27(3/4):305–
322, 2003.
Long, J.M. Drug use patterns in two Los Angeles barrio gangs. In: Glick, R., and Moore, J., eds.
Drugs in Hispanic Communities (pp. 155–165). New Brunswick, NJ: Rutgers University Press,
1990.
Longshore, D. Desire for help among drug-using Mexican-American arrestees. Substance Use &
Misuse 33(6):1387–1406, 1998.
Longshore, D., and Grills, C. Motivating illegal drug use recovery: Evidence for a culturally
congruent intervention. Journal of Black Psychology 26(3):288–301, 2000.
Longshore, D., Grills, C., Anglin, M.D., and Annon, K. Treatment motivation among African
American drug-using arrestees. Journal of Black Psychology 24(2):126–144, 1998a.

219
 Improving Cultural Competence

Longshore, D., Grills, C., and Annon, K. Effects of a culturally congruent intervention on cogni-
tive factors related to drug use-recovery. Substance Use & Misuse 34(9):1223–1241, 1999.
Longshore, D., Grills, C., Annon, K., and Grady, R. Promoting recovery from drug abuse: An
Africentric intervention. Journal of Black Studies 28(3):319–332, 1998b.
Lopez-Class, M., Castro, F.G., and Ramirez, A.G. Conceptions of acculturation: A review and
statement of critical issues. Social Science and Medicine 72(9):1555–1562, 2011.
Lynch, E.W., and Hanson, M.J. Steps in the right direction: Implications for service providers.
In: Lynch, E.W., and Hanson, M.J., eds. Developing Cross-Cultural Competence: A Guide for
Working With Children and Their Families. 4th ed. (pp. 472–489). Baltimore: Paul H. Brookes
Publishing, 2011.
Mail, P.D., and Shelton, C. Treating Indian alcoholics. In: Mail, P.D., Heurtin-Roberts, S., Martin,
S.E., and Howard, J., eds. Alcohol Use Among American Indians and Alaska Natives: Multiple Per-
spectives on a Complex Problem (pp. 141–184). NIH Pub. No. 02-4231. NIAAA Research Mono-
graph 37. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism, 2002.
Maisto, S.A., Zywiak, W.H., and Connors, G.J. Course of functioning 1 year following admission
for treatment of alcohol use disorders. Addictive Behaviors 31(1):69–79, 2006.
Makambi, K.H., Williams, C.D., Taylor, T.R., Rosenberg, L., and Adams-Campbell, L.L. An
assessment of the CES-D scale factor structure in Black women: The Black Women’s Health
Study. Psychiatry Research 168:163–170, 2009.
Makimoto, K. Drinking patterns and drinking problems among Asian-Americans and Pacific
Islanders. Alcohol Health and Research World 22(4):270–275, 1998.
Manning, P. Drugs and Popular Culture: Drugs, Media and Identity in Contemporary Society. Devon,
United Kingdom: Willan Publishing, 2007.
Manson, S.M. The wounded spirit: A cultural formulation of post-traumatic stress disorder.
Culture, Medicine & Psychiatry 20(4):489–498, 1996.
Manson, S.M., Beals, J., Klein, S.A., Croy, C.D., and the American Indian Service Utilization
Psychiatric Epidemiology Risk and Protective Factors Project Team: Big Crow, C.K., Buch-
wald, D., Chambers, B., Christensen, M.L., Dillard, D.A., DuBray, K., Espinoza, P.A., Flem-
ing, C.M., Frederick, A.W., Gurley, D., Jervis L.L., Jim, S.M., Kaufman, C.E., Keane, E.M.,
Klein, S.A., Lee, D., McNulty, M.C., Middlebrook, D.L., Moore, L.A., Nez, T.D., Norton,
I.M., Orton, H.D., Randall, C.J., Sam, A., Shore, J.H., Simpson, S.G., and Yazzie, L.L. Social
epidemiology of trauma among 2 American Indian reservation populations. American Journal
of Public Health 95(5):851–859, 2005.
Marin, G. Expectancies for drinking and excessive drinking among Mexican Americans and
non-Hispanic Whites. In: Organista, P.B., Chun, K.M., and Marin, G., eds. Readings in Eth-
nic Psychology (pp. 204–221). New York: Routledge, 1998.
Marin, G., and Gamba, R.J. A new measurement of acculturation for Hispanics: The bidimensional
acculturation scale for Hispanics (BAS). Hispanic Journal of Behavioral Sciences 18:297–317, 1996.
Marin, G., Sabogal, F., Marin, B. V., Otero-Sabogal, R., and Perez-Stable, E.J. Development of a
short acculturation scale for Hispanics. Hispanic Journal of Behavioral Sciences 9:183–205, 1987.

220
 Appendix A—Bibliography

Marinangeli, P. Italian culture and its impact on addiction. In: Straussner, S.L.A., ed. Ethnocultur-
al Factors in Substance Abuse Treatment (pp. 216–233). New York: Guilford Press, 2001.
Markides, K.S., Al Snih, S., Walsh, T., Cutchin, M., Ju, H., and Goodwin, J.S. Problem drinking
among Mexican-Americans: The influence of nativity and neighborhood context? American
Journal of Health Promotion 26:225–229, 2012.
Markides, K.S., Ray, L.A., Stroup-Benham, C.A., and Trevino, F.M. Acculturation and alcohol
consumption in the Mexican American population of the southwestern United States: Findings
from HHANES 1982-84. American Journal of Public Health 80(Supplement):42–46, 1990.
Marsh, J.C., Cao, D., Guerrero, E., and Shin, H.C. Need-service matching in substance abuse
treatment: Racial/ethnic differences. Evaluation and Program Planning 32(1):43–51, 2009.
Martin, M.A. Ethnobotanical aspects of cannabis in Southeast Asia. In: Rubin, V., ed. Cannabis
and Culture (pp. 63–76). Paris: Mouton Publishers, 1975.
Martinez, C. Hispanic psychiatric issues. In: Wilkinson, C.B., ed. Ethnic Psychiatry (pp. 61–87).
New York: Plenum, 1986.
Martinez, L.C. DSM-IV-TR cultural formulation of psychiatric cases: Two proposals for clini-
cians. Transcultural Psychiatry, 46, 506–523, 2009.
Martinez, S., Stillerman, L., and Waldo, M. Reliability and validity of the SCL-90-R with His-
panic college students. Hispanic Journal of Behavioral Sciences 27:254–264, 2005.
Masson, C.L., Shopshire, M.S., Sen, S., Hoffman, K.A., Hengl, N.S., Bartolome, J., McCarty, D.,
Sorensen, J.L., and Iguchi, M.Y. Possible barriers to enrollment in substance abuse treatment
among a diverse sample of Asian Americans and Pacific Islanders: Opinions of treatment cli-
ents. Journal of Substance Abuse Treatment 44(3):309–315, 2013.
Mateu-Gelabert, P., Maslow, C., Flom, P.L., Sandoval, M., Bolyard, M., and Friedman, S.R. Keep-
ing it together: Stigma, response, and perception of risk in relationships between drug injectors
and crack smokers, and other community residents. AIDS Care 17(7):802–813, 2005.
Mather, M., Pollard, K., and Jacobsen, L.A. First Results From the 2010 Census. Washington, DC:
Population Reference Bureau, 2011.
Matsuoka, J.K., Breaux, C., and Ryujin, D.H. National utilization of mental health services by
Asian Americans/Pacific Islanders. Journal of Community Psychology 25(2):141–145, 1997.
Maude-Griffin, P.M., Hohenstein, J.M., Humfleet, G.L., Reilly, P.M., Tusel, D.J., and Hall, S.M.
Superior efficacy of cognitive–behavioral therapy for urban crack cocaine abusers: Main and
matching effects. Journal of Consulting and Clinical Psychology 66(5):832–837, 1998.
May, P.A., and Gossage, P. New data on the epidemiology of adult drinking and substance use among
American Indians of the Northern States: Male and female data on prevalence, patterns, and
consequences. American Indian and Alaska Native Mental Health Research 10(2):1–26, 2001.
May, P.A., Serna, P., Hurt, L., and DeBruyn, L.M. Outcome evaluation of a public health ap-
proach to suicide prevention in an American Indian tribal nation. American Journal of Public
Health 95(7):1238–1244, 2005.

221
 Improving Cultural Competence

Mayfield, D., McLeod, G., and Hall, P. The CAGE questionnaire: Validation of a new alcohol-
ism screening instrument. American Journal of Psychiatry 131:1121–1123, 1974.
Mays, V.M., Yancey, A.K., Cochran, S.D., Weber, M., and Fielding, J.E. Heterogeneity of health
disparities among African American, Hispanic, and Asian American women: Unrecognized
influences of sexual orientation. American Journal of Public Health 92(4):632–639, 2002.
McCaul, M.E., Svikis, D.S., and Moore, R.D. Predictors of outpatient treatment retention: Pa-
tient versus substance use characteristics. Drug and Alcohol Dependence 62(1):9–17, 2001.
McCoy, K., McGuire, J., Curtis, R., and Spunt, B. White chicks on dope: Heroin and identity
dynamics in New York in the 1990’s. Journal of Drug Issues 35(4):817–842, 2005.
McCrady, B.S., Epstein, E.E., and Kahler, C.W. Alcoholics Anonymous and relapse prevention
as maintenance strategies after conjoint behavioral alcohol treatment for men: 18-month out-
comes. Journal of Consulting and Clinical Psychology 72(5):870–878, 2004.
McDonald, J.D., and Gonzales, J. Cognitive behavior therapy with American Indians. In: Hays,
P.A., and Iwamasa, G., eds. Culturally Responsive Cognitive–Behavioral Therapy: Assessment,
Practice, and Supervision. 1st ed. (pp. 23–45) Washington, DC: American Psychological Asso-
ciation, 2006.
McFarland, B.H., Gabriel, R.M., Bigelow, D.A., and Walker, R.D. Organization and financing of
alcohol and substance abuse programs for American Indians and Alaska Natives. American
Journal of Public Health 96(8):1469–1477, 2006.
McGill, D.W., and Pearce, J.K. American families with English ancestors from the colonial era:
Anglo Americans. In: McGoldrick, M., Giordano, J., and Garcia-Preto, N., eds. Ethnicity and
Family Therapy. 3rd ed. (pp. 520–533). New York: Guilford Press, 2005.
McGoldrick, M. Normal families: An ethnic perspective. In: Walsh, F., ed. Normal Family Pro-
cesses (pp. 399–424). New York: Guilford Press, 1982.
McGoldrick, M., Giordano, J., and Garcia-Preto, N. Overview: Ethnicity and family therapy. In:
McGoldrick, M., Giordano, J., and Garcia-Preto, N., eds. Ethnicity and Family Therapy. 3rd
ed. (pp. 1–40). New York: Guilford Press, 2005.
McGrath, J., Saha, S., Welham, J., Saadi, O.E., MacCauley, C., and Chant, D. A systematic re-
view of the incidence of schizophrenia: The distribution of rates and the influence of sex, ur-
banicity, migrant status and methodology. BMC Medicine 2:13, 2004.
McIntosh, J., and McKeganey, N. The recovery from dependent drug use: Addicts’ strategies for
reducing the risk of relapse. Drugs: Education, Prevention & Policy 7(2):179–192, 2000.
McKee-Ryan, F., Song, Z., Wanberg, C.R., and Kinicki, A.J. Psychological and physical well-
being during unemployment: A meta-analytic study. Journal of Applied Psychology 90(1):53–
76, 2005.
McKim, W.A. Drugs and Behavior: An Introduction to Behavioral Pharmacology. 5th ed. Upper
Saddle River, NJ: Prentice Hall, 2003.
McKinney, C.M., Chartier, K.G., Caetano, R., and Harris, T.R. Alcohol availability and neigh-
borhood poverty and their relationship to binge drinking and related problems among drink-
ers in committed relationships. Journal of Interpersonal Violence 27(13):2703–2727, 2012.

222
 Appendix A—Bibliography

McLaughlin, L.A., and Braun, K.L. Asian and Pacific Islander cultural values: Considerations for
health care decision making. Health and Social Work 23(2):116–126, 1998.
McLellan, A.T., Luborsky, L., Cacciola, J., Griffith, J., Evans, F., Barr, H.L., and O’Brien, C.P.
New data from the Addiction Severity Index: Reliability and validity in three centers. Journal
of Nervous and Mental Disease 173:412–423, 1985.
McLellan, A.T., Luborsky, L., Woody, G.E., and O’Brien, C. P. An improved diagnostic evalua-
tion instrument for substance abuse patients: The Addiction Severity Index. Journal of Nerv-
ous and Mental Disease 168:26–33, 1980.
McNulty, J.L., Forbey, J.D., Graham, J.R., Ben-Porath, Y.S., Black, M.S., Anderson, S.V., and
Burlew, A.K. MMPI-2 validity scale characteristics in a correctional sample. Assessment
10:288–298, 2003.
Medina, C. Toward an understanding of Puerto Rican ethnicity and substance abuse. In: Strauss-
ner, S.L.A., ed. Ethnocultural Factors in Substance Abuse Treatment (pp. 137–163). New York:
Guilford Press, 2001.
Medina-Mora, E., Carreno, S., and de la Fuente, J.R. Experience with the alcohol use disorders
identification test (AUDIT) in Mexico. Recent Developments in Alcoholism 14:383–396, 1998.
Mendoza, R.H. (1989). An empirical scale to measure type and degree of acculturation in Mexi-
can-American adolescents and adults. Journal of Cross-Cultural Psychology 20:372–385, 1989.
Mericle, A.A., Ta Park, V.M., Holck, P., and Arria, A.M. Prevalence, patterns, and correlates of
co-occurring substance use and mental disorders in the United States: Variations by
race/ethnicity. Comprehensive Psychiatry 53(6):657–665, 2012.
Meyer, O.L., Dhindsa, M., and Zane, N. Psychology of Asian American adults: Challenges and
strengths. In: Chang, E.C., ed. Handbook of Race and Development in Mental Health (pp. 169–
187). New York: Springer Science + Business Media, 2012.
Mezzich, J.E., and Caracci, G., eds. Cultural Formulation: A Reader for Psychiatric Diagnosis.
Lanham, MD: Jason Aronson, Inc., 2008.
Mezzich, J.E., Caracci, G., Fabrega, H., Jr., and Kirmayer, L.J. Cultural formulation guidelines.
Transcultural Psychiatry 46(3):383–405, 2009.
Miller, K.A., Stanley, L.R., & Beauvais, F. Regional differences in drug use rates among Ameri-
can Indian youth. Drug and Alcohol Dependence 126:35–41, 2012.
Miller, R. and Mason, S.E. (2011). Diagnosis: Schizophrenia: A Comprehensive Resource for Con-
sumers, Families, and Helping Professionals. 2nd ed. New York: Columbia University Press,
2011.
Miller, W.R., Hendrickson, S.M.L., Venner, K., Bisono, A., Daugherty, M., and Yahne, C.E.
Cross-cultural training in motivational interviewing. Journal of Teaching in the Addictions
7(1):4–15, 2008.
Miller, W.R., and Rollnick, S. Motivational Interviewing: Preparing People for Change. 2nd ed.
New York: Guilford Press, 2002.

223
 Improving Cultural Competence

Miller, W.R., and Rollnick, S. Motivational Interviewing: Helping People Change,.3rd ed. New
York: Guilford Press, 2013.
Milligan, C. O., Nich, C., and Carroll, K. M. (2004). Ethnic differences in substance abuse
treatment retention, compliance, and outcome from two clinical trials. Psychiatric Service
55:167–173, 2004.
Millon, T., Davis, R., Millon, C., and Grossman, S. The Millon Clinical Multiaxial Inventory-III,
Third Edition (MCMI-III) (2009) With New Norms and Updated Scoring. San Antonio, TX:
Pearson, 2009.
Mills, P.A. Incorporating Yup’ik and Cup’ik Eskimo traditions into behavioral health treatment.
Journal of Psychoactive Drugs 35:85–88, 2003.
Minnesota Department of Human Services. Guidelines for Culturally Competent Organizations. St.
Paul, MN: Minnesota Department of Human Services, 2004.
Minsky, S., Vega, W., Miskimen, T., Gara, M., and Escobar, J. Diagnostic patterns in Latino,
African American, and European American psychiatric patients. Archives of General Psychiatry
60(6):637–644, 2003.
Miranda, J., Bernal, G., Lau, A., Kohn, L., Hwang, W.C., and LaFromboise, T. State of the sci-
ence on psychosocial interventions for ethnic minorities. Annual Review of Clinical Psychology
1(1):113–142, 2005a.
Miranda, J., Siddique, J., Belin, T.R., and Kohn-Wood, L.P. Depression prevalence in disadvan-
taged young black women: African and Caribbean immigrants compared to U.S.-born Afri-
can Americans. Social Psychiatry and Psychiatric Epidemiology 40(4):253–258, 2005b.
Mishra, S.I., Lucksted, A., Gioia, D., Barnet, B., and Baquet, C.R. Needs and preferences for
receiving mental health information in an African American focus group sample. Community
Mental Health Journal 45(2):117–126, 2009.
Mitchell, C.M., Beals, J., Novins, D.K., and Spicer, P. Drug use among two American Indian
populations: Prevalence of lifetime use and DSM-IV substance use disorders. Drug and Alco-
hol Dependence 69:29-41, 2003.
Miville, M.L., Rosa, D., and Constantine, M.G. Building multicultural competence in clinical
supervision. In: Strategies for Building Multicultural Competence in Mental Health and Educa-
tional Settings (pp. 192–211). Hoboken, NJ: John Wiley & Sons Inc, 2005.
Mohamed, A.R., and Fritsvold, E. Damn, it feels good to be a gangsta: The social organization of
the illicit drug trade servicing a private college campus. Deviant Behavior 27(1):97–125, 2006.
Mohatt, G.V., Allen, J., and Thomas, L.R. Drug and alcohol abuse in cross-cultural counseling.
In: Pedersen, P.B., Draguns, J.G., Lonner, W.J., and Trimble, J.E., eds. Counseling Across Cul-
tures. 6th ed. (pp. 395–413). Thousand Oaks, CA: Sage Publications, 2008a.
Mohatt, G.V., Rasmus, S.M., Thomas, L., Allen, J., Hazel, K., and Marlatt, G.A. Risk, resilience,
and natural recovery: A model of recovery from alcohol abuse for Alaska Natives. Addiction
103(2):205–215, 2008b.

224
 Appendix A—Bibliography

Mokuau, N. Reality and vision: A cultural perspective in addressing alcohol and drug abuse
among Pacific Islanders. In: Mokuau, N., Epstein, L.G., Pacheco, G., and Quinlan, J.W., eds.
Responding to Pacific Islanders: Culturally Competent Perspectives for Substance Abuse Prevention
(pp. 25–47). CSAP Cultural Competence Series 8. HHS Publication No. (SMA) 98-3195.
Rockville, MD: Center for Substance Abuse Prevention, 1998.
Mokuau, N., and Tauili’ili, P. Families with Native Hawaiian and Samoan roots. In: Lynch, E.W.,
and Hanson, M.J., eds. Developing Cross-Cultural Competence: A Guide for Working with Chil-
dren and Their Families. 4th ed. (pp. 365–391). Baltimore: Paul H. Brookes Publishing, 2011.
Molina, M.A.N. Community healing among Puerto Ricans: Espiritismo as a therapy for the
soul. In: Olmos, M.F., and Paravisini-Gebert, L., eds. Healing Cultures: Art and Religion as
Curative Practices in the Caribbean and Its Diaspora (pp. 115–130). New York: Palgrave, 2001.
Monnot, M.J., Quirk, S.W., Hoerger, M., and Brewer, L. Racial bias in personality assessment:
using the MMPI-2 to predict psychiatric diagnoses of African American and Caucasian
chemical dependency inpatients. Psychological Assessment 21:137–151, 2009.
Montgomery, G.T. Comfort with acculturation status among students from south Texas. Hispanic
Journal of Behavioral Sciences 14:201–223, 1992.
Montgomery, L., Burlew, A.K., Kosinski, A.S., and Forcehimes, A.A. Motivational enhancement
therapy for African American substance users: A randomized clinical trial. Cultural Diversity
and Ethnic Minority Psychology 17(4):357–365, 2011.
Moos, R.H. Addictive disorders in context: Principles and puzzles of effective treatment and
recovery. Psychology of Addictive Behaviors 17(1):3–12, 2003.
Moos, R.H., and Moos, B.S. Rates and predictors of relapse after natural and treated remission
from alcohol use disorders. Addiction 101(2):212–222, 2006.
Mora, J. Latinas in cultural transition: Addiction, treatment and recovery. In: Straussner, S.L.A.,
and Brown, S., eds. The Handbook of Addiction Treatment for Women: Theory and Practice (pp.
323–347). San Francisco: Jossey Bass, 2002.
Morales, R. Alcohol Abuse and the Asian American. Presentation at the NIDA National Conference
on Drug Abuse Research and Practice, January 21, 1991, Washington, DC. 1991.
Morelli, P.T., and Fong, R. The role of Hawaiian elders in substance abuse treatment among
Asian/Pacific Island women. Journal of Family Social Work 4(4):33–44, 2000.
Morgan, P., and Beck, J.E. The legacy and the paradox: Hidden contexts of methamphetamine
use in the United States. In: Klee, H., ed. Amphetamine Misuse: International Perspectives on
Current Trends (pp. 135–162). The Netherlands: Harwood Academic Publishers, 1997.
Morning Star, L. Chronic Volatile Substance Abuse Among the Adult Kickapoo Traditional Tribe of
Texas: Disease and Disability Profiles, Neuropsychosocial Consequences, and Social Implications for
Treatment [Doctoral dissertation]. Houston, TX: The University of Texas Health Sciences
Center at Houston School of Public Health, 2005.
Moshier, S.J., McHugh, R.K., Calkins, A.W., Hearon, B.A., Rosellini, A.J., Weitzman, M.L., and
Otto, M.W. The role of perceived belongingness to a drug subculture among opioid-
dependent patients. Psychology of Addictive Behaviors 6(4):812–820, 2012.

225
 Improving Cultural Competence

Moss, R.K., Taylor, T., and May, P.A. Robert Wood Johnson Foundation Healthy Nations Initiative
Evaluation: The Stories and Lessons of Fighting Substance Abuse in Native American Communi-
ties. Anchorage, AK: Institute of Social and Economic Research, University of Alaska, An-
chorage, 2003.
Mouanoutoua, V.L., Brown, L.G., Cappelletty, G.G., and Levine, R.V. A Hmong adaptation of
the Beck Depression Inventory. Journal of Personality Assessment 57:309–322, 1991.
Moulton, P., McDonald, L., Muus, K., Knudson, A., Wakefield, M., and Ludtke, R. Prevalence of
Chronic Disease Among American Indian and Alaska Native Elders. Grand Forks, ND: Univer-
sity of North Dakota, School of Medicine & Health Sciences, Center for Rural Health, 2005.
Mulia, N., Ye, Y., Zemore, S.E., and Greenfield, T.K. Social disadvantage, stress, and alcohol use
among Black, Hispanic, and White Americans: Findings from the 2005 U.S. national alcohol
survey. Journal of Studies on Alcohol and Drugs 69(6):824–833, 2008.
Murali, V., and Oyebode, F. Poverty, social inequality and mental health. In: Bhattacharya, R.,
Cross, S., and Bhugra, D., eds. Clinical Topics in Cultural Psychiatry (pp. 84–99). London:
Royal College of Psychiatrists, 2010.
Murguia, A., Zea, M.C., Reisen, C.A., and Peterson, R.A. The development of the cultural
health attributions questionnaire (CHAQ). Cultural Diversity & Ethnic Minority Psychology
6(3):268–283, 2000.
Murguia, E., Tackett-Gibson, M., and Willard, R. Club drugs, online communities, and harm
reduction websites on the internet. In: Murguâia, E., Tackett-Gibson, M., and Lessem, A.,
eds. Real Drugs in a Virtual World: Drug Discourse and Community Online (pp. 5–22). Lanham,
MD: Lexington Books, 2007.
Murray, C.J., Kulkarni, S.C., Michaud, C., Tomijima, N., Bulzacchelli, M.T., Iandiorio, T.J., and
Ezzati, M. Eight Americas: Investigating mortality disparities across races, counties, and
race-counties in the United States. PLoS Medicine 3(9):e260, 2006.
Myers, B., Fakier, N., and Louw, J. Stigma, treatment beliefs, and substance abuse treatment use
in historically disadvantaged communities. African Journal of Psychiatry 12(3):218–222, 2009.
Nadeem, E., Lange, J.M., Edge, D., Fongwa, M., Belin, T., and Miranda, J. Does stigma keep
poor young immigrant and U.S.-born Black and Latina women from seeking mental health
care? Psychiatric Services 58(12):1547–1554, 2007.
Nadeem, E., Lange, J.M., and Miranda, J. Mental health care preferences among low-income and
minority women. Archives of Women’s Mental Health 11(2):93–102, 2008.
Nanakorn, S., Fukuda, K., Ogimoto, I., Tangseree, T., and Treethiptikhun, S. Validation of the
Short Michigan Alcoholism Screening Test Thai version in northeastern Thailand. Southeast
Asian Journal of Tropical Medicine and Public Health 31:780–786, 2000.
National Asian Pacific American Families Against Substance Abuse. Alcohol, Tobacco, and Other
Drug Use Among Vietnamese American High School Students in California: Findings From a
1995 Survey. Los Angeles: NAPAFASA, 2000.
National Association of Social Workers. NASW Standards for Cultural Competence in Social Work
Practice. Washington, DC: National Association of Social Workers, 2001.

226
 Appendix A—Bibliography

National Center for Cultural Competence. Rationale for Self-Assessment. Washington, DC:
Georgetown University, Center for Child and Human Development, 2013.
National Center for Health Statistics. Health, United States, 2011: With Special Feature on Socioec-
onomic Status and Health. Hyattsville, MD: Centers for Disease Control and Prevention, Na-
tional Center for Health Statistics, 2012.
National Center on Addiction and Substance Abuse. Family Matters: Substance Abuse and the
American Family: A CASA White Paper. New York: Columbia University, 2005.
National Congress of American Indians (NCAI). Methamphetamines in Indian Country: An
American Problem Uniquely Affecting Indian Country. Washington, DC: The National Con-
gress of American Indians, 2006.
National Institutes of Health. Biennial Report of the Director, National Institutes of Health Fiscal
Years 2008 & 2009. Bethesda, MD: National Institutes of Health, 2012.
Neighbors, H.W., Musick, M.A., and Williams, D.R. The African American minister as a source
of help for serious personal crises: Bridge or barrier to mental health care? Health Education
& Behavior 25(6):759–777, 1998.
Nemoto, T., Aoki, B., Huang, K., Morris, A., Nguyen, H., and Wong, W. Drug use behaviors
among Asian drug users in San Francisco. Addictive Behaviors 24(6):823–838, 1999.
Nemoto, T., Operario, D., and Soma, T. Risk behaviors of Filipino methamphetamine users in
San Francisco: Implications for prevention and treatment of drug use and HIV. Public Health
Reports 117(Suppl 1):S30–S38, 2002.
Nguyen, H.T., Kitner-Triolo, M., Evans, M.K., and Zonderman, A.B. Factorial invariance of the
CES-D in low socioeconomic status African Americans compared with a nationally repre-
sentative sample. Psychiatry Research 126:177–187, 2004.
Niv, N., Wong, E.C., and Hser, Y.I. Asian Americans in community-based substance abuse
treatment: service needs, utilization, and outcomes. Journal of Substance Abuse Treatment
33(3):313–319, 2007.
Niven, J.A. Client-centered, culture-friendly behavioral health care techniques for work with
Alaska natives in the Bering Strait Region. Social Work in Mental Health 8(4):398–420, 2010.
Norris, A.E., Ford, K., and Bova, C.A. Psychometrics of a brief acculturation scale for Hispanics
in a probability sample of urban Hispanic adolescents and young adults. Hispanic Journal of
Behavioral Sciences 18:29–38, 1996.
Norris, T., Vines, P.L., and Hoeffel, E.M. The American Indian and Alaska Native Population:
2010. Census 2010 Brief. Washington, DC: U.S. Census Bureau, 2012.
Novy, D.M., Stanley, M.A., Averill, P., and Daza, P. Psychometric comparability of English- and
Spanish-language measures of anxiety and related affective symptoms. Psychological Assessment
13:347–355, 2001.
Nyunt, M.S.Z., Fones, C., Niti, M., and Ng, T.P. Criterion-based validity and reliability of the
Geriatric Depression Screening Scale (GDS-15) in a large validation sample of community-
living Asian older adults. Aging and Mental Health 13:376–382, 2009.

227
 Improving Cultural Competence

Obasi, E.M., and Leong, F.T.L. Psychological distress, acculturation, and mental health-seeking
attitudes among people of African descent in the United States: A preliminary investigation.
Journal of Counseling Psychology 56(2):227–238, 2009.
O’Connell, J.M., Novins, D.K., Beals, J., and Spicer, P. Disparities in patterns of alcohol use
among reservation-based and geographically dispersed American Indian populations. Alcohol-
ism: Clinical and Experimental Research 29(1):107–116, 2005.
O’Dwyer, P. The Irish and substance abuse. In: Straussner, S.L.A., ed. Ethnocultural Factors in
Substance Abuse Treatment (pp. 199–215). New York: Guilford Press, 2001.
Oetting, E.R., and Beauvais, F. Orthogonal cultural identification theory: The cultural identifica-
tion of minority adolescents. The International Journal of the Addictions 25(5A-6A):655–685,
1990.
Office of Applied Studies. 2003 National Survey on Drug Use & Health: Detailed Tables. Results
from the 2003 National Survey on Drug Use and Health: National Findings. Rockville, MD:
Department of Health and Human Services, Substance Abuse and Mental Health Services
Administration, 2004.
Office of Applied Studies. Substance Abuse Treatment Admissions Among Asians and Pacific Is-
landers: 2002. The Dasis Report June 10. Rockville, MD: Substance Abuse and Mental
Health Services Administration, 2005a.
Office of Applied Studies. Treatment Admissions in Rural Areas: 2003. The DASIS Report, Sep-
tember 30, 2005. Rockville, MD: Substance Abuse and Mental Health Services Administra-
tion, 2005b.
Office of Applied Studies. Substance Use and Substance Use Disorders Among American Indians and
Alaska Natives. The NSDUH Report. Rockville, MD: Substance Abuse and Mental Health
Services Administration, 2007.
Office of Communications. Summary Report CARAVAN® Survey for SAMHSA on Addictions and
Recovery. Rockville, MD: Office of Communications, Substance Abuse and Mental Health
Services Administration, 2008.
Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human
Services. Social determinants of health. Healthy People 2020. Rockville, MD: Office of Disease
Prevention and Health Promotion, 2013.
Office of Minority Health. Assuring Cultural Competence in Health Care: Recommendations for
National Standards and an Outcomes-Focused Research Agenda. Rockville, MD: Office of Mi-
nority Health, 2000.
Office of Minority Health. National Standards for Culturally and Linguistically Appropriate Ser-
vices in Health and Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and
Practice. Washington, DC: Office of Minority Health, 2013.
Office of Minority Health. What is Cultural Competency? Washington, DC: Office of Minority
Health, 2005.
Ogunwole, S.U. We the People: American Indians and Alaska Natives in the United States. Census
2000 Special Reports. Washington, DC: U.S. Census Bureau, 2006.

228
 Appendix A—Bibliography

Oksanen, A. To hell and back: Excessive drug use, addiction, and the process of recovery in main-
stream rock autobiographies. Substance Use & Misuse 47(2):143–154, 2012.
Oliveira, J.M., Austin, A.A., Miyamoto, R.E.S., Kaholokula, J.K., Yano, K.B., and Lunasco, T.
The rural Hawai’i behavioral health program: increasing access to primary care behavioral
health for Native Hawaiians in rural settings. Professional Psychology: Research and Practice
37(2):174–182, 2006.
Organista, K.C. Cognitive–behavioral therapy with Latinos and Latinas. In: Hays, P.A., and
Iwamasa, G.Y., eds. Culturally Responsive Cognitive–Behavioral Therapy: Assessment, Practice,
and Supervision (pp. 73–96). Washington, DC: American Psychological Association, 2006.
Organista, K.C., and Muñoz, R.F. Cognitive–behavioral therapy with Latinos. In: Organista, P.B.,
Chun, K.M., and Marin, G., eds. Readings in Ethnic Psychology (pp. 353–366). New York:
Routledge, 1998.
Organista, P.B., Organista, K.C., and Kurasaki, K. The relationship between acculturation and
ethnic minority health. In: Chun, K.M., Balls-Organista, P., and Marin, G., eds. Acculturation:
Advances in Theory, Measurement and Applied Research (pp. 139–161). Washington, DC:
American Psychological Association, 2003.
Ornelas, I.J., and Hong, S. Gender differences in the relationship between discrimination and
substance use disorder among Latinos. Substance Use and Misuse 47(12):1349–1358, 2012.
Otiniano Verissimo, A.D., Gee, G. C., Ford, C.L., and Iguchi, M.Y. Racial discrimination, gen-
der discrimination, and substance abuse among Latina/os nationwide. Cultural Diversity and
Ethnic Minority Psychology 20(1): 43–51, 2014.
Otsubo, T., Tanaka, K., Koda, R., Shinoda, J., Sano, N., Tanaka, S., Aoyama, H., Mimura, M., and
Kamijima, K. Reliability and validity of Japanese version of the Mini-International Neuro-
psychiatric Interview. Psychiatry and Clinical Neurosciences 59:517–526, 2005.
Pacek, L.R., Malcolm, R.J., and Martins, S.S. Race/ethnicity differences between alcohol, mariju-
ana, and co-occurring alcohol and marijuana use disorders and their association with public
health and social problems using a national sample. The American Journal on Addictions
21(5):435–444, 2012.
Pack-Brown, S.P., and Williams, C.B. Ethics in a Multicultural Context: Multicultural Aspects of
Counseling Series. Thousand Oaks, CA: Sage Publications, 2003.
Padilla, A.M. The role of cultural awareness and ethnic loyalty in acculturation. In Padilla, A.M., ed.
Acculturation: Theory, Models and Some New Findings (pp. 47–84). Boulder, CO: Westview, 1980.
Padilla, A.M., and Salgado de Snyder, V.N. Hispanics: What the culturally informed evaluator
needs to know. In: Orlandi, M.A., Weston, R., and Epstein, L.G., eds. Cultural Competence for
Evaluators: A Guide for Alcohol and Other Drug Abuse Prevention Practitioners Working With
Ethnic/Racial Communities (pp. 117–146). OSAP Cultural Competence Series I. HHS Publi-
cation No. (ADM) 92-1884. Rockville, MD: Office for Substance Abuse Prevention, 1992.
Pal, H.R., Jena, R., and Yadav, D. Validation of the Alcohol Use Disorders Identification Test
(AUDIT) in urban community outreach and de-addiction center samples in north India.
Journal of Studies on Alcohol 65:794–800, 2004.

