Cross Cultural Studies - Alaska Natives


This guide is intended to enhance cultural competence while providing services to
American Indians/Alaska Native communities. (Cultural competence is defined as the ability to function effectively in the context of cultural differences.)

Service providers should use this guide to ensure the following Five Elements of Cultural Competence are being addressed:
1. Awareness, acceptance and  valuing of cultural differences
2. Awareness of one’s own culture and values
3. Understanding the range of dynamics that result from the interaction between people of different cultures
4. Developing cultural knowledge of the particular community served or to access cultural brokers who may have that knowledge
5. Ability to adapt individual interventions, programs, and policies to fit the cultural context of the individual, family, or community

Myths and Facts

Myth: American Indians/Alaska Native people are spiritual and live in harmony with nature.
Fact: The idea of all American Indians/Alaska Natives having a mystical spirituality is a broad generalization. This romantic stereotype can be just as damaging as other more negative stereotypes and impairs one’s ability to provide services to American Indians/Alaska Nativess as real people.

Myth: American Indians/Alaska Native people have distinguishing physical characteristics, and you can identify them by how they look.
Fact: Due to Tribal diversity, as well as hundreds of years of inter-Tribal and inter- racial marriages, there is no single distinguishing “look" for American Indians/Alaska Natives.

Myth: Casinos have made American Indians/Alaska Natives rich.
Fact: Out of more than 560 Federally recognized tribes, only 224 operate gaming facilities. About three-fourths of those tribes reinvest revenue in the community. In 2006, only 73 tribes distributed direct payments to individual Tribal members.

Myth: The Bureau of Indian Affairs (BIA) and the Indian Health Service (IHS) are the only agencies responsible for working with tribes.
Fact: The U.S. Constitution, Executive Orders, and Presidential memos outline policy requiring that ALL executive departments have the responsibility to consult with and respect Tribal sovereignty.

Myth: American Indians/Alaska Natives have the highest rate of alcoholism.
Fact: While many tribes and American Indians/Alaska Native villages do experience the negative effects of alcohol abuse, what is less known is that American Indians/Alaska Natives also have the highest rate of complete abstinence. When socioeconomic level is accounted for in a comparison group, alcoholism rates are no different for American Indians/Alaska Natives than for other ethnic or racial groups. Most American Indians/Alaska Native-sponsored events ban the use of alcohol and even “social” drinking is often frowned upon.

Myth: American Indians/Alaska Native people all get “Indian money” and don’t pay taxes.
Fact: Few Tribal members receive payments from the BIA for land held in trust and most do not get significant “Indian money.” American Indians/Alaska Natives pay income tax and sales tax like any other citizen of their State while the U.S. Alaska Natives may get dividend payments from their Native Corporation or the State of Alaska as State citizens.

Tribal Sovereignty

Presently, there are more than 560 Federally recognized American Indians/Alaska Native tribes in the United States.
Over half of these are Alaska Native villages. Additionally, there are almost 245 non-Federally recognized tribes. Many of those are recognized by their States and are seeking Federal recognition.

There is a unique legal and political relationship between the Federal government and Indian tribes and a special legal relationship with Alaska Native Corporations. The U.S. Constitution (Article 1 Section 8, and Article 6), treaties, Supreme Court decisions, Federal laws, and Executive Orders provide authority to the Federal government for Indian affairs with Federally recognized tribes. As sovereign nations, Tribal governments have the right to hold elections, determine their own citizenship (enrollment), and to consult directly with the U.S. government on policy, regulations, legislation, and funding.

Tribal governments can create and enforce laws that are stricter or more lenient than State laws, but they are not subservient to State law. State laws cannot be applied where they interfere with the right of a tribe to make its own laws protecting the health and welfare of its citizens, or where it would interfere with any Federal interest. Criminal legal jurisdiction issues are very complex, depend on a variety of factors, and must be assessed based on the specific law as applied to a specific tribe.

In general, the Federal law applies. The Indian Self-Determination Act (Public Law 93-638) gives the authority to Tribal governments to contract programs and services that are carried out by the Federal government, such as services provided by the BIA or IHS.

The Alaska Native Claims Settlement Act was signed into law on December 18, 1971. Settlement benefits would accrue to those with at least one-fourth Native ancestry, and would be administered by the 12 regional corporations within the State.

Regional and Cultural Differences

Prior to European contact, American Indians/Alaska Native communities existed throughout various areas of North America. Federal policies led to voluntary and forced relocation from familiar territory to the current day reservation system. When the reservation system was formed in the late 1800s, some bands and tribes were forced by the U.S. government to live together. In some instances, these groups were related linguistically and culturally; in others, they were not closely related and may even have been historic enemies. On reservations where different AI/ AN groups were forced to co-exist, repercussions occurred that still can be experienced today in those communities.

Historic rivalries, family or clan conflicts, and “Tribal politics” may present challenges for an outsider unaware of local dynamics who is trying to interact with different groups in the community.

While there is great diversity across and within tribes, there are within-region similarities based on adaptation to ecology, climate, and geography (including traditional foods); linguistic and cultural affiliations; and sharing of information for long periods of time. Differences in cultural groups are closely related to regional differences and may be distinguished by their language or spiritual belief systems. They are also a result of the diversity of historic homelands across the Nation and migration patterns of Tribal groups.  Cultures developed in adaptation to their natural environment and the influence of trade and interaction with non-Indians and other American Indians/Alaska Native groups. Urban Indian communities can be found in most major metropolitan areas.

These populations are represented by members of a large number of different tribes and cultures that have different degrees of traditional culture and adaptation to Western culture norms. They form a sense of community through social interaction and activities, but are often “invisible,” geographically disbursed, and multi-racial.

Cultural Customs

Cultural customs can be viewed as a particular group or individual’s preferred way of meeting their basic human needs and conducting daily activities as passed on through generations.

Specific cultural customs among AI/ AN groups may vary significantly, even within a single community.

Customs are influenced by: ethnicity, origin, language, religious/spiritual beliefs, socioeconomic status, gender, sexual orientation, age, marital status, ancestry, history, gender identity, geography, and so on. Cultural customs are often seen explicitly through material culture such as food, dress, dance, ceremony, drumming, song, stories, symbols, and other visible manifestations.

Such outward cultural customs are a reflection of a much more ingrained and implicit culture that is not easily seen or verbalized.

 Deeply held values, general world view, patterns of communication, and interaction are often the differences that affect the helping relationship.

A common practice of a group or individual that represents thoughts, core values, and beliefs may be described by community members as “the way we do things” in a particular tribe, community, clan, or family. This includes decision-making processes.

Respectful questions about cultural customs are generally welcomed, yet not always answered directly.

Any questions about culture should be for the purpose of improving the service provider’s understanding related to the services being provided. Many American Indians/Alaska Native people have learned to “walk in two worlds” and will observe the cultural practices of their American Indians/Alaska Native traditions when in those settings, and will observe other cultural practices when in dominant culture settings.

Sharing food is a way of welcoming visitors, similar to offering a handshake.

Food is usually offered at community meetings and other gatherings as a way to build relationships.


A strong respect for spirituality, whether traditional (prior to European contact), Christian (resulting from European contact), or a combination of both, is common among all American Indians/Alaska Native communities and often forms a sense of group unity.

Many American Indians/Alaska Native communities have a strong church community and organized religion that is integrated within their culture. Traditional spirituality and practices are integrated into American Indians/Alaska Native cultures and
day-to-day living.

Traditional spirituality and/or organized religions are usually community-oriented, rather than individual-oriented. Spirituality, world view, and the meaning of  life are very diverse concepts among regions, tribes, and/or individuals.

