Providing Individualized, Culturally Responsive, Flexible, and Relevant Services for Each Family

Zhang Min, a 25-twelvemonth-old get-go-generation Chinese woman, was referred to a advisor past her primary care physician because she reported having episodes of low. The counselor who conducted the intake interview had received training in cultural competence and was mindful of cultural factors in evaluating Zhang Min. The referral noted that Zhang Min was built-in in Hong Kong, so the therapist expected her to exist hesitant to discuss her problems, given the prejudices attached to mental illness and substance abuse in Chinese culture. During the evaluation, however, the therapist was surprised to find that Zhang Min was quite forthcoming. She mentioned missing of import deadlines at piece of work and calling in ill at to the lowest degree one time a week, and she noted that her coworkers had expressed concern afterwards finding a bottle of wine in her desk. She admitted that she had been drinking heavily, which she linked to work stress and contempo discord with her Irish American spouse.

Further inquiry revealed that Zhang Min'due south parents, both Chinese, went to school in England and sent her to a British school in Hong Kong. She grew up close to the British departer community, and her mother was a nurse with the British Army. Zhang Min came to the United states at the historic period of 8 and grew up in an Irish American neighborhood. She stated that she knew more about Irish culture than about Chinese culture. She felt, with the exception of her concrete features, that she was more Irish than Chinese—a view accepted past many of her Irish American friends. Almost men she had dated were Irish gaelic Americans, and she socialized in groups in which alcohol consumption was not only accepted merely expected.

Zhang Min first started to drink in loftier school with her friends. The counselor realized that what she had learned about Asian Americans was non necessarily applicable to Zhang Min and that knowledge of Zhang Min'southward entire history was necessary to capeesh the influence of culture in her life. The advisor thus developed handling strategies more suitable to Zhang Min's background.

Graphic: 3-D drawing of a cube, segmented. Along the Z axis is labeled

Multidimensional Model for Developing Cultural Competence: Clinical/Program Level

Zhang Min's instance demonstrates why thorough evaluation, including assessment of the client's sociocultural background, is essential for handling planning. To provide culturally responsive evaluation and handling planning, counselors and programs must sympathize and incorporate relevant cultural factors into the process while avoiding a stereotypical or "one-size-fits-all" arroyo to handling. Cultural responsiveness in planning and evaluation entails being open minded, asking the right questions, selecting appropriate screening and cess instruments, and choosing effective handling providers and modalities for each client. Moreover, information technology involves identifying culturally relevant concerns and issues that should exist addressed to improve the customer'south recovery process.

This chapter offers clinical staff guidance in providing and facilitating culturally responsive interviews, assessments, evaluations, and treatment planning. Using Sue's (2001) multidimensional model for developing cultural competence, this chapter focuses on clinical and programmatic decisions and skills that are important in evaluation and treatment planning processes. The affiliate is organized around ix steps to exist incorporated past clinicians, supported in clinical supervision, and endorsed by administrators.

Step ane. Engage Clients

Once clients are in contact with a treatment program, they stand up on the far side of a still-to-be-established therapeutic relationship. It is up to counselors and other staff members to bridge the gap. Handshakes, facial expressions, greetings, and small talk are simple gestures that establish a first impression and brainstorm edifice the therapeutic relationship. Involving one'south whole beingness in a greeting—thought, body, attitude, and spirit—is most engaging.

Fifty percentage of racially and ethnically diverse clients cease treatment or counseling subsequently 1 visit with a mental health practitioner (Sue and Sue 2013e). At the outset of treatment, clients can experience scared, vulnerable, and uncertain near whether handling volition really help. The initial meeting is often the first encounter clients have with the treatment arrangement, so it is vital that they exit feeling hopeful and understood. Paniagua (1998) describes how, if a counselor lacks sensitivity and jumps to premature conclusions, the first visit can become the concluding:

Pretend that you lot are a Puerto Rican taxi driver in New York City, and at three:00 p.m. on a hot summer day you realize that y'all accept your first appointment with the therapist…later, y'all learned that the therapist made a note that y'all were probably depressed or psychotic because you dressed carelessly and had dirty nails and hands…would you lot render for a second date? (p. 120)

To appoint the client, the counselor should try to establish rapport before launching into a series of questions. Paniagua (1998) suggests that counselors should draw attending to the presenting problem "without giving the impression that too much data is needed to understand the problem" (p. 18). It is also important that the client feel engaged with whatever interpreter used in the intake procedure. A common framework used in many healthcare training programs to highlight culturally responsive interview behaviors is the LEARN model (Berlin and Fowkes 1983). The how-to box on the next page presents this model.