229
 Improving Cultural Competence

Paniagua, F.A. Assessing and Treating Culturally Diverse Clients: A Practical Guide. 2nd ed. Thou-
sand Oaks, CA: Sage Publications, 1998.
Park, M., Chesla, C.A., Rehm, R.S., and Chun, K.M. Working with culture: culturally appropriate
mental health care for Asian Americans. Journal of Advanced Nursing 67(11):2373–2382, 2011.
Passel, J.S. Unauthorized Migrants: Numbers and Characteristics. Background Briefing Prepared for
Task Force on Immigration and America’s Future. Washington, DC: Pew Hispanic Center, Pew
Research Center, 2005.
Passel, J.S., and Cohn, D. U.S. Population Projections: 2005–2050. Washington, DC: Pew Re-
search Center, 2008.
Passel, J.S., and Cohn, D. A Portrait of Unauthorized Immigrants in the United States. Washington,
DC: Pew Research Center, 2009.
Pawson, M., and Kelly, B.C. Consumption and community: The subcultural contexts of disparate
marijuana practices in jam band and hip-hop scenes. Deviant Behavior 35(5):347–363, 2014.
Peace Corps Information Collection and Exchange. Culture Matters: The Peace Corps Cross-
Cultural Workbook. Washington, DC: Peace Corps Information Collection and Exchange,
2012.
Pearson, C., and Bourgois, P. Hope to die a dope fiend. Cultural Anthropology 10(4):587–593, 1995.
Pena, J.M., Bland, I.J., Shervington, D., Rice, J.C., and Foulks, E.F. Racial identity and its as-
sessment in a sample of African-American men in treatment for cocaine dependence. Ameri-
can Journal of Drug and Alcohol Abuse 26:97–112, 2000.
People Awakening Project. The People Awakening Project: Discovering Alaska Native Pathways to
Sobriety. Final Report 2004. Fairbanks, AK: University of Alaska Fairbanks, 2004.
Perez, M.A., and Luquis, R.R. Cultural Competence in Health Education and Health Promotion,.1st
ed. San Francisco: Jossey-Bass, 2008.
Pernell-Arnold, A., Finley, L., Sands, R.G., Bourjolly, J., and Stanhope, V. Training mental health
providers in cultural competence: A transformative learning process. American Journal of
Psychiatric Rehabilitation 15(4):334–356, 2012.
Perron, B.E., Mowbray, O.P., Glass, J.E., Delva, J., Vaughn, M.G., and Howard, M.O. Differ-
ences in service utilization and barriers among Blacks, Hispanics, and Whites with drug use
disorders. Substance Abuse Treatment, Prevention and Policy 4:3, 2009.
Peters, M.L., Sawyer, C.B., and Guzman, M. Supporting the development of Latino bilingual
mental health professionals. Journal of Hispanic Higher Education 13(1):15–31, 2014.
Petry, N.M. A comparison of African American and non-Hispanic Caucasian cocaine-abusing
outpatients. Drug and Alcohol Dependence 69(1):43–49, 2003.
Petry, N.M., Alessi, S.M., and Hanson, T. Contingency management improves abstinence and quality
of life in cocaine abusers. Journal of Consulting and Clinical Psychology 75(2):307–315, 2007.
Petry, N.M., Alessi, S.M., Marx, J., Austin, M., and Tardif, M. Vouchers versus prizes: Contin-
gency management treatment of substance abusers in community settings. Journal of Consult-
ing and Clinical Psychology 73(6):1005–1014, 2005.

230
 Appendix A—Bibliography

Petry, N.M., Tedford, J., Austin, M., Nich, C., Carroll, K.M., and Rounsaville, B.J. Prize rein-
forcement contingency management for treating cocaine users: How low can we go, and with
whom? Addiction 99(3):349–360, 2004.
Pew Forum on Religion and Public Life. U.S. Religious Landscape Survey: Religious Affiliation:
Diverse and Dynamic. Washington, DC: Pew Research Center, 2008.
Pew Research Center for the People & the Press. Interdiction and Incarceration Still Top Remedies:
74% Say Drug War Being Lost. Washington, DC: Pew Research Center, 2001.
Pierce, T.G. Gen-X junkie: Ethnographic research with young White heroin users in Washing-
ton, DC. Substance Use & Misuse 34(14):2095–2114, 1999.
Pieterse, A.L., Todd, N.R., Neville, H.A., and Carter, R.T. Perceived racism and mental health
among Black American adults: A meta-analytic review. Journal of Counseling Psychology, 59,
1–9, 2012.
Polednak, A.P. Temporal trend in the U.S. Black-White disparity in mortality rates from selected
alcohol-related chronic diseases. Journal of Ethnicity in Substance Abuse 7(2):154–164, 2008.
Ponterotto, J.G., Fuertes, J.N., and Chen, E.C. Models of multicultural counseling. In: Brown,
S.D., and Lent, R.W., eds. Handbook of Counseling Psychology (pp. 639–669). New York: John
Wiley & Sons, 2000. Portes, A., Fernandez-Kelly, P., and Haller, W. Segmented assimilation
on the ground: The new second generation in early adulthood. Ethnic and Racial Studies
28(6):1000–1040, 2005.
Portes, A., and Rumbaut, R.G. Introduction: The second generation and the children of immi-
grants longitudinal study. Ethnic and Racial Studies 28(6):983–999, 2005.
Posner, S.F., Stewart, A.L., Martin, G., and Perez-Stable, E. J. Factor variability of the Center for
Epidemiological Studies Depression Scale (CES-D) among urban Latinos. Ethnicity and
Health 6:137–144, 2001.
Pouget, E.R., Friedman, S.R., Cleland, C.M., Tempalski, B., and Cooper, H.L. Estimates of the
population prevalence of injection drug users among Hispanic residents of large US metro-
politan areas. Journal of Urban Health 89(3):527–564, 2012.
Prochaska, J.O., and DiClemente, C.C. The Transtheoretical Approach: Crossing Traditional Bound-
aries of Therapy. Homewood, IL: Dow Jones-Irwin, 1984.
Prochaska, J.O., DiClemente, C.C., and Norcross, J.C. In search of how people change: Applica-
tions to addictive behaviors. The American Psychologist 47(9):1102–1114, 1992.
Quintana, M.I., Andreoli, S.B., Jorge, M.R., Gastal, F.L., and Miranda, C.T. The reliability of the
Brazilian version of the composite international diagnostic interview (CIDI 2.1). Brazilian
Journal of Medical and Biological Research 37(11):1739–1745, 2004.
Quintero, G.A., Lilliott, E., and Willging, C. Substance abuse treatment provider views of “cul-
ture”: Implications for behavioral health care in rural settings. Qualitative Health Research
17(9):1256–1267, 2007.
Radloff, L.S. The CES-D Scale: A self-report depression scale for research in the general popu-
lation. Applied Psychological Measurement 1:385–401, 1977.

231
 Improving Cultural Competence

Ramirez, M. Multicultural Psychotherapy: An Approach to Individual and Cultural Differences. 2nd

ed. Boston: Allyn and Bacon, 1999.
Ramirez, R.R., and de la Cruz, G.P. The Hispanic Population in the United States: March 2002.
Current Population Reports. Washington, DC: U.S. Census Bureau, 2003.
Ramos-Sanchez, L. The psychology of undocumented Latinos: Living an invisible existence. In:
Chin, J.L., ed. Diversity in Mind and in Action, Vol 1: Multiple Faces of Identity (pp. 105-115).
Santa Barbara, CA: Praeger/ABC-CLIO, 2009.
Rastogi, M., and Wadhwa, S. Substance abuse among Asian Indians in the United States: A
consideration of cultural factors in etiology and treatment. Substance Use & Misuse
41(9):1239–1249, 2006.
Reardon, S.F., and Buka, S.L. Differences in onset and persistence of substance abuse and de-
pendence among Whites, Blacks, and Hispanics. Public Health Reports 117(Suppl 1):S51–
S59, 2002.
Reback, C.J. The Social Construction of a Gay Drug: Methamphetamine Use Among Gay and Bisexual
Males in Los Angeles. Los Angeles: City of Los Angeles, AIDS Coordinator, 1997.
Reback, C.J., and Shoptaw, S. Development of an evidence-based, gay-specific cognitive behav-
ioral therapy intervention for methamphetamine-abusing gay and bisexual men. Addictive Be-
haviors 39(8):1286–1291, 2011.
Reeves, T., and Bennett, C. The Asian and Pacific Islander Population in the United States: March
2002. Current Population Reports. Washington, DC: U.S. Census Bureau, 2003.
Reid, D.J. Addiction, African Americans, and a Christian recovery. In: Krestan, J.A., ed. Bridges to
Recovery: Addiction, Family Therapy, and Multicultural Treatment (pp. 145–172). New York:
The Free Press, 2000.
Reinert, D.F. and Allen, J.P. The alcohol use disorders identification test: an update of research
findings. Alcoholism: Clinical and Experimental Research 31:185–199, 2005.
Reuland, D.S., Cherrington, A., Watkins, G.S., Bradford, D.W., Blanco, R.A., and Gaynes, B.N.
Diagnostic accuracy of Spanish language depression-screening instruments. Annals of Family
Medicine 7:455–462, 2009.
Reyna, J.M., and Cadena, C.H.G. Masculinity, machismo and their relation with some familiar
variables. In: Columbus, A.M., ed. Advances in Psychology Research, Vol. 42 (pp. 123–145).
Hauppauge, NY: Nova Science Publishers, 2007.
Reynolds, S. Generation Ecstasy: Into the World of Techno and Rave Culture. New York: Routledge,
1998.
Reynoso-Vallejo, H., Chassler, D., Witas, J., and Lundgren, L.M. Patterns of drug treatment
entry by Latino male injection drug users from different national/geographical backgrounds.
Evaluation and Program Planning 31(1):92–101, 2008.
Rezentes, W.C. Na Mea Hawaii: A Hawaiian acculturation scale. Psychological Reports 73:383–
393, 1993.

232
 Appendix A—Bibliography

Rich, J.A., and Grey, C.M. Pathways to recurrent trauma among young Black men: Traumatic
stress, substance use, and the “code of the street”. American Journal of Public Health 95(5):816–
824, 2005.
Richardson, T.M., and Williams, B.A. African-Americans in Treatment: Dealing With Cultural
Differences. Center City, MN: Hazelden, 1990.
Riehman, K.S., Wechsberg, W.M., Zule, W., Lam, W.K., and Levine, B. Gender differences in
the impact of social support on crack use among African Americans. Substance Use & Misuse
43(1):85–104, 2008.
Ring, J.M. Curriculum for Culturally Responsive Health Care: The Step-by-Step Guide for Cultural
Competence Training. Oxford: Radcliffe Publishing, 2008.
Ritsher, J.B., Moos, R.H., and Finney, J.W. Relationship of treatment orientation and continuing
care to remission among substance abuse patients. Psychiatric Services 53(5):595–601, 2002.
Roberts, R.E., Rhoades, H.M., and Vernon, S.W. Using the CES-D scale to screen for depres-
sion and anxiety: Effects of language and ethnic status. Psychiatry Research 31:69–83, 1990.
Robin, R.W., Saremi, A., Albaugh, B., Hanson, R.L., Williams, D., and Goldman, D. Validity of
the SMAST in two American Indian tribal populations. Substance Use and Misuse 39:601–
624, 2004.
Rodriguez-Andrew, S. Alcohol use and abuse among Latinos: Issues and examples of culturally
competent services. Alcoholism Treatment Quarterly 16(1-2):55–70, 1998.
Rogers, A.T. Exploring health beliefs and care-seeking behaviors of older USA-dwelling Mexi-
cans and Mexican-Americans. Ethnicity & Health 15(6):581–599, 2010.
Room, R. Gender roles and interactions in drinking and drug use. Journal of Substance Abuse
8(2):227–239, 1996.
Room, R. Taking account of cultural and societal influences on substance use diagnoses and
criteria. Addiction 101(Suppl 1):31–39, 2006.
Room, R., Graham, K., Rehm, J., Jernigan, D., and Monteiro, M. Drinking and its burden in a
global perspective: Policy considerations and options. European Addiction Research 9(4):165–
175, 2003.
Room, R., Janca, A., Bennett, L.A., Schmidt, L., and Sartorius, N. WHO cross-cultural applica-
bility research on diagnosis and assessment of substance use disorders: An overview of meth-
ods and selected results. Addiction 91(2):199–220, 1996.
Room, R., Rehm, J., Trotter, R.T., Paglia, A., and Ustun, T.B. Cross-cultural views on stigma,
valuation, parity, and societal values towards disability. In: Ustun, T.B., Chatterji, S., Bicken-
bach, J., Trotter, R.T., II, Room, R., Rehm, J., and Saxena, S., eds. Disability and Culture: Uni-
versalism and Diversity (pp. 247–291). Seattle, WA: Published on behalf of the World Health
Organization by Hogrefe & Huber Publishers, 2001.
Rose, P.R. Cultural Competency for Health Administration and Public Health. Sudbury, MA: Jones
and Bartlett, 2011.

233
 Improving Cultural Competence

Rosenbaum, S., and Shin, P. Migrant and Seasonal Farmworkers: Health Insurance Coverage and
Access to Care. Washington, DC: Kaiser Commission on Medicaid and the Uninsured, 2005.
Rosenbaum, S., and Teitelbaum, J. Cultural Competence in Medicaid Managed Care Purchasing:
General and Behavioral Health Services for Persons With Mental and Addiction-Related Illnesses
and Disorders. Issue Brief #4. Rockville, MD: Substance Abuse and Mental Health Services
Administration, 1999.
Ross-Durow, P.L., and Boyd, C.J. Sexual abuse, depression, and eating disorders in African Ameri-
can women who smoke cocaine. Journal of Substance Abuse Treatment 18(1):79–81, 2000.
Rossi, A., Alberio, R., Porta, A., Sandri, M., Tansella, M., and Amaddeo, F. The reliability of the
Mini-International Neuropsychiatric Interview–Italian version. Journal of Clinical Psycho-
pharmacology 24:561–563, 2004.
Roysircar, G. Research in multicultural counseling: Client needs and counselor competencies. In:
Lee, C., ed. Multicultural Issues in Counseling: New Approaches to Diversity. 3rd ed. (pp. 369–
387). Alexandria, VA: American Counseling Association, 2006.
Ruan, W.J., Goldstein, R.B., Chou, S.P., Smith, S.M., Saha, T.D., Pickering, R.P., Dawson, D.A.,
Huang, B., Stinson, F.S., and Grant, B.F. The alcohol use disorder and associated disabilities
interview schedule-IV (AUDADIS-IV): Reliability of new psychiatric diagnostic modules
and risk factors in a general population sample. Drug and Alcohol Dependence 92:27–36, 2008.
Ruiz, P. Issues in the psychiatric care of Hispanics. Psychiatric Services 48(4):539–540, 1997.
Rumpf, H.J., Bischof, G., Hapke, U., Meyer, C., and John, U. The role of family and partnership
in recovery from alcohol dependence: Comparison of individuals remitting with and without
formal help. European Addiction Research 8(3):122–127, 2002.
Russell, C. A Report on Cultural Competency Training for Health Care Professionals in Connecticut.
Hartford, CT: Connecticut Multicultural Health Partnership, 2009.
Russell, L.M. Reducing Disparities in Life Expectancy: What Factors Matter? Washington, DC:
Institute of Medicine, 2011.
Russell, M. New assessment tools for risk drinking during pregnancy: T-ACE, TWEAK, and
others. Alcohol Health and Research World 18:55–61, 1994.
Ryder, A.G., Alden, L.E., and Paulhus, D.L. Is acculturation unidimensional or bidimensional? A
head-to-head comparison in the prediction of personality, self-identity, and adjustment. Jour-
nal of Personality and Social Psychology 79:49–65, 2000.
Sabin, C., Benally, H., Bennett, S.K., and Jones, E. Walking in Beauty on the Red Road: A Holistic
Cultural Treatment Model for American Indian & Alaska Native Adolescents and Families: Pro-
gram Description and Clinical Manual. Rockville, MD: Substance Abuse and Mental Health
Services Administration, 2004.
Sabogal, F., Marin, G., Otero-Sabogal, R., and Marin, B.V. Hispanic familism and acculturation:
What changes and what doesn’t? Hispanic Journal of Behavioral Sciences 9:397–412, 1987.
Saitz, R., Lepore, M.F., Sullivan, L.M., Amaro, H., and Samet, J.H. Alcohol abuse and depend-
ence in Latinos living in the United States: Validation of the CAGE (4M) questions. Archives
of Internal Medicine 159:718–724, 1999.

234
 Appendix A—Bibliography

Saldaña, D. Cultural Competency: A Practical Guide for Mental Health Service Providers. Austin,
TX: Hogg Foundation for Mental Health, 2001.
Salgado de Snyder, V.N. Factors associated with acculturative stress and depressive symptomatol-
ogy among married Mexican immigrant women. Psychology of Women Quarterly 11(4):475–
488, 1987.
Sanchez, K., Chapa, T., Ybarra, R., and Martinez, O.N. Enhancing the Delivery of Health Care:
Eliminating Health Disparities Through a Culturally & Linguistically Centered Integrated Health
Care Approach. Rockville, MD: U.S. Department of Health and Human Services, Office of
Minority Health, Hogg Foundation for Mental Health, 2012.
Sandberg, S. Cannabis culture: A stable subculture in a changing world. Criminology & Criminal
Justice: An International Journal 13(1):63–79, 2013.
Sanders, M. The response of African American communities to alcohol and other drug prob-
lems: An opportunity for treatment providers. Alcoholism Treatment Quarterly 20(3-4):167–
174, 2002.
Sandhu, D.S., and Malik, R. Ethnocultural background and substance abuse treatment of Asian
Indian Americans. In: Straussner, S.L.A., ed. Ethnocultural Factors in Substance Abuse Treat-
ment (pp. 368–392). New York: Guilford Press, 2001.
Sandi Esquivel, L.E. and Avila, C.K. Validity of the Addiction Severity Index (adapted version)
in a Costa Rican population group. Bulletin of the Pan American Health Organization 24:70–
76, 1990.
Sandoval, M.C. Santeria as a mental health care system: An historical overview. Social Science and
Medicine: Medical Anthropology 13B(2):137–151, 1979.
Santisteban, D.A., Coatsworth, J.D., Perez-Vidal, A., Kurtines, W.M., Schwartz, S.J., LaPerriere,
A., and Szapocznik, J. Efficacy of brief strategic family therapy in modifying Hispanic adoles-
cent behavior problems and substance use. Journal of Family Psychology 17(1):121–133, 2003.
Santisteban, D.A., Coatsworth, J.D., Perez-Vidal, A., Mitrani, V., Jean-Gilles, M., and Szapocz-
nik, J. Brief structural/strategic family therapy with African American and Hispanic high-
risk youth. Journal of Community Psychology 25(5):453–471, 1997.
Satre, D.D., Campbell, C.I., Gordon, N.S., and Weisner, C. Ethnic disparities in accessing treat-
ment for depression and substance use disorders in an integrated health plan. International
Journal of Psychiatry in Medicine 40(1):57–76, 2010.
Saunders, J.B., Aasland, O.G., Babor, T.F., de la Fuente, J.R., and Grant, M. Development of the
Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early
detection of persons with harmful alcohol consumption–II. Addiction 88:791–804, 1993.
Sayegh, L., and Lasry, J. Immigrants’ adaptation in Canada: Assimilation, acculturation, and
orthogonal cultural identification. Canadian Psychology 34(1):98–109, 1993.
Schensul, J.J., Huebner, C., Singer, M., Snow, M., Feliciano, P., and Broomhall, L. The high, the
money, and the fame: The emergent social context of “new marijuana” use among urban
youth. Medical Anthropology 18(4):389–414, 2000.
Schiele, J.H. Human Services and the Afrocentric Paradigm. Binghamton, NY: Haworth Press, 2000.

235
 Improving Cultural Competence

Schiff, J.W., and Moore, K. The impact of the sweat lodge ceremony on dimensions of well-
being. American Indian and Alaska Native Mental Health Research 13(3):48–69, 2006.
Schiller, J.S., Martinez, M., and Barnes, P. Early Release of Selected Estimates Based on Data From
the 2004 National Health Interview Survey. Hyattsville, MD: National Center for Health Sta-
tistics, 2005.
Schmidt, L., Greenfield, T., and Mulia, N. Unequal treatment: Racial and ethnic disparities in
alcoholism treatment services. Alcohol Research & Health 29(1):49–54, 2006.
Schmidt, L.A., and Weisner, C.M. Private insurance and the utilization of chemical dependency
treatment. Journal of Substance Abuse Treatment 28(1):67–76, 2005.
Schmidt, L.A., Ye, Y., Greenfield, T.K., and Bond, J. Ethnic disparities in clinical severity and
services for alcohol problems: Results from the national alcohol survey. Alcoholism: Clinical &
Experimental Research 31(1):48–56, 2007.
Schoeneberger, M.L., Leukefeld, C.G., Hiller, M.L., and Townsend, M. Substance abuse among
rural and very rural drug users at treatment entry. In: The National Rural Alcohol and Drug
Abuse Network Awards for Excellence 2004 (pp. 59–75). Technical Assistance Publication
(TAP) 28. HHS Publication No. (SMA) 06-4183. Rockville, MD: Substance Abuse and
Mental Health Services Administration, Center for Substance Abuse Treatment, 2006.
Schroeder, J.R., Schmittner, J.P., Epstein, D.H., and Preston, K.L. Adverse events among patients
in a behavioral treatment trial for heroin and cocaine dependence: Effects of age, race, and
gender. Drug and Alcohol Dependence 80(1):45–51, 2005.
Schuster, M.A., Halfon, N., and Wood, D.L. African American mothers in South Central Los
Angeles: Their fears for their newborn’s future. Archives of Pediatrics Adolescent Medicine
152(3):264–268, 1998.
Schwartz, A.C., Bradley, R.L., Sexton, M., Sherry, A., and Ressler, K.J. Posttraumatic stress
disorder among African Americans in an inner city mental health clinic. Psychiatric Services
56(2):212–215, 2005.
Seale, J.P., Shellenberger, S., and Spence, J. Alcohol problems in Alaska Natives: Lessons from
the Inuit. American Indian and Alaska Native Mental Health Research: The Journal of the Na-
tional Center 13(1):1–31. 2006.
Segal, B., Burgess, D., DeGross, D., Frank, P., Hild, C., and Saylor, B. Alaska Natives Combating
Substance Abuse and Related Violence Through Self-Healing: A Report for the People. Anchorage,
AK: University of Alaska Anchorage, 1999.
Sellers, R.M., Rowley, S.A.J., Chavous, T.M., Shelton, J.N., and Smith, M.A. Multidimensional
Inventory of Black Identity: A preliminary investigation of reliability and constuct validity.
Journal of Personality and Social Psychology 73:805–815, 1997.
Selzer, M.L., Vinokur, A., and van Rooijen, L. A self-administered Short Michigan Alcoholism
Screening Test (SMAST). Journal of Studies on Alcohol 36:117–126, 1975.
Semple, S.J., Grant, I., and Patterson, T.L. Utilization of drug treatment programs by methamphet-
amine users: The role of social stigma. The American Journal of Addiction 14(4):367–380, 2005.

236
 Appendix A—Bibliography

Sexton, R.L., Carlson, R.G., Siegal, H., Leukefeld, C.G., and Booth, B. The role of African-
American clergy in providing informal services to drug users in the rural South: Preliminary
ethnographic findings. Journal of Ethnicity in Substance Abuse 5(1):1–21, 2006.
Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., Hergueta, T.,
Baker, R., and Dunbar, G.C. The Mini-International Neuropsychiatric Interview (M.I.N.I):
The development and validation of a structured diagnostic psychiatric interview for DSM-IV
and ICD-10. Journal of Clinical Psychiatry 59:22–33, 1998.
Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Janavs, J., Weiller, E., Keskiner, A., Schinka, J.,
Knapp, E., Sheehan, M.F., and Dunbar, G.C. The validity of the Mini International Neuro-
psychiatric Interview (MINI) according to the SCID-P and its reliability. European Psychiatry
12:232–241, 1997.
Sheikh, J. I. and Yesavage, J. A. Geriatric Depression Scale (GDS): Recent evidence and devel-
opment of a shorter version. Clinical Gerontologist 5:165–173, 1986.
Sheu, H. B. and Lent, R. W. Development and initial validation of the Multicultural Counseling
Self-Efficacy Scale–Racial Diversity Form. Psychotherapy: Theory, Research, Practice, Training
44:30–45, 2007.
Shin, H.B., and Bruno, R. Language Use and English-Speaking Ability: 2000. Census 2000 Brief.
Washington, DC: U.S. Census Bureau, 2003.
Shorkey, C., Windsor, L.C., and Spence, R. Assessing culturally competent chemical dependence
treatment services for Mexican Americans. The Journal of Behavior Health Services Research
36(1):61–74, 2009.
Shorter-Gooden, K. Therapy with African American men and women. In: Neville, H.A., Tynes,
B.M., and Utsey, S.O., eds. Handbook of African American Psychology (pp. 445–458). Thousand
Oaks, CA: Sage Publications, 2009.
Silverman, K., Svikis, D., Wong, C.J., Hampton, J., Stitzer, M.L., and Bigelow, G.E. A rein-
forcement-based therapeutic workplace for the treatment of drug abuse: Three-year absti-
nence outcomes. Experimental and Clinical Psychopharmacology 10(3):228–240, 2002.
Silverman, K., Wong, C.J., Needham, M., Diemer, K.N., Knealing, T., Crone-Todd, D., Finger-
hood, M., Nuzzo, P., and Kolodner, K. A randomized trial of employment-based reinforce-
ment of cocaine abstinence in injection drug users. Journal of Applied Behavior Analysis
40(3):387–410, 2007.
Simon, D., and Burns, E. The Corner: A Year in the Life of an Inner-City Neighborhood. New York:
Broadway Books, 1997.
Singer, J.B. Visual Assessment Tools: The Culturagram. Interview With Dr. Elaine Congress. [Audio
podcast]. 2007, December 1.
Singer, M. Why do Puerto-Rican injection drug users inject so often? Journal of Anthropology and
Medicine 6(1):31–58, 1999.
Singer, M., Valentin, F., Baer, H., and Jia, Z. Why does Juan Garcia have a drinking problem?
The perspective of critical medical anthropology. Medical Anthropology 14(1):77–108, 1992.
Skinner, H.A. The Drug Abuse Screening Test. Addictive Behaviors 7:363–371, 1982.

237
 Improving Cultural Competence

Skinner, J.H. Acculturation: Measures of ethnic accommodation to the dominant American

culture. Journal of Mental Health and Aging 7:41–51, 2001.
Smedley, B.D., Stith, A.Y., Nelson, A.R., Institute of Medicine, and Committee on Understand-
ing and Eliminating Racial and Ethnic Disparities in Health Care. Unequal Treatment: Con-
fronting Racial and Ethnic Disparities in Health Care. Washington, D.C: National Academy
Press, 2003.
Smokowski, P.R., Rose, R., and Bacallao, M.L. Acculturation and Latino family processes: How
cultural involvement, biculturalism, and acculturation gaps influence family dynamics. Family
Relations 57(3):295–308, 2008.
Snowden, L.R., and Hines, A.M. A scale to assess African American acculturation. Journal of
Black Psychology 25:36–47, 1999.
Sobralske, M. Machismo sustains health and illness beliefs of Mexican American men. Journal of
American Academy of Nurse Practitioners 18(8):348-350, 2006.
Sodowsky, G. R., and. Wai Ming Lai, E. Asian immigrant variables and structural models of
cross-cultural distress. In Booth, A., Crouter, A.C., and Landale, N., eds. Immigration and the
Family: Research and Policy on U.S. Immigrants (pp. 211-234). Mahwah, NJ: Lawrence Erl-
baum Associates, 1997.
Solomon, B.B. Counseling Black families at inner-city church sites. In: Cheatham, H.E., and
Steward, J.B., eds. Black Families (pp. 353–371). New Brunswick, NJ: Transaction Publishers,
1990.
Sonn, C., and Walker, R. Working as a culturally competent mental health practitioner. In: Pur-
die, N., Dudgeon, P., and Walker, R., eds. Working Together: Aboriginal and Torres Strait Is-
lander Mental Health and Wellbeing Principles and Practice (pp. 157–180). Australian Council
for Educational Research, the Kulunga Research Network, and Telethon Institute for Child
Health Research, 2010.
Sosulski, M.R., and Woodward, A.T. American women living with mental disorders: Factors
associated with helpseeking from professional services and informal supports. Social Work in
Public Health 28(7):660–671, 2013.
Sotero, M.A. Conceptual model of historical trauma: Implications for public health practice and
research. Journal of Health Disparities Research and Practice 1(1):93–108, 2006.
Spear, S., Crevecoeur, D.A., Rawson, R.A., and Clark, R. The rise in methamphetamine use
among American Indians in Los Angeles County. American Indian and Alaska Native Mental
Health Research 14(2):1–15, 2007.
Spencer, M.S., and Chen, J. Effect of discrimination on mental health service utilization among
Chinese Americans. American Journal of Public Health 94(5):809–814, 2004.
Spicer, P. Culture and the restoration of self among former American Indian drinkers. Social
Science and Medicine 53(2):227–240, 2001.
Spunt, B. The current New York City heroin scene. Substance Use & Misuse 38(10):1539–1549,
2003.

238
 Appendix A—Bibliography

Srivastava, R. Understanding cultural competence in health care. In: Srivastava, R., ed. The
Healthcare Professional’s Guide to Clinical Cultural Competence (pp. 3–27). Toronto, Ontario:
Mosby, 2007.
St. Martin, M. How Important Is Racial/Cultural Identity? Transracial Adoption Part II. Evanston,
IL: iParenting.com, 2005.
Stahler, G.J., Kirby, K.C., and Kerwin, M.E. A faith-based intervention for cocaine-dependent
Black women. Journal of Psychoactive Drugs 39(2):183–190, 2007.
State of New Jersey Department of Human Services. A New Beginning: The Future of Child Wel-
fare in New Jersey. Trenton, NJ: New Jersey Department of Human Services, 2004.
Stephens, R.C. The Street Addict Role: A Theory of Heroin Addiction. Albany, NY: State University
of New York Press, 1991.
Stephens, R.C., Levine, S., and Ross, W. Street addict values: A factor analytic study. Journal of
Social Psychology 99(2):273–281, 1976.
Stephenson, M. Development and validation of the Stephenson Multigroup Acculturation Scale
(SMAS). Psychological Assessment 12:77–88, 2000.
Stockdale, S.E., Lagomasino, I.T., Siddique, J., McGuire, T., and Miranda, J. Racial and ethnic
disparities in detection and treatment of depression and anxiety among psychiatric and pri-
mary health care visits, 1995–2005. Medical Care 46(7):668–677, 2008.
Stone, R.A., Whitbeck, L.B., Chen, X., Johnson, K., and Olson, D.M. Traditional practices,
traditional spirituality, and alcohol cessation among American Indians. Journal of Studies on
Alcohol 67(2):236–244, 2006.
Straits, K.J.E., Bird, D.M., Tsinajinnie, E., Espinoza, J., Goodkind, J., Spencer, O., Tafoya, N.,
Willging, C., and the Guiding Principles Workgroup. Guiding Principles for Engaging in Re-
search with Native American Communities, Version 1. Albuquerque, NM: UNM Center for Ru-
ral and Community Behavioral Health and Albuquerque Area Southwest Tribal
Epidemiology Center, 2012.
Strakowski, S.M., Keck, P.E., Jr., Arnold, L.M., Collins, J., Wilson, R.M., Fleck, D.E., Corey,
K.B., Amicone, J., and Adebimpe, V.R. Ethnicity and diagnosis in patients with affective dis-
orders. The Journal of Clinical Psychiatry 64(7):747–754, 2003.
Straussner, S.L.A. Jewish substance abusers: Existing but invisible. In: Straussner, S.L.A., ed. Eth-
nocultural Factors in Substance Abuse Treatment (pp. 291–317). New York: Guilford Press, 2001.
Streissguth, A.P., Moon-Jordan, A., and Clarren, S.K. Alcoholism in four patients with fetal
alcohol syndrome: Recommendations for treatment. Alcoholism Treatment Quarterly 13(2):89–
103, 1995.
Suarez-Morales, L., Martino, S., Bedregal, L., McCabe, B.E., Cuzmar, I.Y., Paris, M., Feaster
D.J., Carroll, K.M., and Szapocznik, J. Do therapist cultural characteristics influence the out-
come of substance abuse treatment for Spanish-speaking adults? Cultural Diversity & Ethnic
Minority Psychology 16(2):199–205, 2010.

