MENTAL HEALTH WORKERS’ PERCEPTIONS OF CULTURAL COMPETENCY
A Project
Presented to the faculty of the Division of Social Work
California State University, Sacramento
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SOCIAL WORK
by
Karen Calivara Villar
SPRING
2012
© 2012
Karen Calivara Villar
ALL RIGHTS RESERVED
ii
MENTAL HEALTH WORKERS’ PERCEPTIONS OF CULTURAL COMPETENCY
A Project
by
Karen Calivara Villar
Approved by:
__________________________________, Committee Chair
Maria Dinis, Ph.D., MSW
____________________________
Date
iii
Student: Karen Calivara Villar
I certify that this student has met the requirements for format contained in the University
format manual, and that this project is suitable for shelving in the Library and credit is to
be awarded for the project.
__________________________________, Graduate Coordinator _________________
Dale Russell, Ed.D., LCSW
Date
Division of Social Work
iv
Abstract
of
MENTAL HEALTH WORKERS’ PERCEPTIONS OF CULTURAL COMPETENCY
by
Karen Calivara Villar
This study explores mental health workers’ perceptions of cultural competence. This
qualitative study was conducted through face-to-face interviews. This study takes on a
phenomenological approach and utilizes content analysis, particularly latent analysis. Ten
participants were selected through a snowball sampling method. All participants provide
some form of direct mental health services, mostly work with children and families as
well as crisis services. The themes that emerged are as follows: cultural competence is
typically defined as being culturally aware; 2) the development of a personal connection
with the client is the primary culturally competent skill utilized; and 3) the main role
agencies have in facilitating cultural competence is by continually raising awareness of
culture and cultural issues. Implication for social work policy and practice are also
discussed.
____________________________, Committee Chair
Maria Dinis, Ph.D., MSW
_______________________
Date
v
ACKNOWLEDGEMENTS
I would like to those employees of Solano County Mental Health and the contract
agencies who have taken time to participate in this study. I have learned more about
culture and cultural competence listening to your responses than I ever had in any course
or training. Thank you, Dr. Dinis, for advising me through this experience. Your
straightforward guidance kept the Queen of Procrastination from being the Queen of Not
Finishing Thesis. Finally, I would like to thank my cat who is the exact thing I need when
I am stressed. The sound of purring was never more comforting.
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TABLE OF CONTENTS
Page
Acknowledgements ....................................................................................................... v
Chapter
1. THE PROBLEM ………………….……………………………………………….1
Introduction ....................................................................................................... 1
Background of the Problem .............................................................................. 1
Statement of Research Problem ........................................................................ 6
Purpose of the Study ......................................................................................... 6
Research Question ............................................................................................ 7
Theoretical Framework ..................................................................................... 7
Definition of Terms......................................................................................... 12
Assumptions.................................................................................................... 13
Justification ..................................................................................................... 13
Delimitations ................................................................................................... 14
Summary ......................................................................................................... 15
2. REVIEW OF THE LITERATURE ...................................................................... 16
Introduction ..................................................................................................... 16
History of Cultural Competency ..................................................................... 16
Conceptualizations of Cultural Competency .................................................. 19
Professional Guidelines for Cultural Competency ......................................... 25
Skills and Techniques for Individual Practitioners ......................................... 28
Organizational Cultural Competence .............................................................. 36
Gaps in the Literature...................................................................................... 39
Summary ......................................................................................................... 41
3. METHODOLOGY ............................................................................................... 42
Introduction ..................................................................................................... 42
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Research Question .......................................................................................... 42
Research Design.............................................................................................. 42
Study Population ............................................................................................. 45
Sampling Population ....................................................................................... 46
Instrumentation ............................................................................................... 47
Data Collection Procedures............................................................................. 48
Data Analysis .................................................................................................. 49
Protection of Human Subjects ........................................................................ 49
Summary ......................................................................................................... 50
4. DATA ANALYSIS ............................................................................................... 51
Introduction ..................................................................................................... 51
Participant Demographics ............................................................................... 52
Participant Conceptualizations of Cultural Competence ................................ 53
Participant Use of Skills and Interventions ..................................................... 57
Participant Perceptions of Organizational Cultural Competence ................... 63
Summary ......................................................................................................... 67
5. CONCLUSIONS & RECOMMENDATIONS ..................................................... 68
Introduction ..................................................................................................... 68
Conclusions ..................................................................................................... 68
Recommendations ........................................................................................... 70
Limitations ...................................................................................................... 74
Implications for Social Work Policy and Practice .......................................... 74
Conclusion ...................................................................................................... 76
Appendix A. Consent to Participate in a Research Study ........................................ 79
Appendix B. Interview Questions ............................................................................. 81
References ................................................................................................................... 82
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1
Chapter 1
THE PROBLEM
Introduction
The United States has a long history of encounters between different racial,
ethnic, and cultural groups. These encounters have often been marked with
discrimination and oppression of many forms against the non-white populations
(Department of Health and Human Services, 2001). Given this history in combination of
the ongoing shifts of cultural diversity within the United States, the issue of being able to
competently serve the ever changing population is tantamount in all professions and
within the United States. In the field of mental health, workers and the agencies in which
they practice will inevitably encounter different cultural groups who conceptualize and
deal with mental health in culturally different ways and therefore may not be effectively
treated by services that were developed solely from a Western perspective. The
development of cultural competence is a response to and an acknowledgement of the role
cultural plays in one’s mental health. As D’Andrea, Daniels, Arredondo, Ivey, Locke,
O’Bryant, Parham, and Sue (2001) have noted, mental health practitioners who are
unable to demonstrate cultural competent practices are at risk of being viewed as
“irrelevant, unethical and ineffective” (p. 224) by the diverse populations they serve.
Background of the Problem
For all individuals regardless of racial, ethnic, and cultural identification,
untreated mental health needs can have dire consequences for the individual, their
families, and the community at large. The passage of the Mental Health Services Act
2
(2009) is a step in acknowledging those consequences and the need to address those
issues. Some of the consequences of untreated mental health issues include loss of the
ability to function in society, difficulty finding and maintaining work, which can lead to
financial stress. Children may have difficulty concentrating in school, which can lead to
poor academic performance and social adjustment. Severe levels of mental health issues
may also lead to more severe consequences such as disability or suicide. The Mental
Health Services Act sites the financial consequences of untreated mental health with
billions of dollars going into emergency care, nursing home care, unemployment, law
enforcement, and the involvement of both adult and juvenile justice.
The US Surgeon General’s (DHSS, 2001) report on mental health disparities
among minorities brought to attention the mental health needs specifically for racial and
ethnic minorities. The report starts with information on how culture, race, and ethnicity
impact how an individual experiences mental health and mental health services. For
instance, those of lower economic levels are at a higher risk for mental illness. Therefore,
racial and ethnic minorities are particularly susceptible because they tend to have higher
levels of poverty. Similarly, the effects of mental illness become more severe with
increased stressors. Racial and ethnic minorities are especially vulnerable due to their
exposure to racism, discrimination, and violence. In terms of receiving mental health
services, clinician biases and stereotypes have deterred minorities form seeking services
due to their mistrust of said clinicians. Minorities who seek services will need different
types of treatment based on their culture. At the time of this report’s release, most service
3
providers were not considered compatible with the needs of such minority clients, thus
further deterring them from seeking services.
Given the importance of mental health services, delivery to minority groups is of
special interest because the additional barriers minority groups face when accessing and
receiving services. Some common examples of these disparities include higher incidence
of mental disorder, but lower rates of seeking help among African Americans when
compared to white Americans. Asians are less likely to seek services when compared to
white Americans, African Americans, and Hispanics and are more likely to be seen as
having no diagnosis (Centers for Disease Control, 2007). Additional impetus for
improving services to the culturally diverse include limited access and availability of
services, lower quality of care, and the lack of representation in mental health research
(DHSS, 2001). When compared to their white counterparts, the impact of inadequately
treated mental health needs may have a larger negative impact on a minority’s life. A
minority individual may suffer similar consequences to their white counterparts such as
missed work days or loss of social functioning, but in the case of a minority, the effect
may add to or be impacted by both individual and institutionalized oppression not
experienced by a majority group (National Association of Social Workers, n.d.).
The Surgeon General Report was released in 1999 and later revised in 2001.While
the report may be considered outdated, it should still be given credence given that the US
population is continually becoming diverse. According to the US Census Bureau, whites
continue to make up a majority of the total population, but the rate of increase is
considerably lower compared to other racial groups. Between 2000 and 2010, the white
4
population increased at a rate of 5.3 %, African Americans increased at 12.3%, Alaskan
and Native Americans at 18.4%, and the Asian population increased at a rate of 43%.
Those identifying as Hispanic account for a majority of the increases in total population
(Humes, Jones, & Ramirez, 2011).
The state of California is particularly racially diverse when compared to the
United States as a whole. For the 2010 census, 57.6% of Californians identified as white
compared 72.4% of individuals in the United States as a whole. California also has a
higher proportion of Asians and persons of Hispanic or Latino origins, each taking up
13% and 37.6% respectively, when compared to the rest of the country which is
comprised of 4.8% Asian and 16.3% Hispanic or Latino origin. However, those
identifying as black are of a lesser proportion in California, 6.2%, when compared to the
rest of the country at 12.6% (U.S. Census Bureau, 2011).
One sign of the inability to adequately address the needs of culturally diverse
clients is the lack of diversity within the helping Professions. While the population at
large becomes more diverse, those identifying as white or Caucasian continue to
dominate the social work profession. The US Department of Labor and Bureau of Labor
(2011) report in their statistics that the social work profession is comprised of 70.8%
white, 22.8% black or African American, 3.3% Asian, and 11.3% Hispanic or Latino
ethnicity (2011).
The California Board of Behavioral Sciences (2007) came to a similar conclusion
based on a large-scale survey of its licensees and registrants in the fall of 2006. The
license categories of this survey included Marriage and Family Therapists (MFT),
5
Licensed Clinical Social Workers (LCSW), Licensed Educational Psychologists (LEP),
Marriage and Family Therapist Interns (IMF), and Associate Clinical Social Workers
(ASW). Of all of the aforementioned license categories, 74.40% identified as nonHispanic white, 8.38% as Hispanic Latino, 6.36% as Multi-Race/Other, 4.70% as Asian,
3.59% as African American, 0.78% as American Indian/Alaska Native, 0.40% as Pacific
Islander, and 1.41% left no response. When broken down by license category, MFTs
LCSW, and LEP tended to be disproportionally non-Hispanic white when compared to
the California population. With the California population at 44.40% non-Hispanic white,
the MFT category comprised of 81.98% non-Hispanic white, LCSW at 72.49%, and LEP
at 81.49%. Both IMF and ASW were closer to the California population compared to
their licensed counterparts, but both were still disproportionately non-Hispanic white at
61.5% and 49.89%, respectively.
This same study reported on non-English language ability compared to that of the
California population. The languages surveyed include Spanish, Chinese, Korean,
Tagalog, and Vietnamese. Twenty-five percent of California is Spanish proficient,
whereas all license categories were 11.83% Spanish proficient. Similar to the
identification of non-Hispanic whites in the survey, MFT, LCSW, and LEP had the
lowest representation of Spanish speakers, while IMF and ASW were closer to
California’s rate of Spanish proficiency. The ASW was closest at 24.30%. Similar
patterns can be found for Chinese, Korean, Tagalog and Vietnamese in which some
license categories were lower than others, but overall all rates for all categories fell below
the language proficiency of California as a whole. The lack of non-English language
6
proficiency further demonstrates the inability to provide culturally and linguistically
appropriate services to diverse populations.
Statement of Research Problem
The need for cultural awareness and cultural competency is widely recognized in
the helping profession. Many graduate programs will have some component regarding
issues of diversity. For instance, the social work profession seems to go hand in hand
with cultural awareness and competency, given the profession’s dedication to the
empowerment of vulnerable populations (NASW, 2008). Despite the acknowledgement
of cultural awareness and competency, workers in the mental health field are unable to
speak fully on how cultural competence is integrated into their work. Some of the
challenges to consistent implementation of cultural competence include varying
definitions of cultural competence and lack of frameworks to organize these concepts
(Sue, 2001). In addition to this, cultural competence is typically seen as the responsibility
of the individual mental health worker, with little attention paid to the role of the agencies
they represent (Adamson, Warfa & Bhui, 2011).
Purpose of the Study
The purpose of this study is to explore the ways in which mental health workers
identify issues of culture, what cultural competency skills are used, the level of
effectiveness workers feel they have when using these skills, and the role their agency
plays in facilitating cultural competency. This researcher hopes to better understand how
mental health workers are able to integrate cultural competency skills in their daily
practice. This includes the level of awareness of issues of cultures, actual integration of
7
cultural knowledge, and barriers to use of cultural competency skills. In gaining an
understanding of the process of cultural competency from the worker’s perspective, this
researcher hopes to produce recommendation for the improvement of cultural
competency education and training
Research Question
This study examines the following research question. Do mental health workers
perceive cultural competence primarily as having an awareness of culture?
