How to Take a Test Again Ce4less

Zhang Min, a 25-twelvemonth-onetime first-generation Chinese woman, was referred to a counselor by her chief care physician considering she reported having episodes of depression. The advisor who conducted the intake interview had received training in cultural competence and was mindful of cultural factors in evaluating Zhang Min. The referral noted that Zhang Min was born in Hong Kong, and then the therapist expected her to exist hesitant to talk over her problems, given the prejudices attached to mental illness and substance abuse in Chinese culture. During the evaluation, however, the therapist was surprised to observe that Zhang Min was quite forthcoming. She mentioned missing important deadlines at piece of work and calling in sick at least once a week, and she noted that her coworkers had expressed business afterwards finding a bottle of wine in her desk. She admitted that she had been drinking heavily, which she linked to work stress and contempo discord with her Irish gaelic American spouse.

Further inquiry revealed that Zhang Min'southward parents, both Chinese, went to school in England and sent her to a British school in Hong Kong. She grew up shut to the British expatriate community, and her mother was a nurse with the British Regular army. Zhang Min came to the U.s.a. at the age of viii and grew up in an Irish American neighborhood. She stated that she knew more well-nigh Irish civilisation than almost Chinese culture. She felt, with the exception of her physical features, that she was more Irish than Chinese—a view accepted past many of her Irish American friends. Most men she had dated were Irish Americans, and she socialized in groups in which alcohol consumption was not but accustomed only expected.

Zhang Min outset started to beverage in high schoolhouse with her friends. The counselor realized that what she had learned almost Asian Americans was not necessarily applicable to Zhang Min and that noesis of Zhang Min'south unabridged history was necessary to appreciate the influence of civilization in her life. The counselor thus developed treatment strategies more than suitable to Zhang Min'south background.

Graphic: 3-D drawing of a cube, segmented. Along the Z axis is labeled

Multidimensional Model for Developing Cultural Competence: Clinical/Plan Level

Zhang Min's instance demonstrates why thorough evaluation, including assessment of the client'southward sociocultural background, is essential for treatment planning. To provide culturally responsive evaluation and treatment planning, counselors and programs must understand and incorporate relevant cultural factors into the process while avoiding a stereotypical or "one-size-fits-all" approach to handling. Cultural responsiveness in planning and evaluation entails beingness open minded, asking the correct questions, selecting appropriate screening and assessment instruments, and choosing effective treatment providers and modalities for each customer. Moreover, information technology involves identifying culturally relevant concerns and issues that should be addressed to improve the customer's recovery process.

This chapter offers clinical staff guidance in providing and facilitating culturally responsive interviews, assessments, evaluations, and treatment planning. Using Sue's (2001) multidimensional model for developing cultural competence, this affiliate focuses on clinical and programmatic decisions and skills that are important in evaluation and handling planning processes. The affiliate is organized around ix steps to be incorporated past clinicians, supported in clinical supervision, and endorsed by administrators.

Stride 1. Engage Clients

In one case clients are in contact with a treatment program, they stand on the far side of a still-to-be-established therapeutic relationship. It is up to counselors and other staff members to span the gap. Handshakes, facial expressions, greetings, and small talk are uncomplicated gestures that establish a starting time impression and begin building the therapeutic relationship. Involving one'south whole being in a greeting—idea, body, attitude, and spirit—is nigh engaging.

Fifty percent of racially and ethnically diverse clients end treatment or counseling later on one visit with a mental wellness practitioner (Sue and Sue 2013e). At the kickoff of treatment, clients can feel scared, vulnerable, and uncertain about whether treatment will really help. The initial meeting is often the outset encounter clients have with the treatment system, and then it is vital that they leave feeling hopeful and understood. Paniagua (1998) describes how, if a counselor lacks sensitivity and jumps to premature conclusions, the first visit tin go the final:

Pretend that you are a Puerto Rican taxi driver in New York City, and at 3:00 p.k. on a hot summertime day y'all realize that you accept your starting time appointment with the therapist…later on, you learned that the therapist fabricated a annotation that you were probably depressed or psychotic considering yous dressed carelessly and had dingy nails and hands…would y'all return for a second engagement? (p. 120)

To appoint the customer, the counselor should endeavour to institute rapport earlier launching into a series of questions. Paniagua (1998) suggests that counselors should draw attending to the presenting problem "without giving the impression that too much information is needed to empathise the problem" (p. 18). It is besides of import that the customer feel engaged with any interpreter used in the intake process. A common framework used in many healthcare training programs to highlight culturally responsive interview behaviors is the LEARN model (Berlin and Fowkes 1983). The how-to box on the adjacent page presents this model.

