As behavioral health professionals, almost all of us have received training and continuing education in the areas of cultural awareness, competence and diversity. Most are aware of how essential it is for counselors to be sensitive to a client’s culture and to also have some awareness of how culture impacts all of us. It is not likely that counseling can be effective if there is a lack of understanding or appreciation of the client’s culture, and why cultural competence is important. While there are some variations, professional organizations like the American Psychological Association, the American Counseling Association, and the National Association of Social Workers have all provided guidelines for the practice of culturally competent behavioral health treatment.
The U.S. population becomes increasingly diverse every year, with immigrants coming from many different countries. According to U.S. Census Bureau projections, African Americans, American Indians, Asian Americans, and Latinos will make up roughly 50 percent of the total U.S. population by 2050 (Cultural Competence in Mental Health Care, 2014). Each person has a unique culture that infuses their life and influences their interactions with others and with systems, including the behavioral healthcare system.
What does cultural competence in behavioral health really mean? How can we measure cultural competence, and how can counselors increase their ability to do effective work with clients from diverse backgrounds? Providing culturally competent, sensitive, and respectful counseling goes beyond having a general understanding about different cultures. We must appreciate the role culture plays in seeking and participating in behavioral health services, and we must be aware of our own culture, our beliefs, and our possible biases.
There are a myriad of definitions of what culture is. Things like race and ethnicity often come to mind, and are certainly a part of culture, but a person’s culture can encompass so much more. According to Dr. Albert Gaw, Professor of Psychiatry at the University of California in San Francisco (n.d.), culture can include:
- Sets of standards (norms) for behavior that a group of people may expect from or attribute to other people in their environment (how they expect people to act). People also use these standards to orient their own behavior.
- Race: This a number of broad divisions of the human species based on a common geographic origin and certain shared physical or genetic characteristics (Gaw, n.d.).
- Sub-groups of people within a larger group or society that share common origins, symbols, and standards for behavior of self and others
- Beliefs about others and the world that are held to be true (e.g. suicide is a sin, mental illness is a weakness, women should not be employed outside the home)
- Values and lasting beliefs about ethics, preferences, and the way things should be done
- Language (including deaf and hearing impaired)
Additional components of culture could include where people live (urban or rural), socioeconomic status, gender, age, sexual orientation, religion, exposure to trauma, health, or the presence of a disability. All of these components of culture can play a role in how people view mental illness or substance abuse, whether or not they seek help for these issues, and what type of services the seek. Culture can also play a role in what coping style a person uses, their support system, and what treatments may, or may not be effective for them (Cultural Competence, 2014).
Culture and Behavioral Health Services
A person’s culture can have a significant impact on how they interact with behavioral healthcare systems and providers. Providers who are culturally competent are able to work effectively and sensitively with people from a variety of cultural backgrounds and situations. They remember that culture matters, and always have culture in mind as they interact with clients. They honor and respect the beliefs, values, behaviors, and needs of people and their families as they access behavioral health treatment services. They are also sensitive to the culture of others who are also providing behavioral healthcare services.
When behavioral health services are not provided with cultural awareness and competence, there is the risk that clients will be negatively impacted by the services they receive. Studies have demonstrated that because of cultural insensitivity or incompetence, people of color may avoid seeking services though the established systems have trouble accessing the services they need, drop out of treatment, be misdiagnosed by providers, or only seek treatment when their illness is very advanced (Cultural Competence, 2014).
Becoming Self-Aware as a Counselor
In my role as a clinical supervisor, a young counselor once shared a bias she had toward Hispanic females because of her mother’s experience with this population. Her mother told her that she had been frequently bullied and physically assaulted by Hispanic females when she was in high school, and still harbored negative feelings and attitudes about this population (felt they were hostile, aggressive, and dangerous). The counselor admitted that she had taken on some of her mother’s biases, and it was impacting her ability to work with this population. In supervision, she was able to work through this and begin working effectively with Hispanic women, but may have been unable to do so if she had not had the willingness to question her beliefs and overcome her biases.
This is an excellent example of self-awareness, which is essential for counselors to work effectively with diverse populations. As counselors, we must be aware of our attitudes, fears, beliefs, and biases, and how they impact our work with clients. A good first step toward cultural competence is to understand and appreciate our own culture and heritage. Everyone has a culture, and culture can evolve over time. For example, we may have very different beliefs, attitudes, and values than we did 20 years ago.