Theoretical Framework
Cultural competency is a multi-dimensional issue and therefore warrants the
application of multiple theoretical frameworks. Three will be utilized here: Feminist
Standpoint Theory, Theory Internalized Culture, and Systems Theory. Before discussing
each of these frameworks, there will be a brief explanation of epistemology because it
will allow for a better understanding of how theory operates and is of particular interest
for Feminist Standpoint Theory.
Epistemology
Epistemology is the study of knowledge. It looks at how and why some
knowledge is accepted as reality, while other knowledge is rejected (Williams, 2006).
Theoretical frameworks are of interest to epistemology because they are themselves ways
of knowing in that they seek to organize knowledge. Also related to epistemology is
research itself, which generates what later becomes accepted as knowledge. One of the
most widely held methods of knowing, particularly in Western societies, is through the
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positivist approach. Positivism accepts only that which can be observed and scientifically
tested as true knowledge or true reality (Robbins, Chatterjee, & Canda, 2006).
Feminist Standpoint Theory
Feminist Standpoint Theory criticizes traditional ways of knowing, particularly
the positivist approach, are generated and justified by people of privilege, i.e.
heterosexual white males, which in turn excludes the experiences of the oppressed, i.e.
women (Ritzer, 2004) . Scientifically generated knowledge is assumed to be unbiased and
true to reality. However, Standpoint Feminists point out that research itself is shaped by
the sociopolitical interest of those who administer research (Robbins et al., 2006).
Therefore, the knowledge generated by that research, rather than being unbiased and
universally held as reality, is actually a product of a particular standpoint.
Standpoint refers to position in society and affects how one views reality. For
instance, the male standpoint will have a much different view of reality compared to the
female standpoint because each has vastly different life experiences. There are two
assumptions of this theory that are of use to this research: life experiences shape one’s
understanding of reality; members of the most powerful group and members of the least
power group may have opposed views of reality (Robbins et al., 2006). In terms of its
weaknesses, this theory is that the focus is exclusively on the inclusion of the female
perspective. The theory also fails to acknowledge differences within a group.
Application of Feminist Standpoint Theory. Standpoint theory will be used as
an overarching framework in understanding the intentions of this research. The main
application of Standpoint Theory is its ability to validate the experiences of those who are
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outside of the mainstream white, upper/middle class, male perspective. While the original
theory lacks the inclusion of other standpoints as well as the recognition of diversity
within a given group, the framework itself has the potential to be inclusive, which is how
it will be utilized within this research. This researcher acknowledges and accepts that
each individual who participates in the study comes with a unique life experience that
shapes their view of reality. Each view is different, but no single view is considered
superior than another, including the view of this researcher. Although no clients of the
participants in this study will be involved directly, the same underlying principle is
applied to them as well. In fact, the acknowledgement of the standpoints of the culturally
diverse, i.e. the client population, is part of what propels the need for cultural
competence.
Internalized Culture
Another underlying theoretical framework will be Ho’s (1995) model of
internalized culture and speaks specifically to the cultural competence aspects of this
study. Under this framework, all counseling encounters are considered cross cultural.
Counselors must have an in-depth knowledge of the culture of their client, but must also
understand that individuals are unique within their own culture (Brown, 2009). The idea
of internalized culture refers to culture as it affects, but not determine, an individual’s
psychological processes such as cognition and personality formation (Ho, 1995). That is
to say, culture influences how one sees reality and experiences life, but it does not define
who is that person. Ho makes this distinction in order to highlight that while individuals
from a particular cultural group may share the same cultural background, each individual
10
is unique in their identities and experiences. Therefore, interventions and strategies that
are meant to be culturally appropriate for a particular group may in fact be inappropriate
for some members of that group because their individual experience differs from the
generalized cultural knowledge in which the intervention is based. For instance, an
intervention may be geared towards African American clients, but that intervention may
be more effective for an African American client with a middle class upbringing and less
effective for an African American of a lower economic status.
Application of Internalized Culture. Internalized culture has three components
common to many conceptualizations and definitions of cultural competency: awareness
of one’s own culture, awareness of the culture of the client, and use of intervention. This
framework was chosen because it qualifies awareness of other cultures and use of
interventions in its acknowledgement of the uniqueness of individual experience within a
cultural group. It will be considered the default definition of cultural competency within
this study. The responses of the participants will be analyzed in the extent to which their
views echo the tenets of this framework. However, it must be noted that this analysis is a
matter of comparison and not judgment.
Ecosystems Theory
The Ecosystems Theory is a specific kind of Ecological perspective. Because
Ecosystems theory is based on the concepts of the Ecological Perspective, an explanation
of the Ecological Perspective will precede the discussion of Ecosystems Theory.
Ecological Perspective. A subset of Systems Theory, the Ecological perspective
is a widely held framework in the social work profession (Robbins et al., 2006). This
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perspective looks at the process by which groups or populations interact with their
environment, both physical and social, in order to ensure their survival. The defining
feature of this perspective within social work is the emphasis on the interaction between
groups and their environment, a relationship that is characterized as being reciprocal and
interdependent. That is to say, the environment affects its inhabitants while at the same
time it is affected by those same inhabitants (Robbins et al., 2006).
Ecosystems Theory. Ecosystems Theory draws from the Ecological Perspective
with influences from functionalism, dynamic systems theory, among others. This theory
is concerned with the “goodness of fit” between individuals and their environment and
likewise between the environment and its people. It highlights the ability between these
people and the environment as being fluid and adaptable while at the same time shaping
and influencing each other. A poor fit between person and the environment when the
inputs and stimuli are too much, too little, or completely missing (Robbins et al., 2006).
The strength of this perspective is that it accounts for the creative capacities for
individuals to adapt and grow into the full potential of their lives (Goldstein, 1979).
Application of Ecosystems Theory. This framework was chosen for its emphasis
on the interaction between individuals in their environment as well as the belief in
potential and growth. It will be applied to the interactions between the client and their
worker where the treatment space, which the worker is considered a part of, is the
environment. The “goodness of fit” in this relationship refers to the extent to which the
treatment environment is able to respond to the cultural needs of the client. Follow this
same line of thought, this theory will also frame individual mental health workers in the
12
environment of their agencies. The “goodness of fit” here is the extent to which agencies
are able to help facilitate cultural competency of the mental health workers.
Definition of Terms
The following terms will be used in this study. These terms are relevant to the
perceptions of mental health workers regarding cultural competency.
Culture: an integrated pattern of human behavior that includes thoughts, communication,
customs, beliefs, values, and institutions (Cross et al., 1982). Culture can be identified
along many dimensions including race, ethnicity, gender, profession, sexual orientation,
and common interests and an individual may be associated multiple cultural identities
with varying degrees of strength. For the purpose of this study, it is assumed that
“culture” refers to race and ethnicity, unless noted otherwise by participants or within the
literature.
Race: race is generally seen as a set of physical, i.e. biological, characteristics shared by a
group of people. Given that more research supports the idea of there being no genetic or
biological basis for race, the use of the word race in this study will not have the
assumption of biological basis. For this study, race will be considered a socially
attributed set of characteristics shared by a group of people (California News Reel, 2003).
Ethnicity: a common heritage of history, language, rituals, food, music shared by a
particular group of people (DHHS, 2001). While there is overlap between race and
ethnicity, there are important distinctions between the two. For example, while many
African Americans may be racially identified as black, their ethnic background differs
vastly from an individual who is also considered racially black, but identifies with a
13
Caribbean ethnicity. Similarly, both Japanese and Chinese individuals may both be
considered Asian racially; however, their ethnic heritages are distinct from one another.
Mental health worker: an individual working for a program funded by MHSA funding in
a direct practice capacity. This includes counselors, therapists, and crisis intervention
workers. This study will look at perspectives from social workers practicing in mental
health, but will include individuals from different professional backgrounds including
Marriage and Family Therapists and non-licensed employees and interns in the field.
Assumptions
The assumptions of this study are as follows: 1) Each individual’s experience and
perception of reality is affected by their culture, though each individual may experience
their culture differently; 2) Mental health services was developed from the prospective of
the dominant white, western culture and are by default delivered in that manner; 3) All
mental health workers have some level of familiarity with issues of culture and cultural
competency; and 4) Mental health workers do not inherently have discriminatory attitude
towards people of other cultures nor do they consciously work with such clients in way
that is harmful to them because of that difference.
Justification
The content of this study is relevant to the social work profession because it
speaks to multiple parts of the National Association of Social Workers Code of Ethics
(NASW, 2008). Code 1.01 speaks to the responsibility social workers have to promote
the well- being of their clients, in this case mental health. Code 1.04 emphasizes the need
for social workers to provide services in a competent manner, specifically that social
14
workers should utilize certain skills after receiving the proper training, certification, and
proper supervision. The intent of this study is to provide information that will improve
the process of becoming competent in the realm of working with other cultures. The
entirety of Code 1.05 describes the expectations specifically for cultural competency in
social work practice. This code highlights the need to recognize and value the role of
culture in the lives of clients, the need for a knowledge base of other cultures,
demonstrated competence in delivering services to clients of different cultures, and
continual education and training about social diversity.
As mentioned earlier, the therapeutic relationship between the worker and client
can greatly impact the outcome for that client. The worker contributes significantly to
creating that relationship, which is why this research is focusing on the worker’s
perspective. The results of this study will identify themes of what facilitates the use of
cultural competency skills as well as what acts as barriers to those skills. The results can
be used as a guide for future research aimed at improving cultural competency. The
information can also be used to identify target areas for improving education programs
and professional training on the subject. This study will also focus on the role of the
agency in facilitating cultural competency. The results may help identify areas in which
agencies are able to help facilitate more culturally competent practice.
Delimitations
Because of the small sample size, the results of this study may not be generalized
to the population at large. This sample is drawn primarily from two agencies; therefore,
the results are more likely a reflection of these two agencies rather than the mental health
15
field as a whole. This research does not include a quantitative analysis of the data,
making it difficult to draw any relationships or observe patterns along certain
characteristics such as age, race/ethnicity, and gender. Although the survey used in this
study has undergone an approval process conducted by an expert panel, it is a creation of
this researcher that has not been rigorously tested for validity. Finally, the educational
backgrounds of the participants vary, so the results are not unique to the social work
profession.
Summary
Chapter 1 presents the background of the problem, the statement of research
problem, the purpose of the study, the research question, the theoretical framework, the
definitions of terms, the assumptions, the justification, and the delimitations. Chapter 2
will be a review of the literature which will be structured around the following themes:
history of cultural competency, conceptualizations of cultural competency, professional
guidelines for cultural competency, skills and techniques for individual practitioners, and
organizational cultural competence. Chapter 2 will also go over gaps in the literature.
Chapter 3 will go over the research design. Chapter 4 will include an analysis of the data.
Chapter 5 will present the study’s conclusions and implications.
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Chapter 2
REVIEW OF LITERATURE
Introduction
This literature review will be broken up into six sections. The first section will give
a brief overview of the history of cultural competency in mental health. The second
section will look at definitions of cultural competency. The third section will look
professional guidelines for cultural competency, specifically for the National Association
of Social Workers, American Psychological Association, American Association of
Marriage and Family Therapy, and the American Counseling Association. The fourth
section will discuss skills and techniques for individual practitioners. This section will
have three sub-sections: issues in evidence based practice, nonspecific skills and
techniques, and culturally specific skills and techniques. The fifth section will look at
organizational cultural competency. The final section will discuss gaps in the literature.
History of Cultural Competency
The history of cultural competence in the United States begins with the history of
the cultures that existed in, were introduced to and evolved from the country as it
developed. The United States began with an encounter between the would-be American
colonists and the people indigenous to those lands. Since then, the people and the culture
who share the nation both influences and is influenced by each other. One poignant
example is that of the Cherokee who were forced to abandon their cultural identity in
order to appease the white Americans who were continually encroaching upon their lands
(California News Reel, 2003). The interfacing of the different cultures within the United
17
States is constant and will continue to be so given the ever changing nature of the U.S.
population.
Culture has had a role in social work since the field’s inception. One of the
pioneers of social work, Jane Addams, dealt intimately with immigrants and their culture
in the mid-1800s. Her settlement house, Hull House, offered a number of services to the
poor immigrants from the surrounding neighborhood. Some of the services and resources
offered include home cooked meals from the immigrants’ home country, literature clubs,
and an art gallery. In addition to this, Hull House classes which intended to verse
immigrants about American government, culture, and the English language (University of
Illinois College of Architecture and Arts, 2009). Even within the practice of social work,
in general this varied by cultural context. Early African American social workers
necessarily approach their work differently from their white American counterparts and
receive less recognition for their contributions to the profession (O’Donnell, 2001). Some
differences include African American social workers who saw their work more as selfempowerment rather than charity and that they viewed issues in terms of community
rather than individuals.