Improving Cantankerous-Cultural Advice

Health disparities have multiple causes. One specific influence is cantankerous-cultural communication between the counselor and the client. Weiss (2007) recommends these half-dozen steps to improve communication with clients:

Slow downwards.
Use plain, nonpsychiatric language.
Testify or describe pictures.
Limit the corporeality of data provided at once.
Use the "teach-back" method. Enquire the customer, in a nonthreatening manner, to explicate or evidence what he or she has been told.
Create a shame-gratis environs that encourages questions and participation.

Step 2. Familiarize Clients and Their Families With Treatment and Evaluation Processes

Behavioral health treatment facilities maintain their own culture (i.e., the handling milieu). Counselors, clinical supervisors, and bureau administrators tin hands become accustomed to this civilisation and presume that clients are used to it as well. Withal, clients are typically new to treatment language or jargon, program expectations and schedules, and the intake and handling process. Unfortunately, clients from diverse racial and ethnic groups can feel more than estranged and disconnected from treatment services when staff members fail to brainwash them and their families about treatment expectations or when the clients are not walked through the treatment process, starting with the goals of the initial intake and interview. By taking the time to acclimate clients and their families to the handling procedure, counselors and other behavioral health staff members tackle one obstacle that could further impede treatment engagement and retention amid racially and ethnically various clients.

How To Use the Larn Mnemonic for Intake Interviews

Listen to each customer from his or her cultural perspective. Avoid interrupting or posing questions before the customer finishes talking; instead, find creative means to redirect dialog (or explain session limitations if time is curt). Take fourth dimension to learn the client's perception of his or her problems, concerns about presenting bug and handling, and preferences for handling and healing practices.

Explain the overall purpose of the interview and intake process. Walk through the general agenda for the initial session and hash out the reasons for asking about personal information. Call back that the client's needs come up before the set agenda for the interview; don't cover every intake question at the expense of taking time (usually cursory) to accost questions and concerns expressed by the client.

Acknowledge client concerns and discuss the likely differences between you and your clients. Take time to empathize each client's explanatory model of illness and health. Recognize, when appropriate, the customer'southward healing beliefs and practices and explore ways to comprise these into the handling plan.

Recommend a grade of activeness through collaboration with the client. The customer must know the importance of his or her participation in the handling planning process. With client assistance, client behavior and traditions can serve as a framework for healing in treatment. However, not all clients have the same expectations of treatment interest; some see the counselor equally the skillful, want a directive approach, and have little desire to participate in developing the handling plan themselves.

Due northegotiate a treatment programme that weaves the client's cultural norms and lifeways into handling goals, objectives, and steps. Once the treatment program and modality are established and implemented, encourage regular dialog to gain feedback and appraise treatment satisfaction. Respecting the client'south culture and encouraging communication throughout the procedure increases client willing to engage in treatment and to adhere to the treatment programme and continuing care recommendations.

Sources: Berlin and Fowkes 1983; Dreachslin et al. 2013; Ring 2008.

Pace 3. Endorse Collaboration in Interviews, Assessments, and Handling Planning

Well-nigh clients are unfamiliar with the evaluation and treatment planning process and how they can participate in it. Some clients may view the initial interview and evaluation as intrusive if also much data is requested or if the content is a source of family unit dishonor or shame. Other clients may resist or distrust the process based on a long history of racism and oppression. Nonetheless others feel inhibited from actively participating because they view the counselor equally the authority or sole expert.

The counselor can help decrease the influence of these issues in the interview process through a collaborative arroyo that allows fourth dimension to discuss the expectations of both counselor and client; to explain interview, intake, and treatment planning processes; and to establish ways for the client to seek description of his or her cess results (Mohatt et al. 2008a). The counselor tin can encourage collaboration by emphasizing the importance of clients' input and interpretations. Client feedback is integral in interpreting results and can identify cultural issues that may affect intake and evaluation (Acevedo-Polakovich et al. 2007). Collaboration should extend to client preferences and desires regarding inclusion of family and community members in evaluation and handling planning.

Step 4. Integrate Culturally Relevant Data and Themes

By exploring culturally relevant themes, counselors can more fully understand their clients and identify their cultural strengths and challenges. For example, a Korean adult female'due south family may serve every bit a source of support and provide a sense of identity. At the same time, however, her family could be ashamed of her co-occurring generalized anxiety and substance apply disorders and reply to her treatment equally a source of further shame because information technology encourages her to disclose personal matters to people outside the family unit. The post-obit section provides a brief overview of suggested strength-based topics to contain into the intake and evaluation procedure.