Specific practices such as ceremonies, prayers, and religious protocols will vary among American Indians/Alaska Native communities.

A blend of traditions, traditional spiritual practices, and/or mainstream faiths may coexist. It is best to inquire about an individual’s faith or beliefs instead of making assumptions, but be aware that many American Indians/Alaska Natives spiritual beliefs and practices are considered sacred and are not to be shared publicly or with outsiders.

Until passage of the Indian Religious Freedom Act in 1978, many traditional American Indians/Alaska Natives practices were illegal and kept secret. Social/health problems and their solutions are often seen as spiritually based and as part of a holistic world view of balance between mind, body, spirit, and the environment.

It is a common practice to open and close meetings with a prayer or short ceremony.

Elders are often asked to offer such opening and closing words and given a small gift as a sign of respect for sharing this offering.

Communication Styles

Nonverbal Messages

• American Indians/Alaska Native people communicate a great deal through non-verbal gestures. Careful observation is necessary to avoid misinterpretation of non-verbal

•A I / A N people may look down to show respect or deference to elders, or ignoring an individual to show disagreement or displeasure.

• A gentle handshake is often seen as a sign of respect, not weakness.


American Indians/Alaska Native people may convey truths or difficult messages through humor, and might cover great pain with smiles or jokes. It is important to listen closely to humor, as it may be seen as invasive to ask for too much direct clarification about sensitive topics.

It is a common conception that “laughter is good medicine” and is a way to cope. The use of humor and teasing to show affection or offer corrective advice is also common.

Indirect Communication

It is often considered unacceptable for an American Indians/Alaska Native person to criticize another directly.

This is important to understand, especially when children and youth are asked
to speak out against or testify against another person. It may be considered disloyal or disrespectful to speak negatively about the other person.

There is a common belief that people who have acted wrongly will pay for their acts in one way or another, although the method may not be through the legal system.


Getting messages across through telling a story (traditional teachings and personal stories) is very common and sometimes in contrast with the “get to the point” frame of mind in non-American Indians/Alaska Native society.

Health and Wellness Challenges

Concepts of health and wellness are broad. The foundations of these concepts are living in a harmonious balance with all elements, as well as balance and harmony of spirit, mind, body, and the environment. Health and wellness may be all encompassing, not just one’s own physical body; it is holistic in nature. American Indians/Alaska Natives define what health and wellness is to them, which may be very different from how Western medicine defines health and wellness. Many health and wellness issues are not unique to American Indians/Alaska Native communities, but are statistically higher than in the general population. It is important to learn about the key health issues in a particular community.

Among most American Indians/Alaska Native communities, 50 percent or more of the population is under 21 years of age.

Health disparities exist with limited access to culturally appropriate health care in most American Indians/Alaska Natives communities.

Only 55 percent of American Indians/Alaska Native people rely on the Federally funded IHS or Tribally operated clinics/ hospitals for care.

Suicide is the second leading cause of death among American Indians/Alaska Native people age 10- 34. The highest rates are among males between the ages of 24 and 34 and 15 and 24, respectively.  Following a death by suicide in the community, concern about suicide clusters, suicide contagion, and the possibility of suicide pacts may be heightened. A response to a suicide or other traumatic occurrence requires a community-based and culturally competent strategy. Prevention and intervention efforts must include supporting/enhancing strengths of the community resources as well as individual and family clinical interventions.  Service providers must take great care in the assessment process to consider cultural differences in symptoms and health concepts when making a specific diagnosis or drawing conclusions about the presenting problem or bio-psychological history.

Every effort should be made to consult with local cultural advisors for questions about symptomology and treatment options.

Self-Awareness and Etiquette

Prior to making contact with a community, examine your own belief system aboutAmerican Indians/Alaska Natives people related to social issues, such as mental health stigma, poverty, teen suicide, and drug or alcohol use. You are being observed at all times, so avoid making assumptions and be conscious that you are laying the groundwork for others to follow. Adapt your tone of voice, volume, and speed of speech patterns to that of local community members to fit their manner of communication style.

Prefered body language, posture, and concept of personal space depend on community norms and the nature of the personal relationship. Observe others and allow them to create the space and initiate or ask for any physical contact. You may experience people expressing their mistrust, frustration, or disappointment from other situations that are outside of your control. Learn not to take it personally.

If community members tease you, understand that this can indicate rapport- building and may be a form of guidance or an indirect way of correcting inappropriate behavior. You will be more easily accepted and forgiven for mistakes if you can learn to laugh at yourself and listen to lessons being brought to you through humor.

Living accommodations and local resources will vary in each community. Remember that you are a guest. Observe and ask questions humbly when necessary. Rapport and trust do not come easily in a limited amount of time; however, don’t be surprised if community members speak to you about highly charged issues (e.g., sexual abuse, suicide) as you may be perceived as an objective expert.

Issues around gender roles can vary significantly in various American Indians/Alaska Natives communities.

Males and females typically have very distinct social rules for behavior in every day interactions and in ceremonies. Common behaviors for service providers to be aware of as they relate to gender issues are eye contact, style of dress, physical touch, personal space, decision making, and the influence of male and/or female elders. Careful observation and seeking guidance from a community member on appropriate gender-specific behavior can help service providers to follow local customs and demonstrate cultural respect.

Etiquette – Do’s
Learn how the community refers to itself as a group of people (e.g., Tribal name).

Be honest and clear about your role and expectations and be willing to adapt to meet the needs of the community. Show respect by being open to other ways of thinking and behaving. Listen and observe more than you speak. Learn to be comfortable with silence or long pauses in conversation by observing community members’ typical length of time between turns at talking. Casual conversation is important to establish rapport, so be genuine and use self-disclosure (e.g., where you are from, general information about children or spouse, personal interests).

Avoid jargon. An American Indians/Alaska Natives community member may nod their head politely, but not understand what you are saying. It is acceptable to admit limited knowledge of American Indians/Alaska Native cultures, and invite people to educate you about specific cultural protocols in their community. If you are visiting the home of an American Indians/Alaska Native family, you may be offered a beverage and/or food, and it is important to accept it as a sign of respect. Explain what you are writing when making clinical documentation or charting in the presence of the individual and family. During formal interviews, it may be best to offer general invitations to speak, then remain quiet, sit back, and listen. Allow the person to tell their story before engaging in a specific line of questioning. Be open to allow things to proceed according to the idea that “things happen when they are supposed tohappen.” Respect confidentiality and the right of the tribe to control information, data, and public information about services provided to the tribe.

Etiquette – Don’ts

Avoid stereotyping based on looks, language, dress, and other outward appearances. Avoid intrusive questions early in conversation. Do not interrupt others during conversation or interject during pauses or long silences. Do not stand too close to others and/or talk too loud or fast. Be careful not to impose your personal values, morals, or beliefs. Be careful about telling stories of distant American Indians/Alaska Natives relatives in your genealogy as an attempt to establish rapport unless you have maintained a connection with that American Indians/Alaska Native community.

Be careful about pointing with your finger, which may be interpreted as rude behavior in many tribes. Avoid frequently looking at your watch and do not rush things. Avoid pressing all family members to participate in a formal interview. During a formal interview, if the person you are working with begins to cry, support the crying without asking further questions until they compose themselves and are ready to speak.  Do not touch sacred items, such as medicine bags, other ceremonial items, hair, jewelry, and other personal or cultural things. Do not take pictures without permission. NEVER use any information gained by working in the community for personal presentations, case studies, research, and so on, without the expressed written consent of themTribal government or Alaska Native Corporation.