As noted by Arredondo & Toporek (2004), ethical codes and competencies
emerge as a result of consumer demands and sociopolitical changes. Changes in The
movement towards cultural competence has its roots in the 1950s, following the Civil
Rights movements which demanded equal rights and equitable treatment for minority
groups (National Association of Social Work, n.d.). The increased visibility of minority
groups in combination with the influx of immigrants to the United States has made it
18
increasingly important to develop cultural competency in all professions (NASW, n.d.).
The concept of cultural competence has been applied to many different fields and
professions including education, health care, and business. The need for cultural
competence in mental health took off in 1999 following the release of a report by the
United States Surgeon General which brought attention to mental health disparities for
racial and ethnic minorities. Some of the major findings include: minorities have less
access to mental health services, those who receive services receive poorer quality of
care, minorities are underrepresented in mental health research, and minorities experience
a greater burden due to their mental illness compared to their white counterparts (DHHS,
1999). The publication of this official governmental document has provided practical
impetus to consider culture in relation to quality of care in mental health.
Scholars have attempted to define cultural competency in the helping professions.
One of the earliest definitions come from Cross, Bazron, Dennis, and Isaacs (1989), the
details of which will be discussed below. Since then, many scholars within the helping
professions have developed and revised other frame works and definitions. All of them
have in common three elements: knowledge of one’s own culture, knowledge of the
client’s cultural experience of reality, and use of culturally appropriate interventions and
skills (Sue, 2001). Further discussions over cultural competency have called for an
expansion of what is meant by “culture.” Early uses of culture refer specifically to race
and ethnicity, including the US Surgeon general. For these scholars, an expanded
definition should include other facets of identity such as gender, sexual orientation,
religion, age, socioeconomic status (Brown, 2009; Sue, 2001).
19
In addition to scholarly works, much development around cultural competence
can be identified within professional organizations. Some professions who outline
culturally competent practice include the National Association of Social Workers and the
American Psychological Association, both of which will be further discussed below.
Beyond this, deliberate culturally competent practice is left to the discretion of the agency
and their employees.
Conceptualizations of Cultural Competency
Early conceptualizations of cultural competence revolved around self-awareness,
knowledge of other cultures, and the use of specific skills and interventions that are
culturally appropriate. Since then, the definition of cultural competence has remained
relatively unchanged (Collins & Arthur, 2007).
Fischer, Jome, and Atkinson (1998) attempt to fit cultural competency into a field
built on theoretical and practice models that are assumed to be universal. While the
evidence presented in the first chapter of this thesis indicates otherwise, this is not to say
that cultural competence and these already existing models are mutually exclusive.
Fischer et al. conceptualizes cultural competence at a theoretical level and attempts to
bridge the gap between etic and emic approaches to mental health. Here, an etic
approach is considered universally applicable while an emic approach is culturally
specific (Fischer et al). They do so this by taking on a common factors perspective, which
assumes there are certain components that are universal to all therapeutic models. The
common factors identified by Fischer et al. include the therapeutic relationship, a shared
20
worldview, client expectations for positive change, and interventions that both client and
therapists feel have healing potential.
By looking at these common factors Fischer et al. (1998) was able to demonstrate
how cultural competency, an emic approach, necessarily becomes part of the fulfillment
of a common factor, an etic approach. Take for example a positive therapeutic
relationship. The therapeutic relationship itself is universal to all mental health
interactions. In cases where the mental health worker is working with a client of a
different culture, that worker must demonstrate cultural competence in order to build that
positive relationship (Fischer et al.).
Sue (2001) has noted that part of the challenge in implementing cultural
competency is the multitude of different definitions for cultural competency as well as
the lack of conceptual frameworks that can organize its many facets. Sue attempts to
develop a framework which addresses some of the major facets identified in cultural
competency. These facets are categorized along three dimensions. In an attempt to
address the issue of etic/emic approaches to cultural competence, Dimension 1 includes
race and culture specific attributes to cultural competence. Along this dimension, Sue
presents an additional framework that helps practitioners understand a client’s identity.
The center is comprised of those unique aspects of the individual, the shared similarities
and differences with the individuals’ cultural groups, and the universal level of existence
is shared by all humans. Dimension 2 involves components of cultural competency which
includes awareness of beliefs and attitudes, knowledge, and skill. Dimension 3 is the foci
of cultural competency, which looks at cultural competency at different levels of practice.
21
This includes individual, professional, organizational, and societal levels. In developing a
multidimensional and multifaceted framework for cultural competency, Sue expanded
possibilities for treatments and approaches to cultural competency in general.
Whaley and Davis (2007) also considers cultural competence at a model level
before discussing what it looks like for individual mental health workers. They categorize
definitions of cultural competence as being either a model of content ( i.e. having
knowledge of other cultures, or a model of process). Cultural competence is developed
through interaction and problem solving. Whaley and Davis combine content and process
in their definition of cultural competence into the following components: understanding
of how the heritage and adaptation aspects of culture interact in shaping behavior; the use
of that knowledge in order to effectively assess, diagnose, and treat an individual; and
internalizing this process in order to routinely apply it to diverse groups. The ability to
routinely apply this process to different cultural groups also speaks to the gap between
emic and etic approaches mentioned by Fischer et al.(1998). Davis and Whaley’s
conceptualization speaks to a process that becomes culturally specific, but can also be
utilized with diverse groups. This suggests the process can be applied universally.
Collins and Arthur (2007) reconceptualizes the basic definition of cultural
competence, by focusing on a more inclusive way of defining the use of interventions and
techniques. As a critique of the already established definition of culture, they mentioned
the tendency for early definitions to associate culture only with race and ethnicity. In
addition to this, the emphasis on interventions and techniques can be narrow in focus. To
address these weaknesses, Collins and Arthur’s revised vision of cultural competence
22
uses the development of the therapeutic alliance as the overarching framework for
cultural competence. Among their reasons for using the therapeutic alliance as a
framework is strong empirical evidence associating positive client-therapist relationship
and positive outcomes. Also, a therapeutic alliance is considered necessary in order for a
practitioner to effectively utilize any techniques or interventions, sentiment that was also
expressed by Fischer et al. (1998). Finally, the therapeutic alliance is not dependent on a
single conceptualization of culture. It can be responsive to any cultural group or groups a
client may be associated.
Collins and Arthur take the common components of cultural self-awareness,
knowledge of other cultures, and utilization of culturally appropriate skills and
reconceptualize them as three domains. Under each domain, they list a set of core
competencies. Domain I is focused on developing awareness of the self and how culture
impacts self. Domain II is about developing awareness of the other and how culture
impacts that other. Domain III looks specifically at the building of a therapeutic alliance.
The core competencies associated with Domain III include a mutual agreement on the
treatment goals, a mutual agreement on the task each person in the alliance will fulfill,
and the presence of mutual trust and respect.
Cross et al. (1989) define cultural competency at both an individual and agency
level. Cultural competency is a set of “congruent behaviors, attitudes, and polices in a
system agency” (p. iv), which allows that agency and individuals within that agency to
effectively work across cultures. They go on to propose that cultural competence is not a
state of being that one either is or is not, but that it is a process in which practitioners may
23
fall along a spectrum of competence with cultural proficiency being the most desirable
level and cultural destruction being the least desirable.
Similarly, Livingston et al. (2008) defines cultural competency as a set of
behaviors, attitudes, and policies which enables agencies and individual practitioners to
effectively function with culturally diverse clients and communities. Three components
to cultural competency include the following: an in-depth understanding of one’s own
culture, development of knowledge of other cultures, and acquiring skills that facilitate
the use of interventions with clients of diverse cultures. Livingston et al. et al. echoes
Davis and Whaley (2007) in that they also speak to cultural competency as both content,
development of knowledge, and as a process, application in practice.
A persistent theme within the literature is the need to gain in-depth knowledge of
one’s own culture as well as the cultures of others. Livingston et al. (2008) suggests that
one should research one’s own culture and help mental health workers realize how their
own cultures may create biases against others. Livingston et al. et al. gives a poignant
example of expectations about time management in America.. Practitioners may not be
conscious of the fact the expectation for clients to be on time for their appointment is
product of a value specific to white American culture. This may lead that practitioner to
see the client as uncommitted to their treatment, not realizing the role of their own bias in
playing in that interaction.
At the same time, mental health workers should gain knowledge of culture that
goes beyond superficial details such as food and language. Instead this knowledge should
center on a culture’s values or how that culture organizes the world from their
24
standpoint. Some examples would include becoming acquainted with how one’s culture
approaches spirituality or cosmology (Livingston et al., 2008).
Similarly, Brown (2009) also calls for mental health workers to look at the
complexities of how culture operates within an individual life. In particular, Brown
suggests that rather than looking at one aspects of a an individual’s culture in a vacuum,
it is more effective to think of an individual as having many cultures and to consider how
those different aspects come together to create that individual’s viewpoint. The term
given by brown is “intersectionality.” Based on this concept, individuals may experience
the same culture differently because each individual is comprised of a multitude of
cultural identities that interact with one another and impact that individual’s view of
reality.
In addition to the efforts of individual workers and the agencies that employ them,
the extent to which individual mental health workers are able to become culturally
competent depends on the training and education that individual receives. Mattar (2011)
presented a few ways that may help mental health workers who specialize in trauma
provide services in a culturally competent manner. For instance, at the training level, not
only should students be required to receive coursework specifically on cultural
competence, but that content should be delivered by an instructor who is aware of
cultural competency issues. This includes not only being aware of the dynamics of
culture between practitioners and clients, but also within the classroom where the
instructor is aware of his or her own cultural standpoint in relation to that of his or her
25
students. Mattar also makes the same point for clinical supervisors, who must also be
aware of the cultural dynamics between the supervisor and supervisee.
Professional Guidelines for Cultural Competency
It must be noted that there are subjects within many code of ethics that do not
specifically mention “culture” in its wording, but may be related to cultural issues. For
example, code 3.10 for the American Association of Marriage and Family Therapists
prohibits the giving or reception of gifts of substantial value or gifts that negatively
impact the therapeutic relationship (AAMFT, 2001). This code may have cultural
implication given that in some cultures gratitude is expressed through gift giving. While a
code of ethics may include topics in which culture may be relevant, this study will not
mention those codes unless the word “culture” is explicitly stated. This will be done to
ensure consistency and avoid misinterpretations. In addition to this, only the National
Association for Social Workers, the American Psychological Association, the American
Counseling Association, and the American Association of Marriage and Family Therapist
will be explored here because these are the professions that are represented within the
sample.
As mentioned in the justification for his research, the National Association for
Social Workers explicitly dedicated code on cultural competency. The underlying themes
of the code 1.05 include the acknowledgement of the importance of culture, having and
obtaining knowledge of different cultures, and competence in integrating that knowledge
into practice (NASW, 2008). As part of its ethical principles, which can be seen as the
core values underlying the code itself; the NASW identifies social justice, i.e. the pursuit
26
of social change on behalf of oppressed populations, as a root value for the profession. In
addition to the code of ethics, the NASW produced a set of specific indicators for cultural
competency. The standards outlined by the NASW is as follows: ethics and values, selfawareness, cross-cultural knowledge, cross-cultural skills, service delivery,
empowerment and advocacy, diverse workforce, professional education, language
diversity, and cross-cultural leadership (NASW, 2007). The standards are given specific
actions and skills social workers must demonstrate in order to be considered culturally
competent. For instance, the standard for self-awareness will be indicated by a social
worker’s ability to recognize their own culture, values, and beliefs in order to become
more aware of how such assumptions operate in the lives of their clients. While the
language of the standards is directed towards social workers in general, i.e. “social
workers will...,” the scope of the standards goes beyond individual practice. The standard
of diverse workforce and language diversity can also be applied to agency level
actions. Empowerment and advocacy can also enter the realm of mezzo level practice.
Similar to the NASW’s ethical principles, the American Psychological
Association acknowledges the importance of culture under their general principle E:
respect for people’s rights and dignity (The American Psychological Association, 2010).
The APA standard 2.01(b) require practitioners to gain expertise in areas in which
understanding factors such as culture impact effective service delivery, which is similar
to the NASW code 1.05(c). Standard 3.01 prohibits discrimination against individuals
based on race, age, gender, culture, etc. Standard 3.03 similarly prohibits harassment
based on those same social categories. In addition to this, the APA (2002) has released
27
guidelines for work with individuals of diverse social and historical backgrounds.
Guideline #6 encourages psychologists to use their knowledge about culture at the
organizational level, which would result in more culturally competent practice. .
The American Counseling Association (ACA) makes multiple references to
culture throughout its code of ethics. Code A.2.C, A.12.g specifies the need to discuss
matters of informed consent in a culturally sensitive manner. A.10.c and A.20.d both
acknowledge the role culture may play when engaging in bartering or receiving gifts
from clients. A.11b requires that practitioners will be knowledgeable of culturally
appropriate referrals should the practitioner feel that he or she is unable to professionally
assist the client (American Counseling Association, 2005). While the ACA does not go
into great depth about how a practitioner would demonstrate cultural competence, the
code of ethics includes specific contexts in which cultural awareness should be exercised.