Improving Cross-Cultural Communication

Wellness disparities have multiple causes. I specific influence is cross-cultural advice between the counselor and the client. Weiss (2007) recommends these six steps to meliorate advice with clients:

Ho-hum down.
Utilise plain, nonpsychiatric language.
Evidence or draw pictures.
Limit the corporeality of information provided at 1 fourth dimension.
Apply the "teach-back" method. Ask the client, in a nonthreatening manner, to explicate or show what he or she has been told.
Create a shame-free environment that encourages questions and participation.

Step 2. Familiarize Clients and Their Families With Treatment and Evaluation Processes

Behavioral health handling facilities maintain their own culture (i.e., the treatment milieu). Counselors, clinical supervisors, and agency administrators tin easily get accustomed to this culture and assume that clients are used to information technology equally well. However, clients are typically new to handling language or jargon, plan expectations and schedules, and the intake and treatment procedure. Unfortunately, clients from diverse racial and ethnic groups tin can feel more estranged and disconnected from treatment services when staff members fail to educate them and their families about handling expectations or when the clients are not walked through the treatment process, starting with the goals of the initial intake and interview. Past taking the time to acclimate clients and their families to the treatment process, counselors and other behavioral health staff members tackle one obstacle that could further impede treatment date and memory among racially and ethnically diverse clients.

How To Utilise the LEARN Mnemonic for Intake Interviews

50isten to each client from his or her cultural perspective. Avert interrupting or posing questions earlier the client finishes talking; instead, find creative means to redirect dialog (or explain session limitations if time is short). Take time to learn the client's perception of his or her bug, concerns about presenting problems and treatment, and preferences for treatment and healing practices.

Due eastxplain the overall purpose of the interview and intake process. Walk through the general agenda for the initial session and talk over the reasons for asking about personal information. Call back that the client's needs come before the set agenda for the interview; don't cover every intake question at the expense of taking fourth dimension (usually brief) to address questions and concerns expressed by the client.

Acknowledge client concerns and discuss the probable differences between you and your clients. Accept time to empathise each client's explanatory model of affliction and health. Recognize, when appropriate, the client'southward healing behavior and practices and explore ways to contain these into the treatment plan.

Recommend a course of activeness through collaboration with the client. The client must know the importance of his or her participation in the treatment planning process. With client assistance, customer beliefs and traditions can serve as a framework for healing in handling. However, not all clients have the same expectations of handling involvement; some see the counselor every bit the expert, want a directive approach, and have footling desire to participate in developing the treatment program themselves.

Negotiate a treatment plan that weaves the client'south cultural norms and lifeways into handling goals, objectives, and steps. Once the treatment plan and modality are established and implemented, encourage regular dialog to gain feedback and assess treatment satisfaction. Respecting the customer's culture and encouraging communication throughout the process increases customer willing to appoint in treatment and to adhere to the treatment plan and continuing care recommendations.

Sources: Berlin and Fowkes 1983; Dreachslin et al. 2013; Ring 2008.

Step 3. Endorse Collaboration in Interviews, Assessments, and Handling Planning

Near clients are unfamiliar with the evaluation and treatment planning process and how they can participate in information technology. Some clients may view the initial interview and evaluation as intrusive if too much information is requested or if the content is a source of family dishonor or shame. Other clients may resist or distrust the process based on a long history of racism and oppression. Still others feel inhibited from actively participating because they view the counselor as the authority or sole practiced.

The counselor tin assist decrease the influence of these issues in the interview process through a collaborative approach that allows fourth dimension to discuss the expectations of both advisor and client; to explicate interview, intake, and treatment planning processes; and to institute ways for the customer to seek clarification of his or her assessment results (Mohatt et al. 2008a). The counselor can encourage collaboration by emphasizing the importance of clients' input and interpretations. Client feedback is integral in interpreting results and can place cultural bug that may affect intake and evaluation (Acevedo-Polakovich et al. 2007). Collaboration should extend to customer preferences and desires regarding inclusion of family and community members in evaluation and treatment planning.

Stride 4. Integrate Culturally Relevant Information and Themes

Past exploring culturally relevant themes, counselors can more fully understand their clients and identify their cultural strengths and challenges. For example, a Korean woman'southward family unit may serve as a source of back up and provide a sense of identity. At the same fourth dimension, however, her family could be aback of her co-occurring generalized anxiety and substance utilize disorders and respond to her handling equally a source of further shame because information technology encourages her to disembalm personal matters to people exterior the family. The post-obit section provides a brief overview of suggested strength-based topics to contain into the intake and evaluation process.

