ADDRESSING

1. ADDRESSING Culturally Competent Clinical Interviews

2. “It is said that we are spirits on a human journey. In this journey, health and well-being are a result of the complex interplay between the physical world (i.e., our bodies), our mental processes (our thoughts and emotions), our environment (our family, culture, etc.), and the spiritual forces outside of us and the spiritual learned practices that become part of us. This perspective is sometimes referred to as the relational world view.” Terry Cross (1998, p. 1). Spirituality & Mental Health: A Native American Perspective. Focal Point, 15(2), pp. 1-4.

3. Caveats • What I have to Offer • Educator/practitioner • My perspective is limited by my sociopolitical location • Am engaged in learning • Will make mistakes • Please remind me about strengths!

4. Integrate Diversity • From now on I expect you to integrate diversity more thoroughly into assessment & service planning, especially: • With clients who don’t have an immediate awareness of their “culture” or do not see its relevance • Without stereotyping clients • By going beyond race/ethnicity & religion & “cultural preferences” as dimensions of diversity

5. Cultural Competence More Than Cultural Preferences

6. Multiple Dimensions of Cultural Competence Skills Context Context Relationship Awareness Knowledge

7. Culture & Assessment

8. Historical & Modern Context for Assessment & Service Planning • Clients strengths/challenges related to: • Local, State, National, & Global Events • Oppression • Privilege • Accessibility of services • Stigma

9. Identity & Identity Development in Context • The importance of names • Honoring identities (allowing for self-definition) • Intersectionality of identity • Expression of identity context-dependent

10. Asking Good Questions(Hays, 2001) • Establish respect and rapport (respeto) • Use knowledge/experience to formulate questions & hypotheses • Framing open-ended questions • Providing a client-centered rationale • Using your knowledge of client’s culture • Using the client’s language • Using self-disclosure (personalismo)

11. ADDRESSING Cultural Complexities in Practice

12. Cultural Complexities Appear as: • Internalized beliefs & attitudes • External resources & barriers • Behaviors • Decisions • Actions and… Feelings/emotions!

13. ADDRESSING Framework(Hays, 2001) • Age & generational influences • Developmental disabilities & acquired • Disabilities • Religion & Spiritual Orientation • Ethnicity • Socioeconomic Status • Sexual Orientation • Indigenous Heritage • National Origin • Gender

14. Age & Generational Influences

15. Age & Generational Influences • Intergenerational resources • Intergenerational conflict • Suicide risks vary by age (related to developmental crises, exacerbated by substance abuse, psychopathology, & social isolation) • Timeline

16. Developmental & Acquired Disabilities

17. Developmental & Acquired Disabilities(Olkin, 2002) • 15% of U.S. population are people with disabilities • 66% of people with disabilities unemployed • Largest minority group [hidden] in U.S. • Topic of disability neglected by graduate programs • If offered, focus on medical model

18. Experience prejudice, stigma, oppression Experience barriers to accessing services Not automatically included – marginalized by majority group Underrepresented Underserved Have to “appear happy & grateful” Separate may be equal Often the only one in their family (like LGB) Non-adaptive environment at home Often include pain, fatigue, and muscle weakness Often require adaptive equipment etc. Costly Disability a Minority Status (Olkin, 2002)Similarities Dissimilarities

19. Developmental & Acquired Disabilities: Three Models(Olkin, 2002, p. 133) • Moral Model (most common worldwide) • Disability: • Is a defect, result of immorality, a test of faith, a curse • Elicits shame in the person and the family • “God gives us only what we can bear” “Things like this only happen for a reason” “What did I do to serve this?”

20. (Olkin, 2002, p. 133) • Implications of Moral Model: • Acceptance of disability on spiritual grounds • May embrace a greater sense of purpose in relation to the disability • May assume a special relationship with God • May experience acute shame and ostracization • May hide the disability or the person with the disability

21. (Olkin, 2002, p. 133) • Medical Model (Most common model in U.S.) • Disability is • A physical defect or failure • Result of pathology • Result of poor health, bad habits, unhealthy behavior • Patients treated as their diagnosis

22. (Olkin, 2002, p. 133) • Implications of Medical Model: • Receive treatment and get “cure” or “relief” • Reduced shame or stigma • Trust in medical interventions • Surge in medical research • Paternalism and marginalization • Services provided to, but not by people with disabilities

23. (Olkin, 2002, p. 133) • Social Model(empowerment model) • Disability • Is a social construct • Problems in the environment NOT the person • Negative effects from oppression & stigma • 1970’s “reframe” part of consumer rights movement - “Nothing about us without us”

24. (Olkin, 2002, p. 133) • Implications of Social Model: • Increased access and influence on policy, politics, economics, rights, and protections • Integration of disability with sense identity • Pride in oneself and in membership with disability community • De-pathologizes disability • Social construct seems immutable • Hard to change entrenched attitudes

25. Public Stigma Blocks acquisition of good jobs & housing Criminalizes mental illness Barrier to health care Lack of parity for insurance benefits Avoidance of services & reduced compliance Self-Stigma Internalized prejudice Reduced self-esteem Diminished self-efficacy Shame Family shame Culturally mediated Avoidance of services & reduced compliance Stigma of Mental Illness Causes Harm(Corrigan, 2004)

26. Religion & Spiritual Orientation

27. Religions are organized beliefs systems & include: Institutionalized moral values Beliefs about God Involvement in a religious community Spirituality is an overarching construct & involves: Personal beliefs about the ultimate human condition or a supreme being or unity of nature & universe A set of values Can be found inside or outside of formal religion Religion & Spiritual Orientation(Walsh, 1998, p. 64)

