This Web site is a component of the SAMHSA Health Information Network

This Site Mental Health at HHS All Mental Health

About the Program Evidence-Based Practices Related Topics Featured Publications In The News Related Links Community Support Homepage  CMHS Programs:   Go to... Children's Campaign Community Support Emergency Services Financing HIV/AIDS Homelessness Managing Anxiety Mental Health Statistics Protection & Advocacy Special Programs State Planning Traumatic Events Suicide Prevention Programs Homepage  CMHS Activities:   Go to... 15+ School Violence Stigma Suicide Prevention Surgeon General

printer friendly page e-mail this page bookmark this page shopping cart  current or new account

This Web site is a component of the SAMHSA Health Information Network.

Community Support

Notes from a Roundtable on Conceptualizing and Measuring Cultural Competence

Recommendations for Four Constructs to be Measured in an Instrument on Cultural Competency of Mental Health Services Delivery

Daniel A. Santisteban, Ph.D. and Frederick L. Newman, Ph.D.
Center for Family Studies
Department of Psychiatry and Behavioral Sciences
University of Miami

December 1998

Introduction¹

The measurement of cultural competence is a complex but critically important endeavor. Without cultural competence, a service delivery system cannot be expected to effectively engage into services, or effectively treat, consumers of different ethnic and racial backgrounds. In developing an instrument that can be used in evaluating a service system's cultural competence, there are a number of domains that should be assessed. First, and at the most basic level, the instrument must assess "overall competence", for example, the extent to which the service system can deliver interventions consistent with a specified treatment model. Second, the instrument must assess the degree to which a system has knowledge of the range of basic values orientations that consumers from diverse cultures may endorse. Third, the instrument must be capable of assessing the service system's knowledge of the life experiences (immigration and acculturation stress, racial prejudice and discrimination, the socio-political standing of the consumer's ethnic group within the host society) that shape the consumer's everyday lives. Finally, the instrument must be capable of measuring the systems ability to engage and treat the consumer with "ease", showing tolerance of and comfort with diversity.

This paper describes our work on these issues and offers specific recommendations for dimensions that should be included in any measure of cultural competence. Although the Round Table Discussion focuses on Adult Mental Health Services, there is much to be learned from taking a family perspective and focusing on the struggles that an adult must go through with spouses, extended family, and with their children, resulting from acculturation and other immigration-related processes. In the special case of ethnic families, where there is an identifiable clash of the family's cultural values with that of the larger community, research findings appear to offer the clearest guides as to how these cultural value dimensions are related to family functioning. Our own work at the University of Miami's Center for Family Studies has been enriched by our efforts to work with families of troubled youth where the cultures and their respective values have been wonderfully diverse (Hispanic, African-American, Caribbean-Non Hispanic, and Caribbean Non-African American). Even within these bold cultural headings, the heading labels do not clearly identify the diversity within each. It is from the experience of confronting this diversity in our treatment and preventive intervention research, that we needed to find a set of guidelines for understanding how cultural values related to family interactions and the family's functioning that would transcend the specific ethnic label, yet inform the intervention approach. Further, in developing new manualized interventions, we were challenged to specify ways in which therapists could be trained to be culturally competent. In the discussion that follows, we describe the dimensions that we use to guide our family intervention services research, along with specific recommendations as to including these in an instrument on a mental health service's cultural competence.

1. Basic competence: Having a solid foundation

One of the most common mistakes in attempting to achieve cultural competence is failing to start from a foundation of technical competence and assuming that a practitioner can be culturally competent while having weak technical skills in the treatment model used. For this reason, it is important to stress that practitioners must be competent in delivering a specified model of treatment before attempting to be culturally competent in extending this model to ethnic individuals or families. The practitioner must know how and when to use certain interventions and when to deviate from the model and add components of other therapeutic approaches. An example of our work with family therapy is that the practitioner must know the destructive nature of runaway negativity in families and therapy sessions (Alexander, Holtzworth?Munroe & Jameson, 1994) and the importance of promoting good conflict resolution (Szapocznik, Rio, Hervis, Mitrani, Kurtines & Faraci,1991). This knowledge and expertise must be attained before attempting to understand the different ways in which this may emerge in ethnic families and how techniques might need take into account special family characteristics of ethnic families such as lower tolerance for negativity and face to face challenges/disputes (Santisteban, Muir-Malcolm, Mitrani & Szapocznik, in press).

Recommended Cultural Competency Construct Regarding Basic Competence in the Treatment Model

Does the service system have the technical expertise to deliver their core treatment model competently? Do they understand the theoretical assumptions on which their models are based?