Advice to Counselors: Asking About Culture and Acculturation

A thoughtful exploration of cultural and ethnic identity issues volition provide clues for determining cultural, racial, and ethnic identity. At that place are numerous clues that y'all may derive from your clients' answers, and they cannot all be covered in this TIP; this is merely ane set of sample questions (Fontes 2008). Ask these questions tactfully and so they do non sound similar an interrogation. Try to integrate them naturally into a conversation rather than request one after another. Not all questions are relevant in all settings. Counselors can adapt wording to suit clients' cultural contexts and styles of advice, because the questions listed here and throughout this chapter are just examples:

Where were you born?
Whom do you consider family?
What was the beginning linguistic communication you learned?
Which other language(south) do you speak?
What language or languages are spoken in your home?
What is your organized religion? How observant are you lot in practicing that religion?
What activities practise you enjoy when you are not working?
How do you identify yourself culturally?
What aspects of being ________ are most important to yous? (Use the same term for the identified culture as the client.)
How would yous describe your domicile and neighborhood?
Whom practice you commonly turn to for help when facing a problem?
What are your goals for this interview?

Clearing History

Clearing history can shed light on client back up systems and place possible isolation or breach. Some immigrants who live in ethnic enclaves take many sources of social support and resources. By contrast, others may exist isolated, living autonomously from family, friends, and the back up systems extant in their countries of origin. Culturally competent evaluation should always include questions about the client's country of origin, immigration status, length of time in the The states, and connections to his or her country of origin. Ask American-born clients well-nigh their parents' country of origin, the language(due south) spoken at home, and affiliation with their parents' civilisation(south). Questions like these requite the counselor important clues nigh the client's degree of acculturation in early on life and at present, cultural identity, ties to culture of origin, potential cultural conflicts, and resources. Specific questions should elicit information about:

Length of time in the United States, noting when clearing occurred or the number of generations who accept resided in the United States.
Frequency of returns and psychological and personal ties to the country of origin.
Chief language and level of English proficiency in speaking and writing.
Psychological reactions to immigration and adjustments made in the process.
Changes in social status and other areas as a outcome of coming to this country.
Major differences in attitudes toward alcohol and drug use from the time of immigration to at present.

Advice to Counselors: Conducting Strength-Based Interviews

By nature, initial interviews and evaluations can overemphasize presenting bug and concerns while underplaying client strengths and supports. This listing, although not exhaustive, reminds clinicians to acknowledge customer strengths and supports from the outset.

Strengths and supports

Pride and participation in one's culture
Social skills, traditions, cognition, and practical skills specific to the client's civilisation
Bilingual or multilingual skills
Traditional, religious, or spiritual practices, beliefs, and faith
Generational wisdom
Extended families and nonblood kinships
Ability to maintain cultural heritage and practices
Perseverance in coping with racism and oppression
Culturally specific means of coping
Community involvement and support

Source: Hays 2008.

Cultural Identity and Acculturation

As shown in Zhang Min's case at the beginning of this affiliate, cultural identity is a unique feature of each customer. Counselors should guard against making assumptions almost client identity based on general ethnic and racial identification past evaluating the caste to which an individual identifies with his or her culture(southward) of origin. Every bit Castro and colleagues (1999b) explain, "for each group, the level of within-grouping variability tin exist assessed using a cadre dimension that ranges from high cultural interest and acceptance of the traditional culture's values to depression or no cultural involvement" (p. 515). For African Americans, for instance, this dimension is called "Afrocentricity." Scales for Afrocentricity take been adult in an attempt to provide an indicator of an individual'south level of involvement within the traditional or core African-oriented culture (Baldwin and Bell 1985; Cokley and Williams 2005; Klonoff and Landrine 2000). Many other instruments based on models of identity evaluate acculturation and identity. A detailed discussion of the theory behind such models is across the scope of this Treatment Improvement Protocol (TIP); however, counselors should have a general understanding of what is beingness measured when administering such instruments. The "Asking Near Culture and Acculturation" communication box at right addresses exploration of civilization and acculturation with clients. For more information on instruments that measure acculturation and/or identity, run into Appendix B.

Other areas to explore include the cross-cutting factors outlined in Affiliate 1, such equally socioeconomic status (SES), occupation, teaching, gender, and other variables that can distinguish an individual from others who share his or her cultural identity. For case, a biracial client could identify with African American culture, White American culture, or both. When a client has ii or more racial/ethnic identities, counselors should assess how the client self-identifies and how he or she negotiates the dissimilar worlds.