239
 Improving Cultural Competence

Substance Abuse and Mental Health Services Administration. Trauma Recovery and Empower-
ment Model (TREM). Rockville, MD: National Registry of Evidence-Based Programs and
Practices (NREPP), 2006.
Substance Abuse and Mental Health Services Administration. The Recovery Community Services
Program (RCSP). Rockville, MD: U.S. Department of Health and Human Services, Sub-
stance Abuse and Mental Health Services Administration, Center for Substance Abuse
Treatment, 2008.
Substance Abuse and Mental Health Services Administration. Results From the 2009 National
Survey on Drug Use and Health: Mental Health Findings. NSDUH Series H-39, HHS Publi-
cation No. (SMA) 10-4609. Rockville, MD: Center for Behavioral Health Statistics and
Quality, 2010.
Substance Abuse and Mental Health Services Administration. Results From the 2010 National
Survey on Drug Use and Health: Summary of National Findings. NSDUH Series H-41, HHS
Publication No. (SMA) 11-4658. Rockville, MD: Substance Abuse and Mental Health Ser-
vices Administration, 2011a.
Substance Abuse and Mental Health Services Administration. SAMHSA Announces a Working
Definition of “Recovery” From Mental Disorders and Substance Use Disorders. [News Release].
Rockville, MD: SAMHSA Press Office, 2011b.
Substance Abuse and Mental Health Services Administration. Treatment Episode Data Set
(TEDS) 1999–2009: National Admissions to Substance Abuse Treatment Services. DASIS Series:
S-56, HHS Publication No. (SMA) 11-4646. Rockville, MD: substance Abuse and Mental
Health Services Administration, 2011c.
Substance Abuse and Mental Health Services Administration. Mental Health United States, 2010.
HHS Publication No. (SMA) 12-4681. Rockville, MD: Substance Abuse and Mental Health
Services Administration, 2012a.
Substance Abuse and Mental Health Services Administration. Results From the 2011 National Survey
on Drug Use and Health: Detailed Tables. NSDUH Series H-44, HHS Publication No. (SMA)
12-4713. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012b.
Substance Abuse and Mental Health Services Administration. Addressing the Specific Behavioral
Health Needs of Men. Treatment Improvement Protocol (TIP) Series 56. HHS Publication
No. (SMA) 13-4736. Rockville, MD: Substance Abuse and Mental Health Services Admin-
istration, 2013a.
Substance Abuse and Mental Health Services Administration. Behavioral Health Services for
People Who Are Homeless. Treatment Improvement Protocol (TIP) Series 55-R. HHS Publi-
cation No. (SMA) 13-4734. Rockville, MD: Substance Abuse and Mental Health Services
Administration, 2013b.
Substance Abuse and Mental Health Services Administration. Results from the 2012 National
Survey on Drug Use and Health: Mental Health Findings. NSDUH Series H-47, HHS Publi-
cation No. (SMA) 13-4805. Rockville, MD: Substance Abuse and Mental Health Services
Administration, 2013c.

240
 Appendix A—Bibliography

Substance Abuse and Mental Health Services Administration. Results from the 2012 National
Survey on Drug Use and Health: Summary of National Findings. NSDUH Series H-46, HHS
Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Ser-
vices Administration, 2013d.
Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behav-
ioral Health Services. Treatment Improvement Protocol (TIP) Series 57. Rockville, MD: Sub-
stance Abuse and Mental Health Services Administration, 2014.
Substance Abuse and Mental Health Services Administration. Behavioral Health Services for
American Indians and Alaska Natives. Treatment Improvement Protocol (TIP) Series. Rock-
ville, MD: Substance Abuse and Mental Health Services Administration, planned a.
Substance Abuse and Mental Health Services Administration. Building Health, Wellness, and
Quality of Life for Sustained Recovery. Treatment Improvement Protocol (TIP) Series. Rock-
ville, MD: Substance Abuse and Mental Health Services Administration, planned b.
Substance Abuse and Mental Health Services Administration. Managing Anxiety Symptoms in
Behavioral Health Services. Treatment Improvement Protocol (TIP) Series. Rockville, MD:
Substance Abuse and Mental Health Services Administration, planned c.
Substance Abuse and Mental Health Services Administration. Reintegration-Related Behavioral
Health Issues in Veterans and Military Families. Treatment Improvement Protocol (TIP) Series.
Rockville, MD: Substance Abuse and Mental Health Services Administration, planned d.
Substance Abuse and Mental Health Services Administration. Relapse Prevention and Recovery
Promotion in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series.
Rockville, MD: Substance Abuse and Mental Health Services Administration, planned e.
Substance Abuse and Mental Health Services Administration. Using Technology-Based Therapeu-
tic Tools in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series. Rock-
ville, MD: Substance Abuse and Mental Health Services Administration, planned f.
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health
Statistics and Quality. The NSDUH Report: Need For and Receipt of Substance Abuse Treatment
Among Asian Americans and Pacific Islanders. Rockville, MD: Substance Abuse and Mental
Health Services Administration, 2005.
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health
Statistics and Quality. Substance Use Among Asian Adolescents. The NSDUH Report. Rock-
ville, MD: Substance Abuse and Mental Health Services Administration, 2011.
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health
Statistics and Quality. Treatment Episode Data Set (TEDS): 2000–2010. National Admissions
to Substance Abuse Treatment Services. DASIS Series: S-61, HHS Publication No. (SMA) 12-
4701. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health
Statistics and Quality. Highlights of the 2011 Drug Abuse Warning Network (DAWN) Findings
on Drug-Related Emergency Department Visits. The DAWN Report. Rockville, MD: Sub-
stance Abuse and Mental Health Services Administration, 2013a.

241
 Improving Cultural Competence

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Sta-
tistics and Quality. Need for and Receipt of Substance Use Treatment Among Blacks. The NSDUH
Report. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013b.
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health
Statistics and Quality. Treatment Episode Data Set (TEDS): 2001–2011. National Admissions
to Substance Abuse Treatment Services. BHSIS Series S-65, HHS Publication No. (SMA) 13-
4772. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013c.
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health
Statistics and Quality. Update on Emergency Department Visits Involving Energy Drinks: A
Continuing Public Health Concern. The DAWN Report. Rockville, MD: Substance Abuse and
Mental Health Services Administration, 2013d.
Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Partici-
pation in Self-Help Groups for Alcohol and Illicit Drug Use: 2006 and 2007. The NSDUH Re-
port. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2008.
Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Mental
Health Support and Self-Help Groups. The NSDUH Report. Rockville, MD: Substance Abuse
and Mental Health Services Administration, 2009.
Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Sub-
stance Use Among American Indian or Alaska Native Adults. The NSDUH Report. Rockville,
MD: Substance Abuse and Mental Health Services Administration, 2010.
Substance Abuse and Mental Health Services Administration, Office of Applied Studies. The
NSDUH Report: Need For and Receipt of Substance Use Treatment Among American Indians or Alas-
ka Natives. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.
Sue, D.W. Multidimensional facets of cultural competence. The Counseling Psychologist
29(6):790–821, 2001.
Sue, D.W., and Constantine, M.G. Effective multicultural consultation and organizational devel-
opment. In: Constantine, M.G., and Sue, D.W., eds. Strategies for Building Multicultural Com-
petence in Mental Health and Educational Settings (pp. 212–226). Hoboken, NJ: John Wiley &
Sons Inc., 2005.
Sue, D.W., and Sue, D. Counseling the Culturally Different: Theory and Practice. 3rd ed. New York:
John Wiley & Sons, 1999a.
Sue, D.W., and Sue, D. Racial/cultural identity development models (pp. 235–242). In: Counsel-
ing the Culturally Different: Theory and Practice. 3rd ed. New York: John Wiley & Sons, 1999b.
Sue, D.W., and Sue, D. Sociopolitical considerations of trust and mistrust (pp. 63–91). In: Coun-
seling the Culturally Diverse: Theory and Practice. 4th ed. New York: John Wiley and Sons,
2003a.
Sue, D.W., and Sue, D. The politics of counseling and psychotherapy (pp. 33–62). In: Counseling
the Culturally Diverse: Theory and Practice. 4th ed. New York: John Wiley and Sons, 2003b.
Sue, D.W., and Sue, D. Counseling the Culturally Diverse: Theory and Practice. 5th ed. Hoboken,
NJ: John Wiley & Sons, 2008.

242
 Appendix A—Bibliography

Sue, D.W., and Sue, D. Communication styles (pp. 160–168). In: Counseling the Culturally Di-
verse: Theory and Practice. 6th ed. Hoboken, NJ: John Wiley & Sons, 2013a.
Sue, D.W., and Sue, D. Counseling African Americans (pp. 365–378). In: Counseling the Cultur-
ally Diverse: Theory and Practice. 6th ed. Hoboken, NJ: John Wiley & Sons, 2013b.
Sue, D.W., and Sue, D. Counseling the Culturally Diverse: Theory and Practice. 6th ed. Hoboken,
NJ: John Wiley & Sons, 2013c.
Sue, D.W., and Sue, D. Implications for clinical practice (pp. 205–207). In: Counseling the Cul-
turally Diverse: Theory and Practice. 6th ed. Hoboken, NJ: John Wiley & Sons, 2013d.
Sue, D.W., and Sue, D. The education and training of mental health professionals (pp. 64–70).
In: Counseling the Culturally Diverse: Theory and Practice. 6th ed. Hoboken, NJ: John Wiley &
Sons, 2013e.
Sue, S., Fujino, D.C., Hu, L.T., Takeuchi, D.T., and Zane, N.W. Community mental health
services for ethnic minority groups: A test of the cultural responsiveness hypothesis. Journal of
Consulting and Clinical Psychology 59(4):533–540, 1991.
Suinn, R.M., Ahuna, C., & Khoo, G. The Suinn-Lew Asian Self-Identity Acculturation Scale:
Concurrent and factorial validation. Educational and Psychological Measurement 52(4):1041-
1046, 1992.
Summers, N. Fundamentals of Case Management Practice Skills for the Human Services. 4th ed.
Belmont, CA: Brooks/Cole Cengage Learning, 2012.
Sussman, L.K. The role of culture in definitions, interpretations, and management of illness. In:
Gielen, U.P., Fish, J.M., and Draguns, J.G., eds. Handbook of Culture, Therapy, and Healing
(pp. 37–65). Mahwah, NJ: Lawrence Erlbaum Associates Publishers, 2004.
Suzuki, L.A., and Ponterotto, J.G. Handbook of Multicultural Assessment: Clinical, Psychological, and
Educational Applications. 3rd ed. San Francisco: Jossey-Bass, 2008.
Szaflarski, M., Cubbins, L.A., and Ying, J. Epidemiology of alcohol abuse among US immigrant
populations. Journal of Immigrant and Minority Health 13(4):647–658, 2011.
Szapocznik, J., Kurtines, W.M., and Fernandez, T. Bicultural involvement and adjustment in
Hispanic-American youths. International Journal of Intercultural Relations 4:353–365, 1980.
Szapocznik, J., Scopetta, M.A., Kurtines, W., and Aranalde, M.D. Theory and measurement of
acculturation. Revista Interamericana de Psicologia 12:113–130, 1978.
Szapocznik, J., and Williams, R.A. Brief strategic family therapy: Twenty-five years of interplay
among theory, research and practice in adolescent behavior problems and drug abuse. Clinical
Child and Family Psychology Review 3(2):117–134, 2000.
Ta, V.M., Juon, H.S., Gielen, A.C., Steinwachs, D., and Duggan, A. Disparities in use of mental
health and substance abuse services by Asian and Native Hawaiian/other Pacific Islander
women. The Journal of Behavior Health Services Research 35(1):20–36, 2008.
Tackett-Gibson, M. Scripters and freaks: Knowledge and use of prescription stimulants online.
In: Murguâia, E., Tackett-Gibson, M., and Lessem, A., eds. Real Drugs in a Virtual World:
Drug Discourse and Community Online (pp. 121–134). Lanham, MD: Lexington Books, 2007.

243
 Improving Cultural Competence

Taggart, M. Scots-Irish Families. In: McGoldrick, M., Giordano, J., and Garcia-Preto, N., eds.
Ethnicity and Family Therapy. 3rd ed. (pp. 654–663). New York: Guilford Press, 2005.
Takeuchi, D.T., Sue, S., and Yeh, M. Return rates and outcomes from ethnicity-specific mental
health programs in Los Angeles. American Journal of Public Health 85(5):638–643, 1995.
Takeuchi, D.T., Zane, N., Hong, S., Chae, D.H., Gong, F., Gee, G.C., Walton, E., Sue, S., and
Alegria, M. Immigration-related factors and mental disorders among Asian Americans.
American Journal of Public Health 97(1):84–90, 2007.
Tang, W.W.H., and Bigby, J. Cultural perspectives on substance abuse. In: Friedman, L., Fleming,
N., Roberts, D., and Hyman, S.E., eds. Source Book of Substance Abuse and Addiction (pp. 41–
56). Baltimore: Williams & Wilkins, 1996.
Tann, S.S., Yabiku, S.T., Okamoto, S.K., and Yanow, J. TRIADD: The risk for alcohol abuse,
depression, and diabetes multimorbidity in the American Indian and Alaska Native popula-
tion. American Indian and Alaska Native Mental Health Research 14(1):1–23, 2007.
Taylor, P., Lopez, M.H., Martínez, J.H., and Velasco, G. When Labels Don’t Fit: Hispanics and
Their Views of Identity. Washington, DC: Pew Research Center, 2012.
Taylor, R.J., Ellison, C.G., Chatters, L.M., Levin, J.S., and Lincoln, K.D. Mental health services
in faith communities: The role of clergy in Black church. Social Work 45(1):73–87, 2000.
Taylor, T. Effective cross-cultural communication in drug abuse intervention among ethnic mi-
nority populations. In: Xueqin Ma, G., and Henderson, G., eds. Ethnicity and Substance Abuse:
Prevention and Intervention (pp. 19–37). Springfield, IL: Charles C. Thomas Publisher, Ltd.,
2002.
Telzer, E.H. Expanding the acculturation gap-distress model: An integrative review of research.
Human Development 53:313–340, 2010.
The Connecticut Department of Children and Families, Office of Multicultural Affairs. Develop-
ing a Multiculturally Competent Service System for an Organization or Program. Hartford, CT:
Office of Multicultural Affairs, 2002.
The Joint Commission. The Joint Commission 2008 Requirements Related to the Provision of Cul-
turally and Linguistically Appropriate Health Care. Oakbrook Terrace, IL: The Joint Commis-
sion, 2009.
The Mental Health Center of Dane County. Vision & Values for Culturally Competent Services.
Madison, WI: Mental Health Center of Dane County, 2009.
The Office of Nursing Practice and Professional Services, Centre for Addiction and Mental
Health & Faculty of Social Work, University of Toronto. Clinical Supervision Handbook: A
Guide for Clinical Supervisors for Addiction and Mental Health. Toronto, Ontario: Centre for
Addiction and Mental Health, 2008.
Thomas, A.J., and Schwarzbaum, S. Culture & Identity: Life Stories for Counselors and Therapists.
2nd ed. Los Angeles: SAGE, 2011.
Thomas, T.N. Acculturative stress in the adjustment of immigrant families. Journal of Social Dis-
tress and the Homeless 4(2):131–142, 1995.

244
 Appendix A—Bibliography

Tilburt, J., and Geller, G. Viewpoint: The importance of worldviews for medical education.
Academic Medicine 82(8):819–822, 2007.
Timble, J.E. Working with North American Indian and Alaska Native clients: Understanding the
deep culture within. In: Gallardo, M.E., Yeh, C.J., Timble, J.E., and Parham, T.A., eds. Cultur-
ally Adaptive Counseling Skills (pp. 181–200). Thousand Oaks, CA: Sage Publications, 2012.
Timko, C., Billow, R., and Debenedetti, A. Determinants of 12-Step group affiliation and modera-
tors of the affiliation-abstinence relationship. Drug and Alcohol Dependence 83(2):111–121, 2006.
Tondora, J., O’Connell, M., Miller, R., Dinzeo, T., Bellamy, C., Andres-Hyman, R., and Da-
vidson, L. A clinical trial of peer-based culturally responsive person-centered care for psycho-
sis for African Americans and Latinos. Clinical Trials 7(4):368–379, 2010.
Tonigan, J.S. Project MATCH treatment participation and outcome by self-reported ethnicity.
Alcoholism: Clinical & Experimental Research 27(8):1340–1344, 2003.
Tonigan, J.S., Connors, G.J., and Miller, W.R. Special populations in Alcoholics Anonymous.
Alcohol Health and Research World 22(4):281–285, 1998.
Topolski, J.M., and Anderson-Harper, R. Methamphetamine in Missouri 2004. Jefferson City,
MO: Missouri Department of Mental Health, 2004.
Torres, J.B., Solberg, V.S., and Carlstrom, A.H. The myth of sameness among Latino men and
their machismo. The American Journal of Orthopsychiatry 72(2):163–181, 2002.
Torres, L.R., Zayas, L.H., Cabassa, L.J., and Perez, M.C. Diagnosing co-occurring substance-
related disorders: Agreement between SCID, Hispanic clinicians, and non-Hispanic clini-
cians. The Journal of Clinical Psychiatry 68(11):1655–1662, 2007.
Torres-Rivera, E., Wilbur, M.P., Roberts-Wilbur, J., and Phan, L. Group work with Latino cli-
ents: A psychoeducational model. Journal for Specialists in Group Work 24(4):383–404, 1999.
Torsch, V.L., and Ma, G.X. Cross-cultural comparison of health perceptions, concerns, and cop-
ing strategies among Asian and Pacific Islander American elders. Qualitative Health Research
10(4):471–489, 2000.
Trierweiler, S.J., Neighbors, H.W., Munday, C., Thompson, E.E., Binion, V.J., and Gomez, J.P.
Clinician attributions associated with the diagnosis of schizophrenia in African American
and non-African American patients. Journal of Consulting & Clinical Psychology 68(1):171–
175, 2000.
Trierweiler, S.J., Neighbors, H.W., Munday, C., Thompson, E.E., Jackson, J.S., and Binion, V.J.
Differences in patterns of symptom attribution in diagnosing schizophrenia between African
American and non-African American clinicians. The American Journal of Orthopsychiatry
76(2):154–160, 2006.
Trimble, J.E., and Jumper Thurman, P. Ethnocultural considerations and strategies for providing
counseling services to Native American Indians. In: Pedersen, P.B., Draguns, J.G., Lonner,
W.J., and Trimble, J.E., eds. Counseling Across Cultures (pp. 53–91). Thousand Oaks, CA: Sage
Publications, 2002.

245
 Improving Cultural Competence

Trimble, J.E., Scharron-del-Rio, M.R., and Hill, J.S. Ethical considerations in the application of
cultural adaptation models with ethnocultural populations. In: Bernal, G., and Domenech
Rodriguez, M.M., eds. Cultural Adaptations: Tools for Evidence-Based Practice With Diverse
Populations (pp. 45–67). Washington, D.C: American Psychological Association, 2012.
Tsai, C.T.L. A reflection on cultural conflicts in women’s leisure. Leisure Sciences 32:386–390, 2010.
Tsai, J.L., Ying, Y.W., and Lee, P.A. The meaning of "being Chinese" and "being American”:
Variation among Chinese American young adults. Journal of Cross-Cultural Psychology
31:302–332, 2000.
Tseng, W.S. and Streltzer, J. Introduction: Culture and psychiatry. In Tseng, W.S., and Streltzer, J., eds.
Cultural Competence in Clinical Psychiatry (pp. 1–20). American Psychiatric Publishing, 2004.
Tsushima, W.T. and Tsushima, V.G. Comparison of MMPI-2 validity scales among compensa-
tion-seeking Caucasian and Asian American medical patients. Assessment 16:159–164, 2009.
Uba, L. Asian Americans: Personality Patterns, Identity, and Mental Health. New York: Guilford
Press, 1994.
U.S. Census Bureau. Profiles of General Demographic Characteristics 2000. Washington, DC: 2000
Census of Population and Housing, 2001a.
U.S. Census Bureau. Table 1: Population by Race and Hispanic or Latino Origin, for all Ages and for
18 Years and Over, for the United States. 2000. Washington, DC: U.S. Census Bureau, 2001b.
U.S. Department of Health and Human Services. Mental Health: Culture, Race, and Ethnicity. A
Supplement to Mental Health: A Report of the Surgeon General. HHS Publication No. (SMA)
01-3613. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse
and Mental Health Services Administration, Center for Mental Health Services, 2001.
U.S. Department of Health and Human Services. Developing Cultural Competence in Disaster
Mental Health Programs: Guiding Principles and Recommendations. HHS Publication No.
(SMA) 3828. Rockville, MD: U.S. Department of Health and Human Services, Center for
Mental Health Services, Substance Abuse and Mental Health Services Administration, 2003a.
U.S. Department of Health and Human Services. Eliminating Health Disparities in the American
Indian and Alaska Native Community. Washington, DC: U.S. Department of Health and
Human Services, 2003b.
U.S. Department of Health and Human Services. To Live To See the Great Day That Dawns:
Preventing Suicide by American Indian and Alaska Native Youth and Young Adults. HHS Publi-
cation No. SMA (10)-4480. Rockville, MD: Center for Mental Health Services, Substance
Abuse and Mental Health Services Administration, 2010.
U.S. Department of Health and Human Services. Frequently Asked Questions. Rockville, MD:
National Partnership for Action to End Health Disparities, 2011a.
U.S. Department of Health and Human Services. HHS Action Plan to Reduce Racial and Ethnic
Disparities: A Nation Free of Disparities in Health and Health Care. Washington, DC: U.S. De-
partment of Health and Human Services, 2011b.

246
 Appendix A—Bibliography

U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality.
National Healthcare Disparities Report 2011. AHRQ Publication No. 12-0006. Rockville,
MD: Agency for Healthcare Research and Quality, 2012.
U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services
Administration. Center for Behavioral Health Statistics and Quality. 2010 Treatment Episode
Data Set -- Admissions (TEDS-A). ICPSR33261-v1. Ann Arbor, MI: Inter-university Con-
sortium for Political and Social Research [distributor], 2012.
U.S. Department of Justice. Information Bulletin: Drugs, Youth and the Internet. Johnston, PA:
National Drug Intelligence Center, 2002.
U.S. Department of the Interior, Indian Affairs. Indian Affairs: Who We Are. Washington, DC:
Department of the Interior, 2013a.
U.S. Department of the Interior, Indian Affairs. Indian Affairs: What We Do. Washington, DC:
Department of the Interior, 2013b.
United Nations Office on Drugs and Crime. World Drug Report 2008. United Nations publica-
tion Sales No. E.08.XI.1. Vienna, Austria: United Nations Office on Drugs and Crime, 2008.
United Nations Office on Drugs and Crime. World Drug Report 2012. United Nations publica-
tion Sales No. E.12.XI.1. Vienna, Austria: United Nations Office on Drugs and Crime, 2012.
Urban Indian Health Institute. Reported Health and Health-Influencing Behaviors Among Urban
American Indians and Alaska Natives: An Analysis of Data Collected by the Behavioral Risk Factor
Surveillance System. Seattle, WA: Urban Indian Health Institute, 2008.
Üstün, B., Compton, W., Mager, D., Babor, T., Baiyewu, O., Chatterji, S., Cottler, L., Göğüş, A.,
Mavreas, V., Peters, L., Pull, C., Saunders, J., Smeets, R., Stipec, M.R., Vrasti, R., Hasin, D.,
Room, R., Van den Brink, W., Regier, D., Blaine, J., Grant, B.F., and Sartorius, N. WHO
study on the reliability and validity of the alcohol and drug use disorder instruments: Over-
view of methods and results. Drug and Alcohol Dependence 47:161–169, 1997.
Vaeth, P.A., Caetano, R., and Rodriguez, L.A. The Hispanic Americans Baseline Alcohol Survey
(HABLAS): The association between acculturation, birthplace and alcohol consumption
across Hispanic national groups. Addictive Behaviors 37(9):1029–1037, 2012.
Vaillant, G.E. The Natural History of Alcoholism. Cambridge, MA: Harvard University Press,
1983.
van Oers, J.A.M., Bongers, I.M.B., Van de Goor, L.A.M., and Garretsen, H.F.L. Alcohol con-
sumption, alcohol-related problems, problem drinking, and socioeconomic status. Alcohol &
Alcoholism 34(1):78–88, 1999.
van Wormer, K.S. Substance abuse among Americans of British descent. In: Straussner, S.L.A.,
ed. Ethnocultural Factors in Substance Abuse Treatment (pp. 167–179). New York: Guilford
Press, 2001.
Vega, W.A., Canino, G., Cao, Z., and Alegria, M. Prevalence and correlates of dual diagnoses in
U.S. Latinos. Drug and Alcohol Dependence 100(1-2):32–38, 2009.
Vega, W.A., Kolody, B., and Aguilar-Gaxiola, S. Help seeking for mental health problems among
Mexican Americans. Journal of Immigrant Health 3(3):133–140, 2001.

247
 Improving Cultural Competence

Vega, W.A., Sribney, W.M., Aguilar-Gaxiola, S., and Kolody, B. 12-month prevalence of DSM-
III-R psychiatric disorders among Mexican Americans: Nativity, social assimilation, and age
determinants. Journal of Nervous and Mental Disease 192(8):532–541, 2004.
Vega, W.A., Zimmerman, R.S., Warheit, G.J., Apospori, E., and Gil, A.G. Risk factors for early
adolescent drug use in four ethnic and racial groups. In: Organista, P.B., Chun, K.M., and
Marin, G., eds. Readings in Ethnic Psychology (pp. 178–187). New York: Routledge, 1998.
Velasquez, R.J., Chavira, D.A., Karle, H.R., Callahan, W.J., Garcia, J.A., and Castellanos, J. As-
sessing bilingual and monolingual Latino students with translations of the MMPI-2: Initial
data. Cultural Diversity and Ethnic Minority Psychology 6:65–72, 2000.
Velez-Blasini, C.J. A cross-cultural comparison of alcohol expectancies in Puerto Rico and the
United States. Psychology of Addictive Behaviors 11(2):124–141, 1997.
Venner, K.L., and Feldstein, S.W. Natural history of alcohol dependence and remission events for
a Native American sample. Journal of Studies on Alcohol 67(5):675–684, 2006.
Venner, K.L., Feldstein, S.W., and Tafoya, N. Native American Motivational Interviewing: Weav-
ing Native American and Western Practices. A Manual for Counselors in Native American Com-
munities. Albuquerque, NM: Center on Alcoholism, Substance Abuse and Addictions
(CASAA), 2006.
Venner, K.L., Greenfield, B.L., Vicuña, B., Muñoz, R., Bhatt, S., and O’Keefe, V. “I’m not one of
them”: Barriers to help-seeking among American Indians with alcohol dependence. Cultural
Diversity and Ethnic Minority Psychology 18(4):352-362, 2012.
Villanueva, M., Tonigan, J.S., and Miller, W.R. Response of Native American clients to three
treatment methods for alcohol dependence. Journal of Ethnicity in Substance Abuse 6(2):41–48,
2007.
Volk, R.J., Steinbauer, J.R., Cantor, S.B., and Holzer, C.E., III The Alcohol Use Disorders Iden-
tification Test (AUDIT) as a screen for at-risk drinking in primary care patients of different
racial/ethnic backgrounds. Addiction 92:197–206, 1997.
Wahl, A.M.G., and Eitle, T.M. Gender, acculturation and alcohol use among Latina/o adolescents:
A multi-ethnic comparison. Journal of Immigrant and Minority Health 12(2):153–165, 2010.
Wallace, P.M., Pomery, E.A., Latimer, A.E., Martinez, J.L., and Salovey, P. A review of accultura-
tion measures and their utility in studies promoting Latino health. Hispanic Journal of Behav-
ioral Sciences 32(1):37–54, 2010.
Walton, M.A., Blow, F.C., and Booth, B.M. Diversity in relapse prevention needs: gender and
race comparisons among substance abuse treatment patients. The American Journal of Drug
and Alcohol Abuse 27(2):225–240, 2001.
Ward, C.A. The ABCs of acculturation: Implications for counselors. In: Pedersen, P.B., Draguns,
J.G., Lonner, W.J., and Trimble, J.E., eds. Counseling Across Cultures. 6th ed. (pp. 291–306).
Thousand Oaks, CA: Sage Publications, 2008.
Warren, J.I., Stein, J.A., and Grella, C.E. Role of social support and self-efficacy in treatment
outcomes among clients with co-occurring disorders. Drug and Alcohol Dependence 89(2-
3):267–274, 2007.

248
 Appendix A—Bibliography

Washington State Department of Social & Health Services. Cultural Competence Planning Guide:
Cultural Competence Workgroup 2011–2014. Olympia, WA: Department of Social & Health
Services, 2011.
Watkins, W.C., and Ford, J.A. Prescription drug misuse among Asian-American adults: Results
from a national survey. Substance Use & Misuse 46(13):1700–1708, 2011.
Watt, T.T. The race/ethnic age crossover effect in drug use and heavy drinking. Journal of Ethnici-
ty in Substance Abuse 7(1):93–114, 2008.
Weaver, H. The challenges of research in Native American communities: Incorporating princi-
ples of cultural competence. Journal of Social Service Research 12(3-4):1–29, 1997.
Weisner, C., Delucchi, K., Matzger, H., and Schmidt, L. The role of community services and
informal support on five-year drinking trajectories of alcohol dependent and problem drink-
ers. Journal of Studies on Alcohol 64(6):862–873, 2003.
Weiss, B.D. Interpersonal communication (pp. 31–34). In: Removing Barriers To Better, Safer
Care—Health Literacy and Patient Safety: Help Patients Understand. Manual for Clinicians.
Chicago: American Medical Association Foundation, 2007.
Weller, C.E., Ajinkya, J., and Farrell, J. The State of Communities of Color in the U.S. Economy: Still
Feeling the Pain Three Years Into the Recovery. Washington, DC: Center for American Pro-
gress, 2012.
Wells, K., Klap, R., Koike, A., and Sherbourne, C. Ethnic disparities in unmet need for alcohol-
ism, drug abuse, and mental health care. The American Journal of Psychiatry 158(12):2027–
2032, 2001.
Wells, R. Selected Results From the Behavioral Risk Factor Surveillance System for Alaska Natives
2001–2003. Anchorage, AK: Alaska Native Health Board, 2004.
Westermeyer, J. Alcoholism and co-morbid psychiatric disorders among American Indians.
American Indian and Alaska Native Mental Health Research 10(2):27–51, 2001.
Whaley, A.L., and Davis, K.E. Cultural competence and evidence-based practice in mental
health services: a complementary perspective. The American Psychologist 62(6):563–574, 2007.
Whaley, A.L., and Longoria, R.A. Assessing cultural competence readiness in community mental
health centers: A multidimensional scaling analysis. Psychological Services 5(2):169–183, 2008.
Whatley, P.R., Allen, J., and Dana, R.H. Racial identity and the MMPI in African American
male college students. Cultural Diversity and Ethnic Minority Psychology 9:345–353, 2003.
Whealin, J.M., and Ruzek, J. Program evaluation for organizational cultural competence in men-
tal health practices. Professional Psychology: Research and Practice 39(3):320–328, 2008.
Whitbeck, L.B., Chen, X., Hoyt, D.R., and Adams, G.W. Discrimination, historical loss and
enculturation: Culturally specific risk and resiliency factors for alcohol abuse among Ameri-
can Indians. Journal of Studies on Alcohol 65(4):409–418, 2004.
White, K., Clayton, R., and Arndt, S. Culturally Competent Substance Abuse Treatment Project:
Annual Report. Iowa Department of Public Health (Contract # 5888CP43). Iowa City, IA:
Iowa Consortium for Substance Abuse Research and Evaluation, 2009.

249
 Improving Cultural Competence

White, W., and Sanders, M. Recovery Management and People of Color: Redesigning Addiction
Treatment for Historically Disempowered Communities. Chicago: Behavioral Health Recovery
Management, 2004.
White, W.A., and Kurtz, E. Linking Addiction Treatment and Communities of Recovery: A Primer
for Addiction Counselors, Recovery Coaches and the Recovery Community. Pittsburgh, PA: Insti-
tute for Research, Education and Training in Addictions, 2006.
White, W.L. Themes in chemical prohibition. In: Drugs in Perspective (pp. 117–182). Rockville,
MD: National Institute on Drug Abuse, 1979.
White, W.L. Pathways: From the Culture of Addiction to the Culture of Recovery. A Travel Guide for
Addiction Professionals. 2nd ed. Center City, MN: Hazelden, 1996.
White, W.L. Slaying the Dragon: The History of Addiction Treatment and Recovery in America.
Bloomington, IL: Chestnut Health Systems, 1998.
White, W.L. The history of recovered people as wounded healers: II. The era of professionaliza-
tion and specialization. Alcoholism Treatment Quarterly 18(2):1–25, 2000.
White Bison, Inc. The Red Road to Wellbriety: In the Native American Way. Colorado Springs, CO:
White Bison, Inc., 2002.
Whitebread, C.H. The History of the Non-Medical Use of Drugs in the United States. Los Angeles:
University of Southern California Law School, 1995.
Whitesell, N.R., Beals, J., Mitchell, C.M., Novins, D.K., Spicer, P., and Manson, S.M. Latent
class analysis of substance use: Comparison of two American Indian reservation populations
and a national sample. Journal of Studies on Alcohol 67(1):32–43, 2006.
Whitley, R. Religious competence as cultural competence. Transcultural Psychiatry 49(2):245–260,
2012.
Wiebe, J.S. and Penley, J.A. A psychometric comparison of the Beck Depression Inventory-II in
English and Spanish. Psychological Assessment 17:481–485, 2005.
Wiechelt, S.A., Gryczynski, J., Johnson, J.L., and Caldwell, D. Historical trauma among urban
American Indians: Impact on substance abuse and family cohesion. Journal of Loss and Trau-
ma 17:319–336 2012.
Wijeyesinghe, C., and Jackson, B.W. New Perspectives on Racial Identity Development: Integrating
Emerging Frameworks,.2nd ed. New York: New York University Press, 2012.
Wilcox, D.M. Alcoholic Thinking: Language, Culture, and Belief in Alcoholics Anonymous. Westport,
CT: Praeger Publishers/Greenwood Publishing Group, 1998.
Williams, D.R., and Williams-Morris, R. Racism and Mental Health: The African American
experience. Ethnicity & Health 5(3-4):243–268, 2000.
Williams, E.E., and Ellison, F. Culturally informed social work practice with American Indian
clients: Guidelines for non-Indian social workers. Social Work 41(2):147–151, 1996.
Williams, M.T., Domanico, J., Marques, L., Leblanc, N.J., and Turkheimer, E. Barriers to treat-
ment among African Americans with obsessive-compulsive disorder. Journal of Anxiety Disor-
ders 26(4):555–563, 2012.