Advice to Counselors: Asking About Culture and Acculturation

A thoughtful exploration of cultural and indigenous identity bug will provide clues for determining cultural, racial, and indigenous identity. In that location are numerous clues that yous may derive from your clients' answers, and they cannot all be covered in this TIP; this is only one set of sample questions (Fontes 2008). Ask these questions tactfully so they do non sound like an interrogation. Try to integrate them naturally into a conversation rather than request one after another. Not all questions are relevant in all settings. Counselors can adapt wording to suit clients' cultural contexts and styles of communication, because the questions listed here and throughout this chapter are only examples:

Where were yous born?
Whom do y'all consider family unit?
What was the starting time language you learned?
Which other linguistic communication(s) practice yous speak?
What language or languages are spoken in your home?
What is your organized religion? How observant are yous in practicing that religion?
What activities exercise yous bask when you are not working?
How do you place yourself culturally?
What aspects of existence ________ are most important to you? (Use the aforementioned term for the identified culture as the client.)
How would you draw your home and neighborhood?
Whom exercise you commonly turn to for help when facing a problem?
What are your goals for this interview?

Clearing History

Immigration history tin can shed low-cal on client back up systems and identify possible isolation or breach. Some immigrants who alive in ethnic enclaves have many sources of social support and resources. By contrast, others may be isolated, living apart from family, friends, and the support systems extant in their countries of origin. Culturally competent evaluation should always include questions nigh the client's state of origin, clearing condition, length of time in the United States, and connections to his or her state of origin. Enquire American-born clients well-nigh their parents' land of origin, the language(s) spoken at home, and affiliation with their parents' culture(due south). Questions like these give the counselor important clues almost the client's degree of acculturation in early on life and at present, cultural identity, ties to culture of origin, potential cultural conflicts, and resources. Specific questions should elicit information about:

Length of fourth dimension in the Usa, noting when immigration occurred or the number of generations who take resided in the United States.
Frequency of returns and psychological and personal ties to the country of origin.
Primary language and level of English proficiency in speaking and writing.
Psychological reactions to immigration and adjustments fabricated in the process.
Changes in social condition and other areas as a result of coming to this country.
Major differences in attitudes toward alcohol and drug use from the fourth dimension of clearing to now.

Advice to Counselors: Conducting Force-Based Interviews

By nature, initial interviews and evaluations tin overemphasize presenting problems and concerns while underplaying client strengths and supports. This list, although not exhaustive, reminds clinicians to acknowledge customer strengths and supports from the outset.

Strengths and supports

Pride and participation in one's culture
Social skills, traditions, cognition, and practical skills specific to the client'south culture
Bilingual or multilingual skills
Traditional, religious, or spiritual practices, beliefs, and faith
Generational wisdom
Extended families and nonblood kinships
Ability to maintain cultural heritage and practices
Perseverance in coping with racism and oppression
Culturally specific ways of coping
Community involvement and back up

Source: Hays 2008.

Cultural Identity and Acculturation

Every bit shown in Zhang Min's case at the showtime of this chapter, cultural identity is a unique feature of each client. Counselors should guard against making assumptions about client identity based on general ethnic and racial identification by evaluating the degree to which an private identifies with his or her civilization(s) of origin. As Castro and colleagues (1999b) explain, "for each group, the level of within-group variability tin can be assessed using a cadre dimension that ranges from high cultural involvement and acceptance of the traditional civilization's values to low or no cultural involvement" (p. 515). For African Americans, for example, this dimension is called "Afrocentricity." Scales for Afrocentricity take been adult in an endeavour to provide an indicator of an individual's level of interest inside the traditional or cadre African-oriented civilisation (Baldwin and Bell 1985; Cokley and Williams 2005; Klonoff and Landrine 2000). Many other instruments based on models of identity evaluate acculturation and identity. A detailed discussion of the theory behind such models is beyond the scope of this Handling Comeback Protocol (TIP); withal, counselors should have a general understanding of what is being measured when administering such instruments. The "Request Well-nigh Culture and Acculturation" advice box at right addresses exploration of culture and acculturation with clients. For more than information on instruments that measure out acculturation and/or identity, see Appendix B.

Other areas to explore include the cross-cut factors outlined in Chapter 1, such equally socioeconomic status (SES), occupation, education, gender, and other variables that can distinguish an private from others who share his or her cultural identity. For example, a biracial client could identify with African American culture, White American culture, or both. When a client has two or more racial/ethnic identities, counselors should appraise how the client self-identifies and how he or she negotiates the different worlds.

Membership in a Subculture

Clients often identify initially with broader racial, indigenous, and cultural groups. Even so, each person has a unique history that warrants an understanding of how culture is adept and has evolved for the person and his or her family unit; appropriately, counselors should avoid generalizations or assumptions. Clients are oftentimes part of a civilization within a civilization. There is not just i Latino, African American, or Native American civilisation; many variables influence culture and cultural identity (see the "What Are the Cross-Cut Factors in Race, Ethnicity, and Culture" section in Chapter 1). For example, an African American client from East Carroll Parish, LA, might describe his or her culture quite differently than an African American from downtown Hartford, CT.