Membership in a Subculture

Clients often identify initially with broader racial, indigenous, and cultural groups. However, each person has a unique history that warrants an understanding of how culture is practiced and has evolved for the person and his or her family unit; accordingly, counselors should avoid generalizations or assumptions. Clients are frequently part of a culture inside a culture. There is non only one Latino, African American, or Native American culture; many variables influence culture and cultural identity (see the "What Are the Cross-Cut Factors in Race, Ethnicity, and Culture" section in Chapter i). For example, an African American customer from East Carroll Parish, LA, might describe his or her culture quite differently than an African American from downtown Hartford, CT.

Behavior About Health, Healing, Help-Seeking, and Substance Utilise

Simply every bit civilisation shapes an individual's sense of identity, it also shapes attitudes surrounding health practices and substance utilize. Cultural acceptance of a beliefs, for instance, can mask a problem or deter a person from seeking treatment. Counselors should exist enlightened of how the client'south culture conceptualizes problems related to wellness, healing and treatment practices, and the utilise of substances. For example, in cases where alcohol use is discouraged or frowned upon in the community, the customer can feel tremendous shame about drinking. Chapter 5 reviews health-related beliefs and practices that can touch on help-seeking behavior beyond various populations.

Trauma and Loss

Some immigrant subcultures have experienced violent upheavals and have a higher incidence of trauma than others. The theme of trauma and loss should therefore be incorporated into general intake questions. Specific issues under this general theme might include:

Migration, relocation, and emigration history—which considers separation from homeland, family unit, and friends—and the stressors and loss of social support that can back-trail these transitions.
Clients' personal or familial experiences with American Indian boarding schools.
Experiences with genocide, persecution, torture, war, and starvation.

Advice to Counselors: Eliciting Client Views on Presenting Issues

Some clients do not encounter 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, discussion the post-obit questions using the clients' terminology rather than using the give-and-take "problem." These questions help explore how clients view their behavioral health concerns:

I know that clients and counselors sometimes accept different ideas almost illness and diseases, then can yous tell me more about your idea of your problem?
Do you lot consider your use of alcohol and/or drugs a problem?
How practise you label your trouble? Exercise you lot recall it is a serious trouble?
What do yous think caused your problem?
Why do you recollect it started when it did?
What is going on in your body as a result of this problem?
How has this problem affected your life?
What frightens or concerns you virtually almost this problem and its treatment?
How is your problem viewed in your family? Is it acceptable?
How is your problem viewed in your community? Is information technology adequate? Is it considered a disease?
Practise you know others who have had this trouble? How did they treat the problem?
How does your problem affect your stature in the customs?
What kinds of handling do you think will assist or heal y'all?
How have you treated your drug and/or alcohol problem or emotional distress?
What has been your experience with treatment programs?

Sources: Lynch and Hanson 2011; Tang and Bigby 1996; Taylor 2002.

How To Use a Multicultural Intake Checklist

Some clients practice not see their presenting concrete, psychological, and/or behavioral difficulties as problems. Instead, they may view their presenting difficulties as the outcome of stress or another issue, thus defining or labeling the presenting trouble as something other than a concrete or mental disorder. In such cases, word questions about the following topics using the client'due south terminology, rather than using the give-and-take "trouble." Request questions almost the following topics can help you explore how a client may view his or her behavioral wellness concerns:

□: Immigration history
□: Relocations (current migration patterns)
□: Losses associated with immigration and relocation history
□: English fluency
□: Bilingual or multilingual fluency
□: Individualistic/collectivistic orientation
□: Racial, indigenous, and cultural identities
□: Tribal affiliation, if appropriate
□: Geographic location
□: Family and extended family concerns (including nonblood kinships)
□: Acculturation level (east.thou., traditional, bicultural)
□: Acculturation stress
□: History of bigotry/racism
□: Trauma history
□: Historical trauma
□: Intergenerational family history and concerns
□: Gender roles and expectations
□: Nascency order roles and expectations
□: Relationship and dating concerns
□: Sexual and gender orientation
□: Health concerns
□: Traditional healing practices
□: Assistance-seeking patterns
□: Beliefs about wellness
□: Beliefs near mental illness and mental health treatment
□: Beliefs nigh substance utilize, abuse, and dependence
□: Behavior about substance abuse treatment
□: Family unit views on substance use and substance corruption treatment
□: Treatment concerns related to cultural differences
□: Cultural approaches to healing or handling of substance apply and mental disorders
□: Education history and concerns
□: Work history and concerns
□: SES and financial concerns
□: Cultural group amalgamation
□: Current network of support
□: Community concerns
□: Review of confidentiality parameters and concerns
□: Cultural concepts of distress (DSM-5^*)
□: DSM-v culturally related Five-codes

Sources: Comas-Diaz 2012; Constantine and Sue 2005; Sussman 2004.