250
 Appendix A—Bibliography

Williams, T.M. Crackhouse: Notes From the End of the Line. New York: Penguin Books, 1992.
Winawer, H., and Wetzel, N.A. German families. In: McGoldrick, M., Giordano, J., and Garcia-
Preto, N., eds. Ethnicity and Family Therapy. 3rd ed. (pp. 555–572). New York: Guilford Press,
2005.
Wing, J.K., Sartorius, N., and Üstün, T.B., eds. Diagnosis and Clinical Measurement in Psychiatry:
A Reference Manual for SCAN. Geneva: World Health Organization, 1998.
Wong, E.C., Beutler, L.E., and Zane, N.W. Using mediators and moderators to test assumptions
underlying culturally sensitive therapies: An exploratory example. Cultural Diversity and Eth-
nic Minority Psychology 13(2):169–177, 2007a.
Wong, F.Y., Huang, Z.J., Thompson, E.E., De Leon, J.M., Shah, M.S., Park, R.J., and Do, T.D.
Substance use among a sample of foreign- and U.S.-born Southeast Asians in an urban set-
ting. Journal of Ethnicity in Substance Abuse 6(1):45–66, 2007b.
Woody, G.E., McLellan, A.T., Luborsky, L., and O’Brien, C.P. Twelve-month follow-up of psycho-
therapy for opiate dependence [published erratum appears in The American Journal of Psychiatry,
1989. Dec;146(12):1651]. The American Journal of Psychiatry 144(5):590–596, 1987.
Woody, G.E., McLellan, A.T., Luborsky, L., and O’Brien, C.P. Psychotherapy in community
methadone programs: A validation study. The American Journal of Psychiatry 152(9):1302–
1308, 1995.
Worby, P.A., and Organista, K.C. Alcohol use and problem drinking among male Mexican and
Central American immigrant laborers: A review of the literature. Hispanic Journal of Behav-
ioral Sciences 29(4):413–455, 2007.
World Health Organization. Management of Substance Abuse: Facts and Figures. Geneva: World
Health Organization, 2009.
Worrell, F.C., Cross, W.E., Jr., and Vandiver, B.J. Nigrescence theory: Current status and chal-
lenges for the future. Journal of Multicultural Counseling and Development 29:201–213, 2001.
Wright, E.M. Substance abuse in African American communities. In: Straussner, S.L.A., ed. Eth-
nocultural Factors in Substance Abuse Treatment (pp. 31–51). New York: Guilford Press, 2001.
Xie, Y., and Greenman, E. Segmented Assimilation Theory: A Reformulation and Empirical Test. Re-
search Report 05-581, Ann Arbor, MI: University of Michigan Population Studies Center, 2005.
Yamada, A.M., Marsella, A.J., and Yamada, S.Y. The development of the Ethnocultural Identity
Behavioral Index: Psychometric properties and validation with Asian Americans and Pacific
Islanders. Asian American and Pacific Islander Journal of Health 6:35–45, 1998.
Yamamoto, J., and Acosta, F.X. Treatment of Asian-Americans and Hispanic Americans: Simi-
larities and differences. Journal of the Academy of Psychoanalysis 10:585–607, 1982.
Yang, M.J. The Chinese drinking problem: A review of the literature and its implication in a
cross-cultural study. Kaohsiung Journal of Medical Sciences 18(11):543–550, 2002.
Yang, P.Q. Ethnic Studies: Issues and Approaches. Albany, NY: State University of New York Press,
2000.

251
 Improving Cultural Competence

Yeung, A., Neault, N., Sonawalla, S., Howarth, S., Fava, M., and Nierenberg, A. A. Screening for
major depression in Asian-Americans: A comparison of the Beck and the Chinese Depres-
sion Inventory. Acta Psychiatrica Scandinavica 105:252–257, 2002.
Yu, J., and Warner, L.A. Substance abuse treatment readmission patterns of Asian Americans:
comparisons with other ethnic groups. The American Journal of Drug and Alcohol Abuse
39(1):23–27, 2013.
Yudko, E., Lozhkina, O., and Fouts, A. A comprehensive review of the psychometric properties
of the Drug Abuse Screening Test. Journal of Substance Abuse Treatment 32:189–198, 2007.
Zane, N., and Mak, W. Major approaches to the measurement of acculturation among ethnic
minority populations: A content analysis and an alternative empirical strategy. In: Chun, K.M.,
Balls-Organista, P., and Marin, G., eds. Acculturation: Advances in Theory, Measurement, and
Applied Research (pp. 39–60). Washington, DC: American Psychological Association, 2003.
Zea, M.C., Asner-Self, K.K., Birman, D., and Buki, L.P. The Abbreviated Multidimensional
Acculturation Scale: Empirical validation with two Latino/Latina samples. Cultural Diversity
and Ethnic Minority Psychology 9(2):107–126, 2003.
Zemore, S.E. Re-examining whether and why acculturation relates to drinking outcomes in a
rigorous, national survey of Latinos. Alcoholism: Clinical & Experimental Research
29(12):2144–2153, 2005.
Zemore, S.E., and Kaskutas, L.A. Helping, spirituality and Alcoholics Anonymous in recovery.
Journal of Studies on Alcohol 65(3):383–391, 2004.
Zhang, A.Y., Snowden, L.R., and Sue, S. Differences between Asian and White Americans’ help
seeking and utilization patterns in the Los Angeles area. Journal of Community Psychology
26(4):317–326, 1998.
Zhang, W. American counseling in the mind of a Chinese counselor. Journal of Multicultural
Counseling and Development 22:79–85, 1994.
Zhang, Y., Young, D., Lee, S., Li, L., Zhang, H., Xiao, Z., Hao, W., Feng, Y., Zhou, H., and
Chang, D.F. Chinese Taoist cognitive psychotherapy in the treatment of generalized anxiety
disorder in contemporary China. Transcultural Psychiatry 39(1):115–129, 2002.
Zheng, Y. and Lin, K.-M. Comparison of the Chinese Depression Inventory and the Chinese
version of the Beck Depression Inventory. Acta Psychiatrica Scandinavica 84:531–536, 1991.
Zuckerman, M. Some dubious premises in research and theory on racial differences. In: Balls-
Organista, P., Chun, K.M., and Marin, G., eds. Readings in Ethnic Psychology (pp. 59–69).
New York: Routledge, 1998.

252
Appendix B—Instruments To
Measure Identity and Acculturation

Some researchers have tested the usefulness of complex multidimensional models (Skinner
acculturation and identity models with people 2001). The table that begins on the next page
who abuse substances. For example, Peña and summarizes the instruments available to
colleagues’ racial identity attitude scale was measure acculturation and ethnic identity.
found, in a study of African American men in (See also the Center of Excellence for
treatment for cocaine dependence, to help Cultural Competence for additional resources
counselors better understand the roles that at http://nyculturalcompetence.org).
ethnic and cultural identity play in clients’
Other scales have been developed to examine
substance abuse issues (Peña et al. 2000). In
specific culture-related variables, including
1980, Cuellar and colleagues published their
machismo (Cuellar et al. 1995; Fragoso and
acculturation rating scale for Mexican
Kashubeck 2000), simpatía (Griffith et al.
Americans, which conceptualized accultura-
1998), familismo (Sabogal et al. 1987), tradi-
tion as progressing across a 5-point continu-
tionalism–modernism (Ramirez 1999), and
um ranging from Mexican or low acculturated
family traditionalism and rural preferences
(level 1) to American or high acculturated
(Castro and Gutierres 1997). Counselors can
(level 5). The mid-level designation of bicul-
use acculturation scales to help match patients
tural (level 3) was set as the midpoint between
to providers, to make treatment plans, and to
the two extremes, although various investiga-
identify the role of identity in substance abuse.
tors have questioned this assumption
Although these instruments can be helpful,
(Oetting and Beauvais 1990; Sayegh and
the counselor must not rely solely on them to
Lasry 1993). Since then, scholars have devel-
determine the client’s identity or level of
oped new ways to conceptualize identity and
acculturation.
acculturation, ranging from simple scales to

253
 Improving Cultural Competence

Acculturation and Ethnic Identity Measures

Instrument Description Cultural Group

African American Accul- This scale measures eight dimensions of African African Americans
turation Scale-Revised American culture: (1) traditional beliefs and prac-
(Klonoff and Landrine tices, (2) traditional family structure and practices,
2000) (3) traditional socialization, (4) preparation and
consumption of traditional foods, (5) preference
for African American things, (6) interracial atti-
tudes, (7) superstitions, and (8) traditional health
beliefs and practices.
Black Racial Identity This scale measures beliefs or attitudes of Blacks African Americans
Attitude Scale—Form B toward both Blacks and Whites using 5-point
(Helms 1990) scales. It is available in short and long forms.
Cross Racial Identity This scale measures six identity clusters associated African Americans
Scale (Worrell et al. with four stages of racial identity development.
2001)
Multidimensional Inven- The MIBI measures centrality of Black identity, African Americans
tory of Black Identity ideology, and regard for a Black identity. It is
(MIBI; Sellers et al. 1997) available online at
http://sitemaker.umich.edu/aaril/files/mibiscaleand
scoring.pdf.
Scale To Assess African This is a 10-item scale that assesses media prefer- African Americans
American Acculturation ences, racial bias in relationships, race-related
(Snowden and Hines attitudes, and comfort in interacting with other
1999) races.
African Self- This scale measures within-group variability in the African
Consciousness Scale level of acculturation/cultural identity continuum Americans/African
(Baldwin and Bell 1985) (Baldwin and Bell 1985) based on degree of Immigrants
Afrocentricity or Nigrescence (White and Parham
1996). It indicates a client’s level of involvement in
traditional African American culture or the core
African-oriented culture.
Native American Accul- The Native American Acculturation scale asks 20 Native Americans
turation Scale (Garrett questions to ascertain a client’s level of involve-
and Pichette 2000) ment with Native American culture.
Rosebud Personal This assessment evaluates components of accul- Native Americans
Opinion Survey turation, including language use, values, social
(Hoffmann et al. 1985) behaviors, social networks, religious affiliation and
practice, home community, education, ancestry,
and cultural identification.
Asian American Multi- The AAMAS was developed to be easy to use with Asian Americans
dimensional Accultura- a variety of Asian American ethnic groups. It
tion Scale (AAMAS; Gim includes questions relating to cultural identity,
Chung et al. 2004) language use, cultural knowledge, and food
preferences.
(Continued on the next page.)

254
 Appendix B—Instruments To Measure Identity and Acculturation

Acculturation and Ethnic Identity Measures (continued)

Instrument Description Cultural Group

Cultural Adjustment The CADC helps avoid potential problems relating Asian Americans
Difficulties Checklist to acculturation by asking about language use, (East Asians)
(CADC; Sodowsky and social customs, family interactions, perceptions of
Lai 1997) prejudice, friendship networks, and cultural ad-
justment.
East Asian Acculturation This instrument includes 29 items that assess Asian Americans
Measure (Barry 2001) assimilation, level of separation from other Asians, (East Asians)
integration, and marginalization.
General Ethnicity Ques- The GEQ is an instrument designed to be used Asian Americans
tionnaire (GEQ; Tsai et with minor modifications for assessing cultural (although
al. 2000) orientation with different cultural groups. There designed to be
are original and abridged versions. The original multicultural in
includes 75 items asking about language use, orientation)
social affiliations, cultural practices, and cultural
identification.
Suinn-Lew Asian Self- This instrument was modeled after the Accultura- Asian Americans
Identity Acculturation tion Rating Scale for Mexican Americans, and
Scale (Suinn et al. 1992) research indicates it has high reliability.
Ethnocultural Identity This is a 19-item self-report assessment with high Asian Americans
Behavioral Index (Yama- validity. and Pacific
da et al. 1998) Islanders
Internal-External Ethnic The instrument evaluates ethnic friendships and Chinese
Identity Measure (Kwan affiliation, ethnocommunal expression, ethnic food Americans
1997) orientation, and family collectivism, in order to
differentiate three Chinese American identity
groups: (1) internal, (2) external, and (3) internal-
external undifferentiated.
Marín and Marín Accul- This scale is a 12-item instrument that assesses Chinese
turation Scale (Marín et three domains: (1) language use, (2) media prefer- Americans
al. 1987) ences, and (3) ethnic diversity of social relations. It
is available online at
http://www.columbia.edu/cu/ssw/projects/pmap/
docs/gupta_acculturation.pdf
Behavioral Acculturation These two scales, used in conjunction with one Cuban Americans
Scale and Value Accul- another, ask individuals about behaviors and
turation Scale (Szapocz- values in order to determine acculturation. If used
nik et al. 1978) singly, the behavioral scale is the superior measure
for acculturation.
Na Mea Hawai’i This is a 34-item scale. An adolescent version is Native Hawaiians
(Hawaiian Ways), A available (Hishinuma et al. 2000).
Hawaiian Acculturation
Scale (Rezentes 1993)
(Continued on the next page.)

255
 Improving Cultural Competence

Acculturation and Ethnic Identity Measures (continued)

Instrument Description Cultural Group

Abbreviated Multi- The AMAS-ZABB is a multidimensional, bilinear, 42- Latinos

dimensional Accul- item scale that evaluates identity, language compe-
turation Scale tence, and cultural competence.
(AMAS-ZABB; Zea et
al. 2003)
Acculturation Scale This 12-item acculturation scale, available in English Latinos
(Marin et al. 1987) and Spanish, evaluates language use, media prefer-
ences, and social activities. It is available online at
http://casaa.unm.edu/inst/MARIN%20Short%20Scale.
pdf
Bicultural Involve- The BIQ assesses language use and involvement in Latinos
ment Questionnaire both Latino and mainstream American activities. It
(BIQ; Szapocznik et relates two sets of scores to derive a measure of
al. 1980) bicultural involvement, with individuals who are highly
involved in both cultures scoring highest on the scale.
The Bidimensional This 24-item scale asks questions about language use, Latinos
Acculturation Scale language proficiency, and media preferences.
for Hispanics (Marin
and Gamba 1996)
Brief Acculturation This scale has only four items, but scores on the scale Latinos
Scale for Hispanics have been correlated highly with generation, nativity,
(Norris et al. 1996) length of time in the United States, language prefer-
ences, and subjective perceptions of acculturation.
Multidimensional This measure places adolescents in one of four cate- Latinos
Measure of Cultural gories based on language, behavior/familiarity, and
Identity for Latinos values/attitudes: (1) bicultural, (2) Latino-identified, (3)
(Felix-Ortiz et al. American-identified, and (4) low-level bicultural.
1994)
Acculturation Rating The ARSMA-I differentiates between 5 levels of accul- Mexican
Scale for Mexican turation: (1) Very Mexican, (2) Mexican-Oriented Americans
Americans-I Bicultural, (3) True Bicultural, (4) Anglo-Oriented
(ARSMA-I; Cuellar et Bicultural, and (5) Very Anglicized. Established validity.
al. 1980)
Acculturation Rating This scale is like the ARSMA-I, except that it includes Mexican
Scale for Mexican separate subscales to measure multidimensional Americans
Americans-II (Cuellar aspects of cultural orientation toward Mexican and
et al. 1995) Anglo cultures independently.
Cultural Life Style This self-report instrument, available in Spanish and Mexican
Inventory (Mendoza English, evaluates five dimensions of acculturation: Americans
1989) intrafamily language use, extrafamily language use,
social activities and affiliations, cultural knowledge
and activities, and cultural identification and pride.
(Continued on the next page.)

256
 Appendix B—Instruments To Measure Identity and Acculturation

Acculturation and Ethnic Identity Measures (continued)

Instrument Description Cultural Group

Cultural Life Style This self-report instrument, available in Spanish and Mexican
Inventory (Mendoza English, evaluates acculturation on five dimensions: Americans
1989) intrafamily language use, extrafamily language use,
social activities and affiliations, cultural knowledge and
activities, and cultural identification and pride.
Mexican American This 28-item scale evaluates cultural orientation and Mexican
Acculturation Scale comfort with ethnic identity. Items ask about language Americans
(Montgomery 1992) use, media preferences, cultural activities/traditions,
and self-perceived ethnic identity.
Padilla’s Padilla’s Acculturation Scale is a 155-item question- Mexican
Acculturation Scale naire that assesses cultural knowledge and ethnic Americans
(Padilla 1980) loyalties.
Bidimensional This scale measures evaluates two major dimensions Mexican
Acculturation Scale of acculturation (Hispanic and non-Hispanic) using 12 Americans and
for Hispanics (Marín items measuring 3 language-related areas. It has been Central
and Gamba 1996) found to have high consistency and validity. Americans
Stephenson This is a 32-item instrument that evaluates immersion Multicultural
Multigroup in both culture of origin and the dominant culture of
Acculturation Scale the society.
(Stephenson 2000)
Vancouver Index of This instrument includes 20 questions that assess Multicultural
Acculturation (Ryder interest/participation in one’s “heritage culture” and
et al. 2000) “typical American culture” (available online at
http://www2.psych.ubc.ca/~dpaulhus/Paulhus_measur
es/VIA.American.doc).
Bicultural Accultura- Developed for use with first- and second-generation Puerto Rican
tion Scale (Cortés Puerto Rican adults, this scale measures involvement Americans
and Rogler 1994) in American culture and Puerto Rican culture, but it
has limited evidence of validity and reliability.
Psychological The items on this scale pertain to the client’s sense of Puerto Ricans on
Acculturation Scale psychological attachment to and belonging within the U.S. main-
(Tropp et al. 1999) Anglo American and Hispanic/Latino cultures. land
Acculturation Scale This 13-item scale evaluates languages proficiency and Cambodian,
for Southeast Asians preferences regarding social interactions, cultural Laotian, and
(Anderson et al. activities, and food. It includes two subscales for Vietnamese
1993) proficiency in languages, as well as language, social, Americans
and food preferences.
White Racial Identity This 50-item instrument rates items on a 5-point scale White Americans
Attitude Scale (Helms to measure attitudes associated with Helms’s stages of
and Carter 1990) racial identity development for Caucasians.

257
Appendix C—Tools for Assessing
Cultural Competence

There are numerous assessment tools available for evaluating cultural competence in clinical,
training, and organizational settings. These tools are not specific to behavioral health treatment.
Though more work is needed in developing empirically supported instruments to measure cul-
tural competence, there is a wealth of multicultural counseling and healthcare assessment tools
that can provide guidance in identifying areas for improvement of cultural competence. This
appendix examines three resource areas: counselor self-assessment tools, guidelines and assess-
ment tools to implement and evaluate culturally responsive services within treatment programs
and organizations, and forms addressing client satisfaction with and feedback about culturally
responsive services. Though not an exhaustive review of available tools, this appendix does pro-
vide samples of tools that are within the public domain. For additional resources and cultural
competence assessment tools, visit the National Center for Cultural Competence
(http://nccc.georgetown.edu) or refer to the University of Michigan Health System’s Program for
Multicultural Health (http://www.med.umich.edu/multicultural/).

Counselor Self-Assessment Tools

Multicultural Counseling Self Efficacy Scale—Racial Diversity Form
This 60-item self-report instrument assesses perceived ability to perform various counselor be-
haviors in individual counseling with a racially diverse client population. For additional infor-
mation on psychometric properties and scoring, refer to Sheu and Lent (2007).

Self-Assessment Checklist for Personnel Providing Services and Supports to

Children and Youth With Special Health Needs and Their Families
This instrument was developed by Tawara D. Goode of the Georgetown University Center for
Child and Human Development. This version is adapted with permission from Promoting Cultural
Competence and Cultural Diversity in Early Intervention and Early Childhood Settings (June 1989).
It is available from the Web site of the National Center for Cultural Competence
(http://nccc.georgetown.edu/documents/ChecklistEIEC.pdf).
Select A, B, or C for each numbered item listed:
A = Things I do frequently B = Things I do occasionally C = Things I do rarely or never

259
 Improving Cultural Competence

Physical Environment, Materials and Resources

_____ 1. I display pictures, posters, and other materials that reflect the cultures and ethnic back-
grounds of children and families served by my program or agency.
_____ 2. I [e]nsure that magazines, brochures, and other printed materials in reception areas are
of interest to and reflect the different cultures of children and families served by my program or
agency.
_____ 3. When using videos, films, or other media resources for health education, treatment, or
other interventions, I ensure that they reflect the cultures of children and families served by my
program or agency.
_____ 4. When using food during an assessment, I [e]nsure that meals provided include foods
that are unique to the cultural and ethnic backgrounds of children and families served by my
program or agency.
_____ 5. I [e]nsure that toys and other play accessories in reception areas and those used during
assessment are representative of the various cultural and ethnic groups within the local communi-
ty and the society in general.

Communication Styles
_____ 6. For children who speak languages or dialects other than English, I attempt to learn and
use key words in their language so that I am better able to communicate with them during as-
sessment, treatment, or other interventions.
_____ 7. I attempt to determine any familial colloquialisms used by children and families that
may have an impact on assessment, treatment, or other interventions.
_____ 8. I use visual aids, gestures, and physical prompts in my interactions with children who
have limited English proficiency.
_____ 9. I use bilingual staff members or trained/certified interpreters for assessment, treatment,
and other interventions with children who have limited English proficiency.
_____ 10. I use bilingual staff members or trained/certified interpreters during assessments,
treatment sessions, meetings, and for other events for families who would require this level of
assistance.
11. When interacting with parents who have limited English proficiency I always keep in mind that:
_____ Limitation in English proficiency is in no way a reflection of their level of intellec-
tual functioning.
_____ Their limited ability to speak the language of the dominant culture has no bearing
on their ability to communicate effectively in their language of origin.
_____ They may or may not be literate in their language of origin or English.
_____ 12. When possible, I ensure that all notices and communiqués to parents are written in
their language of origin.

260
 Appendix C—Tools for Assessing Cultural Competence

_____ 13. I understand that it may be necessary to use alternatives to written communications
for some families, as word of mouth may be a preferred method of receiving information.

Values and Attitudes

_____ 14. I avoid imposing values that may conflict or be inconsistent with those of cultures or
ethnic groups other than my own.
_____ 15. In group therapy or treatment situations, I discourage children from using racial and
ethnic slurs by helping them understand that certain words can hurt others.
_____ 16. I screen books, movies, and other media resources for negative cultural, ethnic, or racial
stereotypes before sharing them with the children and their parents served by my program or
agency.
_____ 17. I intervene in an appropriate manner when I observe other staff members or parents
within my program or agency engaging in behaviors that show cultural insensitivity, bias, or
prejudice.
_____ 18. I understand and accept that family is defined differently by different cultures (e.g.,
extended family members, fictive kin, godparents).
_____ 19. I recognize and accept that individuals from culturally diverse backgrounds may desire
varying degrees of acculturation into the dominant culture.
_____ 20. I accept and respect that male–female roles in families may vary significantly among
different cultures (e.g., who makes major decisions for the family, play, and social interactions
expected of male and female children).
_____ 21. I understand that age and lifecycle factors must be considered in interactions with
individuals and families (e.g., high value placed on the decisions of elders or the role of the eldest
male in families).
_____ 22. Even though my professional or moral viewpoints may differ, I accept the fami-
ly/parents as the ultimate decisionmakers for services and supports for their children.
_____ 23. I recognize that the meaning or value of medical treatment and health education may
vary greatly among cultures.
_____ 24. I recognize and understand that beliefs and concepts of emotional well-being vary
significantly from culture to culture.
_____ 25. I understand that beliefs about mental illness and emotional disability are culturally
based. I accept that responses to these conditions and related treatment/interventions are heavily
influenced by culture.
_____ 26. I accept that religion and other beliefs may influence how families respond to illnesses,
disease, disability, and death.

261
 Improving Cultural Competence

_____ 27. I recognize and accept that folk and religious beliefs may influence a family’s reaction
and approach to a child born with a disability or later diagnosed with a physical/emotional disa-
bility or special health care needs.
_____ 28. I understand that traditional approaches to disciplining children are influenced by
culture.
_____ 29. I understand that families from different cultures will have different expectations of
their children for acquiring toileting, dressing, feeding, and other self-help skills.
_____ 30. I accept and respect that customs and beliefs about food, its value, preparation, and use
are different from culture to culture.
_____ 31. Before visiting or providing services in the home setting, I seek information on ac-
ceptable behaviors, courtesies, customs, and expectations that are unique to families of specific
cultures and ethnic groups served by my program or agency.
_____ 32. I seek information from family members or other key community informants that will
assist in service adaptation to respond to the needs and preferences of culturally and ethnically
diverse children and families served by my program or agency.
_____ 33. I advocate for the review of my program’s or agency’s mission statement, goals, policies,
and procedures to ensure that they incorporate principles and practices that promote cultural
diversity and cultural competence.
There is no answer key with correct responses. However, if you frequently responded “C,” you
may not necessarily demonstrate values and engage in practices that promote a culturally diverse
and culturally competent service delivery system for children with disabilities or special health
care needs and their families.

Ethnic-Sensitive Inventory (ESI; Ho 1991, reproduced with permission)

Here are some statements made by some practitioners with ethnic minority clients. How often
do you feel this way when you work with ethnic minority clients? Every statement should be
answered by circling one number ranging from 5 (always) to 4 (frequently), 3 (occasionally), 2
(seldom), and 1 (never).
In working with ethnic minority clients, I . . .
A. Realize that my own ethnic and class background may influence my effectiveness.
B. Make an effort to ensure privacy and/or anonymity.
C. Am aware of the systematic sources (racism, poverty, and prejudice) of their problems.
D. Am against speedy contracting unless initiated by them.
E. Assist them to understand whether the problem is of an individual or a collective nature.
F. Am able to engage them in identifying major progress that has taken place.
G. Consider it an obligation to familiarize myself with their culture, history, and other ethnically
related responses to problems.

262
 Appendix C—Tools for Assessing Cultural Competence

H. Am able to understand and “tune in” the meaning of their ethnic dispositions, behaviors, and
experiences.
I. Can identify the links between systematic problems and individual concerns.
J. Am against highly focused efforts to suggest behavioral change or introspection.
K. Am aware that some techniques are too threatening to them.
L. Am able at the termination phase to help them consider alternative sources of support.
M. Am sensitive to their fear of racist or prejudiced orientations.
N. Am able to move slowly in the effort to actively “reach for feelings.”
O. Consider the implications of what is being suggested in relation to each client’s ethnic reality
(unique dispositions, behaviors, and experiences).
P. Clearly delineate agency functions and respectfully inform clients of my professional expecta-
tions of them.
Q. Am aware that lack of progress may be related to ethnicity.
R. Am able to understand that the worker–client relationship may last a long time.
S. Am able to explain clearly the nature of the interview.
T. Am respectful of their definition of the problem to be solved.
U. Am able to specify the problem in practical, concrete terms.
V. Am sensitive to treatment goals consonant to their culture.
W. Am able to mobilize social and extended family networks.
X. Am sensitive to the client’s premature termination of service.
Scoring: The 24 items include four items for each of six treatment phases of client–counselor
interaction. The sum of the numbers circled for each item relating to a treatment phase is the
score for that phase. The scoring grid is given below.

Scoring Grid for ESI

Process Phase Items
Precontact A _______ G _______ M _______ S _______
Problem Identification B _______ H _______ N _______ T _______
Problem Specification C _______ I _______ O _______ U _______
Mutual Goal Formulation D _______ J _______ P _______ V _______
Problem Solving E _______ K _______ Q _______ W _______
Termination F _______ L _______ R _______ X _______

Source: Ho 1991. Reproduced with permission.

263
 Improving Cultural Competence

Evaluating Cultural Competence in Treatment

Programs and Organizations
Agency Cultural Competence Checklist—Revised Form (Dana 1998,
reproduced with permission)
Staff and policy attitudes
______ Bilingual/bicultural
______ Bilingual
______ Bicultural
______ Culture broker
______ Flexible hours/appointments/home visits
______ Treatment immediate/day/week
______ Indigenous intake
______ Match client–staff
______ Agency environment reflects culture
Total possible = 9 Total obtained = ______

Services
______ Culture-relevant assessment
______ Cultural context for problems
______ Cultural-specific intervention model
______ Culture-specific services:
___ Prevention ___ Crisis ___ Brief ___ Individual
___ Couple ___ Family ___ Child ___ Outreach
___ Community ___ Education ___ Non-mental health
___ Resource linkage ___ Natural helpers/systems
Total possible = 4 Total obtained = ______
Total possible services = 13 Total obtained = ______

Relationship to community
______ Agency operated by minority community
______ Agency in minority community
______ Easy access
______ Uses existing minority community facilities
______ Agency ties to minority community
______ Community advocate for services
______ Community as adviser
______ Community as evaluator
Total possible = 8 Total obtained = ______

264
 Appendix C—Tools for Assessing Cultural Competence

Training
______ In-service training for minority staff
______ In-service training for nonminority staff
Total possible = 2 Total obtained = ______

Evaluation
______ Evaluation plan/tool
______ Clients as evaluators/planners
Total possible = 2 Total obtained = ______

Enhanced National Standards for Culturally and Linguistically

Appropriate Services in Health and Health Care
The standards presented in this section were developed by the Office of Minority Health (OMH
2013) in the Centers for Disease Control and Prevention (CDC) and are available online
(https://www.thinkculturalhealth.hhs.gov/pdfs/EnhancedNationalCLASStandards.pdf). This
section is reproduced from material in the public domain. Note that the Centers for Medicare
and Medicaid Services (CMS) have also developed tools to assess linguistic competence and
interpreter services as well as guidelines for planning culturally responsive services (see the CMS
Web site at http://www.cms.gov). The National Standards for Culturally and Linguistically
Appropriate Services (CLAS) are meant to advance health equity, improve quality, and help elimi-
nate health disparities by establishing a blueprint for health and health care organizations to:

Principal standard
1. Provide effective, equitable, understandable, and respectful quality care and services that are
responsive to diverse cultural health beliefs and practices, preferred languages, health literacy,
and other communication needs.

Governance, leadership, and workforce

2. Advance and sustain organizational governance and leadership that promotes CLAS and
health equity through policy, practices, and allocated resources.
3. Recruit, promote, and support a culturally and linguistically diverse governance, leadership,
and workforce that are responsive to the population in the service area.
4. Educate and train governance, leadership, and workforce in culturally and linguistically ap-
propriate policies and practices on an ongoing basis.

Communication and language assistance

5. Offer language assistance to individuals who have limited English proficiency and/or other
communication needs, at no cost to them, to facilitate timely access to all health care and services.
6. Inform all individuals of the availability of language assistance services clearly and in their
preferred language, verbally and in writing.
7. Ensure the competence of individuals providing language assistance, recognizing that the use
of untrained individuals and/or minors as interpreters should be avoided.

265
 Improving Cultural Competence

8. Provide easy-to-understand print and multimedia materials and signage in the languages
commonly used by the populations in the service area.

Engagement, continuous improvement, and accountability

9. Establish culturally and linguistically appropriate goals, policies, and management accounta-
bility, and infuse them throughout the organization’s planning and operations.
10. Conduct ongoing assessments of the organization’s CLAS-related activities and integrate
CLAS-related measures into measurement and continuous quality improvement activities.
11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the
impact of CLAS on health equity and outcomes and to inform service delivery.
12. Conduct regular assessments of community health assets and needs and use the results to
plan and implement services that respond to the cultural and linguistic diversity of popula-
tions in the service area.
13. Partner with the community to design, implement, and evaluate policies, practices, and
services to ensure cultural and linguistic appropriateness.
14. Create conflict and grievance resolution processes that are culturally and linguistically appro-
priate to identify, prevent, and resolve conflicts or complaints.
15. Communicate the organization’s progress in implementing and sustaining CLAS to all
stakeholders, constituents, and the general public.

The Organizational Cultural Competence Assessment Profile

The Health Resources and Services Administration (HRSA) developed the Organizational
Cultural Competence Assessment Profile from the cultural competence literature, guided by a
team of experts. The profile was used during site visits to a variety of healthcare settings. It is an
organizing framework and set of specific indicators to assist in examining, demonstrating, and
documenting cultural responsiveness in organizations involved in the direct delivery of health care
and services. The profile is not intended to be prescriptive; rather, it is designed to be adapted,
modified, or applied in ways that best fit within an organization’s context. The profile is presented
as a matrix that classifies indicators by critical domains of organizational functioning and by
whether the indicators relate to the structures, processes, outputs, or outcomes of the organization.
The indicators suggest that assessment of cultural competence should encompass both qualitative
and quantitative data and evaluate progress toward achieving results, not just the end results. Alt-
hough the profile can be used in whole or in part, the full application enables an organization to
assess its level of cultural competence comprehensively. Adapted here from material in the public
domain are the matrices for process and capacity/structure measures. For more information, see
http://www.hrsa.gov/culturalcompetence/ healthdlvr.pdf.