28. Sources of Resilience:(Walsh, 1998) • Strength found in sense of community & collaboration • Meaning attributed to adversity • Sense of Coherence • Pathways to Integration • Hope • Initiative & invention • Perseverance • Encouragement & Confidence • Humor • Transcendent Beliefs • Values & Purpose • Religion & Spirituality

29. Religion & Spiritual OrientationDalai Lamai (1998, p. 15) “Religions are like medicine in that the important thing is to cure human suffering. In the practice of medicine, it is not a question of how expensive the medicine is; what is important is to cure the illness in a particular patient. Similarly, you see, there is a variety of religions with their different philosophies and traditions. The aim is to cures the pains and unhappiness of the human mind. Here too, it is not a question of which religion is superior as such. The question is which will cure a particular person.”

30. Every Religion has a Gift “Every religion has a specific gift to offer humankind; every religion brings with it a unique viewpoint which enriches the world. Christianity stresses love and sacrifice; Judaism, the value of spiritual wisdom & tradition. Islam emphasizes universal brotherhood and equality while Buddhism advocates compassion & mindfulness. The Native American tradition teaches reverence for the earth and the natural world surrounding us. Vedanta or the Hindu tradition stresses the oneness of existence and the need for direct mystical experience” (Vrajaprana, 1999, p. 56).

31. Ethnicity

32. Ethnicity(Casas, 1995; Phinney, 1990) • Group of persons who share a unique social and cultural heritage. • Ethnic identity varies along the three dimensions: • Cultural norms & values • Strength, salience, & meaning of cultural identity • Experiences & attitudes associated with minority & majority status in U.S. culture

33. Ethnic/Cultural Guideposts • Family life cycle • Definition of family • Roles • Parenting practices • How decisions made • Human development (consider Erikson) • Rituals/markers/milestones • Attitudes toward change • Work Life • definitions of success

34. Ethnic/Cultural Guideposts • Meaning & causes of • Health/wellness • Illness/mental illness • Familiarity with behavioral health services/psychotherapy • Resources • Coping • Kinship Networks • Natural helpers • Racial/Cultural Identity Development • White Racial Identity Development • Biracial Identity Development

35. Ethnic/Cultural Guideposts • Immigration history (legal status) • Acculturation/acculturative Stress • Linguistic capabilities & preferences • Experiences of oppression • Coping with racism, sexism, ableism, anti-Semitism, heterosexism

36. Ethnic/Cultural Guideposts • Values • Collectivism/Individualism • Self-directedness/fatalism • Duty • Respect • Existential themes • Purpose/meaningfulness • Isolation • Loss/Death

37. Acculturation(Falicov, 1998, p. 39) • Individuals gradually lose their culture of origin as they adopt values & behavior of new culture • May experience marginalization by host culture • Leads to ACCULTURATIVE STRESS • Identity conflicts, changing values, linguistic differences • Produces secondary conflict

38. AcculturationBerry (1980) • Assimilation • relinquish ones beliefs & assume beliefs & attitudes of majority group • Separation • Withdraw from dominant culture • Marginalization • Cannot identify with own group or majority culture • Integration (healthiest) • Ethnic identity and dominant culture integrated

39. According to Janet Helms, “task for people of color is to resist negative societal messages and develop an empowered sense of self in the face of a racist society…” “…the task for Whites is to develop a positive White identity based on reality and not on assumed superiority” Identity Development(Tatum, 1997, p. 94)

40. Racial/Cultural Identity Developmental Tasks • Move from a White frame of reference to a positive [racial/cultural] frame of reference (Cross, 1971). • Move towards greater acceptance of one’s culture and ethnicity (Ruiz, 1990). • Commitment to eliminating all forms of oppression.

41. White Racial Identity Development • Two Developmental Tasks: • Abandon individual racism • Recognize and oppose institutional and cultural racism.

42. Biracial Identity Development A complicated process in a racially bifurcated society

43. Strategies for Resolution of Bi-Racial Identity • Acceptance of identity society assigns • Identification with both racial groups • Identification with a single racial group • Identification with a new racial group

44. Socioeconomic Status

45. Socioeconomic Status • More than educational attainment, income, or occupational prestige • Reflects access to • Resources • Societal control, & influence • Social valuation identity (class consciousness) • More powerful predictor of worldview than family structure, race, religion, national origin, income, or subjective class status

46. Poverty associated with: • Poor health • Impaired productivity • Substandard physical environment • Increased stress and diminished emotional well-being • Family conflict & marital strife • Shame & stress (Dr. Steven Bezruchka, 2003) • Class warfare - “There is a war going on right now and it is the rich who are attacking everybody else.” • Wealth brings freedom form stress and many more choices • Culture of poverty and culture of inequality effects health

47. Sexual Orientation

48. Sexual Orientation “an enduring emotional, romantic, sexual or affectional attraction to [(an)other person(s)] … that ranges from exclusively homosexual to exclusively heterosexual & includes various forms of bisexuality” (APA, 1998).

49. Sexual Orientation Identity Development(Worthington, et al., 2002) Sexual orientation identity development is a term that describes the process of accepting and recognizing one’s own sexual identity, typically as straight, gay, lesbian, or bi-.

50. Heterosexual Identity Development(Worthington et al., 2002) • Influenced by: • Biology • Gender norms & socialization • Religious orientation • Microsocial context (one’s social circle) • Culture (including events) • Systemic homonegativity, sexual prejudice, & privilege