IncreasingIncreasing Cultural Competence Cultural Competence

in Clinical Practicein Clinical PracticeLillian Comas-Díaz, PhDLillian Comas-Díaz, PhD

Executive Director, Transcultural Mental Health InstituteExecutive Director, Transcultural Mental Health Institute Clinical Clinical Professor of Psychiatry and Behavioral Sciences The George Professor of Psychiatry and Behavioral Sciences The George

Washington University School of MedicineWashington University School of Medicine

Frederick M. Jacobsen, MD, MPHFrederick M. Jacobsen, MD, MPH Medical Director, Transcultural Mental Health InstituteMedical Director, Transcultural Mental Health Institute

Clinical Professor of Psychiatry and Behavioral Sciences The Clinical Professor of Psychiatry and Behavioral Sciences The George Washington University School of MedicineGeorge Washington University School of Medicine

World Federation of Mental Health World Federation of Mental Health October 30, 2007October 30, 2007

Clinical realities are negotiated by Clinical realities are negotiated by

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

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Race matters in Race matters in healinghealing

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

Cutural CompetenceCutural Competence can promotecan promote resilience resilience through:through:

• Enhanced optimismEnhanced optimism

• Improved regulation of attachment behaviorImproved regulation of attachment behavior

• Positive self conceptPositive self concept

• Active coping styleActive coping style

• Improved ability to convert helplessness into learned Improved ability to convert helplessness into learned helpfulnesshelpfulness

• Better acceptance of social support/altruismBetter acceptance of social support/altruism

• Improved ability to disclose emotionsImproved ability to disclose emotions

Jacobsen and Comas-Díaz, 2007Jacobsen and Comas-Díaz, 2007

APA Multicultural GuidelinesAPA Multicultural Guidelines

Commitment to cultural awareness and knowledge Commitment to cultural awareness and knowledge of self and otherof self and other..

Guideline 1Guideline 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 2Guideline 2: : Psychologists are encouraged to recognize the importance of multicultural sensitivity/responsiveness, knowledge and understanding about ethnically and racially different individuals.

DiversityDiversity: Relationship : Relationship between Self and other 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.

StrategiesStrategies to increase to increase multicultural awareness and multicultural awareness and knowledgeknowledge

• 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

APA Multicultural GuidelinesAPA 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

Explanatory Model of Explanatory Model of DistressDistress• What do you call your distress (problem)?What do you call your distress (problem)?

• What do you think your problem does?What do you think your problem does?

• What do you think the natural course of your problem is?What do you think the natural course of your problem is?

• What do you fear?What do you fear?

• Why do you think this problem has occurred?Why do you think this problem has occurred?

• How do you think the distress should be treated?How do you think the distress should be treated?

• How do you want me to help you?How do you want me to help you?

• Who do you turn to for help?Who do you turn to for help?

• Who should be involved in decision making? Who should be involved in decision making?

Adapted from Kleinman, 1993Adapted from Kleinman, 1993

The The challengechallenge of of multicultural practicemulticultural practice1. 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

Ethnocultural Ethnocultural Transference and Transference and CountertransferenceCountertransference

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, 1991Comas-Díaz and Jacobsen, 1991

INTER-ETHNIC CULTURAL INTER-ETHNIC CULTURAL TRANSFERENCETRANSFERENCE

• Overcompliance and friendliness

• Denial of ethnicity and culture

• Mistrust and suspiciousness

• Hostility

• Ambivalence

Comas-Díaz and Jacobsen, 1991Comas-Díaz and Jacobsen, 1991

INTRA-ETHNIC CULTURAL INTRA-ETHNIC CULTURAL TRANSFERENCETRANSFERENCE

• The Omniscient/omnipotent Therapist

• The Traitor

• The Folk Hero/Heroine

• The Auto-racist

• The Ambivalent

Comas-Díaz and Jacobsen, 1991Comas-Díaz and Jacobsen, 1991

INTER-ETHNIC CULTURAL INTER-ETHNIC CULTURAL COUNTERTRANSFERENCECOUNTERTRANSFERENCE• Denial of cultural differences:

"All patients are the same”

• Guilt

• Pity

• Aggression

• Ambivalence

• The Clinical Anthropologist's Syndrome

Comas-Díaz and Jacobsen, 1991Comas-Díaz and Jacobsen, 1991

INTRA-ETHNIC CULTURAL INTRA-ETHNIC CULTURAL COUNTERTRANSFERENCECOUNTERTRANSFERENCE

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

Comas-Díaz and Jacobsen, 1991Comas-Díaz and Jacobsen, 1991

Culturally Competent PractitionersCulturally Competent Practitioners

Conduct self- reflection and assessmentConduct self- reflection and assessment

Manage the Manage the dynamics of differencedynamics of difference

Incorporate cultural knowledge into interactions Incorporate cultural knowledge into interactions with clients to develop multicultural skills with clients to develop multicultural skills

Adapt to clients’ cultural contexts Adapt to clients’ cultural contexts

Value diversityValue diversity

Some strategies to develop Some strategies to develop multicultural competence skillsmulticultural competence skills

• Identify Cultural identity developmental stages

• Use Explanatory model of distress

• Examine Cultural transference/countertransference

• Develop Cultural empathy

• Acquire Multicultural communication skills

Course objectivesCourse 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

Complex therapist Complex therapist expectations from culturally expectations from culturally diverse individualsdiverse 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.