Sample of Process Measures by Domain

Domain Topic Areas Measures/Indicators
Communication Interpreter Yearly updated directory of trained interpreters is available within
24 hours for routine situations and within 1 hour or less for urgent
situations.
Communication Interpreter Percentage of clients with limited English proficiency who have
access to bilingual staff or interpretation services.

(Continued on the next page.)

266
 Appendix C—Tools for Assessing Cultural Competence

Sample of Process Measures by Domain (continued)

Domain Topic Areas Measures/Indicators
Communication Linguistically Number of trained translators and interpreters available
competent Number of staff proficient in languages of the community
organization
Communication Language Consumer reading and writing levels of primary languages and
ability, dialects is recorded.
written and
oral, of the
consumer
Policies and Choice of Contract continuation and renewal with health plan is contingent
procedures health plan upon successful achievement of performance targets that demon-
network strate effective service, equitable access, and comparability of
benefits for populations of racial/ethnic groups.
Policies and Staff hiring, Number of multilingual/multicultural staff
procedures recruitment Ratio by culture of staff to clients
Family and Community Degree to which families participate in key decisionmaking activities:
community and • Family participation on advisory committees or task forces
participation consumer • Hiring of family members to serve as consultants to provid-
participation ers/programs
• Inclusion of family members in planning, implementation, and
evaluation of activities
Communication Translated Allocated resources for interpretation and translation services for
materials medical encounters and health education/promotion material.
Communication Linguistic Ability to conduct audit of the provider network, which includes the
capacity of following components:
the provider • Languages and dialects of community available at point of first
contact.
• Number of trained translators and interpreters available.
• Number of clinicians and staff proficient in languages of the
community.
Communication Provide • Organization has the capacity to disseminate information on
information, health care plan benefits in languages of community.
education • Organization has the capacity to disseminate information and
explanation of rights to enrollees.

Policies and Grievance Organization has structures in place to address cross-cultural ethi-
procedures and conflict cal and legal conflicts in health care delivery and complaints or
resolution grievances by patients and staff about unfair, culturally insensitive,
or discriminatory treatment, or difficulty in accessing services or
denial of services.

Policies and Grievance Organization has feedback mechanisms in place to track number of
procedures and conflict grievances and complaints and number of incidents.
resolution

Policies and Planning Composition of the governing board, advisory committee, other
procedures and govern- policymaking and influencing groups, and consumers served re-
ance flects service area demographics.

267
 Improving Cultural Competence

Sample of Capacity/Structure Measures by Domain

Domain Topic Areas Measures/Indicators
Facility charac- Available and • Transportation is available from residential areas to culturally
teristics, capaci- accessible competent providers.
ty, and services • Organization has the flexibility to conduct home visits and
infrastructure community outreach.
• Culturally responsive services are available evenings and
weekends.

Facility charac- Information Capacity for tracking of access and utilization rates for popula-
teristics, capaci- systems tion of different racial/ethnic groups in comparison to the
ty, and overall service population.
infrastructure
Monitoring, Organizational Ability to conduct ongoing organizational self-assessments of
evaluation, and assessment cultural and linguistic competence and integration of measures
research of access, satisfaction, quality, and outcomes into other organi-
zational internal audits and performance improvement pro-
grams.

Multiculturally Competent Service System Assessment Guide

Reproduced with permission from The Connecticut Department of Children and Families,
Office of Multicultural Affairs (2002).
Instructions: Rate your organization on each item in Sections I through VIII using the following
scale:
1 2 3 4 5
Not at all To a moderate degree To a great degree
Suggested Rating Interpretations:
#1 and #2: “Priority Concerns”; #3: “Needs Improvement”; #4 and #5: “Adequate”
When you have rated all items and assessed each section, please follow the instructions in Sec-
tion IX to make an assessment of your program or agency and then formulate a culturally compe-
tent plan that addresses the need you feel is a priority.

I. Agency demographic data (assessment)

A culturally competent agency uses basic demographic information to assess and determine the
cultural and linguistic needs of the service area.
____ Have you identified the demographic composition of the program’s service area (from
recent census data, local planning documents, statement of need, etc.) which should in-
clude ethnicity, race, and primary language spoken as reported by the individuals?
____ Have you identified the demographic composition of the persons served?

268
 Appendix C—Tools for Assessing Cultural Competence

____ Have you identified the staff composition (ethnicity, race, language capabilities) in rela-
tion to the demographic composition of your service area?
____ Have you compared the demographic composition of the staff with the client de-
mographics?

II. Policies, procedures and governance

A culturally competent agency has a board of directors, advisory committee, or policy-making
group that is proportionally representative of the staff, client/consumers, and community.
____ Has your organization appointed executives, managers, and administrators who take
responsibility for, and have authority over, the development, implementation, and moni-
toring of the cultural competence plan?
____ Has your organization’s director appointed a standing committee to advise management
on matters pertaining to multicultural services?
____ Does your organization have a mission statement that commits to cultural competence and
reflects compliance with all federal and state statutes, as well as any current Connecticut
Commission on Human Rights and Opportunities nondiscriminatory policies and affirma-
tive action policies?
____ Does your organization have culturally appropriate policies and procedures communicat-
ed orally and/or written in the principal language of the client/consumer to address con-
fidentiality, individual patient rights and grievance procedures, medication fact sheets,
legal assistance, etc. as needed and appropriately?

III. Services/programs
A culturally competent agency offers services that are culturally competent and in a language that
ensures client/consumer comprehension.

A. Linguistic and communication support

____ Has the program arranged to provide materials and services in the language(s) of limited
English-speaking clients/consumer (e.g., bilingual staff, in-house interpreters, or a con-
tract with outside interpreter agency and/or telephone interpreters)?
____ Do medical records indicate the preferred languages of service recipients?
____ Is there a protocol to handle client/consumer/family complaints in languages other than
English?
____ Are the forms that client/consumers sign written in their preferred language?
____ Are the persons answering the telephones, during and after-hours, able to communicate
in the languages of the speakers?
____ Does the organization provide information about programs, policies, covered services, and
procedures for accessing and utilizing services in the primary language(s) of cli-
ent/consumers and families?
____ Does the organization have signs regarding language assistance posted at key locations?

269
 Improving Cultural Competence

____ Are there special protocols for addressing language issues at the emergency room, treat-
ment rooms, intake, etc.?
____ Are cultural and linguistic supports available for clients/consumers throughout different
service offerings along the service continuum?

B. Treatment/rehabilitation planning
____ Does the program consider the client/consumer’s culture, ethnicity and language in treat-
ment planning (assessment of needs, diagnosis, interventions, discharge planning, etc.)?
____ Does the program involve client/consumers and family members in all phases of treat-
ment, assessment, and discharge planning?
____ Has the organization identified community resources (community councils, ethnic cultur-
al social entities, spiritual leaders, faith communities, voluntary associations, etc.) that can
exchange information and services with staff, client/consumers, and family members?
____ Have you identified natural community healers, spiritual healers, clergy, etc., when appro-
priate, in the development and/or implementation of the service plan?
____ Have you identified natural supports (relatives, traditional healers, spiritual resources, etc.)
for purposes of reintegrating the individual into the community?
____ Have you used community resources and natural supports to reintegrate the individual
into the community?

C. Cultural assessments
____ Is the client/consumer’s culture/ethnicity taken into account when formulating a diagno-
sis or assessment?
____ Are culturally relevant assessment tools utilized to augment the assessment/diagnosis
process?
___ Is the client/consumer’s level of acculturation identified, described, and incorporated as
part of cultural assessment?
____ Is the client/consumer’s ethnicity/culture identified, described, and incorporated as part of
cultural assessment?

D. Cultural accommodations
____ Are culturally appropriate, educative approaches, such as films, slide presentations, or
video tapes, utilized for preparation and orientation of client/consumer family members
to your program?
____ Does your program incorporate aspects of each client/consumer’s ethnic/cultural heritage
into the design of specialized interventions or services?
____ Does your program have ethnic/culture-specific group formats available for engagement,
treatment, and/or rehabilitation?
____ Is there provider collaboration with natural community healers, spiritual healers, clergy,
etc., where appropriate, in the development and/or implementation of the service plan?

270
 Appendix C—Tools for Assessing Cultural Competence

E. Program accessibility
____ Do persons from different cultural and linguistic backgrounds have timely and convenient
access to your services?
____ Are services located close to the neighborhoods where persons from different cultures
and linguistic backgrounds reside?
____ Are your services readily accessible by public transportation?
____ Do your programs provide needed supports to families of clients/consumers (e.g., meeting
rooms for extended families, child support, drop-in services)?
____ Do you have services available during evenings and weekends?

IV. Care management

____ Does the level and length of care meet the needs for clients/consumers from different
cultural backgrounds?
___ Is the type of care for clients/consumers from different backgrounds consistently and
effectively managed according to their identified cultural needs?
____ Is the management of the services for people from different groups compatible with their
ethnic/cultural background?

V. Continuity of care
____ Do you have letters of agreement with culturally oriented community services and organ-
izations?
____ Do you have integrated, planned, transitional arrangements between one service modality
and another?
____ Do you have arrangements, financial or otherwise, for securing concrete services needed
by clients/consumers (e.g., housing, income, employment, medical, dental, other emergen-
cy personal support needs)?

VI. Human resources development

A culturally competent agency implements staff training and development in cultural compe-
tence at all levels and across all disciplines, for leadership and governing entities as well as for
management, supervisory, treatment, and support staff.
____ Are the principles of cultural competence (e.g., cultural awareness, language training,
skills training in working with diverse populations) included in staff orientation and on-
going training programs?
____ Is the program making use of other programs or organizations that specialize in serving
persons with diverse cultural and linguistic backgrounds as a resource for staff education
and training?
____ Is the program maximizing recruitment and retention efforts for staff who reflect the
cultural and linguistic diversity of populations needing services?
____ Has the staff ’s training needs in cultural competence been assessed?

271
 Improving Cultural Competence

____ Has the staff attended training programs on cultural competence in the past two years?
Describe:___________________________________________________________
___________________________________________________________________

VII. Quality monitoring and improvement

A culturally competent agency has a quality monitoring and improvement program that ensures
access to culturally competent care.
____ Does the quality improvement (QI) plan address the cultural/ethnic and language needs?
____ Are client/consumers and families asked whether ethnicity/culture and language are appro-
priately addressed in order to receive culturally competent services in the organization?
____ Does the organization maintain copies of minutes, recommendations, and accomplish-
ments of its multicultural advisory committee?
____ Is there a process for continually monitoring, evaluating, and rewarding the cultural com-
petence of staff?

VIII. Information/management system

____ Does the organization monitor, survey, or otherwise access, the QI utilization patterns,
Against Medical Advice (AMA) rates, etc., based on the culture/ethnicity and language?
____ Are client/consumer satisfaction surveys available in different languages in proportion to
the demographic data?
____ Are there data collection systems developed and maintained to track clients/consumers by
demographics, utilization and outcomes across levels of care, transfers, referrals, re-
admissions, etc.?

IX. Formulating a culturally competent plan based on the assessment of your

program or agency
Focus on the following critical areas of concern as you develop goals for a culturally competent
plan for your agency’s service system.
Access: Degree to which services to persons are quickly and readily available.
Engagement: The skill and environment to promote a positive personal impact on the quality of
the client’s commitment to be in treatment.
Retention: The result of quality service that helps maintain a client in treatment with continued
commitment.
Based on an assessment of your agency, determine whether, in your initial plan, you need to direct
efforts of developing cultural competency toward one, or a combination, of the above critical
areas. Then, structure your agency’s cultural competence plan using the following instruc-
tions:
1. Based on the results of this assessment, summarize and describe your organization’s perceived
strengths in providing services to persons from different cultural groups. Please provide
specific examples. Attach supporting documentation (e.g., Data, Policies, Procedures, etc.)

272
 Appendix C—Tools for Assessing Cultural Competence

2. Based on your assessment, summarize and describe your organization’s primary areas consid-
ered either “Priority Concerns” (#1 and/or #2), or “Needs Improvement” (#3) in provid-
ing services to persons from different cultural groups.
3. Based on your organization’s strengths and needs, prioritize both the organizational goals
and objectives addressed in your cultural competence plan. Describe clearly what you will
do to provide services to persons who are culturally and linguistically different.
4. Using the developed goals and objectives, please describe in detail the plans, activities, and/or
strategies you will implement to assist your organization in meeting each of the goals and ob-
jectives indicated.

Patient Satisfaction and Feedback on Clinical and Program

Culturally Responsive Services
Iowa Cultural Understanding Assessment–Client Form
Please indicate your level of agreement with the statements below by circling the number to the
right of the statement that best fits your opinion. All responses are confidential. When you have
completed the survey, please either use the pre-addressed, stamped envelope to return the survey
by mail or place it in the drop box at the facility. Thank you very much for your participation!
Demographic Information
What is your sex? ____Male ____Female
What is your race? ____Alaskan Native ____American Indian ____Asian ____Black or African American
____Native Hawaiian or other Pacific Islander ____White
Are you Hispanic or Latino? ____Yes ____No

RESPONSE
Strongly Neither Agree Strongly
STATEMENT Disagree Disagree Nor Disagree Agree Agree
1. The staff here understands some of
the ideas that I, my family, and others
1 2 3 4 5
from my cultural, racial, or ethnic
group may have.
2. Staff here understands the im-
portance of my cultural beliefs in my 1 2 3 4 5
treatment process.
3. The staff here listens to me and my
1 2 3 4 5
family when we talk to them.
4. If I want, the staff will help me get
1 2 3 4 5
services from clergy or spiritual leaders.
5. The services I get here really help
me work toward things like getting a
job, taking care of my family, going to 1 2 3 4 5
school, and being active with my
friends, family, and community.

(Continued on the next page.)

273
 Improving Cultural Competence

Iowa Cultural Understanding Assessment–Client Form (continued)

RESPONSE
Strongly Neither Agree Strongly
STATEMENT Disagree Disagree Nor Disagree Agree Agree
6. The staff here seems to under-
stand the experiences and problems I 1 2 3 4 5
have in my past life.
7. The waiting room and/or facility
has pictures or reading material that
1 2 3 4 5
show people from my racial or ethnic
group.
8. The staff here knows how to use
their knowledge of my culture to
1 2 3 4 5
help me address my current day-to-
day needs.
9. The staff here understands that I
might want to talk to a person from
1 2 3 4 5
my own racial or ethnic group about
getting the help I want.
10. The staff here respects my reli-
1 2 3 4 5
gious or spiritual beliefs.
11. Staff from this program comes to
my community to let people like me
1 2 3 4 5
and others know about the services
they offer and how to get them.
12. The staff here asks me, my family,
or others close to me to fill out forms
1 2 3 4 5
that tell them what we think of the
place and services.
13. Staff here understands that
people of my racial or ethnic group 1 2 3 4 5
are not all alike.
14. It was easy to get information I
needed about housing, food, cloth-
1 2 3 4 5
ing, child care, and other social
services from this place.
15. The staff here talks to me about
the treatment they will give me to 1 2 3 4 5
help me.
16. The staff here treats me with
1 2 3 4 5
respect.
17. The staff seems to understand
that I might feel more comfortable
1 2 3 4 5
working with someone who is the
same sex as me.

(Continued on the next page.)

274
 Appendix C—Tools for Assessing Cultural Competence

Iowa Cultural Understanding Assessment–Client Form (continued)

RESPONSE
Strongly Neither Agree Strongly
STATEMENT Disagree Disagree Nor Disagree Agree Agree
18. Most of the time, I feel I can trust
1 2 3 4 5
the staff here who work with me.
19. The waiting room has brochures
or handouts that I can easily under-
1 2 3 4 5
stand that tell me about services I
can get here.
20. If I want, my family or friends are
included in discussions about the 1 2 3 4 5
help I need.
21. The services I get here deal with
the problems that affect my day-to-
1 2 3 4 5
day life such as family, work, money,
relationships, etc.
22. Some of the staff here under-
stand the difference between their 1 2 3 4 5
culture and mine.
23. Some of the counselors are from
1 2 3 4 5
my racial or ethnic group.
24. Staff members are willing to be
flexible and provide alternative
1 2 3 4 5
approaches or services to meet my
cultural/ethnic treatment needs.
25. If I need it, there are translators
or interpreters easily available to 1 2 3 4 5
assist me and/or my family.

Source: White et al. 2009. Reproduced with permission.

275
 Appendix D—Screening and
Assessment Instruments

Important Note: The following tables pro- listed in this appendix serve only as a starting
vide an overview of selected instruments that point for investigating the appropriateness of
screen and assess for substance use disorders available instruments within specific popula-
and mental disorders and symptoms. These tions. Citations reflect information about the
tables only represent a sample of instruments. effectiveness of the testing measurements as
In reviewing the tables, do not assume that the well as research that suggests modifications or
instruments have normative data across race reports testing discrepancies among racial and
and ethnicities. The citations and information ethnic populations.

Screening and Assessment Instruments for Substance Use Disorders

Instrument Description Clinical Utility
Alcohol, Smoking, and The ASSIST (version ASSIST was developed by the World Health
Substance Involvement 3.1) has eight items Organization (WHO) as a culturally neutral tool for
Screening Test (ASSIST; to screen for use of use in primary and general medical care settings.
Humeniuk et al. 2010) tobacco products, This paper-pencil instrument takes 5 to 10 minutes
alcohol, and drugs to complete and is designed to be administered by
a health worker. ASSIST determines a risk score for
each substance; the score starts a discussion with
clients about their substance use. For information
about the instrument and its availability in other
languages, see http://www.who.int/substance_
abuse/activities/assist/en/
Alcohol Use Disorders This 10-item screen- The AUDIT was developed by WHO for use in
Identification Test ing questionnaire multinational settings—the original sample includ-
(AUDIT; Babor et al. 1992; was developed to ed subjects from Australia, Bulgaria, Kenya, Mexico,
Saunders et al. 1993) identify people Norway, and the United States (Allen et al. 1997;
whose alcohol Saunders et al. 1993).
consumption is Populations researched: Latinos (Cherpitel 1999;
hazardous or harm- Cherpitel and Bazargan 2003; Cherpitel and Borges
ful to their health. 2000; Frank et al. 2008; Reinert and Allen 2007; Volk
et al. 1997), northern (Asian) Indians (Pal et al. 2004);
Vietnamese (Giang et al. 2005); Brazilians (Lima et al.
2005), and Nigerians (Adewuya 2005).

(Continued on the next page.)

277
 Improving Cultural Competence

Screening and Assessment Instruments for Substance Use Disorders (continued)

Instrument Description Clinical Utility
Languages available in: Numerous languages,
including Spanish (de Torres et al. 2009; Medina-
Mora et al. 1998), French (Gache et al. 2005),
Mandarin and Cantonese (Leung and Arthur 2000),
Nigerian languages (Adewuya 2005), Russian,
German, and Korean (Kim et al. 2008).
Addiction Severity Index Currently in its 5th Populations researched: African Americans (Drake
(McLellan et al. 1980). edition, this instru- et al. 1995; Leonhard et al. 2000; McLellan et al.
Available online at ment assesses the 1985), and Northern Plains American Indians (Carise
http://www.tresearch.org/ severity of substance and McLellan 1999).
index.php/tools/download- use disorders. It has Languages available in: Numerous languages,
asi-instruments-manuals/ 200 items distributed including Spanish (Sandí Esquivel and Avila Corrales
over seven subscales. 1990; for multimedia version see Butler et al. 2009),
French (Daeppen et al. 1996; Krenz et al. 2004),
Japanese (Haraguchi et al. 2009), and Chinese
(Liang et al. 2008).
Alcohol Use Disorder and This structured inter- The AUDADIS has been found reliable in large
Associated Disabilities view is administered general-population studies (Grant et al. 1995; Ruan
Interview Schedule by nonprofessional et al. 2008).
(AUDADIS; Grant and interviewers to diag- Populations researched: African Americans,
Hasin 1990). Available nose substance use Latinos, Asians, and Native Americans (Canino et al.
online at disorders and assess 1999; Chatterji et al. 1997; Grant et al. 1995; Ruan
http://pubs.niaaa.nih.gov/ some co-occurring et al. 2008).
publications/audadis.pdf mental disorders. It Languages available in: Chinese and Spanish
evaluates acculturation (Canino et al. 1999; Horton et al. 2000; Leung and
and racial/ethnic Arthur 2000).
orientation. Currently
in its 4th edition
(AUDADIS-IV).
CAGE (Ewing 1984; May- This is a set of four Populations researched: African Americans
field et al. 1974) questions used to (Cherpitel 1997; Frank et al. 2008); Latino (Saitz et
detect possible al. 1999).
alcohol use disorder. Languages available in: Numerous languages,
including Spanish, Creole, Chinese, and Japanese.
Composite International This structured, The instrument has been well evaluated with inter-
Diagnostic Interview- detailed interview national populations from a variety of different
Substance Abuse Module diagnoses substance nations and found to have good reliability for most
(CIDI-SAM; Cottler 2000) abuse and depend- substances of abuse (Ustün et al. 1997).
ence; it is an expand- Populations researched: African Americans (Horton
ed version of the et al. 2000) and Brazilians (Quintana et al. 2004; 2007).
substance use section Languages available in: Numerous languages,
of the CIDI. including Portuguese, Spanish, Arabic, Japanese,
Vietnamese, and Malay.

(Continued on the next page.)

278
 Appendix D—Screening and Assessment Instruments

Screening and Assessment Instruments for Substance Use Disorders (continued)

Instrument Description Clinical Utility
Drug Abuse Screening This self-report No significant differences in DAST reliability
Test (DAST; Skinner instrument (10- and across race or cultural background were found
1982) 20-item versions) (Yudko et al. 2007).
identifies people who Languages available in: Numerous, including
are abusing psycho- Spanish for the 10-item DAST (DAST-10; Bedregal
active drugs and et al. 2006), Portuguese, Hebrew, Arabic, and
measures degree of Thai.
related problems.
Rapid Alcohol Prob- The RAPS is a five- The RAPS has high sensitivity across both ethnicity
lems Screen (RAPS; question test (also and gender (Cherpitel 1997; 2002). It has also
Cherpitel 1995, 2000) available in a newer been found to work significantly better than the
four-item version, AUDIT for screening African American and Latino
the RAPS-4) that men and to be on par with the AUDIT for women
combines optimal (Cherpitel and Bazargan 2003).
questions from other Populations researched: Mexican Americans
instruments. (Borges and Cherpitel 2001); residents of various
countries (Argentina, Belarus, Brazil, Canada,
China, Czech Republic, India, Mexico,
Mozambique, Poland, South Africa, and Sweden;
Cherpitel et al. 2005).
Languages available in: Numerous, including
Spanish, Chinese, and Portuguese.
Short Michigan Alcohol The S-MAST screens Populations researched: African Americans, Arab
Screening Test (S- for alcohol use Muslims, American Indians, Asian Indians, and
MAST; Selzer et al. disorder. Thai (Al-Ansari and Negrete 1990; Pal et al. 2004;
1975) Nanakorn et al. 2000; Robin et al. 2004).
Languages available in: Numerous, including
Spanish, French, Thai, and Asian Indian languages.
TWEAK (Russell 1994) TWEAK is a five-item Populations researched: Mexican Americans
screening instrument (Borges and Cherpitel 2001) and African
originally created to Americans (Cherpitel 1997).
screen for risky Languages available in: Spanish (Cremonte and
drinking during Cherpitel 2008).
pregnancy (but has
been validated for a
range of male and
female populations).

279
 Improving Cultural Competence

Screening and Assessment Instruments for Mental Disorders and Symptoms

Instrument Description Clinical Utility With Specific Racial/Ethnic Groups
Beck Anxiety Inven- The BAI is a 21-item Populations researched: African Americans
tory (BAI; Beck and scale that distinguishes (Chapman et al. 2009).
Steer 1990) anxiety from depres- Languages available in: Numerous languages,
sion. including Spanish (Novy et al. 2001), Arabic,
Chinese, Farsi, Korean, and Turkish.
Beck Depression The BDI is a 21-item Several versions of the BDI are available with cultur-
Inventory (BDI) and instrument used to al specificity.
Beck Depression assess the intensity of Populations researched: African Americans (Dutton
Inventory, 2nd Edi- depression. et al. 2004; Grothe et al. 2005; Joe et al. 2008),
tion (BDI-II; Beck et al. Asian Americans (Carmody 2005; Crocker et al.
1996) 1994), Hmong (Mouanoutoua et al. 1991), Mexican
Americans (Gatewood-Colwell et al. 1989), and
Latinos (Contreras et al. 2004).
Languages available in: Numerous, including
Spanish (Azocar et al. 2001; Bonilla et al. 2004;
Carmody 2005; Wiebe and Penley 2005), Chinese
(Yeung et al. 2002; Zheng and Lin 1991), French,
Arabic (Abdel-Khalek 1998; Alansari 2006), Hebrew,
and Farsi (Ghassemzadeh et al. 2005).
Center for Epidemio- The CES-D is a 20-item May underestimate symptoms in African Americans
logical Studies- self-report scale de- (Bardwell and Dimsdale 2001; Cole et al. 2000).
Depression Scale signed to measure Populations researched: Latinos (Batistoni et al.
(CES-D; Radloff 1977) depressive symptoms. 2007; Garcia and Marks 1989; Posner et al 2001;
Reuland et al. 2009; Roberts et al.1990), Asian
Indians (Diwan et al. 2004; Gupta et al. 2006),
Native Americans (Chapleski et al. 1997), and
African Americans (Canady et al. 2009; Makambi et
al. 2009; Nguyen et al. 2004).
Languages available in: Numerous languages,
including Spanish (Reuland et al. 2009), Chinese (Lin
1989), Greek, Korean, and Portuguese.
Geriatric Depression Available in 30- and 15- Populations researched: Latinos (Reuland et al.
Scale (Sheikh and item forms, this instru- 2009) and Asians (Broekman et al. 2008; Nyunt et
Yesavage 1986) ment screens for de- al. 2009).
pression in older adults. Languages available in: Available in 30 languages
and validated with a number of different popula-
tions (available online at http://www.stanford.edu/
~yesavage/GDS.html).
Millon Clinical Multi- Assesses 13 personality Populations researched: African Americans (Calsyn
axial Inventory-III disorders (DSM-III-R et al.1991; Craig and Olson 1998) and Latinos
(Millon et al. 2009) Axis II disorders) and 9 (Fernández-Montalvo et al. 2006).
clinical syndromes Languages available in: Multiple languages, includ-
(DSM-III-R Axis I disor- ing Spanish, Korean, Cantonese, and Portuguese.
ders); includes scales to
assess substance relat-
ed problems.

(Continued on the next page.)

280
 Appendix D—Screening and Assessment Instruments

Instruments To Screen and Assess Mental Disorders and Symptoms (continued)

Minnesota Multiphasic The MMPI-2 Normed for Asian Americans, African Americans,
Personality Inventory, measures personali- Latinos, and American Indians (Hathaway et al.1989).
2nd Edition (MMPI-2) ty traits and symp- Populations researched: African Americans (Castro
(Butcher et al. 1989) tom patterns. et al. 2008; McNulty et al. 2003; Monnot et al. 2009;
Whatley et al. 2003) and Asian Americans (Tsai and
Pike 2000; Tsushima and Tsushima 2009).
Languages available in: Numerous, including
French, Hmong, and Spanish (Velasquez et al. 2000).
Mini International This is a short, Populations researched: African Americans (Black
Neuropsychiatric Inter- structured, diagnos- et al. 2004).
view (M.I.N.I.; Sheehan tic interview that The Major Depressive Episode and Posttraumatic
et al. 1998) assesses the most Stress Disorder (PTSD) sections of the M.I.N.I.
common mental have been adapted for use in screening for PTSD
disorders (including in refugees, and found effective across cultures in
substance use a multinational sample (Eytan et al. 2007).
disorders). Languages available in: Over 43 languages,
including French, Italian (Rossi et al. 2004),
Japanese (Otsubo et al. 2005), Spanish, Italian,
and Arabic (Amorim et al. 1998; Lecrubier et al.
1997; Sheehan et al. 1997, 1998).
Schedules for Clinical The SCAN-2 is a set Populations researched: The SCAN-2 was devel-
Assessment in Neuro- of instruments that oped by WHO with an international sample that
psychiatry, 2nd Version measure psycho- included participants from Turkey, Greece, India,
(SCAN-2; Wing et al. pathology and the United States, Nigeria, Romania, Mexico,
1998) behavior associated Spain, and South Korea and is intended to be
with major mental cross-culturally appropriate (Room et al. 1996).
disorders. Languages available in: Chinese (Cheng et al.
2001), Danish, Dutch, English, French, German,
Greek, Italian, Kannada, Portuguese, Spanish,
Thai, Turkish, and Yoruba.
Symptom Checklist-90- This 90-item check- The SCL-90R has been normed for adult inpatient
R (SCL-90R; Derogatis list evaluates psy- and outpatient psychiatric patients and adult and
1992) chiatric symptoms adolescent nonpatients across a number of ethnic
and their intensity in groups (Derogatis 1992).
nine different cate- Populations researched: Latinos (Martinez et al.
gories and screens 2005) and African Americans (Ayalon and Young
for a broad range of 2009).
mental disorders. Languages available in: Spanish, French,
Armenian, and Persian.

281
Appendix E—Cultural Formulation
in Diagnosis and Cultural Concepts
of Distress

nant idioms of distress through which symp-

Cultural Formulation in toms or the need for social support are com-
Diagnosis municated (e.g., “nerves,” possessing spirits,
somatic complaints, inexplicable misfortune),
Clinicians need to consider the effects of cul-
the meaning and perceived severity of the
ture when diagnosing clients. The following
individual’s symptoms in relation to norms of
cultural formulation adopted by the American
the cultural reference group, any local illness
Psychiatric Association (APA) in the Diagnostic
category used by the individual’s family and
and Statistical Manual of Mental Disorders, Fifth
community to identify a condition (see the
Edition (DSM-5; 2013, pp. 749–759) provides
“Cultural Concepts of Distress” section of this
a systematic outline for incorporating culturally
appendix), the perceived causes or explanatory
relevant information when conducting a multi-
models that the individual and the reference
axial diagnostic assessment. Whether or not
group use to explain the illness, and current
they are credentialed to diagnose disorders,
preferences for and past experiences with
counselors and other clinical staff can use the
professional and popular sources of care.
main content areas listed below to guide the
interview, initial intake, and treatment planning 3. Cultural factors related to psychosocial
processes. (For review, see Mezzich and Caracci environment and level of functioning. Note
2008; for Native American application, specifi- culturally relevant interpretations of social
cally Lakota, refer to Brave Heart 2001.) stressors, available social supports, and levels of
functioning and disability, including stresses in
1. Cultural identity of the person. Note the
the local social environment and the role of
person’s ethnic or cultural reference groups. For
religion and kin networks in providing emo-
immigrants and ethnic minorities, also note
tional, instrumental, and informational support.
degree of involvement with culture of origin
and host culture (where applicable). Also note 4. Cultural elements of the relationship
language ability, use, and preference (including between client and clinician. Indicate differ-
multilingualism). ences in culture and social status between
client and clinician, as well as any problems
2. Cultural explanations of the person’s
these differences may cause in diagnosis and
illness. Identify the following: the predomi-

283
 Improving Cultural Competence

treatment (e.g., difficulty communicating in diverse populations, so too are standard diag-
the client’s first language, eliciting symptoms noses. Expressions of psychological problems
or understanding their cultural significance, are, in part, culturally specific, and behavior
negotiating an appropriate relationship or level that is aberrant in one culture can be standard
of intimacy, determining whether a behavior is in another. For example, seemingly paranoid
normative or pathological). thoughts are to be expected in clients who
have migrated from countries with oppressive
5. Overall cultural assessment for diagnosis
governments. Culture plays a large role in
and care. Conclude cultural formulation by
understanding phenomena that might be
discussing how cultural considerations specifi-
construed as mental illnesses in Western
cally influence comprehensive diagnosis and
medicine. These cultural concepts of distress
care.
may or may not be linked to particular DSM-
5 diagnostic criteria (APA 2013). The table
Cultural Concepts of that follows lists DSM-5 cultural concepts of
Distress distress; other concepts exist that are not
recognized in DSM-5.
Just as standard screening instruments can
sometimes be of limited use with culturally

DSM-5 Cultural Concepts of Distress

Syndrome Description Populations
Ataque de Commonly reported symptoms include uncontrollable shouting, Caribbean,
nervios attacks of crying, trembling, heat in the chest rising into the head, Latin
and verbal or physical aggression. Dissociative experiences, sei- American,
zurelike or fainting episodes, and suicidal gestures are prominent in Latin
some attacks but absent in others. A general feature of an ataque Mediterranean
de nervios is a sense of being out of control. Ataques de nervios
frequently occur as a direct result of a stressful event relating to the
family (e.g., death of a close relative, separation or divorce from a
spouse, conflict with spouse or children, or witnessing an accident
involving a family member). People can experience amnesia for
what occurred during the ataque de nervios, but they otherwise
return rapidly to their usual level of functioning. Although descrip-
tions of some ataques de nervios most closely fit with the DSM-IV
description of panic attacks, the association of most ataques with a
precipitating event and the frequent absence of the hallmark symp-
toms of acute fear or apprehension distinguish them from panic
disorder. Ataques range from normal expressions of distress not
associated with a mental disorder to symptom presentations associ-
ated with anxiety, mood dissociative, or somatoform disorders.
Dhat (jiryan A folk diagnosis for severe anxiety and hypochondriacal concerns Asian Indian
in India, skra associated with the discharge of semen, whitish discoloration of
prameha in the urine, weakness, and exhaustion.
Sri Lanka,
shen-k’uei in
China)

(Continued on the next page.)