2. Value Dimensions Directly Relevant to Family Intervention Services

For these reasons, a critical step is to better understand the range of core values and beliefs and how these values/beliefs interact with our work as service delivery systems. It is important to note that while the core values of the ethnic consumer are proximal to the work of the practitioner, the ethnic classification of the consumer is quite distal. We use ethnic classification simply as a proxy to help us predict what is of real importance, namely the individual's world-view in important domains that may predict how ethnic individuals/families perceive problems, seek and accept help, and respond to specific family therapy strategies and interventions.

We have found that the best model for organizing the information on values and beliefs is the values orientations work conducted by Kluckhohn and Strodbeck (1961). Their model identifies the diversity of basic assumptions different people may have, assumptions that are based on shared intergenerational teachings and life-experiences, and which are keys to understanding how different people view the world. Kluckhon and Strodbeck postulated five human problems (Human Nature, Person-Nature, Activity Orientation, Time Orientation, and Relational Orientation) common to all cultures. The solutions provided by each culture to these problems are indicative of world view or basic value orientation. In the remainder of this section we present Kluckhon and Strodbeck's five dimensions and show the profound influences that these differing values orientations can have on core constructs in family intervention science.

2a. The Human Nature dimension pertains to a culture's perception of innate human qualities as good or bad - with a range of a) good, b) bad, or c) neutral. Many western theories take a clear stand on this question, teaching that individual's are good and it is learned behaviors that are bad. In our clinical experience with minority families, we have found that the tendency of parents of some cultures to see their misbehaving children or family member as inherently "bad" or "influenced by evil" is qualitatively different from those who see behavior as bad but perceive the family member as inherently good. Furthermore, the value on this dimension can contribute directly to a core construct in family therapy which is described as the rigidity of Identified Patienthood (Szapocznik, et al, 1991). Identified Patienthood is defined as the extent to which all responsibility for a problem is attributed to one person while other contributions to the problem are dismissed. The degree to which one individual is perceived as "the bad seed" or "the black sheep", may directly determine the extent to which family members are willing to accept the need to change family interactions in order to modify a presenting complaint. In this cases, the assumptions of the therapy model were limited when attempting to understand the family's perspective. It must be acknowledged that failure of the consumer to engage into services or to remain in treatment may be due to the incompatible assumptions that consumers and treatment models have about the etiology of the problem.

2b. The Person-Nature Dimension refers to the perceived relationship of people to natural phenomena - with a range of a) subjugation to nature, b) harmony with nature, and c) mastery over nature. The epitome of Eurocentric Western values is the conquest of the new continent by the Europeans and the conquest of the wild west by "Americans". American "can doism" and perseverance in the face of problems derives from a world view that supports mastery. We must therefore begin by acknowledging that most western models of therapy are founded on the value of mastery over nature (i.e., identifying and changing those characteristics that are problematic). However, many cultures see the role of individuals as accepting rather than conquering nature. Rather than striving to defeat cancer, some may strive to gracefully accept this fate. In therapy the latter group may be less likely to want to harp on problems or talk about how they can "battle" the life situation but on what blocks them from accepting it. This has important implication for working with ethnic families because the clashes of assumptions and the apparent "passivity" that families may show, can easily be labeled as lack of motivation, resistance or dependency. Because family therapy is primarily about mastery (persons changing their condition), it may be perceived by the consumer as antithetical to their preferred belief in acceptance. It should also be noted that from the client perspective, the drive toward battling subjugation may be seen as anti-spiritual because the idea of looking to a higher power may appear to be devalued by the model. Because much has been learned, particularly in working with ethnic minority groups, about the strength of looking to the person's spirituality as a powerful resource (Boyd-Franklin, 1989), the competent therapist must have the ability to meet the family where they are, use the resources the family members have successfully relied on over their lives, and be prepared to discuss this set of assumptions in a respectful manner. Further, the competent clinician must be vigilant to situations in which the family does not follow therapeutic prescriptions because of incompatible beliefs along these dimensions.

2c. The Activity Orientation Dimension refers to the nature of behaviors through which a person is judged or judges herself or himself - with a range of a) doing (i.e., achievement oriented), b) being (i.e., who I am) and c) being in becoming (i.e., a search for understanding about one's self). While doing is an important value in western culture, that is we define ourselves through what we do, in Hispanic culture individuals often define themselves by what family or region they come from (being). In our work with Hispanics we found that discussions of "la preciosidad" inherent in Hispanic values was a key component of many joining maneuvers (Perez-Vidal, A., personal communication,1994). "Preciosidad" refers to the inherent quality of being, of who you are, which gives the individual value that is not attached to what they have achieved. Conversely, achievement oriented parents, often only value their children by what they achieve and not for who they are. One of the potential negative consequences of achievement orientation is that children may learn to value their parents, not for their inherent value, but for what they achieve. This can be particularly destructive among the poor, in which children sometimes de-value their parents for their lack of material achievement. Finally, it should be noted that many of our models of therapy have the goal of bettering the person (promoting growth) by achieving a deeper level of understanding about the self, a concept that may seem alien to persons who do not share the values that would give this type of endeavor its worth.