Beliefs About Health, Healing, Help-Seeking, and Substance Use

Just every bit culture shapes an private'south sense of identity, it also shapes attitudes surrounding wellness practices and substance use. Cultural acceptance of a beliefs, for example, tin mask a trouble or deter a person from seeking handling. Counselors should be aware of how the client'south culture conceptualizes issues related to health, healing and treatment practices, and the use of substances. For instance, in cases where alcohol use is discouraged or frowned upon in the community, the client can experience tremendous shame well-nigh drinking. Chapter 5 reviews health-related beliefs and practices that can impact help-seeking behavior beyond diverse populations.

Trauma and Loss

Some immigrant subcultures have experienced violent upheavals and take a college incidence of trauma than others. The theme of trauma and loss should therefore be incorporated into general intake questions. Specific issues nether this full general theme might include:

Migration, relocation, and emigration history—which considers separation from homeland, family, and friends—and the stressors and loss of social support that can accompany these transitions.
Clients' personal or familial experiences with American Indian boarding schools.
Experiences with genocide, persecution, torture, state of war, and starvation.

Advice to Counselors: Eliciting Client Views on Presenting Issues

Some clients exercise not see their presenting physical, psychological, and/or behavioral difficulties every bit problems. Instead, they may view their presenting difficulties as the effect of stress or some other issue, thus defining or labeling the presenting trouble every bit something other than a concrete or mental disorder. In such cases, word the following questions using the clients' terminology rather than using the word "trouble." These questions help explore how clients view their behavioral health concerns:

I know that clients and counselors sometimes have different ideas about disease and diseases, so can you lot tell me more about your idea of your problem?
Exercise y'all consider your use of alcohol and/or drugs a problem?
How do you label your problem? Do you think it is a serious problem?
What do you lot think caused your problem?
Why do you think it started when it did?
What is going on in your trunk as a result of this problem?
How has this problem affected your life?
What frightens or concerns you almost about this problem and its handling?
How is your problem viewed in your family? Is it acceptable?
How is your problem viewed in your community? Is it acceptable? Is it considered a disease?
Do you lot know others who accept had this problem? How did they treat the trouble?
How does your problem affect your stature in the customs?
What kinds of handling exercise y'all recollect will help or heal you?
How have you treated your drug and/or booze problem or emotional distress?
What has been your experience with handling programs?

Sources: Lynch and Hanson 2011; Tang and Bigby 1996; Taylor 2002.

How To Use a Multicultural Intake Checklist

Some clients exercise not see their presenting physical, psychological, and/or behavioral difficulties as problems. Instead, they may view their presenting difficulties as the result of stress or another issue, thus defining or labeling the presenting problem as something other than a concrete or mental disorder. In such cases, word questions nigh the post-obit topics using the customer's terminology, rather than using the word "problem." Asking questions nearly the following topics tin can help yous explore how a customer may view his or her behavioral health concerns:

□: Immigration history
□: Relocations (current migration patterns)
□: Losses associated with immigration and relocation history
□: English fluency
□: Bilingual or multilingual fluency
□: Individualistic/collectivistic orientation
□: Racial, indigenous, and cultural identities
□: Tribal affiliation, if appropriate
□: Geographic location
□: Family and extended family concerns (including nonblood kinships)
□: Acculturation level (e.yard., traditional, bicultural)
□: Acculturation stress
□: History of bigotry/racism
□: Trauma history
□: Historical trauma
□: Intergenerational family unit history and concerns
□: Gender roles and expectations
□: Nascence order roles and expectations
□: Human relationship and dating concerns
□: Sexual and gender orientation
□: Health concerns
□: Traditional healing practices
□: Help-seeking patterns
□: Behavior virtually wellness
□: Beliefs about mental illness and mental wellness treatment
□: Beliefs about substance use, abuse, and dependence
□: Beliefs almost substance abuse handling
□: Family views on substance use and substance abuse treatment
□: Treatment concerns related to cultural differences
□: Cultural approaches to healing or treatment of substance utilise and mental disorders
□: Education history and concerns
□: Work history and concerns
□: SES and financial concerns
□: Cultural group affiliation
□: Current network of support
□: Community concerns
□: Review of confidentiality parameters and concerns
□: Cultural concepts of distress (DSM-5^*)
□: DSM-5 culturally related V-codes

Sources: Comas-Diaz 2012; Constantine and Sue 2005; Sussman 2004.

*

Step 5. Get together Culturally Relevant Collateral Information

A client who needs behavioral health treatment services may exist unwilling or unable to provide a full personal history from his or her own perspective and may not recall sure events or be aware of how his or her behavior affects his or her well-being and that of others. Collateral information—supplemental data obtained with the client's permission from sources other than the client—can be derived from family members, medical and court records, probation and parole officers, community members, and others. Collateral data should include culturally relevant information obtained from the family, such as the organizational memberships, beliefs, and practices that shape the customer'southward cultural identity and understanding of the earth.