Today, the IHS remains the primary entity responsible for the mental health care of American Indians and Alaska Natives. Until 1965, the delivery of mental health services was sporadic. That year, the first Office of Mental Health was opened on the Navajo Reservation. It remained severely understaffed and underfunded until its dissolution in 1977. Legislation to authorize comprehensive mental health services for tribes has been enacted and amended several times, but Congress consistently failed to appropriate funds for such initiatives (Nelson & Manson, 2000). Financial inadequacies have resulted in four IHS service areas without child or adolescent mental health professionals.

Fragmented Federal, State, tribal, private foundation, and national nonprofit attempts to meet such obvious needs have led to isolation, difficult work conditions, cultural differences, and high turnover rates that dilute efforts to provide mental health services (Barlow & Walkup 1998; Novins, Fleming, et al., 2000).

The Need for Mental Health Care

Historical and Sociocultural Factors That Relate to Mental Health

The history of American Indians and Alaska Natives sets the stage for understanding their mental health needs. Past governmental policies regarding this population have led to mistrust of many government services or care provided by white practitioners. Attempts to eradicate Native culture, including the forced separation of Indian and Native children from parents in order to send them to boarding schools, have been associated with negative mental health consequences (Kleinfeld, 1973; Kleinfeld & Bloom, 1977).

Some argue that, as a consequence of past separation from their families, when these children become parents themselves, they are not able to draw on experiences of growing up in a family to guide their own parenting (Special Subcommittee on Indian Education, 1969). The effect of boarding school education on American Indian students remains controversial (Kunitz et al., 1999; Irwin & Roll, 1995).

The socioeconomic consequences of these historical policies are also telling. The removal of American Indians from their lands, as well as other policies summarized above, has resulted in the high rates of poverty that characterize this ethnic minority group. One of the most robust scientific findings has been the association of lower socioeconomic status with poor general health and mental health. Widespread recognition that many Native people live in stressful environments with potentially negative mental health consequences has led to increasing study and empirical documentation of this link(Manson, 1996b, 1997; Beals et al, under review; Jones et al., 1997).

Key Issues for Understanding the Research

Because American Indians and Alaska Natives comprise such a small percentage of U.S. citizens in general, nationally representative studies do not generate sufficiently large samples of this special population to draw accurate conclusions regarding their need for mental health care. Even when large samples are acquired, findings are constrained by the marked heterogeneity that characterizes the social and cultural ecologies of Native people. There are 561 federally recognized tribes, with over 200 indigenous languages spoken (Fleming, 1992). Differences between some of these languages are as distinct as those between English and Chinese (Chafe, 1962). Similar differences abound among Native customs, family structures, religions, and social relation-ships. The magnitude of this diversity among Indian people has important implications for research observations. Novins and colleagues provide an excellent illustration of this point in a paper that shows that the dynamics underlying suicidal ideation among Indian youth vary significantly with the cultural contexts of the tribes of which they are members (Novins, et al., 1999).

A tension arises, then, between the frequently conflicting objectives of comparability and cultural specificity—a tension not easily resolved in research pursued among this specialpopulation. As widely noted, language is important when assessing the mental health needs of individuals and the communities in which they reside. Approximately 280,000 American Indians and Alaska Natives speak a language other than English at home; more than half of Alaska Natives who are Eskimos speak either Inuit or Yup’ik. Consequently, evaluations of need for mental health care often have to be conducted in a language other than English. Yet the challenge can be more subtle than that implied by stark differences in language. Cultural differences in the expression and reporting of distress are well established among American Indians and Alaska Natives. These often compromise the ability of assessment tools to capture the key signs and symptoms of mental illness (Kinzie & Manson, 1987; Manson, 1994, 1996a). Words such as “depressed” and “anxious” are absent from some American Indian and Alaska Native languages (Manson et al., 1985). Other research has demonstrated that certain DSM diagnoses, such as major depressive disorder, do not correspond directly to the categories of illness recognized by some American Indians. Thus, evaluating the need for mental health care among American Indians and Alaska Natives requires careful clinical inquiry that attends closely to culture.

Census 2000 reports a significant increase in the number of individuals who identify, at least in part, as American Indian or Alaska Native. This finding resurrects longstanding debates about definition and identification (Passel, 1996). The relationship of those who have recently asserted their Indian ancestry to other, tribally defined individuals is unknown and poses a difficult challenge. It suggests a newly emergent need to consider the mental health status and requirements of individuals who live primarily within mainstream society, while continuing to build the body of knowledge on groups already defined.

Mental Disorders

Although not all mental disorders are disabling, these disorders always manifest some level of psychological discomfort and associated impairment. Such symptoms often improve with treatment. Therefore, the presence of a mental disorder is one reasonable indicator of need for mental health care. As noted in previous chapters, in the United States such disorders are identified according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic categories established by the American Psychiatric Association (1994).

Culture-Bound Syndromes

A large body of ethnographic work reveals that some American Indians and Alaska Natives, who may express emotional distress in ways that are inconsistent with the diagnostic categories of the DSM, may conceptualize mental health differently. Many unique expressions of distress shown by American Indians and Alaska Natives have been described (Trimble et al., 1984; Manson et al., 1985; Manson 1994; Nelson & Manson, 2000). Prominent examples include ghost sickness and heart-break syndrome (Manson et al., 1985). The question becomes how to elicit, understand, and incorporate such expressions of distress and suffering within the assessment and treatment process of the DSM–IV.

Working In Indian Communities

Excerpted from the US Department of Health and Human Services Substance Abuse and Mental Health Services Administration’s Cultural Competence Series, Volume 9: Heath Promotion and Substance Abuse Prevention in American Indian and Alaska Native Communities: Issues in Cultural Competence. Chapter 2: “Prevention Principles for American Indian Communities,” by James R. Moran, Ph.D, pp 40-42.

Overcoming Distrust

One of the first issues to consider in understanding the dynamics of carrying out…programs in American Indian Communities is that like many other ethnic minority communities, American Indian communities often have a historical distrust of the dominant society (Lockhart, 1981). This distrust is based in the historical nature of the relationship between the dominant culture and American Indians that includes a 500-year history of oppression and domination – at times approaching genocide. When programs are seen as imposed from outside the community, this distrust is likely to escalate and to form a significant barrier. In such situations…programs are not likely to produce useful results. (emphasis, NAMI)

A key part of making programs relevant is to have them emerge out of a process of community involvement. Beauvais and LaBoueff (1985) present a model of community action that progresses from a few interested people to a core group to a community task force. Each step involves more community members committed to the idea…

There are several ways that noncommunity members can demonstrate their commitment to American Indian communities. Simply responding to the stated needs that are defined by a process of community involvement instead of having a set program that is defined by academic interests or by government or foundation announcements is a strong statement to the community. Providing technical assistance that is needed in the community even though it may not be funded directly by grants also demonstrates commitment. Perhaps most important…being willing to stick around and deal with a problem as long as it takes, even if that means moving beyond the original funding period. This might mean locating and securing additional funding in order to continue a program. In summary, working in American Indian communities requires us to directly address issues of distrust by listening to and then responding in a committed manner to community-defined interest.

Developing Cultural Sensitivity

To accomplish the above, one must be culturally sensitive. But what does this mean? Cultural competency occurs in stages with simple awareness of cultural differences being a necessary first stage. The second stage is self-assessment, that is, the awareness of ones own cultural values. This approach to cultural competence holds that people must understand their own culture (i.e. recognize that they have a cultural lens) before they can be sensitive to other cultures. The third stage is an understanding of the dynamics such as conflict and racism that may occur when members of different cultures interact.