*

Pace five. Gather Culturally Relevant Collateral Information

A client who needs behavioral health handling services may exist unwilling or unable to provide a full personal history from his or her ain perspective and may not retrieve certain events or be aware of how his or her behavior affects his or her well-being and that of others. Collateral data—supplemental information obtained with the client'south permission from sources other than the client—tin can exist derived from family members, medical and court records, probation and parole officers, community members, and others. Collateral information should include culturally relevant information obtained from the family, such as the organizational memberships, behavior, and practices that shape the client'southward cultural identity and understanding of the globe.

Equally families can be a vital source of information, counselors are probable to achieve more support by engaging families earlier in the treatment procedure. Although advisor interactions with family members are often limited to a few formal sessions, the families of racially and ethnically diverse clients tend to play a more significant and influential function in clients' participation in treatment. Consequently, special sensitivity to the cultural background of family members providing collateral information is essential. Families, like clients, cannot exist easily divers in terms of a generic cultural identity (Congress 2004; Taylor et al. 2012). Even families from the aforementioned racial background or ethnic heritage tin be quite dissimilar, thus requiring a multidimensional approach in understanding the part of culture in the lives of clients and their families. Using the culturagram tool on the next folio in preparation for counseling, treatment planning, or clinical supervision, clinicians can learn nearly the unique attributes and histories that influence clients' lives in a cultural context.

Step six. Select Culturally Appropriate Screening and Cess Tools

Discussions of the complexities of psychological testing, the estimation of cess measures, and the appropriateness of screening procedures are exterior the scope of this TIP. However, counselors and other clinical service providers should be able to apply cess and screening information in culturally competent ways. This section discusses several instruments and their appropriateness for specific cultural groups. Counselors should proceed to explore the availability of mental health and substance abuse screening and assessment tools that have been translated into or adjusted for other languages.

Culturally Appropriate Screening Devices

The consensus panel does non recommend any specific instruments for screening or assessing mental or substance use disorders. Rather, when selecting instruments, practitioners should consider their cultural applicability to the client being served (AACE 2012; Jome and Moody 2002). For example, a screening musical instrument that asks the respondent well-nigh his or her guilt about drinking could be ineffective for members of cultural, indigenous, or religious groups that prohibit any consumption of alcohol. Al-Ansari and Negrete'south (1990) research supports this point. They institute that the Short Michigan Alcoholism Screening Test was highly sensitive with people who utilise booze in a traditional Arab Muslim gild; yet, one question—"Practise you ever feel guilty about your drinking?"—failed to distinguish between people with alcohol dependency disorders in treatment and people who drank in the community. Questions designed to measure conflict that results from the utilise of alcohol can skew test results for participants from cultures that expect complete abstinence from alcohol and/or drugs. Appendix D summarizes instruments tested on specific populations (e.chiliad., availability of normative data for the population existence served).

Culturally Valid Clinical Scales

As the literature consistently demonstrates, co-occurring mental disorders are common in people who have substance utilize disorders. Although an cess of psychological issues helps friction match clients to advisable treatment, clinicians are cautioned to proceed carefully. People who are abusing substances or experiencing withdrawal from substances can exhibit behaviors and thinking patterns consistent with mental illness. After a period of forbearance, symptoms that mimic mental disease tin can disappear. Moreover, clinical instruments are imperfect measurements of every bit imperfect psychological constructs that were created to organize and understand clinical patterns and thus better treat them; they do not provide absolute answers. Every bit enquiry and science evolve, so does our agreement of mental illness (Benuto 2012). Assessment tools are mostly developed for particular populations and can be inapplicable to diverse populations (Blume et al. 2005; Suzuki and Ponterotto 2008). Appendix D summarizes inquiry on the clinical utility of instruments for screening and assessing co-occurring disorders in diverse cultural groups.

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 as well questions specific to their family histories. This diagram can guide an interview, counseling, or clinical supervision session to elicit culturally relevant multigenerational information unique to the client and the customer's family. Give a copy of the diagram to the customer or family for utilize every bit an interactive tool in the session. Throughout the interview, the client, family members, and/or the counselor tin 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.

Values most family unit construction, power, myths, and rules

Are at that place specific gender roles and expectations in your family?
Who holds the power within the family?
Are family needs more of import than, or equally every bit of import equally, individual needs?
Whom do you lot consider family?

Reasons for relocation or migration

Are yous and your family able to return home?
What were your reasons for coming to the U.s.a.?
How do you at present view the initial reasons for relocation?
What feelings do you take nigh relocation or migration?
Practise you lot motion back and forth from i location to another?
How often practise you and your family unit return to your homeland?
Are y'all living apart from your family?