The American Association for Marriage and Family Therapy code of ethics has
one explicit reference for work with diverse clientele. Code 1.1 states marriage and
family therapists will “provide professional assistance to persons without discrimination
on the basis of race, age, ethnicity, socioeconomic status, disability, gender, health status,
religion, national origin, or sexual orientation.” (AAMFT, 2001).
In addition to this, the AAMFT (2004) has released core competencies which
make multiple references to integration of culture.. Under the domain of Admission to
treatment, number 1.2.1 states that MFTs should recognize contextual and systemic
dynamics including culture/race/ethnicity in addition to other dimensions such as gender,
age, sexual orientation, etc. The number 1.3.1 requires that cultural, individual, family,
28
and community context be given balanced attention during intake. Under the domain of
clinical assessment and diagnosis, number 2.1.4, MFTs should understand that particular
assessment tools are appropriate for certain presenting problems, practice settings, and
cultural contexts. Similarly, number 2.1.6 notes that certain models of assessment and
diagnosis are more relevant for different cultural, economic, and ethnic groups. Number
2.4.3 asks MFTs to evaluate the cultural relevance of behavioral health and relational
diagnoses. Under the domain of competence, number 4.1.1 requires MFTs to comprehend
a variety of therapeutic models, specifically culturally sensitive approaches. Number
4.1.2 states that one should recognize the strengths and limitations of certain therapy
models, especially with regard to their risk of holding assumptions about cultural deficits.
Number 4.3.2 requires that interventions are delivered in a way that is sensitive to the
specific needs of a group including culture/race/ethnicity. Number 4.4.1 requires MFTs to
evaluate consistency between the model of therapy and theory of culture. The number
4.4.6 asks one to evaluate reactions to the treatment process in terms of the client’s
cultural context (AAMFT, 2004).
Skills and Techniques for Individual Practitioners
This section opens with a discussion of cultural competency issues in evidencebased practice before going into the overview of skills and techniques. The skills and
techniques will be divided into two categories: skills that are not specific to a particular
culture and skills that are culture specific.
29
Issues in Evidence Based Practice
Given that many consumers of mental health services are increasingly coming
from a multitude of cultural backgrounds (Sue, 2001) and that evidence based practices
are gaining prominence in the mental health field, it should follow that evidence based
practices be applied to the culturally diverse populations served. However, evidence
based research for a diverse population is an issue itself. Specifically, it is worth
exploring the extent to which evidenced- based practice research is applicable to diverse
populations (Mattar, 2011).
Research sampling for specific interventions tend to comprise of predominantly
white participants (Whaley & Davis, 2007), which limits the extent such interventions
are relevant to diverse populations. Even when diverse populations are included in a
sample, results may not be universally applicable if that research itself is not specifically
testing for effectiveness among the different cultural groups (Atkinson, Bui, & Mori,
2001).
The very nature of scientific research itself is prohibitive of taking into account
issues of culture. Adherence to randomized control trials and treatment protocols
minimizes cultural and contextual factors by taking out elements of the real world setting
that impact how an individual experiences reality (Mattar, 2011). The cultural factors
which shape an individual’s experience from another will be missed. For instance,
scientific research would not be able to take into account that the manifestations of
mental health symptoms tend to vary by culture. An example is that for some Chinese
30
clients, distress is often expressed through somatopsycholgical symptoms (Cromier et al.,
2009).
Whaley and Davis (2007) acknowledge the role of the researchers in yielding
culturally relevant information, stating that those who are themselves culturally aware
will be more able to do so compared to those who are not. The same logic can be applied
to the research design itself. If a project is designed by a researcher who is not aware of
cultural issues, ideas of abnormal or dysfunctional behavior will be strictly based on a
Western perception. Whaley and Davis (2007) go on to comment that research
development needs to include the communities of color in shaping the project agenda in
order to create culturally competent research information. This is reminiscent of the
NASW’s (2007) cultural competence indicator of empowerment and self-determination.
While this indicator speaks specifically to policy advocacy, the same idea can be applied
to research in that emergent research is what guides the direction mental health practices
will tend towards.
Silverstein and Auerbach (2009) identified three main issues in evidence- based
practice for a culturally diverse population. The first is “top down” in which evidence
based practices are developed by experts who tend to minimize subjective experiences. In
the case of marginalized groups, i.e. non-white cultural groups, their subjective
experiences are overlooked, thus allowing their oppression to perpetuate. The second
issue is “just add culture and stir,” in which interventions are modified to better cater to
different cultural groups, i.e. translating interventions. This issue assumes variables are
the same for all cultures, Rather than assuming the variables are the same, culture itself
31
should be seen as the source for variables. Finally, the last issue is that of “multiplicity,”
in which the existence of so many different cultural groups makes it impossible for there
to be an evidence- based practice for every single group.
Nonspecific Skills and Techniques
Cromier et al. (2009) explores five features that are relevant to culturally
competent decision making. These features include contextual awareness; consciousness
development; diffusing distress and reframing resistance; constructed, contextualspecific, and collaborative interventions; and therapeutic proactivity. While Cromier et al.
presents a number of interventions and strategies for each part of the treatment process,
only a few will be explored here.
One example of a method for gaining contextual awareness involves asking the
client to draw an image of their home, which may reveal underlying cultural values
framing the client’s life. For instance, a client from a culture that emphasizes the need to
support extended family may draw upon that extended family within the home. Other
strategies involve understanding and utilizing the client’s reality as it is shaped by their
cultural frame. Mental health workers must be aware that clients may be displaying
distress or doing so as a natural and logical response to their situation. One way of
effectively diffusing that stress is by looking to existing tools and resources in the client’s
cultural context, such as spiritual beliefs (Cromier et al., 2008).
Lo and Fung (2003) explore different skills and strategies for culturally competent
psychotherapy, with a focus on Asian and Asian American cultures. Their exploration
highlights numerous ways in which a worker must be mindful of the role culture plays
32
when working with a client of a different culture throughout the therapeutic process. For
instance, mental illness is associated with a great deal of stigma and shame in many
Asian cultures. During the engagement phase, mental health workers can lessen those
negative impacts through psychoeducation about what treatment entails and reassuring
the client and the family of their confidentiality. During the assessment phase, the worker
should be aware of group dynamics, especially where family is concerned, spirituality,
and the interplay of the client’s home culture and the dominant culture in the client’s
individual experience. When approaching treatment, the worker should collaborate with
the client on treatment goals, starting with what is most important to the client (Lo &
Fung, 2003).
Barrera and Corso (2003) focus on the quality of the communication and
interaction between the practitioner and the client in their development of Skilled
Dialogue. This model identifies three qualities that are necessary: respect, reciprocity,
and responsiveness. Building off one another, these boundaries emphasize
acknowledging boundaries, valuing the contribution of both practitioner and client
equally, and maintaining an attitude of learning and curiosity in order to be open to
different possibilities. These qualities guide the two main components of Skilled
Dialogue: anchored understanding of diversity and the creation of a 3rd space. Having an
anchored understand of diversity means to have general knowledge that is also and
necessarily anchored in a practitioner’s face- to- face interaction with the client. The
creation of a 3rd space refers to being able to identify a third alternative when the client
and practitioner each have a different and possibly conflicting perspective. Barrera and
33
Corso emphasizes that the alternative incorporates both perspectives and does not require
either perspective to compromise.
Culturally Specific Skills and Techniques
As mentioned by Silverstein and Auerbach (2009), it is infeasible to cover every
cultural group in this section. Only a few examples will be given based on different types
of culture: ethnicity, spirituality, and sexual orientation.
Hurdle (2002) discussed Ho’oponopono, or a family-based conflict resolution
ceremony previously used by Native Hawaiian’s prior to Christianization. The process of
Ho’oponopono takes place within the immediate family and some extended family based
on their involvement in the conflict. The modern use of this process involves either a
family elder or worker who acts as leader. Rather than allowing the family members to
speak directly to one another, all communication is deferred to the leader in order to
prevent further escalation of the conflict or misunderstandings. Ho’oponopono occurs in
stages that must go in order. It begins with a prayer, which includes a description of the
hala, or transgression, as well as any negative entanglements created, or hihia. Each
participant describes their man’o or feelings, during which each person is encouraged to
be honest, communicate openly, and avoid blame. The next stage involves resolution,
starting with mihi, or confession of wrong doing and seeking of forgiveness. All members
of the family involve asking for forgiveness, giving all members equal status with one
another. The closing phase, pani, involves a summary of what had occurred and a
reaffirmation of the family’s bond.
34
The use of spirituality has been associated with positive outcomes when
incorporated into treatment planning (Hodge 2011). Doing so may provide two sources of
motivation: the desire to address the issues and the desire to grow spiritually. Hodge
presents a set of guidelines for utilizing spirituality in social work interventions. To start,
the worker should assess for client’s preference. Some clients may not be interested or
comfortable with sharing their spirituality with their worker, especially in the early stages
of the relationship. Others, however, may be very interested in incorporating spirituality
in their treatment. Second, practitioners must be mindful of the research used to backup
spirituality in treatment. Some factors to consider is using research that is relevant to the
client’s needs and using the best available research available. Third, an ethical
practitioner should consider their level of training and experience when selecting
spirituality based interventions. Hodge points to clergy or other spiritual leaders as
potential collaborators in this area. Finally, the last guideline talks specifically about
cultural competency in terms of “spiritual competency,” which is based on the same
concepts of cultural competence: awareness of one’s own spiritual worldview, an
understanding of the client’s spiritual worldview, and the use of interventions that
resonate with the client’s spirituality.
The American Psychological Association (2011) has released a set of guidelines
for practicing with lesbian, gay, bisexual, transgendered ( LGBT), clients. To some
extent, these guidelines are to be a direct attempt to ameliorate the negative attitudes
towards the LGBT community held by the APA in the past. Guideline 2 specifically
states being gay is not a mental illness. Guideline 3 follows up by indicating that attempts
35
to change sexual orientation are both ineffective and unsafe. These guidelines are not
framed within the context of cultural competence per se, nor does it treat sexual
orientation itself as a cultural grouping. However, the principles underlying these
guidelines are similar to that of developing cultural competence. Elements of these
guidelines that resonate with the principles of cultural competence include self-reflection,
an understanding of the client’s social context, and the application of strategies aimed to
address the needs in a way that is appropriate for that individual. There are 21 guidelines;
however, only a few will be mentioned here.
Guideline 4 states that practitioners should become aware of their own attitudes
towards LGBT clients and how that may affect treatment. Practitioners are encouraged to
understand how their own life experiences shape their attitudes and self-reflect on how
that impacts treatment. This coincides with gaining self-awareness and knowledge of
one’s own cultural group. Guidelines 1, 5, 7 8, 9 are similar to one another in that they
each call for practitioners to understand what it means to be LGBT as well as how
identifying as such impacts their reality. Guideline 1 focuses on the impact of stigma,
while 8 and 9 focuses on how that identity affects family life and structure. Many of the
other guidelines call attention to how the LGBT identity intersects with other facets of the
individual such as their age, socioeconomic status, race or ethnicity, and ability. For
example, guideline 10 focuses on the impact on families who come from a non-white
racial or ethnic background. Given that family is integral to the lives of many racial or
ethnic groups, practitioners are encouraged to seek the family as a point of treatment
through psychoeducation or mediation.
36
Organizational Cultural Competence
An organization that is itself monocultural limits the ability for individual
practitioners from providing services in a culturally competent manner (Sue, 2001).
Characteristics of a culturally competent agency or organization include valuing
diversity, having a capacity for cultural self-assessment, consciousness around the
dynamics inherent when cultures interact, institutionalized cultural knowledge, and the
development of adaptations for diversity (Cross et al., 1989). In addition to this, agencies
will also have a mission statement, program policies, staffing patterns, and services that
promote diversity and cultural competence within the agency.
In terms of capacity for cultural self-assessment as mentioned by Cross et al.,
Siegel et al. (2000) take on the task of developing a method of measuring cultural
competent performance at multiple levels of care. These performance measures are to be
applied at difference levels of care: the administrative level, or managed care entity that
contracts out to agencies; the provider network, or the agencies or organizations that take
on contracts given by the administrative level; and the individual provider level, or those
engaged in direct service. Each of these levels is assessed for adherence to a series of
cultural competence domains. Those domains include needs assessment, information
exchange, services, human resources, policies/procedures, and cultural competency
outcomes. These outcome measures not only provide a basis for identifying areas of
improvement, but it also makes explicit that cultural competency is needed at all levels
within an organization and not just through individual direct service providers.
37
Siegel et al.’s (2000) performance measures were used by Adamson, Warfa and
Bhui (2011) in their assessment of a mental healthcare system in the United Kingdom,
looking specifically at the perceptions of corporate, managerial, and frontline staff. At all
levels, many participants focused on cultural competence as a matter of understanding
differences rather than on eliminating social injustice and inequality. Cultural
competence was seen primarily as the responsibility of individual service providers with
little to no emphasis on organizational responsibility. Another important result to note is
the differences in responses between the different levels of the organization. The study
found that the corporate level and the managerial level tended to be the most similar in
their responses. In contrast, the corporate level was more dissimilar compared to frontline
workers. Corporate level respondents had the least knowledge of cultural competency
while frontline workers were most aware of said issues.