As families can be a vital source of data, counselors are likely to accomplish more back up past engaging families earlier in the treatment process. Although counselor interactions with family members are oftentimes limited to a few formal sessions, the families of racially and ethnically diverse clients tend to play a more significant and influential role in clients' participation in treatment. Consequently, special sensitivity to the cultural groundwork of family members providing collateral data is essential. Families, like clients, cannot be hands defined in terms of a generic cultural identity (Congress 2004; Taylor et al. 2012). Even families from the same racial background or indigenous heritage can be quite dissimilar, thus requiring a multidimensional approach in understanding the role of culture in the lives of clients and their families. Using the culturagram tool on the adjacent page in grooming for counseling, treatment planning, or clinical supervision, clinicians can learn almost the unique attributes and histories that influence clients' lives in a cultural context.

Step six. Select Culturally Appropriate Screening and Cess Tools

Discussions of the complexities of psychological testing, the interpretation of assessment measures, and the appropriateness of screening procedures are exterior the scope of this TIP. Nevertheless, counselors and other clinical service providers should be able to use cess and screening information in culturally competent ways. This department discusses several instruments and their appropriateness for specific cultural groups. Counselors should go along to explore the availability of mental health and substance abuse screening and assessment tools that have been translated into or adapted for other languages.

Culturally Appropriate Screening Devices

The consensus panel does not recommend any specific instruments for screening or assessing mental or substance use disorders. Rather, when selecting instruments, practitioners should consider their cultural applicability to the client beingness served (AACE 2012; Jome and Moody 2002). For example, a screening instrument that asks the respondent virtually his or her guilt about drinking could be ineffective for members of cultural, indigenous, or religious groups that prohibit any consumption of booze. Al-Ansari and Negrete's (1990) inquiry supports this point. They establish that the Brusk Michigan Alcoholism Screening Test was highly sensitive with people who utilize alcohol in a traditional Arab Muslim society; yet, ane question—"Do you ever feel guilty nearly your drinking?"—failed to distinguish between people with alcohol dependency disorders in treatment and people who drank in the customs. Questions designed to measure disharmonize that results from the utilise of alcohol can skew test results for participants from cultures that expect complete forbearance from booze and/or drugs. Appendix D summarizes instruments tested on specific populations (east.g., availability of normative data for the population existence served).

Culturally Valid Clinical Scales

As the literature consistently demonstrates, co-occurring mental disorders are common in people who accept substance utilize disorders. Although an assessment of psychological problems helps friction match clients to appropriate handling, clinicians are cautioned to go along carefully. People who are abusing substances or experiencing withdrawal from substances can exhibit behaviors and thinking patterns consistent with mental disease. Afterward a period of abstinence, symptoms that mimic mental illness can disappear. Moreover, clinical instruments are imperfect measurements of every bit imperfect psychological constructs that were created to organize and empathize clinical patterns and thus better care for them; they practise not provide absolute answers. As enquiry and scientific discipline evolve, and then does our agreement of mental affliction (Benuto 2012). Assessment tools are by and large developed for particular populations and can be inapplicable to diverse populations (Blume et al. 2005; Suzuki and Ponterotto 2008). Appendix D summarizes research on the clinical utility of instruments for screening and assessing co-occurring disorders in various cultural groups.

How To Use a Culturagram for Mapping the Role of Civilisation

The culturagram is an assessment tool that helps clinicians understand culturally diverse clients and their families (Congress 1994, 2004; Congress and Kung 2005). It examines 10 areas of inquiry, which should include non simply questions specific to clients' life experiences, but as well questions specific to their family unit histories. This diagram can guide an interview, counseling, or clinical supervision session to arm-twist culturally relevant multigenerational information unique to the client and the customer'southward family unit. Give a copy of the diagram to the client or family for utilise as an interactive tool in the session. Throughout the interview, the client, family members, and/or the counselor can write brief responses in each box to highlight the unique attributes of the client's history in the family unit context. This diagram has been adapted for clients with co-occurring mental and substance apply disorders; sample questions follow.

Values well-nigh family unit structure, ability, myths, and rules

Are at that place specific gender roles and expectations in your family?
Who holds the power within the family unit?
Are family needs more than important than, or every bit equally important equally, individual needs?
Whom exercise you consider family?

Reasons for relocation or migration

Are you and your family unit able to render home?
What were your reasons for coming to the U.s.?
How do y'all at present view the initial reasons for relocation?
What feelings do yous accept well-nigh relocation or migration?
Exercise y'all move back and forth from one location to another?
How oftentimes do y'all and your family return to your homeland?
Are yous living apart from your family?

