Increasing Cultural Competence in Clinical Practice

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Increasing Cultural Competence in
Clinical Practice

• Lillian Comas-Díaz, PhD
• Executive Director, Transcultural Mental
  Health Institute
  Clinical
  Professor of Psychiatry and Behavioral Sciences
  
  The George Washington
  University School of Medicine
• Frederick M. Jacobsen, MD, MPH
• Medical Director, Transcultural Mental Health
  Institute
• Clinical Professor of Psychiatry and
  Behavioral Sciences
  The
  George Washington University School of Medicine
• World Federation of Mental Health
• October 30, 2007

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• Clinical realities are negotiated by
  therapists and clients not merely in terms of
  cognitive models, but in terms of cultural frames
  deeply invested with personal, ethnic, racial,
  gender, spiritual, sexual orientation, and class
  meanings.

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Race matters in healing

• African American patients rate
  their visits to African
  American practitioners as more
  participatory than those in race
  discordant dyads.
• Cooper-Patrick et. al.
  JAMA, 1999

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Cutural Competence can promote
resilience through

• Enhanced optimism
• Improved regulation of attachment behavior
• Positive self concept
• Active coping style
• Improved ability to convert helplessness into
  learned helpfulness
• Better acceptance of social support/altruism
• Improved ability to disclose emotions
• 
  
  Jacobsen and Comas-Díaz, 2007

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APA Multicultural Guidelines

• Commitment to cultural awareness and knowledge of
  self and other.
• Guideline 1 Psychologists are encouraged to
  recognize that, as cultural beings, they may hold
  attitudes and beliefs that can detrimentally
  influence their perceptions of and interactions
  with individuals who are ethnically and racially
  different from themselves.
• Guideline 2 Psychologists are encouraged to
  recognize the importance of multicultural
  sensitivity/responsiveness, knowledge and
  understanding about ethnically and racially
  different individuals.

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Diversity Relationship between Self and
other

• Diversity variables bear unconscious dimensions
  which tend to emerge during the multicultural
  encounter
• Virtually every therapeutic (human) encounter is
  multicultural in nature.

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Strategies to increase multicultural awareness
and knowledge

• Identify and challenge internalized privilege and
  oppression
• Commit to ongoing self reflection
• Change automatic in-group and out-group
  perceptions
• Increase contact with people of color of equal
  social status
• Transform us and them into us
• Expand your cultural horizons

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APA Multicultural Guidelines

• Practice
• Guideline 5 Psychologists strive to apply
  culturally appropriate skills in clinical and
  other applied psychological practices.
• There are three core areas in this guideline
• Client in context
• Culturally appropriate assessment
• Broad range of interventions

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Explanatory Model of Distress

• What do you call your distress (problem)?
• What do you think your problem does?
• What do you think the natural course of your
  problem is?
• What do you fear?
• Why do you think this problem has occurred?
• How do you think the distress should be treated?
• How do you want me to help you?
• Who do you turn to for help?
• Who should be involved in decision making?

Adapted from Kleinman, 1993
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The challenge of multicultural
practice

• 1. Exciting, gratifying, and challenging
• 2. Complicated strain in the mental health
  practitioner
• 3. More opportunities for projections based on
  race and ethnicity.
• 4. These projections are embedded in the
  therapeutic relationship.
• 5. Potentially missed empathic opportunities

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Ethnocultural Transference and Countertransference

• 1. Cultural and racial differences may have a
  catalytic effect on the development of
  transference leading to a more rapid revelation
  of core problems.
• - racial differences can represent trust and
  mistrust issues within the development
  of a therapeutic alliance.
• 2. References to the race or culture of the
  therapist have been identified as the first sign
  of a developing transferential relationship

Comas-Díaz and Jacobsen, 1991
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INTER-ETHNIC CULTURAL TRANSFERENCE

• Overcompliance and friendliness
• Denial of ethnicity and culture
• Mistrust and suspiciousness
• Hostility
• Ambivalence

Comas-Díaz and Jacobsen, 1991
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INTRA-ETHNIC CULTURAL TRANSFERENCE

• The Omniscient/omnipotent Therapist
• The Traitor
• The Folk Hero/Heroine
• The Auto-racist
• The Ambivalent

Comas-Díaz and Jacobsen, 1991
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INTER-ETHNIC CULTURAL COUNTERTRANSFERENCE

• Denial of cultural differences
  "All patients are the same
• Guilt
• Pity
• Aggression
• Ambivalence
• The Clinical Anthropologist's Syndrome

Comas-Díaz and Jacobsen, 1991
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INTRA-ETHNIC CULTURAL COUNTERTRANSFERENCE

• Overidentification
• Us against them
• Distancing
• Cultural myopia
• Ambivalence
• Anger
• Survivor's guilt
• Hope alternating with despair

Comas-Díaz and Jacobsen, 1991
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Culturally Competent Practitioners

• Conduct self- reflection and assessment
• Manage the dynamics of difference
• Incorporate cultural knowledge into interactions
  with clients to develop multicultural skills
• Adapt to clients cultural contexts
• Value diversity

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Some strategies to develop multicultural
competence skills

• Identify Cultural identity developmental stages
• Use Explanatory model of distress
• Examine Cultural transference/countertransference
• Develop Cultural empathy
• Acquire Multicultural communication skills

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Course objectives

• Apply the APA multicultural guidelines to improve
  psychological practice
• Identify the effect of culture on practice
• Implement strategies to compare worldviews of
• clients and psychologists
• Discuss the usefulness of developmental models
  and
• theories on psychological practice
• Adjust psychological practice to provide
  culturally competent services
• Become familiar with resources available to
  practitioners on cultural competence

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Complex therapist expectations from culturally
diverse individuals

• Integration of clients active and non-
  directive expectations from therapists.
• Patients of color expect their psychological
  practitioner to have diverse roles such as
  counselor, teacher, guide, folk healer, advisor,
  advocate, witness, consultant, coach, therapist,
  and others.

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