Legal condition and SES

Has your SES improved or worsened since coming to this country?
Has there been a change in socioeconomic status across generations?
What is the family history of documentation? (Notation: Clients oft need to develop trust earlier discussing legal status; they may come from a place where confidentiality is unfamiliar.)

Time in the community

How long take you and your family unit members been in the country? Community?
Are you and your family actively involved in a culturally based customs?

Languages spoken in and outside the dwelling

What languages are spoken at abode 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 surrounding the use of English? Have children become the family interpreters?

Health behavior and behavior nearly assistance-seeking

What are the family beliefs almost drug and booze apply? Mental illness? Handling?
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 ascertain illness and wellness?
Are at that place any objections to the use of Western medicine?

Impact of trauma and other crisis events

How has trauma affected your family unit beyond generations?
How have traumas or other crises affected you and/or your family?
Has in that location been a specific family crisis?
Did the family experience traumatic events prior to migration—state of war, other forms of violence, displacement including refugee camps, or like experiences?

Oppression and discrimination

Is at that place a history of oppression and discrimination in your homeland?
How accept you and your family unit experienced discrimination since clearing?

Religious and cultural institutions, nutrient, vesture, and holidays

Are there specific religious holidays that your family unit observes?
What holidays exercise you celebrate?
Are there specific foods that are important to you?
Does clothing play a significant cultural or religious role for you lot?
Do yous vest to a cultural or social guild or organisation?

Values near teaching and work

How much importance do you place on piece of work, family unit, and education?
What are the educational expectations for children within the family?
Has your piece of work status inverse (e.g., level of responsibility, prestige, and power) since migration?
Do you or does anyone in your family piece of work several jobs?

Sources: Comas-Diaz 2012; Congress 1994, 2004; Vocalizer 2007.

Diagnosis

Counselors should consider clients' cultural backgrounds when evaluating and assessing mental and substance use disorders (Bhugra and Gupta 2010). Concerns surrounding diagnoses of mental and substance employ disorders (and the cantankerous-cultural applicability of those diagnoses) include the appropriateness of specific test items or questions, diagnostic criteria, and psychologically oriented concepts (Alarcon 2009; Room 2006). Research into specific techniques that address cultural differences in evaluative and diagnostic processes and then far remains limited and underrepresentative of diverse populations (Guindon and Sobhany 2001; Martinez 2009).

Does the DSM-5 accurately diagnose mental and substance apply disorders among immigrants and other ethnic groups? Caetano and Shafer (1996) plant that diagnostic criteria seemed to identify alcohol dependency consistently across race and ethnicity, but their sample was limited to African Americans, Latinos, and Whites. Other research has shown mixed results.

In 1972, the Earth Health Organization (WHO) and the National Institutes of Health (NIH) embarked on a joint written report to test the cross-cultural applicability of classification systems for diverse diagnoses, including substance use disorders. WHO and NIH identified factors that appeared to exist universal aspects of mental and substance use disorders and then developed instruments to mensurate them. These instruments, the Composite International Diagnostic Interview (CIDI) and the Schedules for Clinical Assessment in Neuropsychiatry (Browse), include some DSM and International Statistical Nomenclature of Diseases and Related Wellness Issues criteria. Studies study that both the CIDI and SCAN were mostly authentic, but the investigators urge caution in translation and interview procedures (Room et al. 2003).

Advice to Counselors and Clinical Supervisors: Culturally Responsive Screening and Assessment

Assess the customer's primary language and linguistic communication proficiency prior to the administration of any evaluation or apply of testing instruments.
Determine whether the cess materials were translated using specific terms, including idioms that correspond to the customer's literacy level, culture, and linguistic communication. Exercise 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 cess and its application to the evolution of the treatment plan. Remember that testing tin generate many emotional reactions.
Know how the test was developed. Is normative data available for the population being served? Exam 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 civilization can affect interpretation of questions, the client-evaluator human relationship, and beliefs, including participation level during evaluation and verbal and behavioral responses.

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

Overall, psychological concepts that are appropriate for and easily translated past some groups are inappropriate for others. In some Asian cultures, for example, feeling refers more to a physical than an emotive country; questions designed to infer emotional states are not hands translated. In most cases, these bug can exist remedied past using civilization-specific resource, measurements, and references while also adopting a cultural conception in the interviewing process (see Appendix E for the A PA's cultural formulation outline). The DSM-5 lists several cultural concepts of distress (see Appendix Eastward), yet in that location is little empirical literature providing data or handling guidance on using the APA's cultural conception or addressing cultural concepts of distress (Martinez 2009; Mezzich et al. 2009).