284
 Appendix E—Cultural Formulation in Diagnosis and Cultural Concepts of Distress

DSM-5 Cultural Concepts of Distress (continued)

Nervios Refers both to a general state of vulnerability to stress and to a Latin
syndrome evoked by difficult life circumstances. Nervios includes a American
wide range of symptoms of emotional distress, somatic disturb-
ance, and inability to function. Common symptoms include head-
aches and “brain aches,” irritability, stomach disturbances, sleep
difficulties, nervousness, tearfulness, inability to concentrate,
trembling, tingling sensations, and mareos (dizziness with occa-
sional vertigo-like exacerbations). Nervios tends to be an ongoing
problem, although it is variable in the degree of disability mani-
fested. Nervios is a broad syndrome that ranges from cases free of
a mental disorder to presentations resembling adjustment, anxie-
ty, depressive, dissociative, somatoform, or psychotic disorders.
Differential diagnosis depends on the constellation of symptoms,
the kind of social events associated with onset and progress, and
the level of disability experienced.
Shenjing A condition characterized by physical and mental fatigue, head- Chinese
shuairuo aches, difficulty concentrating, dizziness, sleep disturbance, and
memory loss. Other symptoms include gastrointestinal problems,
sexual dysfunction, irritability, excitability, and autonomic nervous
system disturbances.
Susto An illness attributed to a frightening event that causes the soul to Latino
(espanto, leave the body and results in unhappiness and sickness. Individuals American,
pasmo, tripa with susto also experience significant strains in key social roles. Mexican,
ida, perdida Symptoms can appear days or years after the fright is experi- Central and
del alma, or enced. In extreme cases, susto can result in death. Typical symp- South
chibih) toms include appetite disturbances, inadequate or excessive American
sleep, troubled sleep or dreams, sadness, lack of motivation, and
feelings of low self-worth or dirtiness. Somatic symptoms accom-
panying susto include muscle aches and pains, headache, stom-
achache, and diarrhea. Ritual healings focus on calling the soul
back to the body and cleansing the person to restore bodily and
spiritual balance. Susto can be related to major depressive disor-
der, posttraumatic stress disorder, and somatoform disorders.
Similar etiological beliefs and symptom configurations are found in
many parts of the world.
Taijin This syndrome refers to an individual’s intense fear that his or her Japanese
kyofusho body, its parts, or its functions displease, embarrass, or are offen-
sive to other people in appearance, odor, facial expressions, or
movement. This syndrome is included in the official Japanese
diagnostic system for mental disorders.

Source: APA 2013. Used with permission.

285
Appendix F—Cultural Resources

guidelines that reflect current professional

General Resources practice. The ATA also has online directories
available. The Directory of Translation and
Addiction Technology Transfer
Interpreting Services is an online directory of
Centers individual translators and interpreters. The
http://www.nattc.org Directory of Language Services Companies is
The Addiction Technology Transfer Centers a directory of companies that offer translating
Network identifies and advances opportunities or interpreting services.
for improving substance abuse treatment. The
Network comprises 14 regional centers as well Center for Research on Ethnicity,
as a national office serving the United States Culture, and Health
and its territories. Regional centers cater to http://www.crech.org
unique needs in their areas while supporting
Established in 1998 in the University of
national initiatives. Improving cultural compe-
Michigan’s School of Public Health, the Center
tence is a major focus for the Network, which
provides a forum for basic and applied public
seeks to improve substance abuse treatment by
health research on relationships among eth-
identifying standards of culturally competent
nicity, culture, socioeconomic status, and
treatment and generating ways to foster their
health. It develop new interdisciplinary
adoption in the field.
frameworks for understanding these relation-
ships while promoting effective collaboration
Agency for Healthcare Research
among public health academicians, healthcare
and Quality–Minority Health providers, and communities to reduce racial
http://www.ahrq.gov/research/findings/factsh and ethnic disparities in health care.
eets/minority/index.html
This site provides research findings, papers, and Community Toolbox: Cultural
press releases related to minority health. Competence in a Multicultural
World
American Translators Association http://ctb.ku.edu/en/table-of-
http://www.atanet.org contents/culture/cultural-competence
The American Translators Association (ATA) The cultural competence section of this Web
offers a certification program that evaluates site provides information (including examples
the competence of translators according to and links) on a number of relevant topics, such

287
 Improving Cultural Competence

as how to build relationships with people from professionals, families, and consumers on the
different cultures, reduce prejudice and racism, panels prepared the document.
build organizations and communities that are
responsive to people from diverse cultures, and
heal the effects of internalized oppression. http://www.diversityrx.org
The Cross Cultural Health Care This Web site offers resources relating to
Program cross-cultural communication issues in
http://www.xculture.org healthcare settings and information on inter-
preter practice, legal issues relating to language
Since 1992, the Cross Cultural Health Care barriers and access to linguistically appropriate
Program (CCHCP) has been addressing services, and the ways language and culture
broad cultural issues that affect the health of can affect the use of healthcare services.
individuals and families in ethnic minority
communities in Seattle and nationwide. Health Resources and Services
Through a combination of cultural competen- Administration Culture, Language
cy trainings, interpreter trainings, research
and Health Literacy Page
projects, community coalition building, and
http://www.hrsa.gov/culturalcompetence/
other services, CCHCP serves as a bridge
between communities and healthcare institu- The Health Resources and Services
tions to ensure full access to quality health care Administration Culture, Language and Health
that is culturally and linguistically appropriate. Literacy Web site provides links to various
online resources relating to cultural compe-
Cultural Competence Standards in tence in general and to providing culturally
Managed Care Mental Health competent health care to a number of specific
Services cultural/ethnic groups.
Western Interstate Commission for Higher
Education. Cultural Competence Standards in Instruments for Measuring
Managed Mental Health Care for Four Under- Acculturation, University of
served/Underrepresented Racial/Ethnic Groups. Calgary
Boulder, CO: Western Interstate Commission http://www.ucalgary.ca/~taras/_private/Accult
for Higher Education, 1998. uration_Survey_Catalogue.pdf
The Center for Mental Health Services This document gives information on accul-
(CMHS) presents cultural competence stand- turation and cultural identity measures, pre-
ards for managed care mental health services to senting many in full. It does not always include
improve the availability of high-quality services scoring information but typically provides
for four underserved and/or underrepresented questions from each instrument.
racial and ethnic groups—African Americans,
Latinos, Native Americans, and Asian/Pacific Minority Health Project
Islander Americans. With help from the http://www.minority.unc.edu/
Western Interstate Commission for Higher
Education Mental Health Program, CMHS The Minority Health Project (MHP) of the
convened national panels representing each University of North Carolina’s Gillings School
major racial/ethnic group. Mental health of Global Public Health seeks to improve the

288
 Appendix F—General Resources

quality of racial and ethnic population data, to strengthened and empowered by its diversity.
expand the capacity for conducting statistical iMCI’s initiatives aim to increase communica-
research and developing research proposals on tion, understanding, and respect among people
minority health, and to foster a network of of diverse backgrounds and address systemic
researchers in minority health. MHP collabo- cultural issues facing our society. The Institute
rates with the Center for Health Statistics accomplishes this through its conferences,
Research, the University of North Carolina, the individualized organizational training and
National Center for Health Statistics, and the consulting interventions, publications, and
Association of Schools of Public Health to leading-edge projects.
conduct educational programs and provide
information on minority health research and Office of Civil Rights
data sources. http://www.hhs.gov/ocr/civilrights/resources/s
pecialtopics/lep/
National Center for Cultural
The Office of Civil Rights of the U.S.
Competence
Department of Health and Human Services
http://nccc.georgetown.edu investigates complaints, enforces rights, devel-
The National Center for Cultural Compe- ops policies, and promulgates regulations to
tence’s (NCCC) mission is to increase the ensure compliance with nondiscrimination
capacity of health and mental health programs and health information privacy laws. The
to design, implement, and evaluate culturally agency offers technical assistance and public
and linguistically responsive service delivery education to ensure understanding of and
systems. NCCC conducts training, technical compliance with these laws, including the
assistance, and consultation; participates in provision of resources and tools to improve
networking, linkages, and information ex- services for individuals with limited English
change; and engages in knowledge and prod- proficiency.
uct development and dissemination.
Office of Minority Health
The National Center on Minority Resource Center
Health and Health Disparities http://minorityhealth.hhs.gov/
http://www.ncmhd.nih.gov The Office of Minority Health (OMH) was
The Center’s mission is to promote minority established by the U.S. Department of Health
health and reduce health disparities. It is and Human Services in 1985 to advise the
particularly useful as a resource for infor- Secretary and the Office of Public Health and
mation about health disparities and the best Science on public health policies and programs
methods to address them. affecting Native Americans, African Ameri-
cans, Asian Americans, Latinos, and Native
International MultiCultural Hawaiians and other Pacific Islanders. The
Institute mission of OMH is to improve and protect the
http://www.imciglobal.org/ health of racial and ethnic minority populations
through the development of policies and pro-
The International MultiCultural Institute grams that will eliminate health disparities.
(iMCI) works with individuals, organizations,
and communities to create a society that is The OMH Resource Center (OMHRC) is a
national resource and referral service for

289
 Improving Cultural Competence

minority health issues. It collects and distrib- less likely to receive quality care than the gen-
utes information on various health topics, eral population. It articulates the foundation for
including substance abuse, cancer, heart dis- understanding relationships among culture,
ease, violence, diabetes, HIV/AIDS, and society, mental health, mental illness, and
infant mortality. OMHRC also facilitates services, and also describes how these issues
information exchange on minority health affect different racial and ethnic groups.
issues, and offers customized database search-
es, publications, mailing lists, referrals, and Stanford University Curriculum in
the like regarding Native American, African Ethnogeriatrics
American, Asian American, Pacific Islander, http://www.stanford.edu/group/ethnoger/
and Latino populations.
This online curriculum explores healthcare
Substance Abuse and Mental issues for older adults from a variety of cultur-
Health Services Administration al groups (with modules on African
Americans, Latinos, Native Americans, and
http://store.samhsa.gov/
several Asian American populations).
The Substance Abuse and Mental Health
Services Administration (SAMHSA) is the African and Black
Nation’s one-stop resource for information
about substance abuse and mental illness American Resources
prevention and behavioral health treatment.
The SAMHSA Store Web site provides in- Congressional Black Caucus
formation on behavioral health topics such as Foundation Health
cultural competence, healthcare-related laws, http://www.cbcfinc.org/what-we-
and mental health and substance abuse. do/researchandpolicy.html

Surgeon General’s Report on Congressional Black Caucus Foundation

Health’s mission is to empower people of
Mental Health: Culture, Race, and African descent to make better decisions
Ethnicity about their health and that of their communi-
U.S. Department of Health and Human ties. The Web site provides information about
Services. Mental Health: Culture, Race, and public health issues, key legislation on public
Ethnicity. A Supplement to Mental Health: A policy issues, health initiatives, and local
Report of the Surgeon General. HHS Pub. No. events directly and indirectly relating to the
SMA 01-3613. Rockville, MD: U.S. health of people of African descent world-
Department of Health and Human Services, wide. It includes a section on substance abuse.
Substance Abuse and Mental Health Services
Administration, Center for Mental Health National Black Alcoholism and
Services, 2001. Addictions Council, Inc.
This report highlights the roles that culture http://www.nbacinc.org
and society play in mental health, mental The National Black Alcoholism and Addictions
illness, and the types of mental health services
Council, Inc. (NBAC) is a nonprofit, tax-
people seek. The report finds that, although
exempt organization of Black individuals
effective, well-documented treatments for concerned about alcoholism and drug abuse.
mental illnesses are available, minorities are

290
 Appendix F—General Resources

NBAC educates the public about the preven- The Asian and Pacific Islander American
tion of alcohol and drug abuse and alcoholism Health Forum (APIAHF) is a national advo-
and is committed to increasing services for cacy organization that promotes policy, pro-
persons who are dependent upon alcohol and gram, and research efforts to improve the
their families, providing quality care and treat- health of Asian and Pacific Islander Americans.
ment, and developing research models designed APIAHF established the Asian and Pacific
for Blacks. NBAC helps Blacks concerned with Islander Health Information Network
or involved in the field of alcoholism and drug- (APIHIN) in 1995. APIHIN was developed
related issues to exchange ideas, offer services, as an integrated telecommunications infra-
and facilitate substance abuse treatment pro- structure that gives Asians and Pacific Is-
grams for Black Americans. landers access to health information and
resources through local community access
National Medical Association points and key provider intermediaries. The
http://www.nmanet.org organization supports two mailing lists: API-
HealthInfo, which concentrates on Asian and
A professional and scientific organization Pacific Islander American health, and API-
representing the interests of more than 25,000 SAMH, which deals with issues related to
physicians and their patients, the National behavioral health of special interest to the
Medical Association (NMA) is the collective Asian and Pacific Islander community.
voice of African American physicians and a
leading force for parity and justice in medicine National Asian American Pacific
and health. Established in 1895, NMA aims
Islander Mental Health
to prevent diseases, disabilities, and adverse
health conditions that disproportionately or Association
differentially affect African American and http://www.naapimha.org
underserved populations; improve quality and The National Asian American Pacific Islander
availability of health care for poor and under- Mental Health Association (NAAPIMHA)
served populations; and increase representa- evolved from an Asian American Pacific
tion and contributions of African Americans Islander Mental Health Summit sponsored by
in medicine. NMA provides educational SAMHSA. NAAPIMHA focuses on five
programs and opportunities for scholarly interrelated areas: enhancing collection of
exchange, conducts outreach to promote im- appropriate and accurate data; identifying
proved public health, and establishes national current best practices and service models;
health policy agendas in support of African capacity building, including provision of tech-
American physicians and their patients. nical assistance and training of service
providers, both professional and paraprofes-
Asian American, Native sional; conducting research and evaluation; and
working to engage consumers and families.
Hawaiian, and Other
Pacific Islander Resources National Asian Pacific American
Families Against Substance Abuse
Asian and Pacific Islander http://www.napafasa.org
American Health Forum
The National Asian Pacific American Families
http://www.apiahf.org
Against Substance Abuse is a nonprofit

291
 Improving Cultural Competence

membership organization that addresses the sionals trying to address their needs. This Web
alcohol, tobacco, and drug issues of Asian site helps bridge the communication barrier by
American and Pacific Islander populations; it offering information about and links to re-
involves providers, families, and youth in sources for substance abuse prevention, general
reaching Asian American and Pacific Islander health information, building cultural pride, and
communities to promote health and social research tools, such as databases and bibliog-
justice and reduce substance abuse and related raphies.
problems.
National Alliance for Hispanic
Psychosocial Measures for Asian Health
American Populations: Tools for http://www.hispanichealth.org
Direct Practice and Research
The National Alliance for Hispanic Health is
http://www.columbia.edu/cu/ssw/projects/pmap the nation’s oldest and largest network of
This Web site presents information on psy- Hispanic health and human service providers.
chosocial measures (including some related to Alliance members deliver quality services to
substance abuse) found to be reliable and valid more than 12 million persons annually. As the
with Asian Americans (in general group or for nation’s action forum for Hispanic health and
a specific subgroup). well-being, the programs of the Alliance
inform and mobilize consumers, support
The Vietnamese Community providers in the delivery of quality care, pro-
Health Promotion Project mote appropriate use of technology, improve
http://www.suckhoelavang.org/main.html the science base for accurate decisionmaking,
and promote philanthropy.
This project’s mission is to improve the health
of Vietnamese Americans. A part of the Uni- National Council of La Raza
versity of California–San Francisco School of Institute for Hispanic Health
Medicine, the Web site provides information
http://www.nclr.org/index.php/issues_and_pr
in Vietnamese and English, along with links
ograms/health_and_nutrition/hispanic_health
to Vietnamese Web sites related to health
issues. The Institute for Hispanic Health (IHH)
works closely with National Council of La
Hispanic and Latino Raza affiliates, government partners, private
funders, and Latino-serving organizations to
Resources deliver quality health interventions and im-
prove access to and use of quality health pro-
Hispanic/Latino Portal to Drug motion and disease prevention programs.
Abuse Prevention IHH provides culturally responsive and lin-
http://www.latino.prev.info guistically appropriate technical assistance and
science-based approaches that emphasize
The Indiana University Prevention Resource public health, rather than disease-specific,
Center created this trilingual Web site to serve themes. Themes include behavior change
the growing Latino population and those who communication, healthy lifestyle promotion,
work with Latinos. Many Latinos face a lan- improving access to quality services, and
guage barrier, as do many prevention profes-

292
 Appendix F—General Resources

increasing the number and level of Latinos in Health Research, as well as information about
health fields. ongoing research projects.

National Hispanic Medical Indian Health Service

Association http://www.ihs.gov
http://www.nhmamd.org The Indian Health Service (IHS) is the prin-
Established in 1994, the National Hispanic cipal federal healthcare provider and advocate
Medical Association (NHMA) is a nonprofit for Native Americans; it ensures that compre-
association representing 36,000 licensed His- hensive, culturally acceptable personal and
panic physicians in the United States. Its public health services are available and acces-
mission is to improve the health of Latinos sible to Native peoples. Its Web site provides a
and other underserved populations. NHMA tour of the IHS and its service areas, adminis-
provides policymakers and healthcare provid- trative reports, legislative news, IHS job op-
ers with expert information and support in portunities, and healthcare resources targeted
strengthening health service delivery to Latino to this group.
communities across the Nation. Its agenda
includes expanding access to quality health National Indian Child Welfare
care; increasing medical education, cultural Association
competence, and research opportunities for http://www.nicwa.org
Latinos; and developing policy and education
to eliminate health disparities for Latinos. The National Indian Child Welfare Associa-
tion (NICWA), a comprehensive source of
information on American Indian child welfare,
Native American works on behalf of Indian children and fami-
Resources lies to provide public policy, research, and
advocacy; information and training on Indian
Centers for American Indian and child welfare; and community development
Alaska Native Health services to Tribal governments and programs,
http://www.ucdenver.edu/academics/colleges/ State child welfare agencies, and other organi-
PublicHealth/research/centers/ zations, agencies, and professionals interested
CAIANH/Pages/caianh.aspx in Indian child welfare. NICWA addresses
child abuse and neglect through training,
The Centers for American Indian and Alaska research, public policy, and grassroots commu-
Native Health (CAIANH) at the University nity development. NICWA also supports
of Colorado, Denver promote the health and compliance with the Indian Child Welfare Act
well-being of American Indians and Alaska of 1978, which seeks to keep American Indian
Natives by pursuing research, training, contin- children with American Indian families.
uing education, technical assistance, and in-
formation dissemination in a biopsychosocial One Sky Center
framework that recognizes the unique cultural http://www.oneskycenter.org
contexts of this special population. The site
provides online access to the group’s journal, One Sky Center aims to improve prevention
American Indian and Alaska Native Mental and treatment of substance abuse for Native
peoples by identifying, promoting, and dis-
seminating effective, evidence-based, culturally

293
 Improving Cultural Competence

appropriate substance abuse prevention and development and capacity building, as well as
treatment services and practices for applica- program planning and implementation. The
tion across diverse Tribal communities. It also Center provides TTA on mental and sub-
provides training, technical assistance, and stance use disorders, bullying and violence,
products to expand the capacity and quality of suicide prevention, and the promotion of
substance abuse prevention and treatment mental health. It offers TTA to federally
services for this population. SAMHSA creat- recognized tribes, other American Indian and
ed, designed, and funds One Sky Center to Alaska Native communities, SAMHSA Tribal
work with all federal and state agencies grantees, and organizations serving Indian
providing services to Native Americans. Country. The Web site provides resources
across behavioral health topics relevant to
SAMHSA’s Tribal Training and Native peoples.
Technical Assistance Center
http://beta.samhsa.gov/tribal-ttac White Bison
http://www.whitebison.org/
The Tribal Training and Technical Assistance
This Web site offers resources related to the
(TTA) Center uses a culturally relevant, evi-
Wellbriety self-help movement for Native
dence-based, holistic approach to support
Americans, including a discussion board and
Native communities in their self-
access to the Wellbriety online magazine.
determination efforts through infrastructure

294
Appendix G—Glossary

Acculturation typically refers to the socializa- people whose origins are “in any of the black
tion process through which people from one racial groups of Africa” (p. A-3). The term
culture adopt certain elements from the domi- includes descendants of African slaves brought
nant culture in a society. to this country against their will and more
recent immigrants from Africa, the Caribbean,
American Indian and Alaska Native people
and South or Central America (many individ-
include those “having origins in any of the
uals from these latter regions, if they come
original peoples of North and South America
from Spanish-speaking cultural groups, iden-
(including Central America), and who main-
tify or are identified primarily as Latino). The
tain tribal affiliation or community attach-
term Black is often used interchangeably with
ment” (Grieco and Cassidy 2001, p. 2).
African American, although for some, the
Asians are defined in the United States (U.S.) term African American is used specifically to
Census as “people having origins in any of the describe those individuals whose families have
original peoples of the Far East, Southeast been in this country since at least the 19th
Asia, or the Indian subcontinent,” including, century and thus have developed distinctly
for example, Cambodia, China, India, Japan, African American cultural groups. Black can
Korea, Malaysia, Pakistan, the Philippine be a more inclusive term describing African
Islands, Thailand, and Vietnam (Grieco and Americans as well as for more recent immi-
Cassidy 2001, p. 2). grants with distinct cultural backgrounds.

Biculturalism is “a well-developed capacity to Confianza means trust or confidence in the

function effectively within two distinct cul- benevolence of the other person.
tures based on the acquisition of the norms,
Conformity in Helms’s model of racial iden-
values, and behavioral routines of the domi-
tity development refers to the tendency of
nant culture” and one’s own culture (Castro
members of a racial group to behave in con-
and Garfinkle 2003, p. 1385).
gruence with the values, beliefs, and attitudes
Biracial individuals have two distinct racial of their own culture to which they have been
heritages, either one from each parent or as a exclusively exposed.
result of racial blending in an earlier genera-
Cultural competence is “a set of congruent
tion (Root 1992).
behaviors, attitudes, and policies that . . . ena-
Blacks/African Americans are, according to ble a system, agency, or group of professionals
the U.S. Census Bureau (2000) definition, to work effectively in cross-cultural situations”

295
 Improving Cultural Competence

(Cross et al. 1989, p. 13). It refers to the people on the basis of common origins, shared
ability to honor and respect the beliefs, lan- beliefs, and shared standards of behavior
guages, interpersonal styles, and behaviors of (culture).
individuals and families receiving services, as
Ethnocentrism is “the tendency to view one’s
well as staff members who are providing such
own culture as best and to judge the behavior
services. “Cultural competence is a dynamic,
and beliefs of culturally different people by
ongoing developmental process that requires a
one’s own standards” (Kottak 1991, p. 47).
long-term commitment and is achieved over
time” (U.S. Department of Health and Health disparity is a particular type of health
Human Services [HHS] 2003a, p. 12). difference that is closely linked with social,
economic, and/or environmental disadvantage.
Cultural competence plans are strategic
Health disparities adversely affect groups of
plans that outline a systematic organizational
people who have systematically experienced
approach to providing culturally responsive
greater obstacles to health based on their racial
services to individuals and to increasing cul-
or ethnic group; religion; socioeconomic
tural competence among staff at each level of
status; gender; age; mental health; cognitive,
the organization.
sensory, or physical disability; sexual orienta-
Cultural diffusion is the process of cultural tion or gender identity; geographic location; or
intermingling. other characteristics historically linked to
discrimination or exclusion (HHS 2011a).
Cultural humility “incorporates a lifelong
commitment to self-evaluation and critique” Hembrismo refers to female strength, endur-
(Tervalon and Murray-García 1998, p. 123) to ance, courage, perseverance, and bravery
redress the power imbalances in counselor– (Falicov 1998).
client relationships.
Latinos are those who identify themselves in
Cultural norms are the spoken or unspoken one of the specific Hispanic or Latino Census
rules or standards for a cultural group that categories—Mexican, Puerto Rican, or
indicate whether a certain social event or Cuban—as well as those who indicate that
behavior is considered appropriate or inappro- they are “other Spanish, Hispanic, or Latino.”
priate. Origin can be viewed as the heritage, nation-
ality, group, lineage, or country of birth of the
Cultural proficiency involves a deep and rich
person or the person’s parents or ancestors
knowledge of a culture—an insider’s view—
before their arrival in the United States.
that allows the counselor to accurately inter-
pret the subtle meanings of cultural behavior Immersion–emersion is a stage in the identi-
(Kim et al. 1992). ty development models of both Cross and
Helms during which a transition takes place
Culture is the conceptual system that struc-
from satisfaction with the old self to commit-
tures the way people view the world—it is the
ment to personal change: from immersion in
particular set of beliefs, norms, and values that
one’s old identity to emerging with a more
influence ideas about the nature of relation-
mature view of one’s identity (Cross 1995b).
ships, the way people live their lives, and the
way people organize their world. Indigenous peoples are those people native
to a particular country or region. In the case
Ethnicity refers to the social identity and
of the United States and its territories, this
mutual belongingness that defines a group of

296
 Appendix G—Glossary

includes Native Hawaiians, Alaska Natives, Nguzo saba are the seven African American
Pacific Islanders, and American Indians. principles celebrated during Kwanzaa:
• Umoja is unity with family, community,
Institutional racism generally “refers to the
nation, and race.
policies, practices, and norms that incidentally
• Kujichagulia means self-determination to
but inevitably perpetuate inequality,” resulting
define collective selves, create for collective
in “significant economic, legal, political and
selves, and speak for collective selves.
social restrictions” (Thompson and Neville
• Ujima refers to collective responsibility to
1999, p. 167).
build and maintain community and solve
Language is a culture’s communication sys- problems together.
tem and the vehicle through which aspects of • Ujamaa refers to cooperative economics to
race, ethnicity, and culture are communicated. build and maintain businesses and to prof-
it from them together.
Machismo is the traditional sense of responsi- • Nia is a sense of purpose to collectively
bility Latino men feel for the welfare and build and develop community to restore
protection of their families. people to their traditional greatness.
Marianismo is the traditional belief that • Kuumba is creativity to always do as much
Latinas should be self-sacrificing, endure as possible to leave the community more
suffering for the sake of their families, and beautiful and beneficial than it was.
defer to their husbands in all matters. The • Imani refers to belief in the community’s
Virgin Mary is held up as the model to which parents, teachers, and leaders and in the
all women should aspire. righteousness and victory of the struggle.

Motivational interviewing is a counseling Organizational cultural competence and

style characterized by the strategic therapeutic responsiveness refers to a set of congruent
activities of expressing empathy, developing behaviors, attitudes, and policies that enable a
discrepancy, avoiding argument, rolling with system, agency, or group of professionals to
resistance, and supporting self-efficacy. In work effectively in cross-cultural situations
motivational interviewing, the counselor’s (Cross et al. 1989). It is a dynamic, ongoing
major tool is reflective listening. process.

Multiracial individuals are any racially mixed Orgullo means pride and dignity.
people and include biracial people, as well as Personalismo is the use of positive personal
those with more than two distinct racial herit- qualities to accomplish a task.
ages (Root 1992).
Race is a social construct that describes people
Native Hawaiians and other Pacific Is- with shared physical characteristics.
landers include those with “origins in any of
the original peoples of Hawaii, Guam, Samoa, Racism is an attitude or belief that people
or other Pacific Islands” (Grieco and Cassidy with certain shared physical characteristics are
2001, p. 2). Other Pacific Islanders include better than others.
Tahitians; Northern Mariana Islanders;
Reculturation occurs when individuals return
Palauans; Fijians; and cultural groups like
to their countries of origin after a prolonged
Melanesians, Micronesians, or Polynesians.
period in other countries and readapt to the
dominant culture.

297
 Improving Cultural Competence

Respeto can be translated as respect but also Transculturation is the acceptance of a part
includes elements of both emotional depend- or a trait of one culture into another culture.
ence and dutifulness (Barón 2000).
White privilege is a form of ethnocentrism
Selective perception is, in Helms’s model of and refers to a position of entitlement based
racial identity development, the tendency of on a presumed culturally superior status.
people early in the process to observe their
Whites/Caucasians are people “having ori-
environment in ways that generally confirm
gins in any of the original peoples of Europe,
their pre-existing beliefs.
the Middle East, or North Africa.” This
Simpatía is an approach to social interaction category includes people who indicate their
that avoids conflict and confrontation. One race as White or report entries “such as Irish,
who is simpático is agreeable and strives to German, Italian, Lebanese, Near Easterner,
maintain harmony within the group. Arab, or Polish” (Grieco and Cassidy 2001,
p. 2).
Syncretism is the result of combining differ-
ing systems, such as traditional and introduced
cultural traits.

298
Appendix H—Resource Panel

Note: Information given indicates each participant’s affiliation during the time the panel was
convened and may no longer reflect the individual’s current affiliation.
Ana Anders, M.S.W., LICSW Edwin M. Craft, Dr.P.H.
Senior Advisor Program Analyst
Special Populations Office Practice Improvement Branch
National Institute on Drug Abuse Division of Services Improvement
National Institutes of Health Center for Substance Abuse Treatment
Bethesda, MD Substance Abuse and Mental Health Services
Administration
Candace Baker, Ph.D.
Rockville, MD
Clinical Affairs Manager
Lesbian, Gay, Bisexual, and Transgender Christina Currier
Special Interest Group Public Health Analyst
National Association of Alcoholism and Drug Practice Improvement Branch
Abuse Counselors Division of Services Improvement
Alexandria, VA Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services
Carole Chrvala, Ph.D.
Administration
Senior Program Officer
Rockville, MD
Board on Neuroscience & Behavioral Health
Institute of Medicine Dorynne Czechowicz, M.D.
Washington, DC Medical Officer
Treatment Development Branch
Christine Cichetti
Division of Treatment Research and Development
Drug Policy Advisor
National Institute on Drug Abuse
United States Department of Health and
National Institutes of Health
Human Services
Bethesda, MD
Washington, DC
Janie B. Dargan
Cathi Coridan, M.A.
Senior Policy Analyst
Senior Director for Substance Abuse
Office of National Drug Control Policy
Programs
Executive Office of the President
National Mental Health Association
Washington, DC
Alexandria, VA

299
 Improving Cultural Competence

James (Gil) Hill, Ph.D. Richard T. Suchinsky, M.D.

Director Associate Chief for Addictive Disorders and
Office of Rural Health and Substance Abuse Psychiatric Rehabilitation
American Psychological Association Mental Health and Behavioral Sciences
Washington, DC Services
Department of Veterans Affairs
Hendree E. Jones, M.A., Ph.D.
Washington, DC
Assistant Professor
CAP Research Director Jan Towers, Ph.D.
Department of Psychiatry and Behavioral Director
Sciences Health Policy
Johns Hopkins University Center American Academy of Nurse Practitioners
Baltimore, MD Washington, DC
Guadelupe Pacheco, M.P.A. Jose Luis Velasco
Special Assistant to the Deputy Assistant Project Director
Secretary National Hispanic Council on Aging
Office of Minority Health Washington, DC
Department of Health and Human Services
Karl D. White, Ed.D.
Rockville, MD
Public Health Analyst
Cecilia Rivera-Casale, Ph.D. Practice Improvement Branch
Senior Project Officer Division of Services Improvement
Center for Mental Health Services Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Substance Abuse and Mental Health Services
Administration Administration
Rockville, MD Rockville, MD
Deidra Roach, M.D. Jeanean Willis, D.P.M., CDR, USPHS
Health Science Administrator Public Health Analyst
National Institute on Alcohol Abuse and Office of Minority Health
Alcoholism Health Resources and Services
Bethesda, MD Administration
Rockville, MD
Kevin Shipman, M.H.S., LPC
Deputy Chief
Grants and Program Management Division
Special Population Services
Washington, DC

300
Appendix I—Cultural Competence
and Diversity Network Participants

Note: Information given indicates each participant’s affiliation during the time the network was
convened and may no longer reflect the individual’s current affiliation.
Elmore T. Briggs, CCDC, NCAC II Terry S. Gock, Ph.D.
President/CEO Director
SuMoe Partners Pacific Clinics Asian Pacific Family Center
Germantown, MD Rosemead, CA
African American Workgroup Member Asian/Pacific Islander Workgroup and Lesbian/
Gay/Bisexual/Transgender Workgroup Member
Deion Cash
Executive Director Renata J. Henry, M.Ed.
Community Treatment and Correction Director
Center, Inc. Delaware Health and Social Services
Canton, OH New Castle, DE
African American Workgroup Member African American Workgroup Member
Magdalen Chang, Ph.D. Adelaida F. Hernandez, M.A., LCDC
Center Manager Youth OSR Services Program Director
Haight Ashbury Free Clinics, Inc. S.C.A.N., Inc.
San Francisco, CA Laredo, TX
Asian/Pacific Islander Workgroup Member Hispanic/Latino Workgroup Member
Diana Yazzie Devine, M.B.A. Ford H. Kuramoto, D.S.W.
Executive Director President
Native American Connections, Inc. National Asian Pacific American Families
Phoenix, AZ Against Substance Abuse
Native American Workgroup Member Los Angeles, CA
Asian/Pacific Islander Workgroup Member

301
 Improving Cultural Competence

Victor Leo, M.S.W., LCSW Tam Khac Nguyen, M.D., CCJS, LMSW
Board Chair President
Asian/Pacific American Consortium on Sub- Vietnamese Mutual Association, Inc.
stance Abuse Polk City, IA
Portland, OR Asian/Pacific Islander Workgroup Member
Aging Workgroup Member and Asian/Pacific
Rick Rodriguez
Islander Workgroup Member
Manager/Counselor
Harry Montoya, M.A. Services United
President/CEO Santa Paula, CA
Hands Across Cultures Hispanic/Latino Workgroup Member
Espanola, NM
Mariela C. Shirley, Ph.D.
Hispanic/Latino Workgroup Member
Assistant Professor
Michael E. Neely, Ph.D., MFCC University of North Carolina at Wilmington
Administrator Wilmington, NC
Integrated Care System Hispanic/Latino Workgroup Member
Los Angeles, CA
African American Workgroup Member

302
Appendix J—Field Reviewers

Note: Information given indicates each participant’s affiliation during the time the review was
conducted and may no longer reflect the individual’s current affiliation.
Alan J. Allery, M.Ed., M.H.A. Rodolfo T. Briseno, M.D., M.P.H.
Director Facilitator
Student Health Services Worker’s Assistance Program–Youth
University of North Dakota Advocacy
Grand Forks, ND Austin, TX
Deborah Altschul, Ph.D. Stephanie Brooks, M.S.W.
Assistant Professor/Psychologist Interim Director & Assistant Professor
Mental Health Services Research and Programs in Couple & Family Therapy
Evaluation Unit College of Nursing and Health Professions
Adult Mental Health Division Drexel University
Hawaii Department of Health Philadelphia, PA
University of Hawaii
Jutta H. Butler, B.S.N., M.S.
Honolulu, HI
Public Health Advisor
Diana S. Amodia, M.D. Practice Improvement Branch
Medical Director Division of Services Improvement
Substance Abuse Treatment Services Center for Substance Abuse Treatment
Haight Ashbury Free Clinics, Inc. Substance Abuse and Mental Health Services
San Francisco, CA Administration
Rockville, MD
Ronald G. Black
Director, Residential Group Flanders Byford, M.S.W., LCSW
Drug Abuse Foundation Licensed Clinical Social Worker
Del Ray Beach, FL Oklahoma City County Health Department
Oklahoma City, OK
Patricia T. Bowman
Probation Counselor Maria J. Carrasco, M.P.A
Fairfax Alcohol Safety Action Program Director
Fairfax, VA Multicultural Action Center
Arlington, VA

303
 Improving Cultural Competence

Gerhard E. Carrier, Ph.D. Lynn Dorman, Ph.D., J.D.