Although lacking in an actual measurement tool, Darnell and Kuperminc (2006)
outlined specific markers of a culturally competent organization as follows: presence of
diverse staff particularly in leadership positions; recruitment, retention, and development
of that diverse staff; a mission statement that explicitly outlines the agency’s commitment
to cultural competence and diversity; and the presence of a diversity committee who have
the actual power to ensure cultural fairness in organizational policy. Darnell and
Kupermic examined how some of these markers influenced mental health workers
perceptions of their agency’s cultural competence as well as the markers’ influence on
clinical practice. They found that mental health workers saw their agency as being
cultural competent more often when the organization required workers to attend cultural
38
competence trainings. Furthermore, perceptions of culturally competent organizations
were related to cultural competent clinical practices. This seems to reflect a relationship
between proactive organizational efforts to foster cultural competence and culturally
competent clinical practice.
In addition to looking at agency level impacts, Guerrero (2011) also looked at
macro level and organizational level influences on early adoption of culturally and
linguistically appropriate practices in an outpatient substance abuse settings. This study
tested three hypotheses. The first hypothesis is that programs with more rigorous
regulation and higher levels of public funding will have a higher level of cultural
competence. The second hypothesis is programs with more professionally trained staff as
reflected by graduate degrees or higher will be more culturally competent. Finally, the
third hypothesis is programs whose managers and decision makers who are more
sensitive to cultural and linguistic issues will be more culturally competent. The findings
of this study indicated that regulation and public funding as well as managerial sensitivity
to cultural issues are strongly associated with the adoption of cultural competence within
an agency. In contrast, programs with higher levels of professionalism are associated with
lower levels of cultural competence. The possible explanation given is that most staff for
the programs surveyed was Caucasian and therefore limited in their ability to provide
bilingual bicultural services.
Another action agencies can take towards becoming more culturally competent is
by hiring and retaining culturally diverse staff. Special attention is given to cultural
matching because it is often cited as being one way to address disparities in the access
39
and use of mental health services among minorities (APA, 2002; Cross et al., 1989).
Cultural matching refers to matching a client with a worker who comes from the same
cultural background. The reasoning behind cultural matching on surface seems to address
issues regarding work with diverse clientele: a worker who comes from the same cultural
background as the client will have a better understanding of that client’s worldview and
should therefore be able to work with that client in a way that is responsive to that
worldview. At the same time, there are reasons why both workers and clients would wish
to avoid cultural matching. For example, a client who comes from a culture in which
mental illness is considered shameful may want to avoid having a worker from the same
cultural background because of that shared understanding (Lo & Fung, 2003).
Gaps in the Literature
One major gap in the literature is the tendency for the material to be more theoretical than
it is practical (Sue, 2001; Auerbach & Silverstein, 2009; Brown, 2009; Whaley & Davis,
2007;). Researchers did not test for the effectiveness of their frameworks and guidelines
in practice. Furthermore, these guidelines all promote the use of culturally appropriate
skills and interventions; but none specify what skills should be used. Nor do they qualify
what is meant by “culturally appropriate”, i.e. appropriate as in the skill is culturally
specific versus a skill is sensitive to culture in general. Both Livingston et al. (2008) and
Hodge (2011) emphasize that their guidelines are only guidelines and that practitioners
should consider the uniqueness of individual experiences. Similarly, Siegel et al. (2000)
developed specific cultural competence measures, but note that certain components will
be more or less relevant to an agency depending on their context. Another limitation that
40
has come up is the lack of information on integrating the information presented. Mattar
(2008), for example, concludes that cultural competence needs to be integrated into
professional and educational training, but does not specify how training programs should
do so.
One reason why these definitions are more theoretical rather than practical may be
due to the lack of research on cultural competence in general. A few authors cited the
need for further research in certain areas. Some of these areas include: the use of culture
and the therapeutic alliance (Collins & Arthur, 2010); how different racial and ethnic
groups themselves define cultural competence (Sue, 2001); and the use of culture –
specific skills for families and communities (Hurdle, 2002). Literature which discuss
specific skills and techniques similarly lack testing for effectiveness when implemented
(APA, 2012; Barrera & Corso, 2002; Hurdle, 2002; Lo & Fung, 2003). Again, the
information presented did not appear subject to any kind of test or trial.
Of the literature which involved some form of statistical analysis, the most
common limitation cited were the biases inherent to the research design. Guerrero (2012)
noted biases as a result of social desirability in participant responses, common methods,
and reverse causality. Darnell & Kuperminc (2006) mentioned biases related to
convenience sampling, including the fact that many of their participants came from the
same agency. One study, Adamson et al. (2011), noted issues with validity given that
their assessment tool was developed in the United States, which may not be valid for
cultural competence in the context of the United Kingdom where their study took place.
41
This research will attempt to bridge the gap between theoretical discussions of
cultural competence and practical integration by individual mental health workers. The
participants will be asked a series of questions about how they define cultural
competence as well as how cultural competence is integrated. In doing so, this study
hopes to understand how individual practitioners go from their theoretical understanding
to practical utilization of those concepts, a connection which is missing within the
literature.
Summary
This chapter provides an overview of literature relevant to this study. The main
topics in this section includes various definitions of cultural competency, professional
guidelines for cultural competency, skills and techniques, organizational cultural
competency, and gaps in the literature. The following chapter will discuss the
methodology involved in this research.
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Chapter 3
METHODOLOGY
Introduction
This section will describe the methodology used for this research. This includes
the research question, research design, sampling, instrumentation, data collection
procedures, and data analysis. This chapter will also discuss the procedures used to
protect human subjects.
Research Question
The broad scope this research asks, “Do mental health workers perceive cultural
competence primarily as having an awareness of culture?” Specifically, the researcher
would like to find out how mental health workers define cultural competency, what
culturally competent skills and interventions they use, and what role does their agency
play in their cultural competence.
Research Design
This research is a descriptive study, which focuses on describing rather than
interpreting information. Descriptive studies are concerned with giving detailed
descriptions of the lived experience of the participants, which may include the physical or
social environment, interactions, and meanings as defined by the participants (Rubin &
Babbie, 2005). This study is qualitative in nature. The merits and applicability of which
will be described below.
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Qualitative Research
Qualitative research is appropriate for topics which cannot be fully captured by
statistical data or are not quantifiable (Rubin & Babbie, 2005). Rubin and Babbie give the
example of the level of “pride” among individuals who see collecting recycling as their
job. It is difficult to quantitatively measure an abstract concept such as pride. Therefore,
qualitative research would be more appropriate. Rather than focusing on whether or not
the sample is culturally competent, this study is interested in how mental health workers
experience of being culturally competent and using cultural competency skills, which is
more appropriately captured by qualitative research. In doing so, this research is better
able to capture the interpersonal dynamics between mental health workers, their clients,
and the agencies in which they operate. In addition to this, qualitative research is able to
capture seemingly minor differences and nuances presented by individual participants
(Rubin & Babbie, 2005). Terms such as “culture” and “cultural competency” can be
interpreted differently from person to person, or from agency to agency. Utilizing a
qualitative approach will capture these differences, rather than assuming that all of the
individuals participating have the same definitions for these terms.
Qualitative research offers a greater level of flexibility as compared to
quantitative research (Creswell, 2003). The use of open-ended questions allows for
participants to speak to ideas and themes which the researcher may not have conceived
beforehand. The researcher is also able to follow up on these ideas, and to expand on
them if necessary.
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Qualitative research also has its share of weaknesses. Qualitative research
typically cannot be backed up through statistical analysis. Because qualitative research
relies heavily on what is observed by the researcher, there is an extent to which the
resulting observations are more subjective than objective (Rubin & Babbie, 2005). As
Creswell (2003) states, qualitative research is interpretive. Data is collected and analyzed
through the researcher’s personal lens and therefore lacks the impartiality that the
quantitative researcher is assumed to have. Finally, qualitative analysis may have limited
generalizability. Because each researcher and participant comes from different life
experiences, the resulting interaction may be unique to that combination of researcher
and participant, therefore making it difficult to generalize results (Rubin & Babbie,
2005). In addition to this, qualitative research tends to have smaller sample sizes, thus
further limiting its generalizability.
Phenomenological Research
This research takes on a phenomenological approach to research.
Phenomenological studies focus on identifying the “essence” of the human experience as
well as understanding the “lived experience” of the participants (Creswell, 2003). This
approach was selected because it coincides with what this researcher seeks to accomplish.
This researcher hopes to understand the experience of being culturally competent and of
using cultural competency skills in mental health work by exploring mental health
workers’ perceptions of these subjects.
45
Content Analysis
Content analysis is a method in which qualitative data analyzed in a quantitative
way. It is a procedure that can be used for already existing material including audio
recordings, video recordings, and written text. Content analysis in this study will be based
on audio recordings. The process involves identifying categories, identifying the source
of the data, and tabulating the data for presentation (Epstein, Tripodi, & Vonk, 2006).
The tabulation process allows for the identification of important themes. In terms of the
level of analysis, this research will focus on the latent content of the interviews. In
contrast to manifest content, which is based on what is visible or on the surface, latent
content focuses on the underlying meaning of what is being said. This study will focus on
latent content because the interview questions are open-ended. Because the participants
are free to respond as they see fit, the actual words said, or manifest content, may vary
wildly even though the meanings of those words, or latent content, may actually be
similar.
One of the main advantages to content analysis is that it is unobtrusive (Epstein et
al., 2006). One disadvantage of this method is its lack of reliability. Because the initial
categories must be determined and the underlying meanings must be interpreted, both of
which are subjective processes for researchers. It is possible that separate researchers
may come to different conclusions (Ruben & Babbie, 2005).
Study Population
This study focused on 10 mental health workers who work for programs funded
by Mental Health Services Act funds. The participants came from any kind of educational
46
background, held any job title, and have worked with any population or group. The only
requirement was that the participant provided mental health services directly to clients.
The participants of this study came from a variety of educational background and
were both licensed and unlicensed. The licenses, degrees, and job classifications within
the sample included LCSW, MFT, Masters in Counseling, Mental Health Specialist, and
Behavior Specialist. The job descriptions fulfilled by this sample included counseling for
children and crisis work. The ethnic and cultural backgrounds included in the sample
were white American, Jewish, Korean American, and Mexican American. All
participants were mental health providers within the city of Fairfield, California.
Sampling Population
The sample size for this study was 10 mental health workers and they were
obtained via snowball sampling, in which participants referred additional participants to
join (Ruben & Babbie, 2005). Participants who were identified beforehand were asked to
enlist 2-3 additional participants who met the sample criteria and might be interested in
the study. Additional contacts were obtained through this process. The main advantage to
snowball sampling is its ability to gather hard-to-reach or hard-to-identify populations. In
addition to this, snowball sampling also allows a sample where participants are
interconnected, i.e. informal leaders within an organization, which may provide more
insight to a topic. One disadvantage to snowball sampling is that the resulting sample
may not be representative of the population at large. In addition to this, the initial contact
may influence how the rest of the sample develops because of his or her personal
relationships or personal characteristics (Grinnell & Unrau, 2007). For example, a study
47
focusing on rape victims that has a male initial contact will likely draw a different sample
compared to an initial female contact.
Instrumentation
Each interview was conducted using a 13-item questionnaire with primarily
standardized, open-ended questions (See Appendix B). The questionnaire is divided into
four themes: introductory questions, integration into practice, specific experiences, and
role of the agency. The introductory questions are meant to obtain a general idea of the
participant’s understanding and experience with cultural competency. Integration into
practice explores how participants consciously use cultural competency skills when
providing services. The section asking for specific experiences asks participants to
describe encounters in which cultural competency played a role. Finally, the role of the
agency asks participants to identify how their agency affects their ability to be culturally
competent.
A face-to-face interview format was chosen in order capture the nuances of the
participants’ perceptions of cultural competency. This includes the participants’ facial
expressions and tone of voice when speaking on a particular subject. The use of
standardized questions helps moderate issues such as time constraints by focusing the
scope of areas covered. While using standardized questions focuses the scope of inquiry,
the questions themselves are open-ended. This allows the participants to respond more
freely (Rubin & Babbie, 2005).
The interview questions used in this study was not subjected to any reliability
testing. This study does have some level of face validity. Although face validity is
48
considered a “pseudo” form of validity in that it does provide actual validity, the presence
of face validity makes the study more easily acceptable as being valid (Grinnell & Unrau,
2007). The questionnaire’s was presented to experts who critiqued its content;
adjustments were made accordingly. This approval process gives the questionnaire some
level of face validity.
Data Collection Procedures
Following the receipt of the Consent to Participate forms, all participants were
asked to schedule a time for an interview that was most convenient to them. Interviews
were scheduled during the participants’ time off, such as during a day off or during lunch.