2d. The Time Orientation Dimension refers to the emphasis placed on a particular time period in one's life - with a range of a) present, b) past, and c) future. An understanding of time orientation of our client has considerable value for the planning of interventions. A therapist implementing a prevention intervention (which is by definition future oriented) may be much more effective when working with a client that has a future orientation rather than with families that are present oriented and focused on "today's" issues. It should be noted that socio-economic conditions may have much to do with a present orientation, such as when a family must struggle to survive day to day. With the present-oriented client, the discussion might be more effective when it focuses on how the intervention will impact current circumstances or difficulties such as important immediate precursors to the main problem to be prevented. For example, it may be more effective to frame an intervention as targeting current behavior problems rather than saying it is designed to prevention future drug use by targeting risk factors. Perhaps because of Confucianism, some far east cultures place great value in the past, in the form of ancestry worship and reverence toward parents and other elders. Native Americans also call up their ancestors to help them deal with life. African Americans are formally embracing their African Ancestry as indicated by the growing number of families celebrating the holiday Kwanza. The principles of Kwanza are based on the African tradition and provide guidelines for healthy families and communities. Consequently, when planning interventions, the role of honoring ancestors or the aversion to dishonoring ancestors, may be integrated into the intervention. These principles have been incorporated into prevention projects for African American youth at risk for substance abuse (Cherry et al., 1998).

2e. The Relational Orientation Dimension refers to the nature of a person's relation to other people -- with a range of a) hierarchical (vertical relationships), b) collateral (i.e. horizontal network) and c) individualistic (i.e., autonomy). Having a hierarchical orientation as opposed to an individual orientation is critical in the extent to which clients will be comfortable with family therapy. Those who view themselves primarily through their connection to family will be most in line with the assumptions of a family model. Problems can be discussed in family terms and it is expected that family will be involved. One of our first clear findings was that Hispanic parents were offended when individually oriented interventions meant that therapists would most often see the youth alone therapists informed parents that due to confidentiality, family participation would be minimal.

The extent to which parents have a markedly hierarchical view of family relations has powerful implications for the process of family therapy. When parents view good family functioning as consisting of marked levels of authority, they can perceive open disagreements between parents and adolescents as disrespectful and unacceptable. One of the critical implications of this world view is that therapy interventions that openly encourage the youngsters to "speak their mind" and "tell parents what they really think" may be seen as incompetent or misguided therapy. The "intervention" may be seen as making the problem worse than it was originally, by encouraging what is perceived to be the dysfunctional behavior (disrespectful challenging). From the point of view of understanding the link between process and outcome, the impact can be profound because the types of family interactions that may be hypothesized to be therapeutic (e.g., direct negotiation and problem solving between adolescents and parents) may not be lead to good outcomes for families who are highly hierarchical.

One of the constructs directly related to a preference for hierarchical relations, is familialism, because of the focus on vertical relationships. Familialism has been an often cited core construct among Hispanics and other ethnic cultures and has been shown to consist of three types of values orientation: 1) perceived obligations toward helping family members, 2) reliance on support from family members, and 3) the use of family members as behavioral and attitudinal referents (Sabogal, Marin, Otero-Sabogal, Marin & Perez-Stable, 1987). When there is a high familialism, it is not uncommon to see individuals motivated to behave in more adaptive ways, by the potential benefit to the family and not merely by the benefit to themselves.

A related and commonly identified pattern among Hispanics is Allocentrism (Hofstede, 1980) which refers to the orientation toward collectivism as opposed to individualism. Allocentrism refers to being connected with, interdependent upon, interested in the well-being of, a particular in-group and not just the self interest of the individual (Marin & Triandis, 1985). A powerful driving force is being in harmony with the in-group and may drive relationships to be less confrontational than an individualistic orientation may generate.