Working through these three stages enables individuals to adapt to diversity and to adjust professional skills to fit within the cultural context of ethnic community. To be culturally competent means to conduct one’s professional work in a way that is congruent with the behaviors and expectations that members of a cultural group recognize as appropriate among themselves. …That does not mean that nonmembers of a community will be able to conduct themselves as though they are a member of the group. Rather, they must be able to engage the community on something other than their own terms and demonstrate acceptance of cultural difference in an open, genuine manner, without condescension.

Cultural Competency:  Changing the Way We Work

The mental health field in the U.S. continues to be dominated by white, middle-class professionals who are primarily English speakers.

What implications does this have for people of color with mental illnesses and their families? This section of the American Indian and Alaska Native Resource Manual recognizes that tremendous racial and cultural barriers persist for American Indian and Alaska Native families seeking resources and support.

If NAMI is to live up to its mission - to serve and advocate for all persons with mental illness and their families - then achieving cultural competency within NAMI groups is paramount.

The following section offers concrete strategies toward reaching out to and serving American Indian and Alaska Native families dealing with mental illness. Creating culturally competent NAMI groups is a critical step toward creating a society in which all persons with mental illness have the dignity, resources and support essential to their wellbeing.

What is Cultural Competency?

Cultural Competency can be defined as:

A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enable them to work effectively in cross-cultural situations. Cultural competency is the assessment regarding culture, an attention to the dynamics of difference, the ongoing development of cultural knowledge, and the resources and flexibility within service models to meet the needs of minority populations (Cross et al., 1989).

Davis (1997) operationally defines cultural competency as the integration and transformation of knowledge, information, and data about individuals and groups of people into specific clinical standards, skills, service approaches, techniques, and marketing programs that match the individual's culture and increase the quality and appropriateness of health care and outcomes.

Cultural competency does not refer to the establishment or maintenance of diversity per se. The concept of competency is not related to numbers of representation, either in clients or in service providers. Competency refers more explicitly to folkways, mores, traditions, customs, formal and informal helping networks, rituals, dialects, and so forth. In these areas, knowledge about various cultures and the development of specific skills and attitudes in providing services in a manner consistent with the consumers' needs are essential.

Why is Cultural Competency Important?

The cultural appropriateness of mental health and support services may be the most important factor in the accessibility of services by people of color. Developing culturally sensitive practices can help reduce barriers to treatment. Knowing whom the consumer perceives as a "natural helper" and whom he/she views as traditional helpers (such as elders, the church) can facilitate the development of trust and enhance the individual's investment and access to treatment.

America's population is not only growing, it is changing dramatically. NAMI groups and chapters must reflect this reality. Shifts in ethnic diversity are not just about numbers, but also the impact of cultural differences. New approaches to organizing, support, and advocacy are needed to address cultural differences among consumers.

Essential Knowledge, Skills, and Attitudes to Developing Cultural Competence Ensuring the provision of culturally competent services to potential members places a great deal of responsibility upon the organization. In particular, there are a number of generally expected levels of knowledge, skills and attitudes that are essential to providing culturally competent support services.


Make efforts to understand self and (if applicable) one's dominant culture position in terms of dynamics of race, ethnicity and power.

Understand the historical factors which impact the health of American Indian/Alaska Native (AI/AN) population, such as racism, dislocation, and immigration patterns.

Understand the particular psycho-social stressors relevant to AI/AN patients. These include poverty, war trauma (historic and present), migration, acculturation stress, disproportionate incarceration, and racism.

Understand historic dismemberment of families, centrality of tribal traditions, and intergenerational conceptual framework among AI/AN families.

Understand indigenous healing practices and the role of spirituality in the treatment of AI/AN people with mental illness.

Understand the cultural beliefs of health and help seeking patterns of AI/AN people with mental illness.

Understand the health service resources for AI/AN population, including the Indian Health Service.

Understand historic and present-day public health policies and their impact on AI/AN patients and communities.


Ability to discuss mental health issues of AI/AN people based on a psychological/social/biological/cultural/political/spiritual model.

Ability to communicate effectively - possibly with cross cultural use of interpreters.

Ability to discuss mental health issues with an understanding of cultural differences in pathology. Awareness of particular risks facing AI/AN communities (substance abuse, suicide).

Ability to appreciate the need for culturally sensitive treatment that fits the family's concept of health and illness.

Ability to utilize community resource (church, CBOs, self-help groups.

Ability to network and draw on other community resources to support the family.


Respect the tremendous survival merits of AI/AN families and tribes.

Respect the importance of cultural forces.

Respect the holistic view of health and illness

Respect the importance of spiritual beliefs

Respect and appreciate the skills and contributions of other professional and
paraprofessional disciplines.

Own a lack of awareness or defensiveness in situations that may require additional
education, resources or support.

Promoting Cultural Diversity and Cultural Competency
Self-Assessment Checklist for Personnel Providing Services and Supports to
Children with Special Health Needs and their Families

This checklist is intended to heighten the awareness and sensitivity of personnel to the importance of cultural diversity and cultural competence in human service settings. It provides concrete examples of the kinds of values and practices that foster such an environment.
A = Things I do frequently
B = Things I do occasionally
C = Things I do rarely or never

Physical Environment, Materials & Resources
_____1. I display pictures, posters and other materials that reflect the cultures and ethnic backgrounds of children and families served by my program or agency.
_____2. I insure that magazines, brochures, and other printed materials in reception areas are of interest to and reflect the different cultures of children and families served by my
program or agency.
_____3. When using videos, films or other media resources for health education, treatment or other interventions, I insure that they reflect the cultures of children and families served by my program or agency.
_____4. When using food during a program, I insure that meals provided include foods that are unique to the cultural and ethnic backgrounds of children and families served by my program and agency.
_____5. I insure that toys and other play accessories in reception areas and those which are used during assessment, are representative of the various cultural and ethnic groups within the local community and the society in general.

Communication Styles

_____6. For families that speak languages or dialects other than English, I attempt to learn and use key words in their language so that I am better able to communicate with them.
_____7. I use visual aids, gestures, and physical prompts in my interactions with families that have limited English proficiency.
_____8. I use bilingual staff or trained/certified interpreters for educational and support programs.
_____9. When interacting with families that have limited English proficiency I always keep in mind this:
_____* limitations in English proficiency is in no way a reflection of their level of intellectual functioning.
_____* they may or may not be literate in their language of origin or English.
_____10. When possible, I insure that all notices and communiqu_s to families are written in their language or origin.
_____11. I understand that it may be necessary to use alternatives to written communications for some families, as word of mouth may be a preferred method of receiving information.