The process of learning about our own culture can be interesting and enlightening. We can learn about our ancestors and their experiences and beliefs. We can also explore the culture we grew up in, and how that shaped our attitudes and beliefs about other people, groups, and the world around us (Clay, 2011). Some of our beliefs and biases about other people may be unconscious, until we explore and assess what we really believe. As we learn about ourselves, it can be helpful to ask ourselves these questions:
- Do I know the main characteristics of my own culture?
- Am I aware of words, connotations, or labels that negatively affect specific groups of people?
- Am I aware of my own biases and stereotypes?
- Am I aware of the different cultures of the people in my workplace?
- Am I curious about different cultures?
- Am I comfortable discussing culture and diversity?
- Do I take the time to learn about other cultures?
- Do I understand the role of culture in a counseling setting?
- Are there any groups or cultures I am uncomfortable working with?
Exploring these questions, along with our own culture, can help ensure we are sensitive and competent counselors. We learn many therapeutic skills and techniques as a counselor, but these must always be considered and utilized within the context of the client’s culture. For example, in the West, we may have been taught that eye-contact means a person is listening or is being honest, and lack of eye contact indicates depression, lack of attentiveness, or even deception. However, in some cultures, eye contact is viewed as threatening, rude, or disrespectful (Cross-Cultural Differences, 2014). Misunderstanding a seemingly small thing like eye-contact can undermine the therapeutic relationship and our ability to be helpful as counselors.
Increasing Cultural Competence
Taking the time and making the effort to become culturally competent counselors will ensure we can work effectively with a diverse population of clients. Many believe that the relationship between the client and the counselor is the most essential component of effective counseling. The lack of cultural competence and sensitivity can undermine the client- counselor relationship and make it less likely the client will make progress toward their goals. The client may even disengage from counseling all together. There are many steps a counselor can take to become more culturally aware and competent. As discussed above, being aware of our own culture and our own beliefs or biases is a great first step, but there is more we can do.
- Learn about different cultures. Of course, traveling is a great way to explore other cultures, but doing research online, reading books and journal articles, and studying unfamiliar cultures is a great way to learn. It can also be helpful to learn about current and historic issues and challenges faced by specific groups and cultures.
- Learn another language. This is especially helpful if you live in an area with a large population of a certain ethnic group. Learning how people express things in their first language can help prevent misunderstandings.
- Spend time interacting with diverse groups of people. Spend time with people from a culture that is unfamiliar to you will enhance your ability to work effectively with different groups. This can be accomplished by volunteering, attending social events, or visiting different religious institutions. Try putting yourself into situations in which you are the minority, and explore how this feels.
- Attend diversity conferences and professional development activities. This will enable you to learn about recent research, behavioral health practice issues, and opportunities to learn about different cultures (Clay, 2011).
A diverse population of people seeks behavioral health services every year, and it’s essential that they receive services that are effective and culturally sensitive. Developing cultural competence is an ongoing, lifelong process. There is always more to learn. When counselors have cultural awareness and competence, the clients they serve are more likely to engage, reach their goals, and have a positive experience with behavioral health services.
Clay, R. A. (2011). How do I become culturally competent? Retrieved October 26, 2014, from http://www.apa.org/gradpsych/2010/09/culturally-competent.aspx
Cross-Cultural Differences in the Assessment and Communication of Uncertainty. (2014). Retrieved October 28, 2014, from http://healthvermont.gov/family/toolkit/tools%5CF-6%20Cultural%20Differences%20in%20Nonverbal%20Communic.pdf
Cultural competence in mental health care. (2014). Retrieved October 27, 2014, from http://nami.org/Content/NavigationMenu/Find_Support/Multicultural_Support/Cultural_Competence/Cultural_Competence.htm
Gaw, A., PhD. (n.d.). Culture in psychiatric care. Retrieved October 26, 2014, from https://view.officeapps.live.com/op/view.aspx?src=http%3A%2F%2Fwww.sjsu.edu%2Fpeople%2Fchia-ling.mao%2Fcourses%2Fc1%2Fs1%2FCulture_and_Clinical_Care__Dr._Gaw.ppt