Step 7. Determine Readiness and Motivation for Modify

Clients enter treatment programs at different levels of readiness for change. Fifty-fifty clients who present voluntarily could have been pushed into information technology by external pressures to accept treatment before reaching the action phase. These dissimilar readiness levels crave unlike approaches. The strategies involved in motivational interviewing can assistance counselors prepare culturally diverse clients to change their behavior and go on them engaged in treatment. To understand motivational interviewing, it is first necessary to examine the procedure of modify that is involved in recovery. Run across TIP 35, Enhancing Motivation for Change in Substance Corruption Treatment (Center for Substance Abuse Handling [CSAT] 1999b), for more information on this technique.

Stages of Change

Prochaska and DiClemente'south (1984) classic transtheoretical model of change is applicative to culturally diverse populations. This model divides the change process into several stages:

Precontemplation. The individual does non see a need to modify. For example, a person at this stage who abuses substances does not run into any need to alter use, denies that there is a problem, or blames the trouble on other people or circumstances.
Contemplation. The person becomes aware of a trouble but is ambivalent about the course of action. For instance, a person struggling with depression recognizes that the depression has afflicted his or her life and thinks about getting aid but remains ambivalent on how he/she may do this.
Preparation. The individual has determined that the consequences of his or her beliefs are too great and that change is necessary. Training includes small steps toward making specific changes, such as when a person who is overweight begins reading about wellness and weight management. The client still engages in poor wellness behaviors but may be altering some behaviors or planning to follow a nutrition.
Activeness. The individual has a specific plan for modify and begins to pursue it. In relation to substance abuse, the client may make an appointment for a drug and alcohol cess prior to becoming abstinent from alcohol and drugs.
Maintenance. The person continues to engage in behaviors that support his or her determination. For instance, an individual with bipolar I disorder follows a daily relapse prevention plan that helps him or her assess warning signs of a manic episode and reminds him or her of the importance of engaging in aid-seeking behaviors to minimize the severity of an episode.

Progress through the stages is nonlinear, with motility back and forth among the stages at dissimilar rates. It is of import to recognize that alter is non a quondam procedure, but rather, a series of trials and errors that eventually translates to successful change. For instance, people who are dependent on substances often attempt to abjure several times before they are able to acquire long-term abstinence.

Motivational Interviewing

Motivational interventions assess a person's phase of change and utilise techniques likely to motility the person forward in the sequence. Miller and Rollnick (2002) developed a therapeutic mode called motivational interviewing, which is characterized by the strategic therapeutic activities of expressing empathy, developing discrepancy, avoiding argument, rolling with resistance, and supporting self-efficacy. The counselor's major tool is reflective listening and soliciting change talk (CSAT 1999c).

This nonconfrontational, client-centered approach to treatment differs significantly from traditional treatments in several means, creating a more welcoming relationship. TIP 35 (CSAT 1999c) assesses Project MATCH and other clinical trials, concluding that the testify strongly supports the use of motivational interviewing with a wide variety of cultural and ethnic groups (Miller and Rollnick 2013; Miller et al. 2008). TIP 35 is a good motivational interviewing resources. For specific application of motivational interviewing with Native Americans, see Venner and colleagues (2006). For comeback of handling compliance among Latinos with depression through motivational interviewing, see Interian and colleagues (2010).

Step 8. Provide Culturally Responsive Case Direction

Clients from various racial, ethnic, and cultural populations seeking behavioral health services may face additional obstacles that can interfere with or preclude admission to treatment and ancillary services, compromise appropriate referrals, impede compliance with treatment recommendations, and produce poorer treatment outcomes. Obstacles may include immigration status, lower SES, language barriers, cultural differences, and lack of or poor coverage with health insurance.

Example direction provides a unmarried professional contact through which clients gain access to a range of services. The goal is to help assess the need for and coordinate social, health, and other essential services for each client. Case direction tin can be an immense help during handling and recovery for a person with limited English language literacy and knowledge of the treatment organisation. Case management focuses on the needs of individual clients and their families and anticipates how those needs will exist affected as handling gain. The example manager advocates for the client (CSAT 1998a; Summers 2012), easing the way to constructive handling past assisting the client with critical aspects of life (e.g., food, childcare, employment, housing, legal bug). Like counselors, instance managers should possess self-knowledge and bones cognition of other cultures, traits conducive to working well with various groups, and the ability to employ cultural competence in applied means.

Cultural competence begins with self-knowledge; counselors and case managers should be enlightened of and responsive to how their culture shapes attitudes and beliefs. This understanding volition broaden as they gain knowledge and straight experience with the cultural groups of their client population, enabling them to amend frame client issues and collaborate with clients in culturally specific and appropriate ways. TIP 27, Comprehensive Case Management for Substance Abuse Treatment (CSAT 1998a), offers more information on constructive case management.