Values & Attitudes

_____12. I avoid imposing values that may conflict or be inconsistent with those of cultures or ethnic groups other than my own.
_____13. In group situations, I discourage participants from using racial and ethnic slurs by helping them understand that certain words can hurt others.
_____14. I screen books, movies, and other media resources for negative cultural, ethnic, or racial stereotypes before sharing them with families served by my program or agency.
_____15. I intervene in an appropriate manner when I observe other parents within my program or agency engaging in behaviors that show cultural insensitivity, bias or prejudice.
_____16. I understand and accept that family is defined differently by different cultures (e.g. extended family members, fictive kin, godparents).
_____17. I recognize and accept that individuals from culturally diverse backgrounds may desire varying degrees of acculturation into the dominant culture.
_____18. I accept and respect that male-female roles in families may vary significantly among different cultures (e.g. who makes major decisions for the family, play and social interactions expected of male and female children).
_____19. I understand that age and life cycle factors must be considered in interactions with individuals and families (e.g. high value placed on the decisions of elders or the role of the eldest male in families.
_____20. Even though my professional or moral viewpoints may differ, I accept the family/parents as the ultimate decision makers for services and supports for their children.
_____21. I recognize that the meaning or value of medical treatment and health education
may vary greatly among cultures.
_____22. I recognize and understand that beliefs and concepts of emotional well-being vary significantly from culture to culture.
_____23. I understand that beliefs about mental illness and emotional disability are culturally-based. I accept that responses to these conditions and related treatment/interventions are heavily influenced by culture.
_____24. I accept that spirituality and other beliefs may influence how families respond to illnesses, disease, disability and death.
_____25. I recognize and accept that folk and religious beliefs may influence a family's reactions and approach to a child with mental illness or special health care needs.
_____26. I understand that traditional approaches to disciplining children are influenced by culture.
_____27. I understand that families from different cultures will have different expectations of their children for acquiring toileting, dressing, feeding, and other selfhelp skills.
_____28. I accept and respect that customs and beliefs about food, its value, preparation, and use are different from culture to culture.
_____29. Before visiting family members in the home setting, I seek information on acceptable behaviors, courtesies, customs and expectations that are unique to families of specific cultures and ethnic groups served by my program or agency.
_____30. I seek information from family members or other key community informants that will assist in service adaptation to respond to the needs and preferences of culturally and ethnically diverse children and families served by my program agency.
_____31. I advocate for the review of my program's or agency's mission treatment, goals, policies, and procedures to insure that they incorporate principles and practices that promote cultural diversity and cultural competence.

There is no answer key with correct responses. However, if you frequently responded "C", you may not necessarily demonstrate values and engage in practices that promote a culturally diverse and culturally competent service delivery system for people with mental illness and their families.

Culture has been defined as "the shared values, traditions, norms, customs, arts, history, folklore, and institutions of a group of people." Why should we even be concerned about culture?

First, understanding culture helps us to understand how others interpret their environment. We know that culture shapes how people see their world and how they function within that world. Culture shapes personal and group values and attitudes, including perceptions about what works and what doesn’t work, what is helpful and what is not, what makes sense and what does not.

Secondly, understanding culture helps service providers avoid stereotypes and biases that can undermine their efforts. It promotes a focus on the positive characteristics of a particular group, and reflects an appreciation of cultural differences. Finally, culture plays a complex role in the development of health and human service delivery programs.

Factors that Influence Culture

While we know that cultural influences shape how individuals and groups create identifiable values, norms, symbols, and ways of living that are transferred from one generation to another, it is important for us to distinguish the differences created by such factors as age, gender, geographic location, and lifestyle. Race and ethnicity are commonly thought to be dominant elements of culture, but a true definition of culture is actually much broader than this.

For example, ethnic and racial groups are usually categorized very broadly as African American, Hispanic, American Indian and Native Alaskan, or Asian American and Pacific Islander. These broad categories are sometimes misleading, because they can often mask substantial differences within groups. The larger group may share nothing more than common physical traits, language, or religious backgrounds. We often fail to consider the distinct factors which influence culture within larger populations that determine how people think and behave. 

Values and Attitudes

Culture shapes how people experience their world. It is a vital component of how services are both delivered and received. Cultural competence begins with an awareness of your own cultural beliefs and practices, and recognition that people from other cultures may not share them. This means more than speaking another language or recognizing the cultural icons of a people. It means changing prejudgments or biases you may have of a people’s cultural beliefs and customs.

It is important to promote mutual respect. Cultural competence is rooted in respect, validation and openness towards someone with different social and cultural perceptions and expectations than your own. People tend to have an “ethnocentric” view in which they see their own culture as the best. Some individuals may be threatened by, or defensive about, cultural differences. Moving toward culturally appropriate service delivery means being:

knowledgeable about cultural differences and their impact on attitudes and behaviors;sensitive, understanding, non-judgmental, and respectful in dealings with people whose culture is different from your own; and flexible and skillful in responding and adapting to different cultural contexts and circumstances.

Also, it means recognizing that acculturation occurs differently for everyone. This means more than different rates among different families from the same cultural background; it means different rates among members of the same family as well.

For example, the beliefs, customs, and traditions of people from other cultures are often at odds with Western medicine and its heavy emphasis on science. Consistent with the Anglo-American emphasis on scientific reasoning, Western medicine tends to emphasize biological explanations for illness (such as bacteria, viruses or environmental causes); whereas in other cultures the natural, supernatural or religious/spiritual reasons explain the cause of the problem (the yin and yang are out of balance; you have broken a taboo; or you have been thinking or doing evil.

Cultural competence is defined as “a set of cultural behaviors and attitudes integrated into the practice methods of a system, agency, or its professionals, that enables them to work effectively in cross cultural situations.” Cultural competency is achieved by translating and integrating knowledge about individuals and groups of people into specific practices and policies applied in appropriate cultural settings. When professionals are culturally competent, they establish positive helping relationships, engage the client, and improve the quality of services they provide.

Culture plays a complex role in the development of health and human service delivery programs the need for the provision of culturally appropriate services is driven by the demographic realities of our nation. Understanding culture and its relationship to service delivery will increase access to services as well as improve the quality of the service outcomes. Research has begun to provide the underpinnings for the development of standards for the delivery of services to diverse populations. The following Principles are drawn from research material on the role culture plays in providing services to older adults.

There is an ethic to culturally competent practice. When professionals practice in a culturally competent way, programs that appropriately serve people of diverse cultures can be developed. Each person must first posses the core fundamental capacities of warmth, empathy and genuineness. To achieve cultural competence, professionals must first have a sense of compassion and respect for people who are culturally different. Then, practitioners can learn behaviors that are congruent with cultural competence. Just learning the behavior is not enough. Underlying the behavior must be an attitudinal set of behavior skills and moral responsibility. It is not about the things one does. It is about fundamental attitudes. When a person has an inherent caring, appreciation and respect for others they can display warmth, empathy and genuineness. This then enables them to have culturally congruent behaviors and attitudes. When these three essentials intersect, practitioners can exemplify cultural competence in a manner that recognizes, values and affirms cultural differences among their clients.

Communication provides an opportunity for persons of different cultures to learn from each other. It is important to build skills that enhance communication. Be open, honest, respectful, nonjudgmental, and - most of all - willing to listen and learn. Listening and observational skills are essential. Letting people know that you are interested in what they have to say is vital to building trust. Communication strategies have to capture the attention of your audience. This means not only using the language and dialect of the people you are serving, it means using communication vehicles that are proven to have significant value and use by your target audience.

Culturally competent service providers must take into account the full range of factors that influence how any one individual service recipient behaves and communicates. The two levels of influencing factors are: overall cultural differences between racial and ethnic groups, as well as  individual-level differences (based on age, education, literacy, income, gender and geographic  location).
Acculturation is a process that occurs when two distinct cultural groups have continuous first-hand contact, resulting in subsequent changes in the original cultural patterns of either or both groups. The degree to which acculturation takes place is influenced directly by both the cultural and individual-level differences.

The DSM-IV TR Outline for Cultural Formulation When Assessing and Diagnosing Patients

Rendering psychological and psychiatric assistance to a diverse population carries with it some special issues as well as those more generally noted in other curricula. Consequently, faculty and clinicians in the mental health and behavioral health fields have been working to include diagnostic and clinical criteria that would assist practitioners in becoming more culturally and linguistically competent. One concise clinical tool to aid the clinician in this process is the Outline for Cultural Formulation (OCF) found in Appendix I of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (known as DSM-IV-TR) from American Psychiatric Association in Arlington, VA.