Chair, Mental Health & Addiction Studies President
Department of Mental Health Creating Solutions
Alvin Community College Portland, OR
Alvin, TX
Gayle R. Edmunds
Carol J. Colleran, CAP, ICADC Director
National Director of Older Adult Services Indian Alcoholism Treatment Services
Center of Recovery for Older Adults Wichita, KS
Hazelden Foundation/Hanley-Hazelden
Michele J. Eliason, Ed.S., Ph.D.
West Palm Beach, FL
Associate Professor
Cynthia C. Crone, APN, MNSC The University of Iowa
Executive Director Iowa City, IA
Center for Addictions Research, Education,
Jill Shepard Erickson, M.S.W., ACSW
and Services
Public Health Advisor
College of Medicine, Department of
Child and Family Branch
Psychiatry and Behavior Health
Center for Mental Health Services
University of Arkansas for Medical Sciences
Substance Abuse and Mental Health Services
Little Rock, AR
Administration
John P. de Miranda, Ed.M. Rockville, MD
Executive Director
Elena Flores, M.A., Ph.D.
National Association on Alcohol, Drugs, and
Associate Professor
Disability, Inc.
School of Education
San Mateo, CA
Counseling and Psychology Department
Efrain R. Diaz, Ph.D., LCSW University of California, San Francisco
Program Supervisor San Francisco, CA
Connecticut Department of Mental Health
Jo Ann Ford, M.R.C.
and Addiction Services
Assistant Director
Hartford, CT
Substance Abuse Resources and Disability
Dedric L. Doolin, M.P.A. Issues
Deputy Director School of Medicine
Area Substance Abuse Council, Inc. Wright State University
Cedar Rapids, IA Dayton, OH
Donna Doolin, LCSW Maria del Mar Garcia, M.S.W., M.H.S.
Director Continuing Education Coordinator
Division of Health Care Policy, Addiction & Caribbean Basin and Hispanic Addiction
Prevention Services Centro de Estudios en Adicción
Kansas Department of Social and Universidad Central del Caribe
Rehabilitation Services Bayamon, PR
Topeka, KS

304
 Appendix J—Field Reviewers

Virgil A. Gooding, Sr., M.A., M.S.W., Susan F. LeLacheur, M.P.H., PA-C

LISC Assistant Professor of Health Care Sciences
Clinical Director The George Washington University
Foundation II, Inc. Washington, DC
Cedar Rapids, IA
Jeanne Mahoney
Maya D. Hennessey, CRADC Director
Women’s Specialist Provider’s Partnership-Women’s Health Issues
Supervisor, Quality Assurance, Technical American College of Obstetricians and
Assistance & Training Gynecologists
Office of Special Programs Washington, DC
Division of Substance Abuse
Michael Mobley, Ph.D., M.Ed.
Illinois Department of Human Services and
Assistant Professor in Counseling Psychology
Substance Abuse
Department of Educational, School and
Chicago, IL
Counseling Psychology
Michael W. Herring, LCSW University of Missouri–Columbia
Wayne Psychiatric Associates, P.A. Columbia, MO
Goldsboro, NC
Valerie Naquin, M.A.
Deborah J. Hollis, M.A. Vice President
Administrator Planning and Development
Office of Drug Control Policy Cook Inlet
Division of Substance Abuse and Gambling Anchorage, AK
Services
Paul C. Purnell, M.S.
Michigan Department of Community Health
President
Lansing, MI
Social Solutions, LLC
Ruth Hurtado, M.H.A. Potomac, MD
Public Health Advisor
Laura Quiros, M.S.W.
Center for Substance Abuse Treatment
Program Associate
Division of Pharmacologic Therapies
Program Planning & Development Department
Substance Abuse and Mental Health Services
Palladia, Inc.
Administration
New York, NY
Rockville, MD
Melissa V. Rael, USPHS
Ting-Fun May Lai, M.S.W., CASAC
Senior Program Management Officer
Director
Co-Occurring and Homeless Branch
Chinatown Alcoholism Center
Division of State and Community Assistance
Hamilton-Madison House
Center for Substance Abuse Treatment
New York, NY
Substance Abuse and Mental Health Services
Tom Laws Administration
Talihina, OK Rockville, MD

305
 Improving Cultural Competence

Susanne R. Rohrer, R.N. Ming Wang, L.C.S.W.

Nurse Consultant Program Manager
Practice Improvement Branch Division of Substance Abuse and Mental
Division of Services Improvement Health
Center for Substance Abuse Treatment Utah Department of Human Services
Substance Abuse and Mental Health Services Salt Lake City, UT
Administration
Mike Watanabe, M.S.W.
Rockville, MD
President and CEO
Laurie J. Rokutani, Ed.S., NCC, CPP, Asian American Drug Abuse Program, Inc.
MAC Los Angeles, CA
Training Coordinator
Debbie A. Webster
Virginia Commonwealth University
Community Program Coordinator
Mid-America Addiction Technology Transfer
Best Practice Team
Center
Division of Mental Health, Developmental
Richmond, VA
Disabilities, and Substance Abuse Services
LaVerne R. Saunders, B.S.N., R.N., M.S. North Carolina Department of Health and
Training Specialist and Consultant Human Services
Dorrington & Saunders and Associates Raleigh, NC
Framingham, MA
Melvin H. Wilson, M.B.A., LCSW-C
Gary Q. Tester, MAC, CCDC III-E, OCPS High Intensity Drug Trafficking Area
II Coordinator
Director Maryland Division of Parole and Probation
Ohio Department of Alcohol and Drug Baltimore, MD
Addiction Services
Ann S. Yabusaki, M.Ed., M.A., Ph.D.
Columbus, OH
Director
Ralph Varela, M.S.W. Coalition for a Drug-Free Hawaii
Chief Executive Officer Honolulu, HI
Pinal Hispanic Council
Eloy, AZ

306
Appendix K—Acknowledgments

Numerous people contributed to the development of this Treatment Improvement Protocol

(TIP), including the TIP Consensus Panel (page vii), the Knowledge Application Program
(KAP) Expert Panel and Federal Government Participants (page ix), the Resource Panel
(Appendix H), the Cultural Competence and Diversity Network Participants (Appendix I), and
the Field Reviewers (Appendix J).
This publication was produced under KAP, a Joint Venture of The CDM Group, Inc. (CDM),
and JBS International, Inc., for the Substance Abuse and Mental Health Services
Administration’s Center for Substance Abuse Treatment.
CDM KAP personnel included Rose M. Urban, M.S.W., J.D., LCSW, CCAC, CSAC, KAP
Executive Project Director; Jessica L. Culotta, M.A., KAP Managing Project Co-Director and
former Managing Editor; Susan Kimner, Former Managing Project Co-Director; Raquel
Witkin, M.S., former Deputy Project Manager; Claudia A. Blackburn, Psy.D., Expert Content
Director; Shel Weinberg, Ph.D., Senior Research/Applied Psychologist; J. Max Gilbert, M.A.,
Ph.D., Senior Editor/Writer; Deborah Steinbach, M.A., and Janet G. Humphrey, M.A., former
Senior Editors/Writers; Claudia Askew, Catalina Bartlett, M.A., Angela Cross, Timothy
Ferguson, M.A., Randi Henderson, and Susan Hills, Ph.D., Writers; Angela Fiastro, Junior
Editor; Sonja Easley, former Editorial Assistant; Virgie D. Paul, M.L.S., Librarian; and Maggie
Nelson, former Project Coordinator.

307
Index

A CODs of, 105–106, 107, 108

AA (Alcoholics Anonymous), 113, 114, 136, cultural identification by, 27
137, 147, 155–156, 173, 174 cultural resources for, 290–291
ACA (American Counseling Association) defined, 14, 103–104, 295
Counselor Competencies, 46, 47, 56 evaluation and treatment planning, 109–
acceptance, culturally competent counselors 116, 110, 112, 115
showing, 49 families, concepts of and attitudes about,
access to care. See also health insurance cover- 19
age gender issues, 19, 104, 107, 111
by African Americans, 106–108 health disparities, 20
by Asians and Asian Americans, 120 health, illness, and healing, attitudes to-
as critical treatment issue, 80 ward, 108–109
by Hispanics and Latinos, 132 as high-context cultural group, 17
by Native Americans, 142–143 historical trauma of, 28, 108, 109–110
outreach strategies, 96–98, 97–98 incarceration rates, 108
for White Americans, 153 Kwanzaa, seven principles of, 297
acculturation, 24–27 mental disorders suffered by, 105–106
asking clients about, 62 organizational cultural competence and,
defined, 24, 295 73
five-level model for, 25 power and trust issues, 109–110
generational gap in, 23 recovery and relapse prevention, 115–116
tools for identifying and measuring, 27, religion and spirituality, 114, 115
253, 254–257, 288 substance use and abuse and drug cul-
acupuncture, 126 tures, 27, 104–105
adapting intervention strategies to clients’ traditional/alternative healing practices
cultural needs, 50, 55, 56, 71–72 and, 114–115
Addiction Technology Transfer Centers, 287 treatment patterns, 106–108
Addressing the Specific Behavioral Health Needs Agency Cultural Competence Checklist, 264–
of Men (TIP 56), 20 265
advisory and governing boards, 79 Agency for Healthcare Research and Quality
affective/mood disorders, 105–106, 153 (AHRQ), 20, 85, 287
Affordable Care Act, 7 AI-SUPER PFP (American Indian Services
African Americans, 14, 103–116 Utilization and Psychiatric Epidemiology
Afrocentricity of, 62

309
 Improving Cultural Competence

Risk and Protective Factors Project), 140, emotional expression and, 69, 119, 123
141, 142, 147 evaluation and treatment planning for,
Alaskan Natives. See Native Americans 121, 121–128, 123
Alcoholics Anonymous (AA), 113, 114, 136, families, role of, 1, 19, 61, 72, 124
137, 147, 155–156, 173, 174 gender issues, 122–123
alcohol abuse. See drug cultures; substance geographic factors, 18
abuse health, illness, and healing, attitudes to-
alcohol flushing response, 119 ward, 119, 120–121
alternative healing practices. See tradition- language and communication issues, 17,
al/alternative healing practices 54
American Counseling Association (ACA) mental disorders, 57, 119–120
Counselor Competencies, 46, 47, 56 recovery and relapse prevention among,
American Indian Services Utilization and 128
Psychiatric Epidemiology Risk and Protec- religion and spirituality, 126–128
tive Factors Project (AI-SUPER PFP), 140, shame and guilt, 1, 117, 119, 121, 122
141, 142, 147 structured approach to counseling often
American Indians. See Native Americans preferred by, 55
American Psychiatric Association (APA), 69, substance use and abuse and drug cul-
283 tures, 1, 57, 117–119
American Religious Identification Survey, 30 traditional/alternative healing practices
American Translators Association, 287 used by, 126–128
anxiety disorders, 61, 72, 105, 107, 109, 124, trauma, personal or historical, 119–120
126, 142, 153 treatment patterns, 120
APA (American Psychiatric Association), 69, assessment. See evaluation and planning;
283 measurement; self-assessment
APIs (Asians and Pacific Islanders), 14. See assimilation, 24
also Asians and Asian Americans; Pacific Association for Multicultural Counseling, 37,
Islanders 45
appreciation, as stage in racial and cultural ataque de nervios, 284
identity development, 40 attitudes and behaviors of culturally compe-
Arab Americans, 32, 65, 150, 152 tent counselors, 49–50
Asian Indians, 14, 116. See also Asians and avoidance of certain counselor behaviors, 51
Asian Americans
Asians and Asian Americans, 14, 116–128. See B
also immigrants Baltimore Epidemiologic Catchment Services
adopted into White families, 117 Area study (1980s), 106
client–counselor matching, 71 behavioral health
CODs, 119–120 critical treatment issues for culturally re-
community fairs, 98 sponsive services, 80
complex cultural problems, counselors al- cultural knowledge about, as core compe-
lowing for, 51 tency, 48, 48–49
in criminal justice system, 120 defined, 3
cultural resources for, 291–292 Behavioral Health Services for American Indians
defined, 295 and Alaska Natives (planned TIP), 139
educational factors, 22

310
 Index

behavioral health service providers and coun- evaluation and treatment planning
selors. See also core competencies; self- (Zhang Min), 57–58, 62
assessment; self-knowledge, as core compe- group clinical supervision case study
tency (Beverly), 72
behaviors to avoid, 51 Hispanics and Latinos (Anna), 136
on continuum of cultural competence, importance of cultural competence
10–11 (Hoshi), 1
diversity of, 4–5, 8 Native Americans (John), 101–102
evaluation and monitoring of staff per- organizational cultural competence
formance, 95–96, 96 (Cavin), 73–74
importance of cultural competence for, 2 racial and cultural identity, 41
matching clients with, 71 Caucasians. See White Americans
organizational staff development, 75, 90– CBT. See cognitive–behavioral therapy
96, 92–96 CCHCP (Cross Cultural Health Care Pro-
professional development tool for super- gram), 288
visor-supervisee discussions, 95 Census Bureau, U.S., racial and ethnic groups,
in Sue’s multidimensional model for de- xvi, 13
veloping cultural competence, 6, 6–7 Center for Integrated Health Solutions
behaviors and attitudes of culturally compe- (CIHS), 98
tent counselors, 49–50 Center for Mental Health Services (CMHS),
biculturalism and mixed cultural identity, 5, 288
24, 57–58, 62, 116–117, 295 Center for Research on Ethnicity, Culture,
bipolar disorders, 41, 69, 153 and Health, 287
biracial or multiracial people, 5, 13, 14, 62, Center for Substance Abuse Treatment
295, 297 (CSAT)
Blacks. See African Americans Targeted Capacity Expansion Program,
boards, governing and advisory, 79 98
Brief Interventions and Brief Therapies for TIPs. See Treatment Improvement Proto-
Substance Abuse (TIP 34), 157 cols
Buddhists and Buddhism, 32–33, 123, 128, Central and South Americans, 32, 129, 131,
156 135, 285. See also Hispanics and Latinos
change, determining readiness and motivation
C for, 69–70
cabellerismo, 19 chibih, 285
Cambodians, 117, 118, 119, 123, 128. See also Chinese, 14, 32, 51, 57, 98, 117, 118, 123, 124,
Asians and Asian Americans 125, 126, 285. See also Asians and Asian
cao gio, 126 Americans
Caribbeans, 104, 106, 113, 128, 284. See also Christians and Christianity, 31, 101, 115, 128,
African Americans; Hispanics and Latinos 138, 149, 156
case management, culturally responsive, 70, CIDI (Composite International Diagnostic
70–71, 71 Interview), 68
Case Management Society of America, 71 CIHS (Center for Integrated Health Solu-
case studies tions), 98
core competencies (Gil), 35 circles, in Native American philosophy, 147,
drug cultures (Lisa), 159–161 148

311
 Improving Cultural Competence

cirrhosis, 105, 140, 141 collateral information of cultural relevance, 64,

Civil Rights Movement, 38 64–65, 66–67
clinical issues, culturally framing, 49 committees, organizational, for cultural com-
clinical/program attributes. See evaluation and petence, 79–80
treatment planning communication. See language and communi-
clinical scales and CODs, 65–68 cation
clinical supervisors and clinical supervision. Community-Defined Solutions for Latino Men-
See also core competencies tal Health Care Disparities (Aguilar-Gaxiola
diversity of, 4–5, 8 et al., 2012), 98
evaluation and monitoring of staff per- community involvement and awareness
formance, 95–96, 96 demographic profiles, 84
group clinical supervision case study environmental appropriateness for popu-
(Beverly), 72 lations served, 96
importance of cultural competence for, 2, feedback, gathering, 86
93–95, 94 as key culturally responsive practice, 8
mapping racial and cultural identity de- Native American treatment planning and,
velopment and, 42 101–102, 143, 144
professional development tool for super- outreach programs, 96–98, 97–98
visor-supervisee discussions, 95 strategies for engaging, 80, 80–81
training content for language services per- Community Toolbox, 287
sonnel, 90 complementary healing practices. See tradi-
clinical worldview, 43 tional/alternative healing practices
CMHS (Center for Mental Health Services), complex cultural problems, counselors allow-
288 ing for, 51
co-occurring disorders (CODs) Composite International Diagnostic Interview
of African Americans, 105–106, 107, 108 (CIDI), 68
of Asians and Asian Americans, 119–120 confianza, 295
clinical scales, culturally valid, 65–68 confidentiality issues, 134, 144
counselor knowledge of cultural distribu- conformity, as stage in racial and cultural
tion of, 48–49 identity development, 40, 295
of Hispanics and Latinos, 131–132 Consumer Assessment of Healthcare Provid-
immigrants and, 26 ers and Systems Cultural Competence Item
of Native Americans, 141–142 Set, 85
Substance Abuse Treatment for Persons With contingency management approaches, 111,
Co-Occurring Disorders (TIP 42), 20, 135
157 continuum of cultural competence, 9–11, 10–
of White Americans, 153 11
cognitive–behavioral therapy (CBT) core assumptions of cultural competence, xvii,
for African Americans, 111 4–5
for Asians and Asian Americans, 123–124 core competencies, xvii–xviii, 3, 36–56. See also
for Hispanics and Latinos, 135 self-knowledge, as core competency
for Native Americans, 145 adapting intervention strategies to clients’
for White Americans, 155 cultural needs, 50, 55, 56
collaborative approach, 60–61, 109, 111 attitudes and behaviors of culturally com-
petent counselors, 49–50

312
 Index

behavioral health, cultural knowledge core competencies for counselors and

about, 48, 48–49 clinical staff, xvii–xviii, 3, 35–56. See
behaviors to avoid, 51 also core competencies
case studies, 35, 41 cross-cutting factors, xvii, 16–33, 46–47,
clinical issues, framing in culturally rele- 62, 63, 150
vant ways, 49 defined, xv, 5–7, 11, 295–296
complex cultural problems, allowing for, development of, xvi, 9–11, 10–11
51 diversity aiding, 4–5, 8
cross-cutting factors affecting, 46–47 drug cultures, xxi, 3, 159–175. See also
knowledge of other cultural groups, 44– drug cultures; substance abuse
47, 45, 47 in evaluation and treatment planning,
personal space issues, dealing with, 51–52 xviii–xix, 3, 57–72. See also evaluation
power and trust issues, 44, 52 and treatment planning
self-assessment tools, 55, 259–63 importance to behavioral health field, xv–
skill development, 49–50, 49–55, 51, 53– xvi, 1–2, 7–9
54 at multiple levels of operation, 4
in Sue’s multidimensional model for de- in organizations, xix–xx, 73–99. See also
veloping cultural competence, 6, 36, 37 organizational cultural competence
touch, awareness of culturally specific public advocacy of, 5
meanings of, 52 purpose and objectives of pursuing, 2
counselors. See behavioral health service pro- for specific racial and ethnic groups, xx–
viders and counselors xxi, 3, 101–57. See also racial and ethnic
criminal justice system groups; specific groups
African Americans in, 108 Sue’s multidimensional model for devel-
Asians and Asian Americans in, 120 oping, xv, 5–7, 6, 36, 37, 58, 74, 102,
Native Americans in, 143 103, 160, 161
Substance Abuse Treatment for Adults in the terminology used in discussing, 3
Criminal Justice System (TIP 44), 157 Cultural Competence for Health Administra-
cross-cultural applicability of diagnostic sys- tion and Public Health, 93
tems, 68–69 cultural competence plans, 81–82, 82, 84, 87,
cross-cultural communication, 59 296
Cross Cultural Health Care Program cultural concepts of distress, 30, 69, 284–285
(CCHCP), 288 cultural destructiveness, 10
cross-cutting factors, xvii, 16–33, 46–47, 62– cultural diffusion, 296
63, 150 cultural formulation, 69, 283–284
CSAT. See Center for Substance Abuse cultural humility, 50, 296
Treatment cultural identity, 24–27
Cubans and Cuban Americans, 129, 130, 131. asking clients about, 62
See also Hispanics and Latinos case study, 41
culturagrams, 65, 66–67 defined, xvii, 16
cultural awareness, 38 diagnosis, cultural formulation in, 283
cultural blindness, 10–11 drug culture, as alternative to, 173
cultural competence, xv–xxi, 1–33 mapping, 41, 42
core assumptions of, xvii, 4–5 mixed, 57–58, 62, 116–117
models of, 39, 40

313
 Improving Cultural Competence

for Native Americans, 26–27, 144–145 drug cultures, xxi, 3, 159–175. See also sub-
self-knowledge of counselors regarding, stance abuse
38, 38–41, 40, 41 of African Americans, 104–105
subcultures, 62–63 of Asians and Asian Americans, 117–119
terminology of, 24 attraction of, 165–169
tools for measuring and identifying, 253, case study (Lisa), 159–161
254–257, 288 cultural identity as alternative to, 173
for White Americans, 39, 154 culture of recovery replacing, xxi, 173,
cultural incapacity, 10 173–175, 174, 175
cultural norms, xvi, 12, 45, 48, 52, 60, 296 daily routines and rituals, assessing, 172
Cultural Orientation Resource Center, 23 defined, 161–164
cultural precompetence, 11 differences between, 161, 162
cultural proficiency, 296 evaluation and treatment planning ad-
culture, defined, xvi, 11–13, 12, 296 dressing, 171–175, 172
Culture Matters: The Peace Corps Cross-Cultural exercise on benefits, losses, and the fu-
Workbook (2012), 52 ture, 170–171
culture of recovery, xxi, 173, 173–175, 174, 175 families and, 169
Cup’ik Eskimo, 148 geographical variations, 161, 162
curanderismo, 138 of Hispanics and Latinos, 129–131, 130
identifying key characteristics of, 162–163
D as initiating and sustaining force for sub-
daily routines and rituals of substance abusers, stance abuse, 167, 169
assessing, 172 language and terminology of, 164
dances, sacred, 148 mainstream culture, relationship to, 164–
demographic profiles, developing, 84 165
Departments, U.S. See entries at U.S. music and, 165, 166–167
depression, 21, 49, 51, 57, 69, 72, 107, 109, of Native Americans, 139–141
119, 124, 131, 141, 142, 153 online, 169–171
development of cultural competence, xvi, 9–11, rituals of, 167, 168
10–11 SES and, 162, 169
dhat, 284 skills required for certain drug use,
diabetes, 49, 141, 290 transmitting, 167, 168
diagnosis, 68–69, 283–285 as subcultural phenomenon, 160, 161–162
Diagnostic and Statistical Manual of Mental Sue’s multidimensional model for devel-
Disorders, Fifth Edition (DSM-5), 30, 68, oping cultural competence and, 160,
283, 284–285 161
dissonance, as stage in racial and cultural of White Americans, 150–152
identity development, 40 worldviews, values, and traditions of, 165,
distress, cultural concepts of, 30, 69, 284–285 166
diversity DSM-5 (Diagnostic and Statistical Manual of
at developmental and organizational lev- Mental Disorders, Fifth Edition), 30, 68,
els, 4–5, 8, 90–91 283, 284–285
within racial and ethnic groups, 17–18,
103
Diversity Rx, 288

314
 Index

E culturagram, 65, 66–67

East Harlem Protestant Parish, 138 cultural identity and acculturation, de-
EBP. See evidence-based practices termining, 62
educational factors, 21–22, 22, 67 diagnosis, 68–69, 283–285
emotional expression, 54–55, 69, 119, 123 distress, cultural concepts of, 30, 69, 284–
enculturation, 24 285
engaging clients, 59, 59–60 diversity of population developing, 4–5
Engaging Moms, 113 drug cultures, addressing, 171–175, 172
Enhanced National Standards for Culturally and eliciting client views on their problems,
Linguistically Appropriate Services in Health 63
and Health Care (OMH, 2013), 8, 75, 265– engaging clients at initial meeting, 59,
266 59–60
Enhancing Motivation for Change in Substance familiarization of client with process, 59–
Abuse Treatment (TIP 35), 69, 70, 157 60
environmental appropriateness for populations families, inclusion of, 1, 59–60, 61, 64–65
served, 96 health, illness, and healing, different cul-
epicanthic eye fold, 13 tural attitudes toward, 60, 61, 63, 64
equality, commitment to, 40, 50 for Hispanics and Latinos, 133–138
ESI (Ethnic-Sensitive Inventory), 262–263 immigration history, taking, 23, 61, 66
espanto, 285 integration of culturally relevant issues,
espiritismo, 138 61–63, 61–64
ethnic groups. See racial and ethnic groups matching clients and counselors, 71, 134
Ethnic-Sensitive Inventory (ESI), 262–263 motivational interviewing, 70
ethnocentrism, 9, 40, 296, 298 multicultural intake checklist, 64
ethnogeriatrics, 290 for Native Americans, 143, 143–150, 145
evaluation and monitoring one-size-fits-all approach, importance of
of organizational cultural competence, 74, avoiding, 58
75, 84–87, 85, 86, 264–273 for Pacific Islanders, 127
of staff performance, 95–96, 96 screening and assessment tools, 65–69,
evaluation and treatment planning, xviii–xix, 3, 68, 277, 277–81
57–72 strength-based interviews, 61
adapting intervention strategies to clients’ subcultures, 62–63
cultural needs, 50, 55, 56, 71–72 in Sue’s multidimensional model for de-
for African Americans, 109–116, 110, veloping cultural competence, 6, 6–7,
112, 115 58
benefits of cultural competency for, 4 traumatic experiences, 63
case management, 70, 70–71, 71 for White Americans, 154–156
case studies, 57–58, 62, 72 evidence-based practices (EBPs)
change, determining readiness and moti- counselors’ cultural sensitivity and, 37
vation for, 69–70 health disparities, reducing, 20
collaborative approach to, 60–61 for Hispanics and Latinos, 134
collateral information of cultural rele-
vance, 64, 64–65, 66–67 F
cross-cutting factors affecting, 62, 63 families
in Asian culture, 1, 19, 61, 72, 124

315
 Improving Cultural Competence

counselor’s worldview of, 72 mental disorders and substance abuse is-

culturagrams, 66 sues, 20
cultural variations regarding, 19 Substance Abuse Treatment: Addressing the
drug cultures and, 169 Specific Needs of Women (TIP 51), 20,
gathering culturally relevant collateral in- 123, 157
formation from, 64–65 White Americans and, 19
health, illness, and healing, cultural atti- genetics and race, 13
tudes toward, 30, 60, 61 geographical factors in cultural competence,
in Hispanic and Latino culture, 129–130, 17–18, 62–63, 161, 162
135 governance, of organizations, 75, 78–80, 80
immigration and migration issues, 22, 23 governing and advisory boards, 79
inclusion in evaluation and treatment group clinical supervision case study (Beverly),
process, 1, 59–60, 61, 64–65 72
in Native American culture, 145–146 group therapy
family therapy, 19, 49 for African Americans, 113
for African Americans, 111–113, 113 for Asians and Asian Americans, 125
for Asians and Asian Americans, 124, exercise on benefits, losses, and the fu-
124–125 ture, 170–171
for Hispanics and Latinos, 135–136, 136, for Hispanics and Latinos, 136
137 Ho’oponopono (used by Native Hawai-
for Native Americans, 145–146 ians), 127
Substance Abuse Treatment and Family for Native Americans, 146
Therapy (TIP 39), 19, 146, 157 Substance Abuse Treatment: Group Therapy
for White Americans, 155 (TIP 41), 155, 157
feedback, gathering, 85, 85–87, 86, 273–275 for White Americans, 155
fetal alcohol syndrome, 141
Filipinos, 14, 118. See also Asians and Asian
Americans H
fiscal support of organizational cultural com- Hands Across Cultures Corporation, New
petence, 96 Mexico, 77–78, 78
flexibility, culturally competent counselors Hawaiians. See Pacific Islanders
showing, 50, 55 health disparities
four circles, 158 causes of, 20
cultural competence reducing, 7
G defined, 7, 296
gender, 19–20 National Center on Minority Health and
acculturation and, 26 Health Disparities, 289
Addressing the Specific Behavioral Health SES and, 21
Needs of Men (TIP 56), 20 health, illness, and healing
African Americans and, 19, 104, 107, 111 African American attitudes toward, 108–
for Asians and Asian Americans, 122– 109
123 Asian and Asian American attitudes to-
client–counselor matching for, 71, 134 ward, 119, 120–121
in Hispanic and Latino culture, 19–20, core competency, cultural knowledge of
129, 134 behavioral health as, 48, 48–49

316
 Index

culturagrams, 67 evaluation and treatment planning for,

different cultural attitudes toward, 29–30, 133–138
60, 61, 63, 64 family role in culture of, 129–130, 135
Hispanic and Latino attitudes toward, gender roles, 19–20, 129, 134
133 geographic factors, 18
Native American attitudes toward, 143, health, illness, and healing, attitudes to-
147–148 ward, 133
Pacific Islanders’ attitudes toward, 127 language and communication issues, 17
White American attitudes toward, 153– mental disorders, 131–132
154 recovery and relapse prevention, 138
health insurance coverage religion and spirituality of, 137, 138
for African Americans, 107 sexual identity and orientation, 29
for Asians and Asian Americans, 120 substance use and abuse and drug cul-
for Hispanics and Latinos, 132, 137 tures, 35–36, 129–131, 130
for Native Americans and Pacific Is- traditional/alternative healing practices,
landers, 142 137–138
SES and treatment access, 20, 22 treatment patterns for, 132
Health Resources and Services Administra- history and heritage, 27–29. See also trauma,
tion (HRSA) personal or historical
Administration Culture, Language and of counselors, 43–44
Health Literacy Page, 288 of organizational cultural competence, 98,
CIHS (Center for Integrated Health So- 99
lutions), 98 HIV/AIDS, 105, 290
domains of organizational cultural com- Hmong, 18, 30, 52, 126
petence, 75, 75–76, 266–268 Hogg Foundation for Mental Health, 86
Organizational Cultural Competence As- Holocaust, 28
sessment Profile, 266–268 homosexuality, 29, 162–163
Healthy People 2020, 21 Ho’oponopono, 127
Health and Human Services (HHS). See U.S. Hopi, 139–140
Department of Health and Human Ser- HRSA. See Health Resources and Services
vices Administration
Helms’s model of racial identity development, humility, culturally competent counselors
298 showing, 50, 296
hembrismo, 296
heritage. See history and heritage I
HHS (Health and Human Services). See U.S. IHS (Indian Health Service), 139, 142, 293
Department of Health and Human Ser- iMCI (International MultiCultural Institute),
vices 289
high-context versus low-context cultural immersion, as stage in racial and cultural
groups, 17, 54 identity development, 40, 296
Hispanics and Latinos, 15, 128–138. See also immigrants, 22–27
immigrants acculturation and cultural identification,
CODs of, 131–132 23, 24, 24–27, 25, 27
cultural resources for, 292–293 culturagrams, 66
distress, cultural concepts of, 284–285 Cultural Orientation Resource Center, 23

