Community Support

Notes from a Roundtable on Conceptualizing and Measuring Cultural Competence

Appendix C: Defining and Measuring Cultural Competence in the Evaluation of Mental Health Services

Lee Sechrest, Ph.D. and Michele Walsh
Evaluation Group for the Analysis of Data (EGAD)
University of Arizona

December 1998

Race, Ethnicity, and Culture

It is necessary to make distinctions between race, ethnicity, and culture, in order both to define cultural competence and to devise methods of bringing it about. Problems abound in the inconsistent ways the terms are used; all three are useful, but they should not be thought interchangeable.

Race is best confined to uses indicative of biological implications of genetic origin. We do not have to take any stance one way or the other about the ultimate scientific legitimacy of the idea of race, but it is useful to mark those occasions when genetic variations are intended. Race does enter into the operations of mental health service systems at times, perhaps not always in the ways intended. For example, pressures for diversity in staffing of organizations are almost always couched in terms of race (more blacks, more Asians) or pseudo-race (more Hispanics).

Ethnicity is a useful term when it refers to sense of identity with or belongingness in relation to some social group. Some black (race) persons may be of Hispanic ethnicity, and some persons with Hispanic surnames (quasi-race) may have only a weak sense of being Hispanic (ethnicity). Ethnicity is often very important for political purposes as it enables the establishing of bonds between persons that are useful for achieving power and political aims. We think that ethnicity as a concept may be extended to cover some identifications beyond those represented by racial, geographic, and linguistic characteristics, the more usual bases for ethnic identification. For example, Page (1993) notes that deaf Hispanics in New Mexico appear to have a much stronger view of themselves as deaf than as Hispanic. It is important to recognize that ethnicity may be assigned as well as adopted. Thus, a person may be regarded by others as a member of some ethnocultural group even though the person may not at all so regard him or herself.

Culture, then, refers to a complex and interrelated set of forces operating on individuals so as to direct their energies and responses along certain lines of thought and action from among the myriad possibilities. Culture is learned and may be thought of generally as the way of life of a group of people with some common and enduring bond among them. Race is not culture, nor is ethnicity. People with highly similar racial background or a common ethnic identification may represent quite different cultures. Some black persons (race) with a strong black identification (ethnicity) may, nonetheless, have much more in common culturally with a white group, say upper middle-class, than with other black groups, e.g., inner-city black culture.

It may be very difficult to specify in particular cases just what is meant by cultural competence, in part because there may be confusion about exactly what is meant by "culture." For example, some investigations have shown that racial-ethnic "matching" of clients and service providers may produce outcomes different from those with unmatched pairs. It seems unlikely that racial (biological) matching could have any effect on characteristics of service encounters. Ethnicity could be important, however, if clients feel more comfortable with someone "of their own kind," and, therefore, respond differently than with persons not having the same identity. It should be clear, however, that even in that case, it would be possible that a client might feel an ethnic affinity that did not exist if the service provider, in fact, had no particular allegiance to the ethnic group of the client. Culture, on the other hand, might be the important determinant of the encounter if the latter depended on a particular understanding of some feature of the client's way of life. If culture were the critical factor in matched interactions, then it should not matter whether the matching reflected racial or ethnic characteristics. Cultural competence cannot substitute for ethnic identity, but the latter may not always be a good cue to culture.

Defining Cultural Competency

It is likely to be difficult to distinguish cultural competency from general sensitivity to individual differences. Any given person or group has multiple "social addresses" (Bronfenbrenner, 1986). Which of those identities will be salient or important at any given time will be dependent on the particular circumstances or context of a situation or interaction. Thus, a person might be culturally sophisticated but not in the way made regnant by a particular interaction. For example, a black, female, small business owner might not be helped at all by being "matched" to a black, male service provider from a working class background. In addition to black ethnicity, it might be that sex, socio-economic status, or business orientation might be important in the example described. In our own work with male veterans, it is veteran identity rather than ethnic identity (Hispancity) that seems to be the more important "ethnic" identification.

