OREGON CENTER OF EXCELLENCE FOR ASSERTIVE COMMUNITY TREATMENT (OCEACT) Cultural Humility

Today Define culture Discuss cultural competency New paradigm of cultural humility How cultural humility is put in practice in working in the healthcare field with patients, clients, ACT participants

Thinking about culture Cultural and ethnic diversity Identify cultural or ethnic groups you work with... Subcultures

Culture Culture is the way of life of a particular people, as ​ shown in their ordinary behavior, habits, attitudes toward each other, and their moral and religious beliefs. (Cambridge Dictionary) Culture refers to the cumulative deposit of knowledge, experience, beliefs, values, attitudes, meanings, hierarchies, religion, notions of time, roles, spatial relations, concepts of the universe and creation, definitions of material objects and possessions. All formulated by a group of people over the course of generations. [Li & Karakowsky (2001). Do We See Eye-to-Eye? Implications of Cultural Differences for Cross-Cultural Management Research and Practice. The Journal of Psychology, 135(5), ]

Cultural Considerations: Core Identities Ethnic Identity Spiritual Beliefs Gender Sexual Orientation Physical Abilities Life Experiences Parental Status Education Marital Status Geographic Location Extended Family Community Network Role in Family Healthcare Beliefs Language Class Employment

Culture is Complex Our culture is shaped not only by our ethnicity and skin color, but also by our class, age, experiences, physical abilities, gender, language(s), religion, politics, education, sexual orientation, socio- economic status, and residential status. Our culture is shaped by our experiences with structural inequalities in society such as racism, sexism, classism, homophobia, and other “isms”

Cultural Competency emerged in the 1980’s The idea of educating health professionals to be culturally competent began in the United States in the 1990s. The term “cultural competence” first emerged in the late 1980s and was defined as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency or amongst professionals and enables that system, agency, or those professionals to work effectively in cross- cultural situations”.

Cultural Competency hopes to reduce health disparities Cultural competence training aims to improve the quality of health care and reduce health disparities by focusing on communication and trust between patients and health care providers and enhancing provider knowledge about sociocultural factors linked to health beliefs, practices and utilization of services. A culturally competent health care system can help improve health outcomes and quality of care, and can contribute to the elimination of racial and ethnic health disparities.

Cultural Competency: Definition Cultural competence is defined as the ability of health care providers and organizations to effectively deliver health care services that meet the social, cultural, and linguistic needs of patients. The ability of health care providers to develop knowledge and understanding of another person’s culture. Adapt interventions and approaches to healthcare to the specific culture of the patient, family and social group.

Goal of Cultural Competency in Healthcare Cultural competence strategies usually target the health workforce with the aim of improving the interactions between the patient, the provider and the health care system- with the ultimate goal of:  improving health care utilization  the delivery of effective services  improving health outcomes

Limitations of Cultural Competency Narrow concepts of culture often conflate culture with race and ethnicity, failing to capture diversity within groups and thus reducing the effectiveness of cultural competence strategies. Structural determinants of inequality and power differentials within health care settings may impact service utilization, health outcomes more than cultural influences.

Risks and Limitations of Cultural Competency Risk of oversimplifying culture and stereotyping Risk of underestimate cultural diversity within groups Risk of “essentialising” culture removes individuals from their complex social worlds in which the structural and material determinants of inequality may be as powerful as cultural influences on health inequity.

Culture is Dynamic and Ever Changing Culture is ever changing and always being revised within the dynamic context of its enactment.

Cultural Humility Cultural humility was introduced as an alternative to cultural competence. Competence assumes that one can learn or know enough that one can actually reach a full understanding of a culture to which they do not belong. Culture is dynamic, not static and each individual has own cultural perspectives and preferences Cultural humility is similar to cultural sensitivity, however, sensitivity does not touch on the necessity of self-reflection, learning, or growth.

Self reflection and Self critique Cultural Humility is a lifelong process of self-reflection and self-critique. The starting point for such an approach is not an examination of the client’s belief system, but rather having health care/service providers give careful consideration to their assumptions and beliefs that are embedded in their own understandings and goals of their encounter with the client. Training for cultural competency, with its emphasis on promoting understanding of the client with her/his ‘own culture’, has often neglected consideration of the providers' worldview. In practicing cultural humility, rather than learning to identify and respond to sets of culturally specific traits, the culturally competent provider develops and practices a process of self- awareness and reflection.

Cultural Humility Cultural humility is the “ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the person. Requires personal awareness, ability to be flexible Empathy, caring, sense of humor, ability to find common understanding It is all about the interaction and being mindful of communication and meaning, goals and expectations – that are shared and different Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Undeserved, 9,

Actively Exploring Cultural Difference To be “other-oriented” is to be open to exploring cultural differences. “Cultural difference" refers to a relationship between two perspectives. It involves self-awareness and an awareness and acceptance of the other person and any differences in the contrasting cultures. Culturally competent providers develop skills for exploring the existence and importance of differences in the basic assumptions, expectations, and goals they and their clients bring to any interaction.

In practice: using cultural humility Providers are encouraged to develop a respectful partnership with each client through client-focused interviewing, exploring similarities and differences between her/his own and each client's priorities, goals, and capacities. In this model, the most serious barrier to culturally appropriate care is not a lack of knowledge of the details of any given cultural orientation, but the providers' failure to develop self-awareness and a respectful attitude toward diverse points of view.

Some exercises in self reflection Identify your own cultural and family beliefs and values. Define your own personal culture/identity: ethnicity, age, experience, education, socio-economic status, gender, sexual orientation, religion… Are you aware of your personal biases and assumptions about people with different values than yours? Challenge yourself in identifying your own values as the “norm.” Describe a time when you became aware of being different from other people.

Developing Personal Awareness What cultural influences have shaped me? What makes me comfortable? What are my areas of privilege? What have been my own experiences with discrimination (racism, sexism or other isms)?

The Asking Stance: What is your language of preference? What would be most helpful to you? How would you like to be addressed? Is there anything you would like me to know about you? Do you want to share anything about your religious or spiritual upbringing or current practice? Do you have a story you’d like to share about coming to this country? Do you have cultural practices that are important to you? What has been your experience with professional providers? Do you use culturally specific healing approaches?

Using Cultural Humility “Cultural humility….is best defined not as a discrete end point but as a commitment and active engagement in a lifelong process that individuals enter into on an ongoing basis with patients, communities, colleagues, and with themselves.”

Tools: The Cultural Formulations Interview 2013 American Psychiatric Association developed the Cultural Formulation Interview:  Helps explore cultural definition of health problem  Cultural perceptions of causes, context and supports  How cultural factors affects self- coping and past help seeking strategies and potential barriers to help seeking or effective solutions  Cultural factors affecting current help seeking and effective solutions  Exploring possible different backgrounds, beliefs and expectations of doctors and patients  file:///C:/Users/Staff/Downloads/APA_DSM5_Cultural- Formulation-Interview.pdf

Cultural Humility in practice Discuss how you incorporate cultural humility practices into your work on the ACT team. What new strategies are you interested in trying? What questions would you like to ask your colleagues for help with regarding cultural humility approaches or challenging situations you have encountered? How is cultural humility important in engagement/retention of ACT participants?

Questions?

OCEACT Contact Information Staff:  Heidi Herinckx, Director of OCEACT    Emily Reynolds, ACT Trainer   Website OCEACT.ORG Website