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THE
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Diversity Wheel
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Self Awareness
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When
meeting with professionals,
clients bring with them their values and
ideas based on their personal histories.
Even though two individuals may share a
cultural identity, other factors may cause
them to respond differently to the same
situation. To illustrate this point, a member of our CRAFT team is a Jewish
woman from a small town in the eastern
United States. She had a friend who
attended the same elementary school,
worshipped at the same synagogue, and
whose family was from the same economic group. Their physical appearance was
similar, they wore similar clothes, and had
the same accents. The significant difference between these girls was that one was
from a family that was first generation in
the United States having survived World
War II in Europe. The other girl was second generation; her parents were born in
this country. This fact shaped how the
families of both of these girls responded to
many life decisions including trust in the
government, familial relationships, and
faith in future endeavors. In this instance,
invisible differences shaped and differentiated two girls who were otherwise very
similar.
In looking at what creates the uniqueness of individuals, it would be inaccurate
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REFERENCES
Like, R. C, 1991. Culturally Sensitive Health Care
Recommendations
for Family Practice Training.
Family Medicine. 23(3),180-181.
Marvel, M.K., Grow, M., & Morphew, P., 1993. Integrating Family and Culture into Medicine: A Family
Systems Block Rotation. Family Medicine. 25(7),
441-442.
Nkongho, N.O., 1992. Teaching Health Professionals
Transcultural
6(3),29-33.
Pahnos, M.L, 1992. The Continuing Challenge of Multicultural Health Education. Journal of School Health.
62(1),24-26.
Pope-Davis, D.B., Prieto, LR., Whitaker, CM., & PopeDavis, S.A., 1993. Exploring Multicultural Competencies for Occupational Therapists: Implications for
Education and Training. The American Journal of
Occupational
by
OiJlersity
Wheel
Conclusion
""
WOrking
successfully with clients/
families requires a family focused
approach which includes being culturally
sensitive and having a heightened awareness of diversity. Having culture specific
information is only a small part of
developing an alliance with clients and
families. Understanding the concept of
diversity is an ongoing, evolving process.
This process includes understanding
self, understanding the uniqueness of the
client/families, and finding a meeting
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Sensitivity. The provider acknowledges differences and tries to address them
by adopting external or formal cultural
expressions and presenting the standard
intervention within these parameters.
Cultural sensitivity usually is limited to
the use of the client's language and literacy level, and limited deference to major
taboos.
Whenever
a provider and a client from
different cultures meet, the former manifests a cultural attitude and the latter
exhibits some reaction. I will briefly
examine what these cultural attitudes are,
and how they may determine to a great
extent the reaction that the client exhibits.
I will use a model of cross-cultural attitudes and client reactions that range, on
the one hand, from superiority to cultural
competence, and on the other from resistance to adaptation.
Because in our society the provider
usually controls important aspects of the
service relationship, including site, environment, time of initiation, duration, and
type of intervention, the cross-cultural
attitude of the provider sets the tone for
the relationship. Possible cross-cultural
attitudes include:
.
Superiority. The provider considers
the client's culture inferior or worthless,
and actively tries to impose his/her values
and world-view. The intervention attempts
to effectively dismiss the client's values
and replace them as a pre-condition for a
service relationship.
.
Incapacity. The provider acknowledges differences, but has no skills or
tools to address them effectively, and
therefore proceeds with a standard intervention based on dominant cultural
values.
.
Competence. The provider identifies,
respects, incorporates and maintains the
values of the client in the design, delivery
and evaluation of the service. The intervention is client-centered, as the provider
listens actively, elicits the client's worldview, acknowledges the differences and
similarities, recommends approaches congruent with the client's values, and negotiates their implementation or adaptation.
t)
Faced with one of these cultural attitudes, clients from a non-dominant culture
might exhibit one of the following reactions:
.
Resistance. Clients refuse to participate in the intervention, are unresponsive,
and may exhibit either hostility or passivity. In some cases, clients will purposely
minimize their understanding of the
provider's language.
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TheLIVE& LEARNModel
I n the LIVE and LEARN Model, each
letter of the acronym stands for an attitude, strategy or activity that providers can
adopt to foster positive interactions with
their clients. This model has been culled
from the accumulated wisdom of diverse
sociologists, psychologists, social workers, interpreters, medical providers (most
notably P.S. Adler, H.A. Bulhan, R. Cashman, A. Castaneda, L. Comas-Diaz, G.
Marin, J. Pares-Avila, M. Ramirez and T.
Tafoya), and the practical experiences of
the staff of the Latino Health Institute of
Massachusetts, which serves more than
10,000 clients through approximately 40
different programs, most of which are
offered through its Family Services
Division.
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Adaptation. Clients maintain their
values, attitudes and behaviors, adapting
them to new circumstances, while simultaneously adopting skills and strategies that
allow them to function effectively in the
dominant culture.
