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

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.

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

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

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.

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.

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

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

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

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

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

INTER-ETHNIC CULTURAL TRANSFERENCE Overcompliance and friendliness Denial of ethnicity and culture Mistrust and suspiciousness Hostility Ambivalence Comas-Díaz and Jacobsen, 1991

INTRA-ETHNIC CULTURAL TRANSFERENCE The Omniscient/omnipotent Therapist The Traitor The Folk Hero/Heroine The Auto-racist The Ambivalent Comas-Díaz and Jacobsen, 1991

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

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

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

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

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 menopause and expectation for pregnancy May want SSRI or NTP rather than other antidepressant there are many examples of culture-bound uses of psychoactive medication or whose function/use varies tremendously in different cultural contexts: coca leaves in the tea - by Peruvian indians vs addiction many foreign born immigrants disdain the use of psychtropics in themselves or their loved ones *S marry not Prozac in the mainstream culture, most patients want quick-fixes explanation of long-term nature crucial from the beginning with EC translocated have to work doubly hard to encourage maintenance of the regimin

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.