Having said that, there is value in being sensitive to the specific needs, values and experiences of ethnically and culturally diverse clients. What may be required is not so much specific cultural knowledge as a developed sensitivity to and tolerance for the fact that people are different in many interesting ways, some of which are moderately predictable from group characteristics (social addresses). If that is so, then training for cultural competence may be better if it is broadly conceived and directed rather than oriented to the acquisition of specific knowledge about cultural habits and traditions. Even if it is believed that specific training in culture is desirable, cultural competence needs to include awareness of the possibility that for any given person at any given time, one or more of many social identities may be more important than what is usually termed culture.

Incorporating cultural values in programs may increase the credibility and perceived relevance of those programs for some participants (Terrell, 1993). Potential increases in "self-esteem and ethnocultural pride" may be particularly important for groups that face discrimination and negative stereotyping. We thought it interesting in our work with Hispanic veterans that they were greatly pleased with printed materials in Spanish even though none of them chose to use the Spanish versions. Again, cultural competence may be manifested more in terms of general sensitivity than specific knowledge or skills.

Cultural competence requires a thorough understanding of the local population being served by an organization and ascertainment of what cultural factors are likely to be at issue. It is not likely that cultural competence can be broadly "manualized." For example, we are acquainted with one American Indian case manager who presents to her co-workers a slide show demonstrating the living conditions of veterans on the reservation and practical considerations limiting access to services. Providing effective mental health services requires developing a unique and complex relationship with each client. Replacing individual evaluations with group-based generalizations can be limiting and promote stereotyping. Lopez and his colleagues (Lopez, Blachar, & Shapiro, in press) have referred to group-based generalizations as the "cultural elements" approach, in which cultural elements are assumed to correlate highly with reports of ethnicity. Yet ethnic groups are by no means homogenous and treating them as such is rarely justified. The empirical evidence for such an approach is weak (Lopez, et al., in press; Phinney, 1996) and may promote fixed, stereotypic views of ethnic groups (Lopez, et al., in press).

Cultural Issues in Overall Quality of Care

A number of factors involving cultural issues may be identified as important to consider in the assessment of the overall quality of care delivery (adapted from WICHE/ AHCPR, 1998; Terrell, 1993).

Language barriers are the most obvious potential impediment to the delivery of good quality mental health services, which depend far more than other health services on accurate understanding of nuances of feelings, values, preferences, and so on. Yet, we are reluctant to designate language competence as a critical feature of cultural competence. One reason is that language facility is to a great extent a fairly straightforward technical skill. Surely the ability to communicate accurately and efficiently should be taken for granted in the delivery of mental health services. Moreover, when language barriers do exist, they are, probably unlike many other cultural barriers, likely to be fairly evident to one or both parties to a transaction so that they can be allowed for. Nonetheless, persons working in mental health service arenas should take care to prepare themselves by acquiring the vocabulary necessary for effective communications, including becoming informed about intricacies of meaning that may be peculiar to particular cultural settings.

Communication expectations have to do with cultural patterns related to the conditions under which communications are undertaken and their preferred forms. For example, it is the current widely accepted practice in the United States to affect a kind and degree of familiarity in interactions, especially by use of informal forms of address such as first names, that is unsuitable, perhaps even offensive in other cultures. On the other hand, professionals are often so accustomed to having legitimacy and authority of their advice taken for granted that they may be disinclined to engage in explanation or justification and may seem presumptuously abrupt.

Health care beliefs and practices are culturally determined, and those of any given subcultural group may or may not be consonant with those of the broader, "science-oriented" society. If a cultural group from which a patient comes is known to believe that mental illness is the result of spirit possession, it is important for clinical personnel working with that patient to know of that belief, but it is also essential that they come to terms with the belief and devise ways of providing effective intervention in light of a belief that they themselves may reject. Mental disorder may be much more stigmatized in some cultures than in others, and understanding both the stigma and how to deal with it in treatment may not be a simple matter. A notable example is the stigma that attaches to mental disorder in the police community. That stigma requires special concern for confidentiality and may even rule out the use of civilian mental health services. When clinical personnel must deal with behaviors that are accepted in another culture but "intolerable" in their own, the limits of cultural competence may be encountered. Cultural competence is often be manifest in the ability of clinicians to engage patients on their own terms and still be effective. Building that sort of competence into organizations is a challenge.