It is important to note that issues of hierarchy are not unique to intrafamily relations. Using the theory of Power-Distance, Hofstede (1980) describes how some societies favor marked power differentials in which some (highly intelligent or educated, high social class, high moral status) may be looked up to and should elicit intense respect, conformity and deference. We have found that this orientation can have a very powerful impact in two key areas. First, families characterized by this orientation often favor hierarchical doctor-patient relationship (expert-patient) in which the doctor tells the patient what to do and the patient complies with little or no questioning. This is not uncommon among many of our Hispanic families but is very different from our experience with African Americans who have a history of being wronged by so called experts, are more skeptical, and may prefer to interact in a more egalitarian fashion. Secondly, when programs include multisystemic interventions that attempt to help parents become partners with the school or juvenile justice systems for the sake of their children involved in these systems. Hispanic parents often look upon these institutions with such a high level of respect and awe that it impedes their sense that parents can and should seek to impact these systems. Research on the optimal doctor patient relationships and on programs that involves modification of interactions between ethnic parents and large institutions, would do well to consider the influence of Hofstede's power-distance orientation in their work.

Adding to the complexity of working with ethnic families is the fact that the original values, beliefs, and behaviors of an ethnic culture do not remain static. Perhaps the greatest challenge to understanding an individual or family, is understanding how these core values change over time. As an individual/family spends time in a host culture that shares a different configuration of values, the values and behaviors of the immigrant will, in most instances, be modified. Acculturation has been defined as "the complex process whereby the behaviors and attitudes of a migrant group change toward the dominant group as a result of exposure to a cultural system that is significantly different" (Rogler, Malgady and Rodriguez, 1989). The natural changing of the original ethnic culture is one big reason why an ethnic label or nation of origin does not tell you all you need to know about the values of the individual consumer.

Recommended Cultural Competency Construct Regarding Values Orientation:

Does the service system consider the nature of a person's Values Orientation along each of the dimensions and understand the compatibility or incompatibility between these sets of assumptions and those of the service delivery system and treatment model? Do they understand the specific ways in which these orientations may affect therapy outcome?

3. Understanding Major Life Experiences that are Keys to Working which Ethnic Families. Not all changes in people's ways of seeing the world result from acculturation. Many ethnic families have major life experiences that directly produce powerful attitudes and beliefs and are crucial to consumer responses to treatment. Among African American families or other black families, a major issue is racial prejudice and the many forms that it takes in daily life. Black families will often be skeptical about a therapists ability to address such powerful and painful issues. Among immigrant families, they may be issues of atrocities and trauma that occurred during the actual immigration process or about the stress of deportation that still exist. Among immigrants it may also be about the stress of acculturation and adjusting to the new society or about the weak "minority" status that they have come to know for the first time in a society that looks down upon them. These powerful life experiences are important to know because the clinician gains credibility by being able to inquire about, understand how these stresses affect daily life, and intelligently and sensitively process these with the client. Work by Jackson (1998), for example, has shown that alliance is improved in the treatment of African American adolescents when issues such as anger/rage/alienation and the journey of boyhood to manhood can be directly processed. Not surprisingly, Sue & Zane (1987) identified "credibility" as a key factor in succeeding with ethnic clients, particularly when the clinician does not belong to the client's ethnic/racial group.

Recommended Cultural Competency Construct Regarding The Family's Major Life Experiences.

Does the service system consider the powerful impact of major life experiences linked to ethnicity/race and can they process these experiences, linking them directly to their intervention?

4. Ease in working with culturally diverse individuals. An important but difficult to measure aspect of working with people of diverse cultures is the ease with which a system interacts with the client. At the practitioner level there are varying degrees to which he/she may feel comfortable, at ease, relaxed, and show flexibility when faced with ethnic diversity and diversity of habits, customs, and forms of expression. At the agency level, there are also varying degrees to which the agency can have flexible operating procedures that make ethnic individuals and families feel at home. This can include such things as the decorations and artwork that hang on walls, the reading material offered to clients, and the accommodations for children for cultures who are very nuclear and extended family oriented and may want to bring children or relatives.

Recommended Cultural Competency Construct Regarding The Ease with which the system works with diverse ethnic characteristics.

Does the service system show ease/comfort in working with people of diverse cultures and do their practices demonstrate that they have made adaptations to meet the expectations of the cultures of their clients?

Conclusions

In this paper we have argued the measurement of cultural competence is a complex but critically important endeavor because without cultural competence, a service delivery system cannot be expected to effectively engage into services, or effectively treat, consumers of different ethnic and racial backgrounds. We have also outlined four constructs that should be included in any measure of cultural competence: 1) Overall Competence, 2) Understanding of basic values orientations endorsed by consumers of diverse cultures, 3) Knowledge of the major life experiences (immigration and acculturation stress, racial prejudice and discrimination, the socio-political standing of the consumer's ethnic group within the host society) that shape the consumer's everyday lives, and 4) the "ease" with which practitioners and systems work with people of diverse ethnicity. Throughout we have attempted to explain how it is that these important dimensions interact with efficacy of treatment.