The interviews were to take place in a private space where each participant was able to be
comfortable. Options included public library study rooms, the participant’s own office
space, or an unused group room. The interviews ranged in length between 15 and 25
minutes, the audio of which was recorded by a digital audio recorder. In addition to the
audio recording, this researcher made explicit to each participant that notes would also be
taken during the interview. Names, locations and agencies were replaced with
pseudonyms by the researcher. Following the completion of the interview, the audio
recording was transcribed into written script. Immediately after transcription, the audio
recording was deleted.
During the interviews, adjustments were made to accommodate the participants’
desired level of confidentiality. Although the researcher assured participants that the
names of the clients mentioned during the interview would be replaced with a
pseudonym, one participant expressed discomfort about being specific about past cases. It
49
was agreed that this participant would speak in generalities when responding to the
question about a specific experience (see Appendix B). A majority of the participants
either spoke in generalities as well or avoided using names and locations altogether.
Data Analysis
Because this research took a phenomenological approach, analysis was focused
on significant statements, the creation of meaning units, and the formation of an
“essence” of the interviews (Creswell, 2003). Following the transcription of the
interviews, the researcher got a general sense of the data. . The researcher then began a
coding process in which segments of each interview were broken down into unit
sentences or paragraphs and then categorized. The coding and labeling process was often
based on the actual content of the interviews (Creswell, 2003). Themes were developed
out of this process. Finally, the researcher made an interpretation of the data by
attempting to identify the “essence” or the “lesson learned” of the interviews (Creswell,
2003).
The specific data analysis approach used was content analysis, particularly latent
analysis which looks at the underlying meanings of the words. The interviews were
transcribed and then categorized into classifications of responses that were developed
ahead of time. In doing so, themes and patterns were in the responses identified and
related to the literature and theoretical frameworks of this study.
Protection of Human Subjects
California State University, Sacramento requires a submission of a human subject
application to the Committee for the Protection of Human Subjects from the Division of
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Social Work. This committee reviewed this study’s application and determined that the
research is of “minimal risk” to the study participants. The approval letter was received
before any research data was collected.
Participants were continuously reminded that their participation in this study was
completely voluntary at each stage of the process. The voluntary nature of their
participation was emphasized during the initial presentation of the study, within the
Consent to Participate, and during the actual interview. Participants were reminded that
they could quit at any time without cost or penalty. No identifying information was
gathered by the researcher. Names and places that came up during the interview were
changed to protect their identity. The only portion of this study which contains
identifying information is the Consent to Participate, which was kept separate from the
research materials in a locked box. After the completion of this research, the Consent to
Participate forms were destroyed. The recorded interviews were also deleted. This
information was described in the participant's consent form (see Appendix A), which was
signed prior to the interview or questionnaire completion taking place.
Summary
Chapter 3 presents the study’s research question and research design, which is a
qualitative design using content analysis. This chapter also includes a description of the
study population and sampling procedures. In addition to this, there was a presentation of
the method of data collection, instrumentation, data analysis, and the procedure to protect
human subjects. Chapter 4 will be a presentation of the data analysis.
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Chapter 4
DATA ANALYSIS
Introduction
Interviews were conducted with ten mental health workers from two mental
health agencies within Fairfield, CA. The ten participants currently work either with
children and families or doing crisis work. The participants also vary in terms of level of
training and licensure. Of the ten, seven have masters level degrees, two are in the
process of receiving a master’s level degree, and one has a bachelor’s degree. The main
purpose of this research is to explore the following question: How do mental health
workers conceptualize and utilize cultural competency? The participants were asked a
series of thirteen questions (See Appendix A) regarding how they define cultural
competency, how they utilize cultural competency in their practice, and what role their
agency plays in helping them be culturally competent. The participants utilized their
knowledge and understanding of cultural competency together with experiences they
have had in which culturally competency may or should have played a role in the client’s
treatment outcomes. The data will be presented around three themes: 1) participant
conceptualizations of culture 2) participant use of skills and interventions, and 3)
participant perceptions of organizational cultural competency
This chapter will start with a presentation of self-identified demographic
information about the participants. Following this will be a detailed exploration of the
responses to the interview questions, including how they relate to the main themes. To
protect the identity of the participants and any clients they mention, they will each be
52
referred to by a pseudonym. The pseudonyms were: Alice, Carl, Charles, Dylon, Gabby,
Jane, Jennifer, Kayla Lulu, and Marsha,.
Participant Demographics
The first question of the interview asks for participants to identify themselves
culturally. Because the term “culture” can be interpreted to mean different things as well
as the fact individuals can identify with many different cultures (Sue, 2001), the
responses given varied. The purpose of using this open ended question was to get an idea
of how the participants define culture for themselves as well as to give them the freedom
to choose what cultures they would like to identify. All respondents answered by
identifying their race or ethnicity. Five identified as “white,” three of whom used
additional terms such as “Anglo American,” “Caucasian,” and “Anglo Saxon.” One
identified as “Korean American,” another as “Filipino American,” and another as
“Mexican.” One participant noted that his cultural identity can be context specific. For
example he identifies as “Latino” with non-Latinos and as “El Salvadorian” with other
Latinos. Another participant identified as a “mix” of different things including
“Caucasian” and “American Indian.”
In addition to identifying their race or ethnicity, a few of the participants also
identified with a religious affiliation, gender, and nationality. For religious affiliations,
one identified as “Jewish” and one as “Protestant.” One noted her father was
“Presbyterian,” though more recently she has become attuned with “Buddhism.” Two
participants identified with their sex of “male” and “female” respectively. One participant
also identified herself as “American.”
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Participant Conceptualizations of Cultural Competence
Within the literature, definitions of cultural competency can vary in terms of how
they are organized, how they define culture, or what aspects they focus on. However,
most definitions and conceptualizations have in common three main aspects: awareness
of one’s own culture, awareness of the culture of the client, and use of appropriate skills
or strategies ( Collins & ArthurArthur, 2003; Cross et al., 1989). Similarly, within this
study no two participants shared the exact same response to the first interview question:
“How do you define cultural competency?”, though there were some similarities around
certain themes. This section will be broken into five subsections as they relate to the
generally accepted definition of cultural competence mentioned above. These sections
include the following: Definition of “Culture,” Understanding Culture of Self versus
Others, Training and Education, Skills and Interventions as Part of the Definition, and
Cultural Competency as an Ongoing Process.
Defining “Culture”
The responses also diverge in terms what “culture” means. Five of the
respondents made no further comments on what “culture” encompasses. Three
specifically mentioned that culture may refer to something other than race and ethnicity.
Jennifer commented that culture is “not just ethnicity, but also religion, sexual
orientation, even just what are their values and morals. are.” Both Jennifer and Charles
refer to knowing and understanding how a client is brought up and how that shapes their
world view as being part of cultural competency. Kayla also expressed an awareness of
the meaning of “culture” when she defines cultural competency as “having a sense of
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what the word ‘culture’ means.” She does not, however, give a specific definition.
Marsha hinted at a comprehensive view of the meaning of “culture” when observing that
translators not only need to know the language, but also the “nuances” of the culture.
These comments reflected portions of the literature that also calls for a comprehensive
definition of culture (Brown, 2009; Livingston, 2008).
Understanding Culture of Self versus Others
In defining cultural competence, all respondents referred to the need for
awareness and understanding of culture itself. Of the ten responses, all ten made
reference to awareness of the client’s culture. Dylon’s simple definition succinctly sums
up the gist of most of the responses: “[Cultural competence is] having an awareness of
different cultures.” Seven of the ten participants spoke only of an awareness of the
client’s culture. Their response speaks to only part of the generic definition of cultural
competence, which calls for an awareness of one’s own culture in addition to the culture
of the client. Cross et al. (1989) states that having an awareness of one’s own culture
enables one to understand how cultures interface, which then enables one to make
decisions that will minimize cultural barriers.
The other three of the ten participants did note an awareness of self. For example,
Charles described cultural competence as “Being conscious of differences and identifying
their needs as well they may even been different than yours." Another participant,
Marsha, who also noted self-awareness hinted at the potential damage discriminatory
attitudes may have: “I define it as not being naïve or egocentric about it. That you have
the only culture (laughs) or the best culture.” Adamson et al. (2011) explored perceptions
55
of cultural competency at multiple levels of practice including frontline staff, managers,
and corporate. Among their findings, they observed the tendency to view cultural
competency as a matter of understanding and not as a means of ameliorating past
discrimination. In addition to Marsha, only one other participant spoke about cultural
competence in relation to combating the effects of discrimination and social injustice. In
talking about her own cultural identity and how that affects how she understands
another’s culture, Alice stated “I don’t care how long I work on it, I will never
understand. Especially with those racial, ethnic, and cultural groups who are
discriminated against. I think there’s a disadvantage.”
The awareness and understanding of one’s own culture was later acknowledged
by many of those participants who did not mention it when defining cultural competence
in response to other questions. In response to being asked about the role of her agency,
Alice said “I have kind of a thing of like ‘I’m white, I have no clue what it’s like to not be
white. It’s really different and I have no clue.’” Kayla recognized her awareness of her
own standpoint around particular beliefs and values. She said, “I think in this job, it’s
shown up in a couple of ways. One is parenting attitudes. Another is attitudes about
relationships and marriage. I think also attitudes about men and women’s positions and
roles in society.” In the common factors model by Fischer et al. (1998), the common
factor of shared world view facilitates the development of a strong therapeutic alliance,
which has been associated with better outcomes for clients across the board. In Kayla’s
case, she was able to identify that there were differences in their world views, however,
she did not comment on what she did to address those differences or any of the outcomes
56
of those relationships. While not all participants recognized an understanding of their
own culture as a part of their definition cultural competency, all of them referred to that
element in other parts of the interview.
Training and Education
The question “What kind of training or education have you received regarding
this subject?” was intended to explore where the participants gained their knowledge of
culture. Six of the ten participants pointed to their graduate education as part of their
training for cultural competency. Of those six, only one specified that her courses were
specifically on cultural competency. Two of those six specified that their courses were on
diversity, but not cultural competency per se. The other three did not specify. These
responses reflect positively on their level of cultural competence given Mattar’s (2011)
discussion on the need for cultural competence in education training. Finally, of the ten
participants, four cited formal trainings as a source of knowledge.
Four participants noted direct experience with clients as a method of gaining
knowledge response to the question of what kind of training or education they have
received. ter Maat (2011) stated that one method of gaining knowledge about other
cultures is through immersion with the community. For instance Carl described part of
his training as “being exposed mostly to minorities. African Americans, Latino clients,
you know, women. And I also think Caucasian clients that are poor.” Lulu made a similar
comment when giving her definition of cultural competency. She said, “The more you
expose yourself to difference cultures and other people’s experiences, I guess you
become more culturally competent.” Mentions of face to face contact with clients have
57
come up in response to other questions. When talking about the role their agency plays in
facilitating their cultural competence, Jane and Jennifer both described how past and
current agencies have put them situations where they must work with a client from a
culture they had never encountered before and that they were able to learn from those
experiences. Jennifer said “there are a lot of different cultural values that I’m now
learning to work with really well. I’m lucky.” The idea of face to face interaction as part
of cultural competence is mentioned in Barrera and Corso’s (2008) Skilled Dialogue,
which cites an anchored understanding of diversity as an essential component to their
model. Anchored understanding of diversity is knowledge of cultural that is both general
knowledge, which may be learned through a class or training, and knowledge based on
direct contact with a client of that culture.
Skills and Interventions as Part of Definition
The last component of cultural competency that is cited in the literature is the use
of appropriate skills and interventions (Collins & Arthur, 2003; Cross et al., 1989). Only
one participant made reference to cultural competence in relation to how she practiced as
part of her definition. Jane defined it as “understanding and knowing about other people’s
culture and responding in a way that is appropriate to their needs.” None of the other
respondents made reference to the use of skills or interventions.
Participant Use of Skills and Interventions
As noted above, most of the participants do not make reference the use of
culturally appropriate skills and techniques as part of their definition for cultural
competence. For many of these respondents, having the awareness of culture is itself
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being culturally competent. Likewise, the process of gaining knowledge about a culture
was often cited as being the culturally competent intervention. Theme will be divided into
three sections: Anchored Understanding, Developing a Therapeutic Alliance, and
Cultural Matching.
Anchored Understanding of Diversity
Anchored understanding of diversity is gaining knowledge of a client through
generally learned knowledge in combination with direct contact with said client (Barrera
& Corso, 2008). Underlying the development of an anchored understanding of diversity
should be the principles of respect (respecting the client’s socially established viewpoint
and boundaries), reciprocity (giving the client’s input equal value as the practitioner), and
responsiveness (maintaining an attitude of learning and curiosity when it comes to the
client’s culture). Barrera and Corso,’ model of Skilled dialogue, particularly its
underlying principles, resonates most with the responses given by the participants in
terms of how they approach providing services in a culturally competent manner.