Although intended for use with the DSM-IV TR in assessing mental disorders, the OCF is applicable to other clinical health care encounters. It provides a systematic review of the individual’s cultural background, the role of the cultural context in the expression and evaluation of symptoms and dysfunction, and the effect that cultural differences may have on the relationship between the individual and the clinician. As a result of using the OCF, the clinician provides a narrative summary for each of the following categories:

1. Cultural identity of the individual
2. Cultural explanations of the individual’s illness
3. Cultural factors related to the psychosocial environment and levels of functioning
4. Cultural elements of the relationship between the individual and the clinician
5. Overall cultural assessment for diagnosis and care

1. Cultural identity of the individual. Note the individual’s ethnic or cultural reference groups. For immigrants and ethnic minorities, note separately the degree of involvement with both the culture of origin and the host culture, where applicable. Also note language abilities, use, and preference, including multilingualism.

2. Cultural explanations of the individual’s illness. The following may be identified: the predominant idioms of distress through which symptoms or the need for social support are communicated (such as “nerves,” possessing spirits, somatic complaints, and inexplicable misfortune), the meaning and perceived severity of the individual’s symptoms in relation to norms of the cultural reference group, any local illness category that the individual’s family and community use to identify the condition (such as those explained in the DSM-IV TR’s “Glossary of Culture-Bound Syndromes”), the perceived causes or explanatory models that the individual and the reference group use to explain the illness, and current preferences for and past experiences with professional and popular sources of care.

3. Cultural factors related to the psychosocial environment and levels of functioning. Note culturally relevant interpretations of social stressors, available social supports, and levels of functioning and disability. These stressors would include those in the local social environment and the role of religion and kin networks in providing emotional, instrumental, and informational support.

4. Cultural elements of the relationship between the individual and the clinician. Indicate differences in culture and social status between the individual and the clinician and problems that these differences may cause in diagnosis and treatment, such as difficulty in communicating in the individual’s first language, in eliciting symptoms or understanding their cultural significance, in negotiating an appropriate relationship or level of intimacy, and in determining whether a behavior is normative or pathological.

5. Overall cultural assessment for diagnosis and care. The formulation concludes with a discussion of how cultural considerations specifically influence comprehensive diagnosis and care.

The clinician assesses the first four interrelated sections, which provide information that will have an effect (in the fifth section) on the differential diagnosis and the treatment plan. Clinicians must cultivate an attitude of “cultural humility” in knowing their limits of knowledge and skills in applying the OCF with accuracy rather than reinforcing potentially damaging stereotypes and over-generalizations.

Cultural identity involves a range of variables not only including ethnicity, acculturation and biculturality, and language, but also age, gender, socioeconomic status, sexual orientation, religious and spiritual beliefs, disabilities, political orientation, and health literacy, among other factors. In addition, assessment of cultural identity must move from merely the clinician’s perspective to include the patient’s self-construal of identity over time.

The second section asks the clinician to inquire about the patient’s idioms of distress, explanatory models, and treatment pathways (including complementary and alternative medicine and indigenous approaches) and to assess these pathways against the norms of the cultural reference group. The third section highlights the importance of the assessment of family and kin systems and religion and spirituality. The fourth section focuses on the complex nature of the interaction between the clinician and the individual including transference and counter-transference, which may either aid or interfere with the treatment relationship. In the final section, the clinician summarizes his or her understanding of the previous sections and can apply this understanding to a differential diagnosis and treatment plan.

AAPI Mental Health

The National Asian American Pacific Islander Mental Health Association (NAAPIMHA) has found the DSM IV TR Outline for Cultural Formulation provides a rich theoretical framework in making culturally appropriate assessments, diagnosis, and treatment plans. Using the DSM IV TR, NAAPIMHA developed a curriculum and pre-service training program in 2002 that is designed to help reduce disparities in mental health care for diverse populations by building a workforce capacity. The aim of the curriculum was to address the mental health needs of Asian Americans and Pacific Islanders and was developed under a grant from the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.

The curriculum, called Growing Our Own, is for the disciplines of psychiatry, psychology, social work, and counseling. It draws upon years of experience, assessing what does and does not work in providing culturally competent mental health services to the AAPI communities.

The five modules of the Growing Our Own curriculum build on each other and are intended to help the intern or resident develop an approach that avoids simplistic cookbook conclusions. The five modules are as follows:

Module 1 – Self Assessment helps interns or residents to recognize the biases that influence what we see and how these biases affect decision-making.

Module 2 – Connecting With Your Client is designed to help trainees become familiar with AAPI in general and provide them with the requisite knowledge, skills, and attitudes to communicate effectively with consumers and work with interpreters.

Module 3 – Culturally Responsive Assessment and Diagnosis is designed to identify factors that lead to the development of a culturally competent assessment and diagnosis.

Module 4 – Culturally Responsive Intervention focuses on concepts and strategies the intern or resident should consider in formulating and implementing a culturally responsive intervention plan, regardless of the particular intervention model employed.

Module 5 – Culturally Responsive Systems identifies barriers that consumers and service providers face under the current mental health system, highlights the important role of mental health professionals as agents of institutional change, and offers recommendations to help guide culturally competent systems change.

Clinicians should follow four steps when caring for all patients, but in particular those patients who are from a social or cultural background different from that of the care provider. Clinicians should think of these four steps as a “review of systems” focused on issues that, if not addressed, may lead to poor health outcomes. The four steps are:

1. Identify the core cross-cultural issues
2. Explore the meaning of the illness
3. Determine the social context
4. Negotiate

Step 1—Identify the Core Cross-Cultural Issues. When a clinician sees a patient from a different or unfamiliar socio-cultural background, he or she should consider a broad set of core cross-cultural issues that may be important for that individual. The clinician should try to place the individual patient on a continuum as it relates to issues that are important to all cultures by considering the following:

Styles of communication: How does the patient communicate? Communication includes issues relating to: eye contact, physical contact, and personal space; and issues about how the patient may prefer to hear “bad news.” For example, is the patient deferential or confrontational? Does the patient display stoicism or express symptoms willingly?

Mistrust and prejudice: Does the patient mistrust the health care system? If so, clinicians should recognize prejudice and its effects and attempt to build trust by reassuring the patient of one’s intentions. Keep in perspective “what’s at stake” for the patient, and show respect for the patient’s concerns.

Autonomy, authority, and family dynamics: How does the patient make decisions? What is the role of the family versus the individual in decision making? What support does the patient have from his or her family of origin, partner, and friends? What is the role of the authority figure within the family or social group? What role does community or spiritual leaders play in important decisions?

The role of the practitioner and biomedicine: What does the patient expect of clinicians and what is the clinician’s role? What are the patients’ expectations for the practitioner and biomedicine? What perspectives does the patient have about the practitioner? Does the patient consider the clinician to be a service provider or gatekeeper, for example? What are the patient’s views on alternative medicine versus biomedicine?

Traditions, customs and spirituality: How do these factors influence the patient? These attitudes include issues regarding medical procedures, such as drawing blood, and rituals pertinent to the medical encounter. What culturally specific “alternative” therapies does the patient consider, including culturally specific diet and preferences?

Sexual and gender issues: How central are these issues to the patient’s life? Is there gender concordance or discordance? What attitudes does the patient have toward the physical exam and the gender of the practitioner? Clinicians should use the preferred pronoun for patients who are transgender or transsexual and consider the issue of shame or embarrassment when discussing sexual issues. Consider also the differences in sexual behavior, orientation, and identity.