Cultural superiority allows for either
resistance or accommodation, but largely
elicits the latter. Incapacity and universality often are met with resistance or accommodation as well, although these attitudes
do not actively lead to the obliteration of
the client's culture. Cultural sensitivity is
met by clients with the entire spectrum of
reaction. When the intervention is so
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ments of our profession (i.e., mandated reporter) can lead us to use some
objective standards of behavior that
conflict with the stated client value
(i.e., harsh disciplining methods).
R is for Recommend. In addressing any
issue, there always are several possible
approaches, even though some may be
preferable to others. It is best to
describe for the client, while matching
their communication style, the entire
range of options and the consequences
associated with them. For this purpose,
we can i]]ustrate for the client several
approaches, from the least desirable to
the most desirable, and inquire from
them which approach seems to make
most sense, given their present situation and resources. This strategy wi]]
prevent us from recommending
impractical solutions, to which clients
may agree out of deference, but which
they have no intention, or insufficient
resources, to implement.
N is for Negotiate. Because, in most
cases, our interventions seek some
form of behavior modification, it is
important to reach an agreementpreferably in the form of a contractbetween the client and the provider as
to which option(s) will be put into
practice, what measures wi]] be jointly
used to monitor progress, and the
timeline for implementation. Should
the client agree to an option that is not
considered tota]]y appropriate by the
provider, negotiation might also
include a timeline for adoption of
more desirable options in the future.
Important Considerations When
Using the LIVE & LEARNModel
When
initiating work with persons
from diverse cultural orientations, standard assessment procedures should be
used in gathering data. Making assumptions solely on the basis of ethnicity is
both inaccurate and inappropriate. However, there are several critical areas that must
be explored in order to insure the gathering of a thorough psychosocial and developmental history that may result in accurate formulation and service planning.
.nant Time.
Some persons with non-domicultural orientations have flexible
understandings of punctuality and aversion to a hurried pace, especia]]y within
the context of their expectation of close
social relations. Thus, emphasis on saving
time versus being cordial is viewed as
rudeness rather than efficiency.
.
Personal Space. Some persons with
non-dominant cultural orientations require
less personal space than those with EuroAmerican orientations. Additionally, some
persons with other cultural orientations
tend to touch more frequently, and handshaking, hugging, knee- and backslapping,
rib-nudging and cheek-kissing are frequently observed.
.
Country of Origin. A first consideration is the client's country of origin. In the
case of foreign-born persons with nondominant cultural orientations, it is important to explore the client's migration history. In the case of U.S.-born persons with
non-dominant cultural orientations, a similar migration history should be obtained
regarding the client's family, including a
determination of how many generations
ago the move occurred. Furthermore, the
provider should explore the client's experiences in the U.S. relative to discrimination and/or racism.
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EXCELLENCE
()
ACTION
IN
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DARTTeam Members
PEP'S
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service systems. For example, the importance of the simple request by an AfricanAmerican client to "have her hair done"
before entering a residential treatment
center is understood and facilitated by
DART members. The request is culturally
significant and, once given the attention
needed, is removed as a barrier to the
recovery process.
DART team members also serve as
role models for clients. They are seen as
"scouts" who travel successfully outside
of the neighborhood, bringing their clients
information, ideas and resources necessary
to assist clients in the recovery process.
They stimulate participant interest in substance abuse rehabilitation and drug-free
life styles. Through models set by team
members, client participants begin to feel
that they, too, can achieve sobriety and
learn life management skills similar to
those exhibited by the recovering "sisters"
on the DART team. The following case
example illustrates the valuable contributions of indigenous counselors.
Staci, a PEPClient
DARTMembers as Team Players
Staci came to the PEP program in 1995,
addicted to both alcohol and crack. From
1988-1995, Staci exchanged sex for money or drugs to support her habits. Staci
reported being in jail for one year on an
assault and battery charge that she says
was directly related to her addictions.
Staci has six children, three of whom
were prenatally exposed to drugs and
alcohol. She is currently receiving AFDC,
food stamps, Medicaid and Section 8
Housing. She is unemployed and has been
for 15 years due to her alcoholism and
drug addictions.
Staci says that she needed the DART
team members to help her realize that she
could actually get clean and sober and stay
that way. This message was conveyed in
an experiential manner; she knew one of
the DART members because she had
used drugs with her in the past. Staci says
that this same woman came to her house
and became an example to her, and that
the transformation she saw in her former
D ART members
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ity as well as other demographic characteristics that often interact with culture, e.g.,
gender, age, socioeconomic status, and
urbanicity. Relating these characteristics
to the geographic region being served
sheds light on factors that influence service delivery, e.g., the proximity of the
population to natural stressors and physical access to services. If there are significant culturally diverse populations, it is
. Is effective cultural competence training available for statl and how does it
impact program philosophy?