Legal status and SES

Has your SES improved or worsened since coming to this country?
Has there been a change in socioeconomic status across generations?
What is the family history of documentation? (Note: Clients often need to develop trust earlier discussing legal status; they may come from a place where confidentiality is unfamiliar.)

Time in the community

How long have you and your family members been in the country? Community?
Are yous and your family actively involved in a culturally based customs?

Languages spoken in and outside the habitation

What languages are spoken at dwelling house and in the community?
What is your and your family unit's level of proficiency in each language?
How dependent are parents and grandparents on their children for negotiating activities surrounding the use of English? Have children become the family interpreters?

Health behavior and behavior about help-seeking

What are the family beliefs near drug and alcohol use? Mental illness? Treatment?
Practise you and your family uphold traditional healing practices?
How practise help-seeking behaviors differ across generations and genders in your family?
How do you and your family unit define disease and wellness?
Are there any objections to the use of Western medicine?

Touch of trauma and other crunch events

How has trauma affected your family across generations?
How have traumas or other crises afflicted y'all and/or your family?
Has there been a specific family unit crisis?
Did the family experience traumatic events prior to migration—war, other forms of violence, displacement including refugee camps, or similar experiences?

Oppression and discrimination

Is there a history of oppression and discrimination in your homeland?
How have yous and your family unit experienced bigotry since immigration?

Religious and cultural institutions, food, wearable, and holidays

Are in that location specific religious holidays that your family observes?
What holidays do you celebrate?
Are there specific foods that are important to y'all?
Does clothing play a significant cultural or religious function for you?
Practise you belong to a cultural or social club or organization?

Values about education and piece of work

How much importance do y'all identify on work, family unit, and education?
What are the educational expectations for children within the family?
Has your work condition inverse (e.k., level of responsibility, prestige, and power) since migration?
Do you or does anyone in your family unit work several jobs?

Sources: Comas-Diaz 2012; Congress 1994, 2004; Vocaliser 2007.

Diagnosis

Counselors should consider clients' cultural backgrounds when evaluating and assessing mental and substance use disorders (Bhugra and Gupta 2010). Concerns surrounding diagnoses of mental and substance use disorders (and the cross-cultural applicability of those diagnoses) include the appropriateness of specific exam items or questions, diagnostic criteria, and psychologically oriented concepts (Alarcon 2009; Room 2006). Enquiry into specific techniques that address cultural differences in evaluative and diagnostic processes so far remains limited and underrepresentative of diverse populations (Guindon and Sobhany 2001; Martinez 2009).

Does the DSM-5 accurately diagnose mental and substance use disorders amongst immigrants and other ethnic groups? Caetano and Shafer (1996) found that diagnostic criteria seemed to identify alcohol dependency consistently across race and ethnicity, only their sample was express to African Americans, Latinos, and Whites. Other research has shown mixed results.

In 1972, the Earth Health Organization (WHO) and the National Institutes of Health (NIH) embarked on a joint study to test the cross-cultural applicability of classification systems for various diagnoses, including substance use disorders. WHO and NIH identified factors that appeared to be universal aspects of mental and substance use disorders and then developed instruments to measure them. These instruments, the Composite International Diagnostic Interview (CIDI) and the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), include some DSM and International Statistical Classification of Diseases and Related Health Problems criteria. Studies report that both the CIDI and SCAN were mostly authentic, but the investigators urge caution in translation and interview procedures (Room et al. 2003).

Advice to Counselors and Clinical Supervisors: Culturally Responsive Screening and Assessment

Assess the customer's principal language and linguistic communication proficiency prior to the administration of whatsoever evaluation or utilise of testing instruments.
Determine whether the assessment materials were translated using specific terms, including idioms that correspond to the client's literacy level, culture, and language. Do not assume that translation into a stated language exactly matches the specific language of the client. Specifically, the client may non understand the translated language if it does not match his or her means of thinking or speaking
Brainwash the client on the purpose of the assessment and its application to the development of the handling plan. Recall that testing tin generate many emotional reactions.
Know how the test was adult. Is normative data available for the population being served? Test results can be inflated, underestimated, or inaccurate due to differences within the client's population.
Consider the function of acculturation in testing, including the influence of the customer's worldview in responses. Unfamiliarity with mainstream United States culture can bear on interpretation of questions, the client-evaluator relationship, and behavior, including participation level during evaluation and verbal and behavioral responses.

Sources: Association for Assessment in Counseling and Educational activity (AACE) 2012; Saldaña 2001.

Overall, psychological concepts that are appropriate for and easily translated by some groups are inappropriate for others. In some Asian cultures, for example, feeling refers more than to a physical than an emotive land; questions designed to infer emotional states are not easily translated. In most cases, these issues tin can be remedied past using culture-specific resources, measurements, and references while also adopting a cultural formulation in the interviewing process (see Appendix E for the A PA's cultural formulation outline). The DSM-5 lists several cultural concepts of distress (see Appendix E), yet there is fiddling empirical literature providing information or treatment guidance on using the APA'due south cultural formulation or addressing cultural concepts of distress (Martinez 2009; Mezzich et al. 2009).