Showroom 3-i discusses the cultural matching of counselors with clients. When counselors cannot provide culturally or linguistically competent services, they must know when and how to bring in an interpreter or to seek other assistance (CSAT 1998a). Case management includes finding an interpreter who communicates well in the client's language and dialect and who is familiar with the vocabulary required to communicate effectively nearly sensitive subject matter. The case manager works within the system to ensure that the interpreter, when needed, tin can be compensated. Instance managers should also take a list of appropriate referrals to run into assorted needs. For example, an immigrant who does not speak English may need legal services in his or her language; an undocumented worker may need to know where to go for medical assist. Culturally competent case managers build and maintain rich referral resources for their clients.

The Case Management Social club of America'south Standards of Practise for Instance Direction (2010) state that instance management is central in coming together client needs throughout the course of handling. The standards stress understanding relevant cultural information and communicating effectively by respecting and being responsive to clients and their cultural contexts. For standards that are also applicable to case management, refer to the National Clan of Social Workers' Standards on Cultural Competence in Social Piece of work Practice (2001).

Step nine. Comprise Cultural Factors Into Treatment Planning

The cultural adaptation of treatment practices is a burgeoning surface area of interest, yet research is limited regarding the process and event of culturally responsive handling planning in behavioral health treatment services for diverse populations. How practice counselors and organizations answer culturally to the various needs of clients in the treatment planning process? How effective are culturally adaptive treatment goals? (For a review, meet Bernal and Domenech Rodriguez 2012.) Typically, programs that provide culturally responsive services approach treatment goals holistically, including objectives to amend physical health and spiritual strength (Howard 2003). Newer approaches stress implementation of forcefulness-based strategies that fortify cultural heritage, identity, and resiliency.

Treatment planning is a dynamic process that evolves along with an understanding of the clients' histories and handling needs. Foremost, counselors should exist mindful of each customer's linguistic requirements and the availability of interpreters (for more detail on interpreters, run across Affiliate 4). Counselors should be flexible in designing treatment plans to meet client needs and, when appropriate, should depict upon the institutions and resources of clients' cultural communities. Culturally responsive treatment planning is accomplished through agile listening and should consider client values, beliefs, and expectations. Client health beliefs and handling preferences (e.m., purification ceremonies for Native American clients) should be incorporated in addressing specific presenting problems. Some people seek help for psychological concerns and substance corruption from alternative sources (e.g., clergy, elders, social supports). Others prefer treatment programs that use principles and approaches specific to their cultures. Counselors can advise appropriate traditional treatment resources to supplement clinical handling activities.

In sum, clinicians need to incorporate culture-based goals and objectives into treatment plans and constitute and support open client–counselor dialog to go feedback on the proposed plan's relevance. Doing so tin improve client appointment in treatment services, compliance with treatment planning and recommendations, and handling outcomes.

Group Clinical Supervision Case Written report

Beverly is a 34-year-sometime White American who feels responsible for the tension and dissension in her family. Beverly works in the lab of an obstetrics and gynecology practice. Since early childhood, her younger blood brother has had bug that have been diagnosed differently by various medical and mental health professionals. He takes several medications, including one for attention arrears disorder. Beverly's begetter has been out of piece of work for several months. He is seeing a psychiatrist for depression and is on an antidepressant medication. Beverly'due south female parent feels burdened by family problems and ineffective in dealing with them. Beverly has always helped her parents with their issues, only she at present feels bad that she cannot improve their situation. She believes that if she were to work harder and be more than astute, she could lessen her family'south distress. She has had trouble sleeping. In the past, she secretly drank in the evenings to salvage her tension and feet.

Well-nigh counselors agree that Beverly is likewise submissive and think assertiveness preparation will help her put her needs first and move out of the family home. Yet, a female person Asian American advisor sees Beverly'south priorities differently, saying that "a morally responsible girl is duty-bound to treat her parents." She thinks that the family needs Beverly'south help, so it would be selfish to go out them.

Discuss

How does the advisor's worldview affect prioritizing the client'southward presenting problems?
How does the advisor's individualistic or collectivistic civilisation affect handling planning?
How might a counselor arroyo the initial interview and evaluation to minimize the influence of his or her worldview in the evaluation and treatment planning process?

Sources: The Part of Nursing Practice and Professional Services, Heart for Addiction and Mental Health & Faculty of Social Work, University of Toronto 2008; Zhang 1994.

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Source: https://www.ncbi.nlm.nih.gov/books/NBK248423/