Step 2—Explore the Meaning of the Illness. Each patient will have a different understanding about disease and treatment. These perspectives will shape the patient’s behavior. It may be particularly helpful to assess the patient’s concept of illness, or “explanatory model,” when the practitioner does not feel he or she understands the patient’s behavior, when there is non-adherence to a treatment plan, or when there is some sort of conflict.

Clinicians can make such determinations by asking the patient the following questions:

What do you think has caused your problem? How?

Why do you think it started when it did?

How does it affect you?

What worries you most: the severity of the condition, or duration of the illness, or both?

What kind of treatment do you think you should receive? What expectations do you have?

Step 3—Determine the Social Context. The “social context” is of equal importance as an area of exploration, given how social and cultural factors are intertwined. Certain key areas should be considered when identifying the patient’s social context:

Tension (social stress and support systems): Does the patient have social support, or is he or she isolated?

Environment change (degree and reason for change, expectations, and acculturation): What was the patient’s previous health care experience, and how does that experience shape his or her interaction with the health care system now?

Life control (including social status, poverty, and education): What resources does the patient have? Can he or she afford medications?

Literacy and language: Does the patient have limited English proficiency or literacy, and how does such a limit affect his or her health care?

Step 4—Negotiate. Once the above information is obtained, the clinician should engage in negotiation with the patient to try to achieve the best possible outcome. Sometimes what is acceptable is better than what is optimal, if the risk of trying to secure the optimal would involve losing the patient’s trust. Such negotiation requires exploring the meaning of the illness for the patient and formulating a mutually acceptable plan.

Counseling Considerations

Counselors bring with them their own degree of effectiveness with these generic characteristics. They also bring with them their cultural manifestations as well as their unique personal, social and psychological background. These factors interact with the cultural and personal factors brought by the client. The interaction of these two sets of factors must be explored along with other counseling-related considerations for each client who comes for counseling. The effective counselor is one who can adapt the counseling models, theories, or techniques to the unique individual needs of each client. This skill requires that the counselor be able to see the client as both an individual and as a member of a particular cultural group. Multicultural counseling requires the recognition of: (1) the importance of racial/ethnic group membership on the socialization of the client; (2) the importance of and the uniqueness of the individual; (3) the presence of and place of values in the counseling process; and (4) the uniqueness of learning styles, vocational goals, and life purposes of clients, within the context of principles of democratic social justice (Locke, 1986).

The Multicultural Awareness Continuum (Locke, 1986) was designed to illustrate the areas of awareness through which a counselor must go in the process of counseling a culturally different client. The continuum is linear and the process is developmental, best understood as a lifelong process.

Self-awareness. The first level through which counselors must pass is self-awareness. Self-understanding is a necessary condition before one begins the process of understanding others. Both intrapersonal and interpersonal dynamics must be considered as important components in the projection of beliefs, attitudes, opinions, and values. The examination of one's own thoughts and feelings allows the counselor a better understanding of the cultural "baggage" he or she brings to the situation.

Awareness of one's own culture. Counselors bring cultural baggage to the counseling situation; baggage that may cause certain things to be taken for granted or create expectations about behaviors and manners. For example, consider your own name and the meaning associated with it. Ask yourself the cultural significance of your name. Could your name have some historical significance to cultures other than the culture of your origin? There may be some relationship between your name and the order of your birth. There may have been a special ceremony conducted when you were named.

The naming process of a child is but one of the many examples of how cultural influences are evident and varied. Language is specific to one's cultural group whether formal, informal, verbal, or nonverbal. Language determines the cultural networks in which an individual participates and contributes specific values to the culture.

Awareness of racism, sexism, and poverty. Racism, sexism, and poverty are all aspects of a culture that must be understood from the perspective of how one views their effect both upon oneself and upon others. The words themselves are obviously powerful terms and frequently evoke some defensiveness. Even when racism and sexism are denied as a part of one's personal belief system, one must recognize that he/she never-the-less exists as a part of the larger culture. Even when the anguish of poverty is not felt personally, the counselor must come to grips with his or her own beliefs regarding financially less fortunate people.

Exploration of the issues of racism, sexism, and poverty may be facilitated by a "systems" approach. Such an exploration may lead to examination of the differences between individual behaviors and organizational behaviors, or what might be called the difference between personal prejudice and institutional prejudice. The influence of organizational prejudice can be seen in the attitudes and beliefs of the system in which the counselor works. Similarly, the awareness that frequently church memberships exist along racial lines, or that some social organizations restrict their membership to one sex, should help counselors come to grips with the organizational prejudice which they may be supporting solely on the basis of participation in a particular organization.

Awareness of individual differences. One of the greatest pitfalls of the novice counselor is to overgeneralize things learned about a specific culture as therefore applicable to all members of the culture. A single thread of commonality is often presumed to exist as interwoven among the group simply because it is observed in one or a few member(s) of the culture. On the contrary, cultural group membership does not require one to sacrifice individualism or uniqueness. In response to the counselor who feels all clients should be treated as "individuals," I say clients must be treated as both individuals and members of their particular cultural group.

Total belief in individualism fails to take into account the "collective family-community" relationship which exists in many cultural groups. A real danger lies in the possibility that counselors may unwittingly discount cultural influences and subconsciously believe they understand the culturally different when, in fact, they view others from their own culture's point of view. In practice, what is put forth as a belief in individualism can become a disregard for any culturally specific behaviors that influence client behaviors. In sum, counselors must be aware of individual differences and come to believe in the uniqueness of the individual before moving to the level of awareness of other cultures.

Awareness of other cultures. The four previously discussed levels of the continuum provide the background and foundation necessary for counselors to explore the varied dynamics of other cultural groups. Most cross-cultural emphasis is currently placed upon African Americans, Native Americans, Mexican Americans or Hispanics, and Asian Americans. Language is of great significance and uniqueness to each of these cultural groups, rendering standard English less than complete in communication of ideas. It is necessary for counselors to be sensitive to words which are unique to a particular culture as well as body language and other nonverbal behaviors to which cultural significance is attached.

Awareness of diversity. The culture of the United States has often been referred to as a "melting pot." This characterization suggests that people came to the United States from many different countries and blended into one new culture. Thus, old world practices were altered, discarded, or maintained within the context of the new culture. For the most part, many cultural groups did not fully participate in the melting pot process. Thus, many African American, Native American, Mexican American, and Asian American cultural practices were not welcomed as the new culture formed.

Of more recent vintage is the term "salad bowl" which implies that the culture of the United States is capable of retaining aspects from all cultures (the various ingredients). Viewed in this manner, we are seen as capable of living, working, and growing together while maintaining a unique cultural identity. "Rainbow coalition" is another term used in a recent political campaign to represent the same idea. Such concepts reflect what many have come to refer to as a multicultural or pluralistic society, where certain features of each culture are encouraged and appreciated by other cultural groups.

Skills/Techniques. The final level on the continuum is to implement what has been learned about working with culturally different groups and add specific techniques to the repertoire of counseling skills. Before a counselor can effectively work with clients of diverse cultural heritage, he or she must have developed general competence as a counselor. Passage through the awareness continuum constitutes professional growth and will contribute to an increase in overall counseling effectiveness, but goes much further than that. Counselors must be aware of learning theory and how theory relates to the development of psychological-cultural factors. Counselors must understand the relationship between theory and counselors' strategies or practices. Most importantly, counselors must have developed a sense of worth in their own cultures before attaining competence in counseling the culturally different.