. How does program philosophy compare and interact with the cultural values
of the target population, e.g., emphasis on
spirituality, individual versus family orientation, and assignment of clients to
different therapeutic modalities? This may
include traditional healing approaches
(religious ceremonies, rituals, specific
cultural interventions such as sweat
lodges, or community intervention), and
which clients benefit from such interventions as opposed to Western approaches.
. What are the points of entry into the
program and the barriers to accessing
care? How do those relate to the clients'
cultural and socioeconomic needs?
Outcome characteristics in evaluation
usually involve symptom change, functional change, safety, cost, community
tenure and level ofrestrictiveness, and
consumer/family burden and satisfaction.
Participation
by the Community
and Providers/Agencies
Staff, child, and family participation
must be fostered in order to evaluate a
program or system of care. Minority community members often are not enthusiastic
about evaluation because of prior negative
experiences. There is also mistrust about
whether research will be used as a tool of
government agencies, immigration, social
services/child welfare agencies for custody termination or termination of benefits. Research methodology sometimes
conflicts with cultural values, tradition,
and accepted means of communication of
sensitive information. Staff may fear that
evaluation might frighten families away
from services.
A number of approaches can be used
to engage the cooperation of minority
children and families. Seeking out advice,
input, and endorsement from leaders and
elders in the minority community is quite
effective, both in building trust and in
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appropriate for use across different cultural groups, and some have subtle but distinct cross-cultural biases (Pumariega,
Holzer & Swanson, 1991). Instruments
being used or compared across cultural
groups should have these characteristics:
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cation and cultural value orientation presents particular challenges. The construct
most commonly endorsed in the crosscultural mental health field is that of
biculturality or multiculturality, i.e., culturally diverse individuals by necessity are
bi-cultural or multi-cultural in order to
adapt successfully. The domain of cultural/ethnic identification must allow for this
construct, and must take into account a
number of domains, e.g., self-identification, relational patterns (friends, intimate
relations, etc.), culturally related traditions
and preferences (clothing, foods, traditions, language, media, etc.), and cultural
value orientation. For many children and
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particular cultural populations. The imperatives for cost effectiveness and clinical
effectiveness which have been promoted
by the transition to managed systems of
care may actually promote the development of higher levels of cultural competence in community-based systems of
care. Culturally competent care may well
be the most cost-effective and clinicallyeffective care.
Behavioral
Symptomatology.
of the
Journal
Clinical Records
Proceedings
NIMH, Division of
REFERENCES
Kilgus, M., Pumariega, A. & Cuffe, S. (1995). Race and
(t
Inpatients.
Evaluation
Comparisou
*TABrielis
the Evaluation of
Conclusion
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appropriate, in descending order of effectiveness are: (1) providing the service with
bilinguallbicultural staff; (2) using trained
interpreters (simultaneous or consecutive)
and providing effective training to interpreters and service providers in the preferable modes of interpretation, team building, and communication strategies; and (3)
teaching monocultural providers the
language(s) of the clients.
Providers should determine whether
clients are English-dominant, language of
origin-dominant, or bilingual. Even for
English-dominant clients, it is important
to assess what language is spoken at home
and what type of schooling the clients had
(bilingual or English-only programs).
Providers should be aware that original
language-dominant or bilingual clients
speaking English may invest more energy
in correct expression, thus giving precedence to the cognitive aspect of communication over the affective component of
language. Thus, these clients may appear
more constricted or flat.
Clients may also use bilingualism as a
defensive structure, utilizing one language
to communicate and reserving another as
the emotional language. Clients may discuss certain emotionally charged topics in
their non-dominant language as a way of
gaining some emotional distance. At other
times, clients may use their dominant
language in order to access meaningful
memories or experiences. Even if the
provider is monolingual, it is useful to
allow clients to think out loud in their
dominant/emotional language to facilitate
their access to and organization of meaningful material.
.
Natural Support Systems. Another
area to consider is the client's natural
support systems. The availability of such
support will be crucial in helping clients to
cope with their family issues. An assessment of the social network should include
a list of friends and acquaintances indicating their ethnic background. The current
state of relationships with the extended
family is particularly important. In this
regard, both family meetings and genograms are useful assessment and intervention techniques that should be considered.
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Betsy Joyce
Principal Investigator
Richard Barth, Ph.D.
Director
Jeanne Pietrzak, M.S.W.
Senior Research
Associate
B.A.
Staff Researcher
Research
Contributing Writers
Scott Briar, Nicolas Carballeira,
Shirley Pinder Cook,
Susan Greenwald, Chela Rios Munoz,
Ruth Pontifiet, Sonia Ricks,
Karen Tanner, Alfreda Turner
Associate
Gwen Edgar-Miles,
Sheryl Goldberg,
"
Editor
AmyPrice
M.S.W., Ph.D.
Assistants
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