Table 1
Recommendations of Four Constructs To Be Measured
In an Instrument on a MH Service's Cultural Competency

1. Recommended Cultural Competency Construct Regarding Basic Competence in the Treatment Model: Does the service system have the technical expertise to deliver their core treatment model competently? Do they understand the theoretical assumptions on which their models are based?

2. Recommended Cultural Competency Construct Regarding Values Orientations: Does the service system consider the nature of a person's Values Orientation along each of the dimensions (Human Nature, Person-Nature, Activity Orientation, Time Orientation, and Relational Orientation) and understand the compatibility or incompatibility between these sets of assumptions and those of the service delivery system and treatment model? Do they understand the specific ways in which these orientations may affect therapy outcome?

3. Recommended Cultural Competency Construct Regarding The Family's Major Life Experiences: Does the service system consider the powerful impact of major life experiences linked to ethnicity/race and can they process these experiences, linking them directly to their intervention?

4. Recommended Cultural Competency Construct Regarding The Ease with Which the System Works with Diverse Ethnic Characteristics: Does the service system show ease/comfort in working with people of diverse cultures and do their practices demonstrate that they have made adaptations to meet the expectations of the cultures of their clients?

¹ Paper prepared for the Round Table Discussion sponsored by the Multicultural Mental Health Research Center (of the Western Interstate Commission for Higher Education, WICHE) and The Evaluation Center@HSRI, December 16-17, 1998. The paper was adapted from a chapter by Daniel A. Santisteban and colleagues to appear in the book edited by Howard Liddle, Daniel A. Santisteban, Ronald Levant, & James Bray on Family Intervention Science. Joan Muir-Malcolm, Victoria Mitrani, and José Szapocznik also contributed to this paper.

References

Alexander, J.F., Holtzworth?Munroe, A., & Jameson, P.B. (1994). The process and outcome of marital and family therapy: Research review and evaluation. In A.E. Bergin, & S.L. Garfield (Eds.), Handbook of Psychotherapy and Behavior Change. New York: N.Y: John Wiley and Sons, Inc.

Boyd-Franklin, N. (1989). Black Families in Therapy. New York, NY: Guilford Press.

Cherry, V., Belgrave, F., Jones, W., Kofi Kennon, D. & Phillips, F. (1998). NTU: An Afrocentric approach to substance abuse prevention among African-American youth. Journal of Primary Prevention, 18, 319-339.

Hofstede, G. (1980). Culture's Consequences: International Differences in Work related Values. Beverly Hills, CA: Sage Publications.

Jackson, A. (1998). The relationship of cultural theme discussion to engagement with acting out African American male adolescents in family therapy. Unpublished doctoral dissertation, University of Miami.

Kluckhohn, F. R. & Strodtbeck, F. L (1961). Variations in Value Orientations. Evanston, IL: Row, Peterson.

Marin, G. & Marin, B. V. (1991). Research With Hispanic Populations. Newbury Park, CA: Sage Publications.

Marin, G., & Triandis, H.C. (1985) Allocentrism as an important characteristic of the behavior of Latin American and Hispanics. In R. Diaz-Guerrero (Ed.), Cross-cultural and National Studies in Social Psychology (pp.85-104). Amsterdam:Elsevier Science Publishers.

Rogler, L.H., Malgady, R.G., & Rodriguez, O. (1989). Hispanics and Mental Health: A Framework for Research. Malabar, FL: Krieger

Sabogal, F., Marin, G., Otero-Sabogal, R., Marin, B.V. & Perez-Stable, E. J. (1987). Hispanic familism and acculturation: What changes and what doesn't?. Hispanic Journal of Behavioral Sciences, 9, 397-412.

Santisteban, D., Muir-Malcom, J., Mitrani, V. B. & Szapocznik, J. (In preparation). Integrating the study of ethnic culture and family psychology intervention science.

Sue, S. & Zane, N. (1987). The role of culture and cultural techniques in psychotherapy: A critique and reformulation. American Psychologist, 42, 37-45.

Szapocznik, J., Rio, A.T., Hervis, O.E., Mitrani, V.B., Kurtines, W.M. & Faraci, A.M. (1991). Assessing change in family functioning as a result of treatment: The Structural Family Systems Rating Scale (SFSR). Journal of Marital and Family Therapy, 17 (3), 295-310.

Table of Contents | Previous | Next