Step 7. Determine Readiness and Motivation for Modify

Clients enter treatment programs at different levels of readiness for change. Even clients who present voluntarily could accept been pushed into it by external pressures to accept treatment before reaching the activeness stage. These different readiness levels require different approaches. The strategies involved in motivational interviewing tin assistance counselors prepare culturally diverse clients to change their behavior and go on them engaged in treatment. To understand motivational interviewing, information technology is start necessary to examine the process of change that is involved in recovery. See TIP 35, Enhancing Motivation for Alter in Substance Abuse Handling (Center for Substance Abuse Handling [CSAT] 1999b), for more information on this technique.

Stages of Change

Prochaska and DiClemente'due south (1984) archetype transtheoretical model of change is applicable to culturally diverse populations. This model divides the change process into several stages:

Precontemplation. The private does not see a need to change. For example, a person at this stage who abuses substances does not see any need to alter use, denies that there is a trouble, or blames the problem on other people or circumstances.
Contemplation. The person becomes aware of a problem but is ambivalent about the class of action. For instance, a person struggling with depression recognizes that the depression has affected his or her life and thinks about getting help but remains ambivalent on how he/she may do this.
Preparation. The private has determined that the consequences of his or her behavior are too great and that change is necessary. Preparation includes small steps toward making specific changes, such every bit when a person who is overweight begins reading about wellness and weight management. The client still engages in poor health behaviors but may be altering some behaviors or planning to follow a diet.
Activeness. The individual has a specific programme for change and begins to pursue information technology. In relation to substance abuse, the client may make an appointment for a drug and booze assessment prior to becoming abstinent from alcohol and drugs.
Maintenance. The person continues to engage in behaviors that support his or her determination. For example, an private with bipolar I disorder follows a daily relapse prevention programme that helps him or her assess warning signs of a manic episode and reminds him or her of the importance of engaging in help-seeking behaviors to minimize the severity of an episode.

Progress through the stages is nonlinear, with motion dorsum and along amongst the stages at unlike rates. It is important to recognize that modify is not a one-time process, but rather, a series of trials and errors that eventually translates to successful modify. For example, people who are dependent on substances oft attempt to abstain several times before they are able to learn long-term abstinence.

Motivational Interviewing

Motivational interventions assess a person's stage of change and utilize techniques likely to move the person frontward in the sequence. Miller and Rollnick (2002) developed a therapeutic style called motivational interviewing, which is characterized by the strategic therapeutic activities of expressing empathy, developing discrepancy, avoiding argument, rolling with resistance, and supporting self-efficacy. The counselor's major tool is reflective listening and soliciting change talk (CSAT 1999c).

This nonconfrontational, client-centered approach to treatment differs significantly from traditional treatments in several ways, creating a more welcoming relationship. TIP 35 (CSAT 1999c) assesses Project MATCH and other clinical trials, last that the bear witness strongly supports the use of motivational interviewing with a wide multifariousness of cultural and ethnic groups (Miller and Rollnick 2013; Miller et al. 2008). TIP 35 is a expert motivational interviewing resource. For specific application of motivational interviewing with Native Americans, meet Venner and colleagues (2006). For comeback of handling compliance among Latinos with depression through motivational interviewing, come across Interian and colleagues (2010).

Step 8. Provide Culturally Responsive Instance Direction

Clients from various racial, ethnic, and cultural populations seeking behavioral health services may face additional obstacles that can interfere with or prevent access to handling and coincident services, compromise appropriate referrals, impede compliance with treatment recommendations, and produce poorer treatment outcomes. Obstacles may include clearing condition, lower SES, linguistic communication barriers, cultural differences, and lack of or poor coverage with wellness insurance.

Case management provides a single professional contact through which clients gain access to a range of services. The goal is to aid assess the need for and coordinate social, health, and other essential services for each client. Case management tin can exist an immense help during treatment and recovery for a person with limited English literacy and knowledge of the handling system. Case direction focuses on the needs of individual clients and their families and anticipates how those needs will be affected as handling proceeds. The instance manager advocates for the client (CSAT 1998a; Summers 2012), easing the fashion to effective handling past assisting the client with critical aspects of life (due east.g., food, childcare, employment, housing, legal problems). Similar counselors, case managers should possess cocky-knowledge and basic knowledge of other cultures, traits conducive to working well with diverse groups, and the ability to apply cultural competence in practical means.