Family organization and relational roles also vary across cultural and subcultural groups and may result in differences in the ways in which mental health services can or ought to be carried out. For example, some cultures may have family systems characterized by patriarchal or matriarchal rule that require elaborate consultations before any decisions are made. Some mental health service providers have been surprised to discover cultural expectations that entire families be present at interviews or treatment sessions. Variations in the ways in which in-law relations are treated are very large.

Sources of stress and coping skills are also important and differ between groups. Both may reflect ethnic as well as cultural differences. For example, discrimination, inadequate employment and educational opportunities, poverty, and a pervasive sense of powerlessness may stem from ethnic identity (Terrell,1993), perhaps even if ethnicity is ascribed to a person rather than being adopted. It is critically important to recognize, however, that two persons of the same apparent racial and ethnic background may differ substantially in, for example, the sense of having suffered from discrimination. Ethnic identification may, of course, also be a source of strengths, e.g., from engendering a sense of social support and belonging.

Coping mechanisms may be fostered by some cultural features or suppressed by others. The approaches taken in mental health services facilities need to be sensitive to the characteristics of the cultures of clients. For example, training in assertiveness should be based on a sense of community and respect for others' experiences to be culturally appropriate for American Indians, who may not share the dominant culture's emphasis on individualism (Terrell, 1993). Enhancing social support resources in clients should also take into account variations in sources of support for different ethnic communities. Some cultures encourage turning to other family members for help rather than seeking treatment from outside the family, let alone from strangers.

Measuring the Facets of Ethnicity and Culture

No characteristic or facet of ethnicity or culture is an invariable consequence of either. In fact, many of the relationships are of modest size, reflecting the fact that nearly all persons are members of numerous subsets or groups and, hence, subject to widely varying influences. It follows, then, that if we are to take account of ethnicity and culture, including assessing competence of service providers to deal with them, we need to undertake the daunting task of identifying the critical variables and locating or developing measures of them. The foregoing list of ethnic and cultural features is a beginning place for initiating a focus on quantifying their effects, but only a beginning place. We wish to emphasize that the measures we list later for potential use in ethnic and cultural studies is only a beginning point.

Theory to guide the understanding of ethnic and cultural factors is underdeveloped. That is especially so if we try to specify the factors that will be central to the development and delivery of effective mental health programs. At present a basis does not exist for anticipating the ethnic and cultural barriers to or facilitators of effective service delivery programs. Consequently, it will be difficult to propose with much confidence any culturally specific mechanisms or programs aimed at preventing or treating the wide array of troubling behavioral and mental disorders.

Mental Health Delivery Systems and Cultural Competence

Attempts at improving the effectiveness of mental health services through increasing cultural competence may address the characteristics of individual providers, settings, or systems. For example, individual providers may be trained to listen for certain cultural themes during early contacts with clients, settings may adjust their ways of operating, such as hours open, to meet the needs of different cultural groups, and systems may adapt their service philosophies so as to become more hospitable, e.g., by coordinating efforts with those of native healers or taking account of family structures.

Many different aspects of service facilities and systems may be the focus of efforts to improve cultural competence. Some of the more important include the following:

Organization of Services
  Access
    Barriers to access
    Structure
    Efficiency (carved out)

Delivery of Services
  Utilization
    Level of service use
    Appropriateness of use
    Drop out rates
  Quality
    Satisfaction with services
    Duration and termination
    Perception of counselor effectiveness
  Effectiveness
    Outcomes (noncompliance, self-esteem, inferiority
    or personal inadequacy, anxiety, perceived discrimination)
  Financing
    Cost containment (co-payments, high deductible amounts, limits on services covered)

Organizational Issues
  Efficiency
  Building structure
  Team diagnosis
  Centralized (versus decentralized)
  Personnel substitution

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