Jennifer reflects the principle of respect in trying to understand “how a person is
brought up, how that person was raised, how that translates if I’m working with a parent
or how that translates with the adult that they’ve become.” Alice demonstrates the
principle of reciprocity, in which both the client and the worker are given equal
deference, in highlighting that the client is the expert in their own lives:
I do the ‘dumb Alice’ thing a lot, especially when I’m trying to learn Spanish. I
find that me trying to speak Spanish and making that a playful encounter gives a
way for joining. It also allows me to take the step down. Instead of being in a
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more authoritarian role, it lets me take a step down and acknowledge the other
person as an expert which helps build a relationship.
In addition to reflect Barrera & Corso’s principle of reciprocity, Alice’s approach
speaks to issues of lack of power minority individual experience in general (DHSS,
2001). Alice’s approach to interacting with her Spanish speaking clients addresses the
power differential within the therapeutic context by making the clients the experts of their
own culture. This approach also reflects Ecosystems Theory in that Alice is making
adjustments in the social environment, equalizing the power differential, in order to
improve the “goodness of fit” between her and her clients.
Barrera & Corso’s (2008) principle of responsiveness can be seen in Kayla’s
approach to working with clients. She said “I kind of feel like I’m a journalist. And so
I’m investigating and asking a lot of questions and not assuming.” Here, the sense of
curiosity and openness to learning is evident. Marsha also demonstrates curiosity,
particularly at the beginning of her assessments: “Often times I ask about the origin of
their name because you’re taking down their name. So right there, you’re often told
what’s important to them.” In addition to this, these comments reflect one of the general
principles of cultural competence: gaining an understanding of the client culture.
(Collins & Arthur, 2001; Cross et al., 1989; Sue, 2001)
Developing a Therapeutic Alliance
The strength of approaching cultural competence through the frame of the
therapeutic alliance is that it is pan-theoretical and is universally recognize as being
associated with positive treatment outcomes (Sue, 2001). The use of developing a
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therapeutic alliance has been noted throughout the literature (Collins & Arthur, 2007;
Cromier et al., 2009; Fischer et al., 1998; Lo & Fung, 2003; Sue, 2001). Collins & Arthur
(2007) proposed specific competencies for the development of a therapeutic alliance
within a culturally competent context. These competencies include: mutual agreement on
treatment goals, mutual agreement on the task the client and the worker will fulfill, and
the presence of mutual trust and respect. Many of the responses that indicated the belief
in the therapeutic alliance lacked some the competencies mentioned by Collins and
Arthur. In particular, none of the respondents mentioned treatment and goal setting in
talking about their work with clients. However, all participants were keen on emphasizing
respect.
One example of developing a therapeutic alliance can be seen through Alice’s
attempts to join with the client by attempting to speak Spanish with Spanish speaking
families: “Maybe they appreciate my trying to step into their world instead of expecting
them to step into my world. It’s certainly a joining technique that I don’t think is
perceived as condescending, but genuinely an effort to connect.”
Fischer et al. (1998) discussed the relationship between etic and emic approaches
to culture, particularly around the idea that the two do not necessarily have to be mutually
exclusive. For example, the therapeutic alliance is considered an etic approach, but it can
also work within a culturally competent framework because it can be assumed that in
order for that alliance to develop, one would need to be culturally aware or sensitive to
the client’s needs. For example, Dylon said that “there have been people in certain
cultures that I feel I’ve connected with and the particular cases have gone well… I can
61
think of Hispanic, Filipino, and other Asian cultures where I felt that there was a good
connection, but it felt like a person-to-person thing.” In this case, Dylon did not feel his
interactions with these clients were necessarily a cultural competence skill. However, it is
possible that in order to have that personal connection, he needed to be able to respond to
the cultural implications of those interactions. In his case, he was not conscious that he
may have indeed been culturally responsive. Lulu expressed similar feelings for her
interaction with an Asian American client. She stated, “I felt like we connected on a
different level other than culture. I felt like it still worked for me to be able to work with
her and she was able to work with me.” In contrast to Dylon and Lulu, who built their
connection with clients without explicitly addressing culture, Charles was more direct:
I was more than willing to say “Hey, tell me more about your culture and how this
relates to your culture. Or how this is outside your regular culture.” [in order] to
be able to 1) help build a better relationships and 2) help build bonds with them.
Cultural Matching
Cultural matching has been received with both positive (Cross et al., 1989) and
negative (Lo & Fung, 2003) responses within the literature. Supporters of cultural
matching feel that practitioners who share the same culture will be better understand how
that culture shapes the client’s experience. On the other hand, Lo and Fung (2003)
recognize the possibility that the client may feel hesitant around that practitioner because
they share a culture in which mental illness carries a heavy stigma. The three participants
who discussed being culturally matched with clients spoke positively about their
experiences.
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Carl described a time when he and another colleague, who is also Latino, met
with a Latino male in crisis. In this instance, Carl and his colleague were able to connect
on the basis of their shared culture, i.e. Latino male, and guiding their intervention based
on those values. Carl was able to avert the crisis and prevent psychiatric hospitalization.
Reflecting on this, Carl said, “I felt really comfortable dealing with that intervention, but
I don’t think I would have reacted the same way if it would have been someone from a
different culture. I think I would have had different reservations.” Carl’s comments
demonstrated how being able to connect through a shared culture allows for different
interventions that would not necessarily come up had the cultural match not been there.
In talking about her experience working with a family who was also Mexican,
Lulu stated, “I found that it was so much easier beginning the conversation or start
offering services or connecting them. We started with an informal conversation ‘So
where are you from?’… I quickly caught onto that it broke the ice.” For Lulu, having a
shared culture made it easier to develop that connection that allows for her to effectively
provide the client with services and resources more quickly. For both Carl and Lulu, the
shared cultural background allowed them to connect with their clients more easily
because they already had a similar world view. This calls back to Fischer et al.’s (1998)
framework which state that a common world view facilitates the development of the
therapeutic alliance.
Jennifer spoke about experience with being matched with other Asian and Asian
American clients in terms of it being a function of her agency:
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There’s not a big Asian population in [that city] so if there was an Asian client, I
would automatically be matched with that person. At first, I was like I wonder
why that’s happened, but it makes sense…With [the agency] it was more
intentional; they really wanted to find the right match.
Jennifer’s comments reflect her agency’s conscious decision to culturally match
her with other Asian clients, which can be considered a form of organizational cultural
competence around staffing patterns (Sue, 2001).
Despite the division around the effectiveness of cultural competence, there is
literature which supports better outcomes for clients who are culturally matched in a
therapeutic relationship. Sue (1998) found that most racial and ethnic groups covered in
his study had higher retention rates and better treatment outcomes.
Participant Perceptions of Organizational Cultural Competency
In their study of a mental health service provider, Adamson et al. (2011) found
that many of their participants at all levels of practice perceived cultural competency as
being the responsibility of the individual mental health worker. Nine out of the ten
participants initially discussed cultural competence in this manner, but would later talk
about the role of their agency after being asked about it specifically. One participant was
able to speak about organizational cultural competence without probing. This may be due
to the fact that she has been the director of a program and therefore has better insight to
the organizational perspective.
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Setting the Stage for Cultural Competence
Sue (2001) notes that organizations and agencies are what set the stage for
culturally competent practice. A monocultural organization limits the ability for the
mental health workers to practice in a culturally competent manner. This idea is reflected
when Alice states that her agency is “pretty white. We’ve always been pretty white. That
clearly is a disadvantage and partly it’s a disadvantage that we’re not aware of. When
you’re the dominate culture you don’t realize.” Prior to these comments, she gave an
example of how monocultural organization can be limiting: “a weakness we certainly
have was not having Spanish speaking families and not being sensitive to that cultural
group. It was sort of a lost population for us simply because we didn’t have anybody that
spoke Spanish.” In this case, her agency was not able to serve the large Spanish speaking
population in that area because they were not aware of that community’s needs.
The policies of an agency can reflect that agency’s level of cultural competence
(Cross et al., 1989; Siegel et al., 2000). Carl also makes a poignant observation on his
agency’s policy on who is allowed to receive services: “I also think that when it comes to
medication refills, I think we become selective because ‘Oh, if you don’t have insurance,
we’re not going to get you your meds.’ But guess who doesn’t have insurance?
Undocumented people.” Here, Carl feels his agency is not as culturally competent as it
should be and he points to a policy which supports his observation.
In addition to dictating services to clients, the agency sets the stage for the
individual mental health workers. Sue (2001) notes an indicator for organizational
cultural competence is the development of consciousness around the dynamics of culture.
65
Kayla observes that her agency “does well… It allows for [cultural competence] to come
up in supervision and staff meetings pretty frequently and I think it’s a good thing.” She
later adds that “It keeps it in the air.” The need for organizations to actively develop
consciousness around culture was echoed by most of the participants. Two out of ten felt
their agencies should do more to raise more awareness in general. Four out of ten felt
their agencies can provide more training to improve their levels of cultural competency.
The call for more training relates to Darnell and Kuperminc’s (2006) study, which found
that mental health workers perception of organization were higher when those
organizations offered mandated cultural competency training.
The Agency’s Role in Relation to Staff
The literature review point to management of the staff in facilitating cultural
competency (Darnell & Kuperminc, 2006; Sue, 2001). This includes the hiring of a
culturally diverse staff, matching staff with clients based on culture, and the development
of a consciousness around the dynamics of culture. As noted earlier, three staff has
expressed positive experiences when being culturally matched with their clients. The
sentiments they mentioned include the ability to use different interventions and the ease
with which they were able to connect with their clients. Similarly, participants have
observed that their agencies facilitated experience with different cultures. Jane notes, “I
think you’re thrown in the water here in a lot of ways and that’s how I’ve learned from
this agency. It’s comfortable for me. I think for other people it wouldn’t be comfortable
to learn out that way.” Jennifer sees being assigned to different cultures as opportunities
66
for her. She said, “I think it’s nice that I am able to go out of what I’m used to and be able
to relate to other people from other cultures. So it’s kind of a nice mix.”
Diverse staffing pattern is another indicator of organizational cultural competence
(Darnell & Kuperminc, 2006; Sue, 2011). Gabby positively notes that at her agency she
“noticed that the staff [there] is pretty diverse and pretty much represents the community
out here.” Dylon observes that previous trainings he has had may be “just as much about
co-workers.” The presence of diverse staff and staff who are aware of cultural issues
allows for colleagues to learn from one another. As Kayla previously mentioned, she has
been able to speak openly about issues of culture in staff meeting and supervision. Lulu
comments on the more experienced staff at her agency:
They talk during supervision and the comment on how they have to do more
research or they have to be more aware, or can you connect me with somebody
who is more familiar with this culture or find out about these beliefs. And they’re
always striving to know more to connect or find out more about diverse
populations. The experience has been great for me.
Mattar (2011) notes that one weakness in training programs is the inability for
curriculum and supervisory staff effectively address issues of culture in supervision. As
stated previously, the reason is that it takes culturally competent staff to train interns to
become culturally competent. From Lulu’s perspective, the staff at her agency appears
culturally competent; therefore, she feels that she has learned a lot from simply being
exposed to them.
67
Summary
Chapter 4 analyzed the research data. The data was organized and discussed
around three main themes: participant conceptualizations of culture, participant use of
skills and interventions, and participant perceptions of organizational cultural
competency. Chapter 5 will describe the conclusion and recommendations of this study.
Limitations, implications for social work practice, and implication for policy will also be
discussed.
68
Chapter 5
CONCLUSIONS AND RECOMMENDATIONS
Introduction
This chapter will discuss the conclusions reached in this study. It will start with
further discussion about the three themes which had emerged from the interviews as they
relate to the primary research question. The themes that will be discussed are cultural
competency as being defined as cultural awareness, developing a personal connection as
the main culturally competent skill, and raising cultural awareness as the main function of
the agency in facilitating cultural competency. This chapter will also explore
recommendations for future studies, the limitations of this study, and implications for
social work practice.
Conclusions
The main question posed by this research is do mental health workers perceive
cultural competence primarily as having an awareness of culture? The answer is yes. The
first theme to emerge from the interviews is that all participants initially focused on their
individual awareness of culture as the main tenet of cultural competence. Much of the
emphasis on the literature is on the need for awareness (Brown, 2009; Collins & Arthur,
2003; Cross et al., 1989; Livingston, 2008). Some of that literature focuses solely on that
awareness (Brown, 2009). In response to the first question, which asked for their
definition of cultural competence, a small number of the participants made references to
other aspects of cultural competence such as the role of their agency or the use of
culturally appropriate interventions. Other participants would later make references to
69
their agencies roles in cultural competence in response to other questions. However, the
component common to all participants is that cultural competence is being culturally
aware.
The importance of cultural awareness plays a role in the second theme to emerge
from the interviews: most of the participants focus on rapport and relationship building as
their main culturally competent skill and intervention. Most participants discussed using
culture as the means of connecting with the client. In these cases, workers take time to
ask the client more about a certain aspect of life that is culturally different from their
own. In doing so, the worker is able to learn more about the culture as well as allow for
the client to take be on more equal grounds with the worker. This can be seen as the
focus on the therapeutic alliance as a means of working with culturally diverse
populations, an approach that has been cited within the literature (Collins & Arthur,
2007; Cromier et al., 2009; Fischer et al., 1998; Lo & Fung, 2003; Sue, 2001). On the
other hand, a small number of the participants have connected with a client around
something other than culture. In these cases, culture itself was not addressed during the
interaction, but the connection was still made. Here, workers feel that the connection
made is, as Dylon put it, “more of a person-to-person thing.”