Cultural competence begins with cocky-knowledge; counselors and case managers should be aware of and responsive to how their culture shapes attitudes and beliefs. This agreement volition augment as they gain noesis and directly feel with the cultural groups of their client population, enabling them to better frame client issues and collaborate with clients in culturally specific and appropriate means. TIP 27, Comprehensive Example Management for Substance Abuse Handling (CSAT 1998a), offers more information on effective case management.

Exhibit 3-i discusses the cultural matching of counselors with clients. When counselors cannot provide culturally or linguistically competent services, they must know when and how to bring in an interpreter or to seek other assistance (CSAT 1998a). Case management includes finding an interpreter who communicates well in the client's language and dialect and who is familiar with the vocabulary required to communicate effectively about sensitive subject matter. The case managing director works within the system to ensure that the interpreter, when needed, can be compensated. Example managers should also accept a listing of appropriate referrals to meet contrasted needs. For case, an immigrant who does not speak English may need legal services in his or her linguistic communication; an undocumented worker may need to know where to go for medical assistance. Culturally competent instance managers build and maintain rich referral resources for their clients.

The Case Management Club of America's Standards of Do for Example Management (2010) land that example management is central in meeting client needs throughout the grade of handling. The standards stress agreement relevant cultural information and communicating effectively by respecting and beingness responsive to clients and their cultural contexts. For standards that are also applicable to case management, refer to the National Association of Social Workers' Standards on Cultural Competence in Social Work Practice (2001).

Stride 9. Incorporate Cultural Factors Into Treatment Planning

The cultural adaptation of treatment practices is a burgeoning area of involvement, yet inquiry is limited regarding the procedure and upshot of culturally responsive treatment planning in behavioral health treatment services for diverse populations. How practice counselors and organizations respond culturally to the diverse needs of clients in the treatment planning process? How effective are culturally adaptive treatment goals? (For a review, see Bernal and Domenech Rodriguez 2012.) Typically, programs that provide culturally responsive services approach treatment goals holistically, including objectives to improve physical health and spiritual strength (Howard 2003). Newer approaches stress implementation of strength-based strategies that fortify cultural heritage, identity, and resiliency.

Treatment planning is a dynamic procedure that evolves along with an understanding of the clients' histories and treatment needs. Foremost, counselors should exist mindful of each client's linguistic requirements and the availability of interpreters (for more than detail on interpreters, meet Chapter 4). Counselors should be flexible in designing handling plans to meet client needs and, when appropriate, should draw upon the institutions and resources of clients' cultural communities. Culturally responsive handling planning is accomplished through active listening and should consider client values, beliefs, and expectations. Customer health beliefs and treatment preferences (due east.g., purification ceremonies for Native American clients) should be incorporated in addressing specific presenting issues. Some people seek help for psychological concerns and substance abuse from alternative sources (e.g., clergy, elders, social supports). Others prefer handling programs that use principles and approaches specific to their cultures. Counselors can suggest appropriate traditional treatment resources to supplement clinical treatment activities.

In sum, clinicians need to incorporate culture-based goals and objectives into treatment plans and institute and support open client–counselor dialog to go feedback on the proposed program's relevance. Doing so tin meliorate client appointment in handling services, compliance with treatment planning and recommendations, and handling outcomes.

Group Clinical Supervision Case Report

Beverly is a 34-year-old White American who feels responsible for the tension and dissension in her family unit. Beverly works in the lab of an obstetrics and gynecology practice. Since early childhood, her younger brother has had problems that have been diagnosed differently past various medical and mental health professionals. He takes several medications, including one for attending deficit disorder. Beverly'southward father has been out of piece of work for several months. He is seeing a psychiatrist for low and is on an antidepressant medication. Beverly's female parent feels encumbered past family unit problems and ineffective in dealing with them. Beverly has always helped her parents with their problems, but she now feels bad that she cannot improve their situation. She believes that if she were to work harder and be more astute, she could lessen her family'south distress. She has had trouble sleeping. In the past, she secretly drank in the evenings to relieve her tension and anxiety.

About counselors agree that Beverly is too submissive and recall assertiveness training will help her put her needs first and move out of the family unit abode. However, a female person Asian American counselor sees Beverly's priorities differently, proverb that "a morally responsible daughter is duty-jump to care for her parents." She thinks that the family needs Beverly's help, so it would be selfish to leave them.

Discuss

How does the counselor'south worldview affect prioritizing the client's presenting bug?
How does the counselor's individualistic or collectivistic culture bear upon treatment planning?
How might a counselor approach the initial interview and evaluation to minimize the influence of his or her worldview in the evaluation and treatment planning process?

Sources: The Office of Nursing Practice and Professional Services, Centre for Habit and Mental Health & Kinesthesia of Social Piece of work, University of Toronto 2008; Zhang 1994.

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Source: https://www.ncbi.nlm.nih.gov/books/NBK248423/