317
 Improving Cultural Competence

evaluation and treatment planning for, Jews and Judaism, 28, 30, 31–32, 156
23, 61, 66 jiryan, 284
family issues, 22, 23 Journey Mental Health Center ( JMHC),
history and heritage, effects of, 27–28 Wisconsin, 76
initial interview and assessment ques-
tions, 23
legal status of, 22, 66–67, 134 K
mental disorders and, 22–23 Kickapoo Reservation, Texas, 141
migrant/seasonal workers, 24 Kiowa gourd dance, 148
refugees, 23, 28, 52 Koreans, 14, 16, 19, 61, 98, 117, 118, 120, 124,
substance abuse issues, 23, 25–26, 130 126, 128. See also Asians and Asian Ameri-
incarceration. See criminal justice system cans
Indian Health Service (IHS), 139, 142, 293 Kung San bushmen, 13
Indians. See Asian Indians; Native Americans Kwanzaa, seven principles of, 297
indigenous peoples, 52, 297. See also Native
Americans; Pacific Islanders
individual counselors. See behavioral health L
service providers and counselors Lakota version of the 12 Steps, 147
infrastructure, organizational, 75, 96–98, 97– language and communication, 16–17
98, 99 assessing cultural differences in, 53–54
initial meeting, engaging clients at, 59, 59–60 counselor adjustment of communication
institutional racism, 46, 297 style, 52–54
Instruments for Measuring Acculturation culturagrams, 67
(University of Calgary), 288 defined, 297
integration of culturally relevant issues into drug cultures, 164
evaluation and treatment planning, 61–63, emotional expression, 54–55, 69, 119
61–64 examples of cultural differences, 17
integrative awareness, as stage in racial and high-context versus low-context cultural
cultural identity development, 40 groups, 17, 54
International MultiCultural Institute (iMCI), improving cross-cultural communication,
289 59
International Statistical Classification of informing clients about language services,
Diseases and Related Health Problems, 68 88
interviews. See evaluation and treatment plan- nonverbal communication, 16–17, 54
ning organizational language services (transla-
introspection, as stage in racial and cultural tors), 75, 88, 88–90, 90
identity development, 40 translators, 88, 88–90, 90, 287
Iowa Cultural Understanding Assessment, 86, White Americans’ issues with, 155
273–275 Laotians, 118. See also Asians and Asian
Islam, 32, 115, 156 Americans
Latinos. See Hispanics and Latinos
J LEARN mnemonic, 59, 60
jail. See criminal justice system legal status of immigrants, 22, 66–67, 134
Japanese, 1, 14, 32, 126, 285. See also Asians LGBT community, 29, 162–163
and Asian Americans Living in the Balance intervention, 111

318
 Index

low-context versus high-context cultural models of racial identity, 38

groups, 17, 54 monitoring and evaluation
of organizational cultural competence, 74,
M 75, 84–87, 85, 86, 264–273
machismo, 19, 137, 297 of staff performance, 95–96, 96
marianismo, 19, 297 Monitoring the Future Study, 131
matching clients, counselors, and programs, mood and affective disorders, 105–106, 153
71, 134 motivation for change
measurement determining, 69–70
acculturation and cultural identity, 27, Enhancing Motivation for Change in Sub-
253, 254–257, 288 stance Abuse Treatment (TIP 35), 69,
communication styles, cultural differences 70, 157
in, 53–54 motivational interviewing, 70
drug cultures, 162–163 for African Americans, 110
Medicare, 22, 265 defined, 297
mental disorders. See also co-occurring disor- for Hispanics and Latinos, 135
ders; specific conditions for Native Americans, 145
of African Americans, 105–106 Multicultural Counseling Self-Efficacy Scale,
of Asians and Asian Americans, 57, 119– 259
120 multicultural intake checklist, 64
cultural differences in understanding of, Multiculturally Competent Service System
30 Assessment Guide, 268–273
diagnosis, 68–69 multiracial or biracial people, 5, 13, 14, 62,
gender roles and, 20 295, 297
geographic factors, 18 music and drug cultures, 165, 166–167
of Hispanics and Latinos, 131–132 Muslims, 32, 115, 156
immigrants and, 22–23, 26 mutual-help groups. See also 12-Step pro-
of Native Americans, 141–142 grams, under T
religion and spirituality, 31 for African Americans, 113–114
SES and, 21 for Asians and Asian Americans, 125–126
trauma-induced, 28–29 for Hispanics and Latinos, 136–137
of White Americans, 153 for Native Americans, 146–147, 147
Mental Health: Culture, Race, and Ethnicity for White Americans, 155–156
(Surgeon General’s report, 2001), 290
methadone programs, 111, 132, 135
Mexicans and Mexican Americans, 18, 25, 26, N
35–36, 128–129, 130, 131, 133, 134, 135, NA (Narcotics Anonymous), 113, 160, 174
137, 138, 167, 285. See also Hispanics and Na Wahine Makalapua Project, 127
Latinos naiveté, as stage in racial and cultural identity
MHP (Minority Health Project), 288–289 development, 40
migrant/seasonal workers, 24 narcocorridos, 167
Minority Health Project (MHP), 288–289 Narcotics Anonymous (NA), 113, 160, 174
mission statements, 77–78, 78 National Alliance on Mental Illness, 156
mixed cultural identity/biculturalism, 5, 24, National Ambulatory Medical Care Survey,
57–58, 62, 116–117, 295 106

319
 Improving Cultural Competence

National Association of Social Workers, 71 health, illness, and healing, attitudes to-
National Center for Cultural Competence ward, 143, 147–148
(NCCC), 86, 259, 289 historical trauma of, 28, 140, 142
National Center on Minority Health and IHS and Tribal service providers, 139,
Health Disparities, 289 142, 293
National Comorbidity Study, 142 language and communication issues, 17
National Congress of American Indians, 141 mental disorders of, 141–142
National Epidemiologic Survey on Alcohol monthly newsletters, 98
and Related Conditions (NESARC), 114, motivational interviewing, 70
115, 154 personal space, cultural differences re-
National Institute on Minority Health and garding, 51
Health Disparities, 20 recovery and relapse prevention, 148,
National Institutes of Health (NIH), 20, 68 149–150
National Latino and Asian American Study religion and spirituality, 102, 144, 149
(NLAAS), 118, 120 substance use and abuse and drug cul-
National Survey on Drug Use and Health tures, 26–27, 139–141
(NSDUH) data traditional/alternative healing practices,
on African Americans, 104, 108, 114 72, 102, 144, 147–149, 148
on Asians and Asian Americans, 117, treatment patterns, 142–143
119, 120, 121, 125 Wellbriety movement, 49, 147
on Hispanics and Latinos, 132, 133 Navajo, 140
on Native Americans, 139, 140, 142 NCCC (National Center for Cultural Com-
on Pacific Islanders, 127 petence), 86, 259, 289
on racial and ethnic groups, 18, 21, 117 nervios, 285
on White Americans, 152, 154 NESARC (National Epidemiologic Survey on
Native Americans, 14–15, 138–150 Alcohol and Related Conditions), 114, 115,
Behavioral Health Services for American Indians 154
and Alaska Natives (planned TIP), 139 nguzo saba, 297
case study (John), 101–102 NIH (National Institutes of Health), 20, 68
CODs of, 141–142 NLAAS (National Latino and Asian Ameri-
community involvement, importance of, can Study), 118, 120
101–102, 143, 144 node-link mapping, 111, 135
complex cultural problems, counselors al- nonverbal communication, 16–17, 54
lowing for, 51 NSDUH. See National Survey on Drug Use
confidentiality issues, 144 and Health (NSDUH) data
in criminal justice system, 143
cultural identification, importance of, 26– O
27, 144–145 Office of Civil Rights, 289
cultural resources for, 293–294 Office of Minority Health (OMH), 289
defined, 295 definition of cultural competence, 5
evaluation and treatment planning for, Enhanced National Standards for Cultural-
143, 143–50, 145 ly and Linguistically Appropriate Services
family in culture of, 145–146 in Health and Health Care (2013), 8,
geographic factors, 18 75, 265–266
Resource Center (OMHRC), 289–290

320
 Index

staff education and training guidelines, Organizational Cultural Competence Assess-

93, 94 ment Profile (HRSA), 266–268
online drug cultures, 169–171 orgullo, 297
openness, culturally competent counselors orientation sessions, 134
showing, 50 outreach strategies and access to care, 96–98,
organizational cultural competence, xix–xx, 97–98
73–99
basic requirements for, 74, 75 P
benefits to organization, 8 Pacific Islanders, 14, 116–117, 127. See also
case study (Cavin), 73–74 Asians and Asian Americans
commitment to, throughout organization, access to care, 142
76–77, 77 client–counselor matching, 71
community involvement in, 8, 80, 80–81, cultural resources for, 291–292
84, 86, 96 defined, 297
continuum of cultural competence, or- evaluation and treatment planning for,
ganizations on, 10–11 127
defined, 297 health, illness, and healing, attitudes to-
diversity necessary for, 4–5, 90–91 ward, 121, 127
engagement of all parties in, 80, 80–81 substance abuse by, 127
evaluation and monitoring of, 74, 75, 84– pasmo, 285
87, 85, 86, 264–273 peer-supported interventions and strategies,
feedback, gathering, 85, 85–87, 86, 273– 110, 113–114. See also group therapy; mutu-
275 al-help groups
fiscal support for, 96 pelea nonga, 133–134
governance, 75, 78–80, 80 People Awakening Project, 150
historical perspective on, 98, 99 perdida del alma, 285
HRSA domains of, 75, 75–76 performance evaluation
importance of organizational commit- of organizational cultural competence, 74,
ment, 2, 4 75, 84–87, 85, 86, 264–273
infrastructure supporting, 75, 96–98, 97– of staff performance, 95–96, 96
98, 99 personal space, 51–52
language services, 75, 88, 88–90, 90 personalismo, 17, 133, 138, 297
mapping racial and cultural identity de- Pew Forum on Religion and Public Life
velopment and, 42 (2008), 30
planning, 75, 80–83, 82, 87 planning. See also evaluation and treatment
self-assessments, 84–87, 85, 86, 264–273 planning
senior management in charge of, 78–79 cultural competence plans, 81–82, 82, 84,
strategic planning, 78 87, 296
in Sue’s multidimensional model for de- fiscal support of organizational cultural
veloping cultural competence, 6, 6–7, competence, 96
74 organizational cultural competence, 75,
values of organization and, 75, 76–78, 77, 80–83, 82, 87
78 plática, 17
workforce and administrative staff devel- policies and procedures, organizational review
opment, 75, 90–96, 92–96 of, 82–83

321
 Improving Cultural Competence

posttraumatic stress disorder (PTSD), 105, health disparities among, 20

106, 119, 142 health, illness, and healing, cultural atti-
power and trust issues, 44, 52, 109–110 tudes toward, 29–30
prejudices, of counselors, 43–44, 44 Jewish, 31
prison. See criminal justice system language and communication issues, 16–
procedures and policies, organizational review 17, 17
of, 82–83 mapping racial and cultural identity de-
professional development programs, 91, 94 velopment, 41, 42
Prohibition, 151 models of racial identity, 38, 39, 40
Project MATCH, 70 Muslims, 32
promotion strategies for workforce and staff, self-knowledge of counselor regarding ra-
90–91 cial, ethnic, and cultural identities, 38,
A Provider’s Introduction to Substance Abuse 39–41, 40, 41
Treatment for Lesbian, Gay, Bisexual, and sexual identity and orientation, 29
Transgender Individuals (CSAT, 2001), 29 sizes and percentages, 13
psychoeducation, 9, 111, 113, 125, 157, 170– in Sue’s multidimensional model for de-
171 veloping cultural competence, 5–6, 6,
PTSD (posttraumatic stress disorder), 105, 102, 103
106, 119, 142 U.S. Census Bureau groupings, xvi, 13
public advocacy of cultural competence, 5 worldviews, values, and traditions, differ-
Puerto Ricans, 59, 129, 130, 131, 132, 135, ences in, 18–19
136, 138. See also Hispanics and Latinos racial/cultural identity development (R/CID)
purification ceremonies, 72, 148 model, 39, 40, 41, 42
racism, 21, 28, 39, 40, 46, 50, 52, 56, 60, 109–
110, 119, 297
R readiness and motivation for change, deter-
R/CID (racial/cultural identity development) mining, 69–70
model, 39, 40, 41, 42 recovery and relapse prevention
racial and ethnic groups, xx–xxi, 3, 101–157. for African Americans, 115–116
See also African Americans; Asians and for Asians and Asian Americans, 128
Asian Americans; Hispanics and Latinos; culture of recovery, xxi, 173, 173–175,
Native Americans; Pacific Islanders; White 174, 175
Americans for Hispanics and Latinos, 138
Buddhists, 32 for Native Americans, 148, 149–150
case studies, 41, 101–102 Relapse Prevention and Recovery Promotion
client–counselor matching, 71, 134 in Behavioral Health Services (planned
definitions of race and ethnicity, xvi, 13– TIP), 128, 157, 173–174
16, 15, 296, 297 for White Americans, 156–157
diversity within, 17–18, 103 recovery camps, Native American, 149
ethnic or token representatives, 90–91 recruitment strategies for workforce and staff,
families, concepts of and attitudes about, 90–91
19 reculturation, 297–298
gender roles, 19 refugees, 23, 28, 52
geographical variations in, 17–18 relapse prevention. See recovery and relapse
global differences in, 13 prevention

322
 Index

religion and spirituality, 30–33. See also rituals selective perception, 298
of African Americans, 114, 115 self-assessment
of Asians and Asian Americans, 126–128 of core competencies, 55, 259–263
Buddhists and Buddhism, 32–33, 123, for counselor training, 93
128, 156 of organizational cultural competence,
Christians and Christianity, 31, 101, 115, 84–87, 85, 86, 264–273
128, 138, 149, 156 Self-Assessment Checklist for Personnel
culturagrams, 67 Providing Services and Supports to Chil-
of Hispanics and Latinos, 137, 138 dren and Youth with Special Health Needs
Islam, 32, 115, 156 and Their Families, 55, 259–262
Jews and Judaism, 28, 30, 31–32, 156 self-knowledge, as core competency, 37–45
of Native Americans, 102, 144, 149 ACA Counselor Competencies, 46
of Pacific Islanders, 127 benefits of, 4, 8–9, 37–38
substance abuse and mental illness, treat- case management and, 70
ing, 31 cultural awareness, 38
syncretistic, 138, 298 limitations and abilities, understanding,
Taoist version of CBT, 124 44–45
of White Americans, 151, 152 racial, ethnic, and cultural identities,
resistance, as stage in racial and cultural iden- identifying, 38, 39–41, 40, 41, 42
tity development, 40 RESPECT mnemonic, 44
respect, culturally competent counselors show- stereotyping, prejudices, and history, 43–
ing, 49 44, 44
RESPECT mnemonic, 44 trust and power issues, 44
respeto, 134, 298 worldviews, individual and clinical, 42–
retention strategies for workforce and staff, 43, 43, 72
90–91 Self-Management and Recovery Training, 156
rituals sensitivity, culturally competent counselors
of cultures of recovery, 174 showing, 50
of drug cultures, 167, 168 SES. See socioeconomic status
Rural Hawai’i Behavioral Health Program, sexual identity and orientation, 29
127 shame, 1, 32, 60, 61, 117, 119, 121, 122
shen-k’uei, 284
S shenjing shuairuo, 285
SAMHSA. See Substance Abuse and Mental silence, cultural comfort with, 17
Health Services Administration simpatía, 17, 253, 298
Santería, 138 skra prameha, 284
Save Our Selves, 156 social constructs
Schedules for Clinical Assessment in Neuro- gender as, 19
psychiatry (SCAN), 68 race as, 13
schizophrenia, 18, 21, 105–106, 119 socioeconomic status (SES), 20–22
screening and assessment tools, 65–69, 68, acculturation and substance abuse, 26
277, 277–281 culturagrams, 66–67
seasonal/migrant workers, 24 drug cultures and, 162, 169
Secular Organizations for Sobriety, 156 education and, 21–22, 22
segmented assimilation, 24 health disparities and, 20

323
 Improving Cultural Competence

health, social determinants of, 21 by Pacific Islanders, 127

solution-focused interventions, 123 religion and spirituality, 31
South and Central Americans, 32, 129, 131, SES and, 21, 22, 26
135, 285. See also Hispanics and Latinos sexual identity and orientation, 29
spirituality. See religion and spirituality by White Americans, 150–152, 155
Standards of Practice for Case Management Substance Abuse and Mental Health Services
(Case Management Society of America, Administration (SAMHSA), 290. See also
2010), 71 Health Resources and Services Administra-
Standards on Cultural Competence in Social Work tion; National Survey on Drug Use and
Practice (National Association of Social Health (NSDUH) data; Treatment Im-
Workers, 2001), 71 provement Protocols
Stanford University Curriculum in Ethnogeri- guiding principles of recovery, 175
atrics, 290 Targeted Capacity Expansion Program,
Star Trek terminology and crack cocaine use, CSAT, 98
164 TTA (Tribal Training and Technical As-
stereotyping, by counselors, 43–44, 44 sistance) Center, 293
strategic planning, by organizations, 78 Sue’s multidimensional model for developing
strength-based interviews, 61 cultural competence, xv, 5–7, 6, 36, 37, 58,
Subanun people, 30 74, 102, 103, 160, 161
subcultures, 62–63, 160, 161–162 suicide, 3, 141, 143
substance abuse. See also co-occurring disor- sun dance, 148
ders; drug cultures; Treatment Improve- supportive-expressive psychotherapy, 111
ment Protocols; 12-Step programs, under T surveys of clients, staff, and community mem-
acculturation and, 25 bers, 85, 85–87, 86, 273–275
by African Americans, 27, 104–105 susto, 285
by Asians and Asian Americans, 1, 57, sweat lodges, 102, 148
117–119 syncretistic religions, 138, 298
Buddhism and, 32–33
cultural identification and, 26–27 T
culture of recovery and, xxi, 173, 173– taijin kyofusho, 285
175, 174, 175 talking circle, 158
defined, 3 Taoist version of CBT, 124
diagnosing, 68–69 Targeted Capacity Expansion Program,
educational factors, 21–22 CSAT, 98
exercise on benefits, losses, and the fu- TEDS (Treatment Episode Data Sets; 2001-
ture, 170–171 2011), 107
gender roles and, 20 Temperance Movement, 151
geographic factors, 18 terapia dura, 137
by Hispanics and Latinos, 35–36, 129– TIPs. See Treatment Improvement Protocols
131, 130 touch, culturally specific meanings of, 52
historical trauma leading to, 28 traditional/alternative healing practices
immigrants and, 23, 25–26, 130 acupuncture, 126
Islam and, 32 adapting intervention strategies to, 72
Judaism and, 31–32 African Americans and, 114–115
by Native Americans, 26–27, 139–141 Asian Americans and, 126–128

324
 Index

cao gio, 126 TIP), 139

circles, in Native American philosophy, Brief Interventions and Brief Therapies for
147, 148 Substance Abuse (TIP 34), 157
complex cultural problems, counselors al- Enhancing Motivation for Change in Sub-
lowing for, 51 stance Abuse Treatment (TIP 35), 69,
counselor attitudes to, 37 70, 157
counselor awareness of, 49 Relapse Prevention and Recovery Promotion
dances, sacred, 148 in Behavioral Health Services (planned
in Hispanic and Latino culture, 137–138 TIP), 128, 157, 173–174
mainstream attitudes to, 10 Substance Abuse: Clinical Issues in Intensive
of Native Americans, 72, 102, 144, 147– Outpatient Treatment (TIP 47), 157
149, 148 Substance Abuse Treatment: Addressing the
organizational attitudes to, 10 Specific Needs of Women (TIP 51), 20,
purification ceremonies, 72, 148 123, 157
sweat lodges, 102, 148 Substance Abuse Treatment and Family
White Americans and, 156 Therapy (TIP 39), 19, 146, 157
yin/yang balance, 126 Substance Abuse Treatment for Adults in the
traditions and values. See worldviews, values, Criminal Justice System (TIP 44), 157
and traditions Substance Abuse Treatment for Persons With
training Co-Occurring Disorders (TIP 42), 20,
exercise on benefits, losses, and the fu- 157
ture, 170–171 Substance Abuse Treatment: Group Therapy
in language services, 89–90 (TIP 41), 155, 157
of workforce and staff, 91, 91–93, 92, 93 Trauma-Informed Care in Behavioral
transculturation, 298 Health Services (TIP 57), 23, 28, 157
translators, 88, 88–90, 90, 287 treatment planning. See evaluation and treat-
trauma, personal or historical, 28–29 ment planning
African American, 28, 108, 109–110 Tribal service providers, 139, 142
Asian or Asian American, 119–120 Tribal Training and Technical Assistance
in evaluation and treatment planning, 63, (TTA) Center, SAMHSA, 293
67 tripa ida, 285
Native American, 28, 140, 142 trust and power issues, 44, 52, 109–110
PTSD, 105, 106, 119, 142 TTA (Tribal Training and Technical Assis-
of racial and ethnic groups, 28–29, 106 tance) Center, SAMHSA, 293
Trauma-Informed Care in Behavioral 12-Step programs
Health Services (TIP 57), 23, 28, 157 for African Americans, 111, 113–114
treatment, attitudes toward. See health, illness, for Asians and Asian Americans, 125
and healing culture of recovery and, 174
Treatment Episode Data Sets (TEDS; 2001- for Hispanics and Latinos, 136–137
2011), 107 for Jewish people, 32
Treatment Improvement Protocols (TIPs) Lakota version, 147
Addressing the Specific Behavioral Health for Native Americans, 49, 102, 146–147,
Needs of Men (TIP 56), 20 147
Behavioral Health Services for American for White Americans, 155, 156
Indians and Alaska Natives (planned

325
 Improving Cultural Competence

U language and communication issues, 17

undocumented immigrants, 22, 66–67, 134 mental disorders, 153
Urban Indian Health Institute, 140 personal space, cultural differences re-
U.S. Census Bureau racial and ethnic groups, garding, 51
xvi, 13 power and trust issues, 52
U.S. Department of Health and Human Ser- recovery and relapse prevention for, 156–
vices (HHS). See also Office of Minority 157
Health religion and spirituality, 151, 152
definition of cultural competence, xv substance use and abuse and drug cul-
health disparities, defined, 7 tures, 150–152, 155
Healthy People 2020, 21 traditional/alternative healing practices,
Mental Health: Culture, Race, and Ethnici- 156
ty (Surgeon General’s report, 2001), treatment patterns, 153
290 White Bison program, 147, 294
Office of Civil Rights, 289 White privilege, 298
U.S. Department of Veterans Affairs, 116 White racial identity development (WRID)
model, 39, 40, 41, 42
V WHO (World Health Organization), 68
value statements, of organizations, 77–78, 78 Women for Sobriety, 156
values. See worldviews, values, and traditions World Health Organization (WHO), 68
Veterans Affairs, U.S. Department of, 116 worldviews, values, and traditions
veterans, Native American, 142 clinical worldview, 43
Vietnamese, 14, 22, 118, 119, 126, 292. See also of counselors, 42–43, 43, 72
Asians and Asian Americans culturagrams, 66–67
Village Sobriety Project, 148 cultural differences in, 18–19
vision statements, 77–78, 78 of culture of recovery, 174
of drug cultures, 165, 166
W organizational cultural competence and,
Wellbriety movement, 49, 147 75, 76–78, 77, 78
White Americans, 13–14, 150–157. See also WRID (White racial identity development)
immigrants model, 39, 40, 41, 42
CODs, 153
cultural identities of, 39, 154 Y
defined, 298 yin/yang balance, 126
evaluation and treatment planning for, Yup’ik Eskimo, 148
154–156
families, concepts of and attitudes about,
19
gender roles, 19
health, illness, and healing, attitudes to-
ward, 153–154

326
SAMHSA TIPs and Publications Based on TIPs
What Is a TIP?
Treatment Improvement Protocols (TIPs) are the products of a systematic and innovative process that
brings together clinicians, researchers, program managers, policymakers, and other federal and non-federal
experts to reach consensus on state-of-the-art treatment practices. TIPs are developed under the Substance
Abuse and Mental Health Services Administration’s (SAMHSA’s) Knowledge Application Program (KAP)
to improve the treatment capabilities of the Nation’s alcohol and drug abuse treatment service system.

What Is a Quick Guide?

A Quick Guide clearly and concisely presents the primary information from a TIP in a pocket-sized
booklet. Each Quick Guide is divided into sections to help readers quickly locate relevant material. Some
contain glossaries of terms or lists of resources. Page numbers from the original TIP are referenced so pro-
viders can refer back to the source document for more information.

What Are KAP Keys?

Also based on TIPs, KAP Keys are handy, durable tools. Keys may include assessment or screening in-
struments, checklists, and summaries of treatment phases. Printed on coated paper, each KAP Keys set is
fastened together with a key ring and can be kept within a treatment provider’s reach and consulted fre-
quently. The Keys allow you, the busy clinician or program administrator, to locate information easily and
to use this information to enhance treatment services.

Ordering Information
Publications may be ordered or downloaded for free at http://store.samhsa.gov. To order over the phone,
please call 1-877-SAMHSA-7 (1-877-726-4727) (English and Español).
TIP 1 State Methadone Treatment Guidelines— TIP 10 Assessment and Treatment of Cocaine-
Replaced by TIP 43 Abusing Methadone-Maintained Patients—
TIP 2 Pregnant, Substance-Using Women— Replaced by TIP 43
Replaced by TIP 51 TIP 11 Simple Screening Instruments for Outreach
TIP 3 Screening and Assessment of Alcohol- and for Alcohol and Other Drug Abuse and
Other Drug-Abusing Adolescents—Replaced Infectious Diseases—Replaced by TIP 53
by TIP 31 TIP 12 Combining Substance Abuse Treatment
TIP 4 Guidelines for the Treatment of Alcohol- With Intermediate Sanctions for Adults in
and Other Drug-Abusing Adolescents— the Criminal Justice System—Replaced by
Replaced by TIP 32 TIP 44
TIP 5 Improving Treatment for Drug-Exposed TIP 13 Role and Current Status of Patient
Infants Placement Criteria in the Treatment of
Substance Use Disorders
TIP 6 Screening for Infectious Diseases Among
Quick Guide for Clinicians
Substance Abusers—Archived
Quick Guide for Administrators
TIP 7 Screening and Assessment for Alcohol and KAP Keys for Clinicians
Other Drug Abuse Among Adults in the
Criminal Justice System—Replaced by TIP 44 TIP 14 Developing State Outcomes Monitoring
Systems for Alcohol and Other Drug Abuse
TIP 8 Intensive Outpatient Treatment for Alcohol
Treatment
and Other Drug Abuse—Replaced by TIPs 46
and 47 TIP 15 Treatment for HIV-Infected Alcohol and
Other Drug Abusers—Replaced by TIP 37
TIP 9 Assessment and Treatment of Patients With
Coexisting Mental Illness and Alcohol and
Other Drug Abuse—Replaced by TIP 42

327
 Improving Cultural Competence

TIP 16 Alcohol and Other Drug Screening of TIP 27 Comprehensive Case Management for
Hospitalized Trauma Patients Substance Abuse Treatment
Quick Guide for Clinicians Case Management for Substance Abuse
KAP Keys for Clinicians Treatment: A Guide for Treatment Providers
TIP 17 Planning for Alcohol and Other Drug Case Management for Substance Abuse
Abuse Treatment for Adults in the Criminal Treatment: A Guide for Administrators
Justice System—Replaced by TIP 44 Quick Guide for Clinicians
Quick Guide for Administrators
TIP 18 The Tuberculosis Epidemic: Legal and
Ethical Issues for Alcohol and Other Drug TIP 28 Naltrexone and Alcoholism Treatment—
Abuse Treatment Providers—Archived Replaced by TIP 49
TIP 19 Detoxification From Alcohol and Other TIP 29 Substance Use Disorder Treatment for
Drugs—Replaced by TIP 45 People With Physical and Cognitive
Disabilities
TIP 20 Matching Treatment to Patient Needs in
Quick Guide for Clinicians
Opioid Substitution Therapy—Replaced by
Quick Guide for Administrators
TIP 43
KAP Keys for Clinicians
TIP 21 Combining Alcohol and Other Drug Abuse
TIP 30 Continuity of Offender Treatment for
Treatment With Diversion for Juveniles in
Substance Use Disorders From Institution
the Justice System
to Community
Quick Guide for Clinicians and
Quick Guide for Clinicians
Administrators
KAP Keys for Clinicians
TIP 22 LAAM in the Treatment of Opiate
TIP 31 Screening and Assessing Adolescents for
Addiction—Replaced by TIP 43
Substance Use Disorders
TIP 23 Treatment Drug Courts: Integrating See companion products for TIP 32.
Substance Abuse Treatment With Legal
TIP 32 Treatment of Adolescents With Substance
Case Processing
Use Disorders
Quick Guide for Administrators
Quick Guide for Clinicians
TIP 24 A Guide to Substance Abuse Services for KAP Keys for Clinicians
Primary Care Clinicians
TIP 33 Treatment for Stimulant Use Disorders
Concise Desk Reference Guide
Quick Guide for Clinicians
Quick Guide for Clinicians
KAP Keys for Clinicians
KAP Keys for Clinicians
TIP 34 Brief Interventions and Brief Therapies for
TIP 25 Substance Abuse Treatment and Domestic
Substance Abuse
Violence
Quick Guide for Clinicians
Linking Substance Abuse Treatment and
KAP Keys for Clinicians
Domestic Violence Services: A Guide for
Treatment Providers TIP 35 Enhancing Motivation for Change in
Linking Substance Abuse Treatment and Substance Abuse Treatment
Domestic Violence Services: A Guide for Quick Guide for Clinicians
Administrators KAP Keys for Clinicians
Quick Guide for Clinicians TIP 36 Substance Abuse Treatment for Persons
KAP Keys for Clinicians With Child Abuse and Neglect Issues
TIP 26 Substance Abuse Among Older Adults Quick Guide for Clinicians
Substance Abuse Among Older Adults: A KAP Keys for Clinicians
Guide for Treatment Providers Helping Yourself Heal: A Recovering Woman’s
Substance Abuse Among Older Adults: A Guide to Coping With Childhood Abuse
Guide for Social Service Providers Issues
Substance Abuse Among Older Adults: Also available in Spanish
Physician’s Guide Helping Yourself Heal: A Recovering Man’s
Quick Guide for Clinicians Guide to Coping With the Effects of
KAP Keys for Clinicians Childhood Abuse
Also available in Spanish

328
 SAMHSA TIPs and Publications Based on TIPs

TIP 37 Substance Abuse Treatment for Persons TIP 47 Substance Abuse: Clinical Issues in
With HIV/AIDS Outpatient Treatment
Quick Guide for Clinicians Quick Guide for Clinicians
KAP Keys for Clinicians KAP Keys for Clinicians
Drugs, Alcohol, and HIV/AIDS: A Consumer TIP 48 Managing Depressive Symptoms in
Guide Substance Abuse Clients During Early
Also available in Spanish Recovery
Drugs, Alcohol, and HIV/AIDS: A Consumer
TIP 49 Incorporating Alcohol Pharmacotherapies
Guide for African Americans
Into Medical Practice
TIP 38 Integrating Substance Abuse Treatment and Quick Guide for Counselors
Vocational Services Quick Guide for Physicians
Quick Guide for Clinicians KAP Keys for Clinicians
Quick Guide for Administrators
TIP 50 Addressing Suicidal Thoughts and
KAP Keys for Clinicians
Behaviors in Substance Abuse Treatment
TIP 39 Substance Abuse Treatment and Family Quick Guide for Clinicians
Therapy Quick Guide for Administrators
Quick Guide for Clinicians
TIP 51 Substance Abuse Treatment: Addressing the
Quick Guide for Administrators
Specific Needs of Women
Family Therapy Can Help: For People in
Quick Guide for Clinicians
Recovery From Mental Illness or Addiction
Quick Guide for Administrators
TIP 40 Clinical Guidelines for the Use of KAP Keys for Clinicians
Buprenorphine in the Treatment of Opioid
TIP 52 Clinical Supervision and Professional
Addiction
Development of the Substance Abuse
Quick Guide for Physicians
Counselor
KAP Keys for Physicians
Quick Guide for Clinical Supervisors
TIP 41 Substance Abuse Treatment: Group Quick Guide for Administrators
Therapy
TIP 53 Addressing Viral Hepatitis in People With
Quick Guide for Clinicians
Substance Use Disorders
TIP 42 Substance Abuse Treatment for Persons Quick Guide for Clinicians and
With Co-Occurring Disorders Administrators
Quick Guide for Clinicians KAP Keys for Clinicians
Quick Guide for Administrators
TIP 54 Managing Chronic Pain in Adults With or
KAP Keys for Clinicians
in Recovery From Substance Use Disorders
TIP 43 Medication-Assisted Treatment for Opioid Quick Guide for Clinicians
Addiction in Opioid Treatment Programs KAP Keys for Clinicians
Quick Guide for Clinicians You Can Manage Your Chronic Pain To Live a
KAP Keys for Clinicians Good Life: A Guide for People in Recovery
TIP 44 Substance Abuse Treatment for Adults in From Mental Illness or Addiction
the Criminal Justice System TIP 55 Behavioral Health Services for People Who
Quick Guide for Clinicians Are Homeless
KAP Keys for Clinicians
TIP 56 Addressing the Specific Behavioral Health
TIP 45 Detoxification and Substance Abuse Needs of Men
Treatment
TIP 57 Trauma-Informed Care in Behavioral
Quick Guide for Clinicians
Health Services
Quick Guide for Administrators
KAP Keys for Clinicians TIP 58 Addressing Fetal Alcohol Spectrum
Disorders (FASD)
TIP 46 Substance Abuse: Administrative Issues in
Outpatient Treatment TIP 59 Improving Cultural Competence
Quick Guide for Administrators

329
HHS publication no. (SmA) 14-4849
First printed 2014
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and mental Health Services Administration
center for Substance Abuse Treatment