The responses to defining cultural competence and describing culturally
competent skills seems to suggest that being culturally is both the definition of cultural
competence as well as the intervention. That is to say, the culturally competent
intervention used is simply being culturally aware. The building of the therapeutic
70
alliance as described by the participants is predicated on the mental health workers
gaining more knowledge about the client’s culture by talking about it with the client.
Cultural awareness continues to be identified as an important component to
cultural competence in third theme: participants perceived organizational cultural
competency as helping create an environment in which workers are made aware of issues
of cultural competency. Many participants cited that their agency does well at creating
awareness about cultural issues for example by encouraging discussions about culture in
supervision and staff meetings. The development of consciousness is one marker of a
culturally competent organization (Darnell & Kuperminc, 2006). Another indication
would be the presence of culturally competent staff (Mattar, 2011). One participant noted
being around culturally competent staff has helped her understand what being culturally
competent means. In addition to creating a welcome environment for discussions about
culture, participants noted that their agency should provide more training to increase
knowledge and awareness about culture. This again highlights the premium the
participants place on knowledge and awareness as being the main marker of cultural
competence.
Recommendations
The recommendations presented in this section will center around three areas:
future research, individual mental health workers, and mental health service agencies.
Future Research
The main finding of this research is that all mental health workers who
participated identified cultural competence as being aware of culture. The focus on
71
awareness was also integrated into their responses of skills used as well as what the
agencies can do to facilitate cultural competence. The main follow up question that these
results pose is whether cultural awareness is enough. The generic definition of cultural
competence by and large emphasizes awareness, but it also identifies the use of skills and
interventions. Cultural competence is not only having that awareness, but also using that
awareness.
For most of the participants, the cultural awareness is utilized as a skill in the
form of the building of a personal connection or building rapport with the client as their
main approach. Areas of the literature have also supported using the therapeutic alliance
as a framework for culturally competent practice (Sue, 2001). The responses that came up
during the interviews supported both an emic approach, in which culture was the basis for
the connection, and an etic approach, in which culture was not used as the basis for the
connection. Both approaches were described as being positive by the participants. Further
research should be conducted to explore the nature of these therapeutic alliances. Are
treatment outcomes as good or better when a culture is not addressed during the
development of the therapeutic alliance when compared to those when culture was
addressed?
At the agency level, both agencies from which participants were drawn fostered
some level of cultural awareness, neither had any kind of performance measures that
would allow for workers to measures their levels of cultural competence. One area that
deserves further exploration is whether the use of performance measures is associated
with better treatment outcomes for clients. In their development of specific performance
72
measures, Siegel et al. (2000), acknowledge the challenges of implementing cultural
competency performance measures including feasibility and deciding which measures are
relevant for the particular program. In the case of the programs represented by the
participants, the outcome measures will surely be different given the divergent functions
of each program. The outcome measures for a children’s mental health program vastly
differs from a program which does crisis evaluations. Additional research should examine
how performance measures can be adjusted for these nuances.
Mental Health Workers Practices
A majority of the mental health workers in this study demonstrated the ability to
recognize the importance of culture. The first recommendation is for mental health
workers to not only maintain that awareness, but to also consciously integrate that
awareness into their practice. In addition to this, rather than addressing culture as an
additive feature to their practice, or as Auerbach & Silverstein (2009) puts it, “just add
culture and stir,” mental health workers should make the cultural context an essential
feature to treatment. One method of doing so is by incorporating cultural considerations
into the theoretical frameworks mental health practitioners utilize. Social workers who go
by the ecological perspective, for example, may consider an immigrant client’s level of
acculturation and how that acculturation shapes their experience of interacting with the
immediate community environment (Robbins et al., 2006).
Mental health workers who come from a social work background may also want
to look to their professional code of ethics as a guide for integrating culture into their
practice. One aspect of cultural competence that was lacking in the responses was the
73
idea of cultural competence as a way addressing discrimination and social injustice. The
NASW code of ethics specifically state that social workers should not condone nor
facilitate anything that may be considered discriminatory (NASW, 2008). In addition to
this, social justice is cited as a core value of the profession. Using these values, social
workers may be able to approach culturally competent practice in a more action oriented
way.
Mental Health Service Agencies
Program development should take note of the resounding call for more training on
culture and cultural competence. The availability of training would help increase the
knowledge base of the mental health workers as well as maintain their levels of
awareness around cultural issues. Also, some participants cited the tendency for their
agency to be reactive to cultural issues, which can be seen in Alice’s comment that for
her agency “it has to be brought up, we don’t bring it up own our own. We have to have
somebody bring it up.” Given the rapid changes in the US population, particularly the
population in California, service agencies will do well to proactively evolve alongside the
population. Rather than making changes regarding cultural competence in response to
issues coming up, agencies should make cultural competence an essential component to
the agency’s services and function. This can be done by integrating cultural competence
into the agency’s mission statement and detailing what it means in terms of the agency’s
core values.
74
Limitations
This research is limited in its generalizability to the population at large. This is
due in part to a small sample size common to qualitative studies. In addition to this, the
participants are drawn primarily from two agencies in the same city in the same county.
Their experiences with cultural competency reflect their specific community context,
which further limits the extent to which results may be generalized.
There are also limitations based on this being a qualitative study. Biases may
emerge because the data is interpreted by the researcher, an activity which is inherently
subjective. Related to this, because interviews were done face-to-face, it is possible that
the responses given were in response to the personal characteristics of the specific
researcher. This limits the extent to which the study may be replicated. There is also the
risk bias in the responses. For instance, participants may respond with what they feel is
more socially desirable rather than what they truly feel.
Implications for Social Work Policy and Practice
Cultural competence in general is of interest in the social work field because it
speaks to the many of the values of the National Association of Social Work’s core
values and code of ethics (NASW, 2008). Among the values are social justice, dignity
and worth of the person, importance of human relationship, and competence. Cultural
competence is also specifically stated in the code of ethics. The implications of this study
may benefit the field of social work at the micro, mezzo, and macro levels.
By the NASW code of ethics, cultural competence should be a means towards the
end of social justice. Cultural competence was first introduced to the field of mental
75
health in response to the disparities experienced by racial and ethnic minorities (DHSS,
2001), which is an issue of equity and social justice. The results of this study seem to
suggest that mental health workers place a heavy emphasis on cultural awareness. While
awareness is an integral part of cultural competence, a severe focus on that awareness
may run the risk of it becoming the end itself rather than being the means to an end. That
is to say, rather than focusing on cultural competence as a means of ameliorating past
discrimination in mental health, cultural competence becomes about simply having
cultural awareness. With this in mind, on a micro level, social workers should continue to
develop their awareness and knowledge about culture and cultural dynamics, but they
could do it in a way that enables them to constantly be aware of the reason why cultural
competence is needed in the first place: to address mental health disparities for racial and
ethnic minorities (DHSS, 1998). Bringing the knowledge gained back to that purpose
may lead to different approaches of working with culturally diverse clients. For example,
Fischer et al. (1998) proposes helping clients understand their own oppression as a way
of working with them in a therapeutic setting. Doing so would also coalesce with the
NASW’s ethical principles of self-determination, empowerment and social justice
(NASW, 2008). A conscious assessment of how cultural knowledge and awareness is
used in mental health practice may allow for a more deliberate way of addressing
discrimination and oppression of the culturally diverse populations.
On a mezzo level, social work agencies should support individual services
providers by continually and proactively facilitate their ability to be and to think in a
culturally competent way. As noted by Mattar (2011), it takes a culturally competent
76
supervisor to help his or her intern become culturally competent. Staffing patterns should
strive to be as culturally diverse as the clients they wish to serve. Trainings put out by
agencies should not only focus providing service providers with information about
different cultures, but also highlight the ongoing disparities in services for culturally
diverse clients. Again, doing so will help social work professions remain mindful of the
social justice aspects of cultural competence. In addition to this, agencies should take
care to choose trainings that address issues specific to the community that surround them.
On a macro level, policies should reflect a commitment serving culturally diverse
clients. For instance, one of the participants observed that his agency refuses services to
those without insurance and that those without insurance tended to be undocumented
immigrants. Culturally competent practice for social workers who develop or advocate
for policy should then support policies that increases access to medical insurance for
undocumented immigrants.
Conclusion
The purpose of this study was to explore of how mental health workers
understand and utilize cultural competence in their practice. In particular, this study
looked at how they define cultural competence, what cultural competency skills they
used, and how they feel their agencies facilitate their cultural competence. By and large,
the participants define cultural competence as being culturally aware. The focus on
cultural awareness is pervasive throughout the other themes found in the results. For
example, the skill most cited by the participants is the building of rapport and personal
connection. The way that connection is made is often by gaining knowledge of the
77
clients’ culture from the client himself or herself. Participants also felt that their agencies
could improve their cultural competence by providing an environment which facilitates
more awareness either in the form of discussing cultural issues in meetings or through the
provision of trainings. Areas for further study includes whether cultural awareness alone
is enough to be culturally competent, the exploration the effectiveness of an emic
approach to the therapeutic alliance versus an etic approach, and the effects on treatment
outcomes with agencies who utilize performance measures for cultural competence. The
implication of this study for the field of social work is that the considerable focus on
cultural awareness may fall short of the social justice aspects of the social work
profession. Should the focus of cultural competence be placed solely on cultural
awareness, social workers may lose sight of the larger issue of discrimination and
inequity which cultural competence was meant to address.
78
APPENDICES
79
Appendix A
Consent to Participate in a Research Study
You have been invited to participate in a research study conducted by Karen Villar, who
is an MSW student in the Division of Social Work at California State University,
Sacramento. The purpose of this study is to explore the ways in which mental health
workers perceive cultural competency, including how cultural competency is integrated
into their practice, as well as the role their agencies play in their use of cultural
competency skills.
Procedure
After reviewing and signing this document, the researcher will set up a time to meet with
you for an individual interview which will take place in a public setting in which you are
comfortable. The interview is expected to last 20-50 minutes long and will be recorded
by a digital audio recorder. Participants may also opt out of audio recording but still join
the interview. The audio recording will be transcribed. Any names and locations will be
replaced with a pseudonym during transcription. After the audio is transcribed, it will be
deleted.
Potential Risks
Discussion of cultural competency may cause some emotional discomfort due to the
recall of potentially uncomfortable experiences with cultural issues. Should you feel the
need for additional emotional support, you will be provided with resources by the
researcher, including the following:
Solano County Access: (800) 547-0495
Psychiatric Emergency, Fairfield, CA: (707) 428-1131
Suicide Prevention 24 Hour Crisis Line: (800) 273-8255
Benefits
Your participation in this study may contribute to the current knowledge base regarding
cultural competency. Your discussion on the subject may also produce recommendations
for changes within agencies and educational training programs.
Compensation
There will be no compensation for your participation in this study.
Confidentiality
This research study will not contain any identifying information about you. Names and
places that are used during the recorded interview will be replaced with pseudonyms
when it is transcribed. After transcription, the audio recording will be deleted. The name
and signature that appear on this consent form will be kept separate from the responses in
a locked cabinet. Once the research is complete, the consent forms are destroyed.
80
Right to Withdraw
Your participation in this research is completely voluntary. You have the right to skip any
question you are not comfortable answering as well as the right to pull out of the study
completely without cost or penalty.
Consent to Participate
I have read and understood the information covered in this document. I understand that
my participation is voluntary and that I have the right to withdraw from the research at
any time. In signing this document, I am confirming that I have received a copy of this
document and agree to participate in this research.
________________________________________
Signature of Participant
____________
Date
Consent to Recorded Interview
I, _______________________________________, (print name) agree to have my
interview recorded for this research study.
________________________________________
Signature of Participant
____________
Date
Contact Information
If you have any questions or comments regarding the research, please contact Karen
Villar at (707) XXX-XXXX or [email protected].
Additionally, you may also contact my faculty sponsor:
Maria Dinis, Ph.D., MSW
c/o Sacramento State University
(916) 278-7161
81
Appendix B
Interview Questions
Introductory Questions
How do you identify culturally?
How do you define cultural competency?
What kind of training or education have you received regarding this subject?
Integration into Practice
How do you recognize when you must utilize cultural competency skills?
What cultural competence skills do you utilize in such situations?
How are they utilized?
What role does your own cultural identity play when working with clients of
different cultures?
Specific Experiences
Describe a time when you felt your level of cultural competence adequately
addressed issues of cultural difference.
Describe a time when you have felt issues of cultural difference were not
adequately addressed.
In that situation, what do you wish you knew more about or would have
improved?
Role of the Agency
How would you describe your agency’s role in your use of cultural competency?
What does your agency do well in facilitating cultural competency?
In what ways do you feel your agency can improve?
82
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