Cultural Constraints

People define cultural constructs within the context of their own life histories, growth, and current situations. A working framework for competence in the care of HIV-infected clients must take the following areas of cultural concern into account for each individual:

  • Demographics: race, ethnicity, gender, age, generation
  • Communication: language(s), literacy (reading, speaking, health)
  • Education level: functional as well as actual
  • Economic status of the individual and the environment in which s/he functions
  • Occupation/means of support: work status, current means of income (legal? illegal? borderline?), labor, profession
  • Geography: current residence, community/neighborhood, place of birth, legal status, travel, nationality, etc.
  • Environment and situational context: safety of communities in which the individual spends a significant amount of time; risks related to violence, fear of violence, or coercion; communities of risk (i.e., drug/alcohol use, anonymous sex)
  • Personal relationships: family, friends, partnerships, sex, drugs, etc.
  • Health (physical, emotional, mental): norms, beliefs, practices, preferred providers, taboos; definitions of health, disease/sick role, disability, and care; HIV and other disease diagnoses, treatments, achievements; perceptions (developed over time) of efficacy, value, and disparity/discrimination in relationships with various healthcare systems and providers
  • Gender and sex: gender, gender roles, transitions, sexual orientation, sexual intercourse
  • Community affiliations: religious, political, service, social, etc.
  • Culture-specific definitions: spirituality, art, ethics, value, locus of control, power
  • Individual experiences: development over time that has lead the individual to accept, reject, and/or modify cultural components that were imparted to him/her as a child; life experiences that have expanded, challenged, realigned, or reinforced early cultural influences; individual constellation of factors that make up her/his cultural orientation
  • Culture comfort: has the individual integrated a personal set of cultural influences into his/her life? how do those beliefs and practices intersect with health practices and self-acceptance? can the individual function within larger social systems (family, community, social structures)? is the individual in a state of cognitive dissonance, discord, or discomfort with/between the values of personal, familial, and/or social cultures?
Providers. Healthcare providers possess knowledge and skills that were developed in a process of professional education. They have their own language, expectations, and professional cultures.  They also have responsibilities:
  • To develop skills to assess individual client cultures and to work with the client to integrate components of that culture into a care and treatment plan that the client can accept.
  • To be open to learning about the ways of others and willing to see past stereotypes when working with individuals and families.
  • To suspend judgment, especially in the assessment phases of care.
  • To remember that individuals are unique even within groups: some Hispanics do not speak Spanish, some women are not mothers, some Catholics use birth control, and some college-educated people use alternative/traditional healthcare practices.
  • To adopt an attitude of service to the client and the community.
  • To explore, understand, and honor their own cultural definitions and values.
  • To constantly compare personal culture(s) within the context of professional obligations.
  • To deal with any dissonance that occurs between cultures by “honoring and setting aside” or by making personally acceptable changes and developing methods of dealing with larger culture clashes and ethical dilemmas that can occur in cross-cultural settings.
  • To accept responsibility as the power broker in healthcare situations to address healthcare in a holistic manner that includes culture.
Client. The client also has obligations:
  1. To share the components of her/his culture that will impact on the ability to seek care, to participate in the process of developing a healthcare plan, and to implement care prescriptions.
  2. To seek care from providers who understand his/her culture.
  3. To teach providers who are open to these discussions.
Unfortunately, many clients feel that they are in a “one down” position in ANY healthcare setting, especially if they are poor, do not understand healthcare systems, have cultural constraints against disagreeing with authority figures, or already suffer from discrimination by virtue of race, ethnicity, gender, status, or diagnosis (especially HIV, drug use, mental health problems, and STDs).  Because of this, the provider’s responsibility to honor various cultures is imperative.

Overview of Cultural Diversity and Mental Health Services

The U.S. mental health system is not well equipped to meet the needs of racial and ethnic minority populations. Racial and ethnic minority groups are generally considered to be underserved by the mental health services system (Neighbors et al., 1992; Takeuchi & Uehara, 1996; Center for Mental Health Services [CMHS], 1998). A constellation of barriers deters ethnic and racial minority group members from seeking treatment, and if individual members of groups succeed in accessing services, their treatment may be inappropriate to meet their needs.

Awareness of the problem dates back to the 1960s and 1970s, with the rise of the civil rights and community mental health movements (Rogler et al., 1987) and with successive waves of immigration from Central America, the Caribbean, and Asia (Takeuchi & Uehara, 1996). These historical forces spurred greater recognition of the problems that minority groups confront in relation to mental health services.

Research documents that many members of minority groups fear, or feel ill at ease with, the mental health system (Lin et al., 1982; Sussman et al., 1987; Scheffler & Miller, 1991). These groups experience it as the product of white, European culture, shaped by research primarily on white, European populations. They may find only clinicians who represent a white middle-class orientation, with its cultural values and beliefs, as well as its biases, misconceptions, and stereotypes of other cultures.

Research and clinical practice have propelled advocates and mental health professionals to press for “linguistically and culturally competent services” to improve utilization and effectiveness of treatment for different cultures. Culturally competent services incorporate respect for and understanding of, ethnic and racial groups, as well as their histories, traditions, beliefs, and value systems (CMHS, 1998). Without culturally competent services, the failure to serve racial and ethnic minority groups adequately is expected to worsen, given the huge demographic growth in these populations predicted over the next decades (Takeuchi & Uehara, 1996; CMHS, 1998; Snowden, 1999).

This section of the chapter amplifies these major conclusions. It explains the confluence of clinical, cultural, organizational, and financial reasons for minority groups being underserved by the mental health system. The first task, however, is to explain which ethnic and racial groups constitute underserved populations, to describe their changing demographics, and to define the term “culture” and its consequences for the mental health system.

Introduction to Cultural Diversity and Demographics

The Federal government officially designates four major racial or ethnic minority groups in the United States: African American (black), Asian/Pacific Islander, Hispanic American (Latino), and Native American/American Indian/Alaska Native/Native Hawaiian (referred to subsequently as “American Indians”) (CMHS, 1998). There are many other racial or ethnic minorities and considerable diversity within each of the four groupings listed above. The representation of the four officially designated groups in the U.S. population in 1999 is as follows: African Americans constitute the largest group, at 12.8 percent of the U.S. population; followed by Hispanics (11.4 percent), Asian/Pacific Islanders (4.0 percent), and American Indians (0.9 percent) (U.S. Census Bureau, 1999). Hispanic Americans are among the fastest-growing groups. Because their population growth outpaces that of African Americans, they are projected to be the predominant minority group (24.5 percent of the U.S. population) by the year 2050 (CMHS, 1998).

Racial and ethnic populations differ from one another and from the larger society with respect to culture. The term “culture” is used loosely to denote a common heritage and set of beliefs, norms, and values. The cultures with which members of minority racial and ethnic groups identify often are markedly different from industrial societies of the West. The phrase “cultural identity” specifies a reference group—an identifiable social entity with whom a person identifies and to whom he or she looks for standards of behavior (Cooper & Denner, 1998). Of course, within any given group, an individual’s cultural identity may also involve language, country of origin, acculturation, gender, age, class, religious/spiritual beliefs, sexual orientation, and physical disabilities (Lu et al., 1995). Many people have multiple ethnic or cultural identities.

The historical experiences of ethnic and minority groups in the United States are reflected in differences in economic, social, and political status. The most measurable difference relates to income. Many racial and ethnic minority groups have limited financial resources. In 1994, families from these groups were at least three times as likely as white families to have incomes placing them below the Federally established poverty line. The disparity is even greater when considering extreme poverty—family incomes at a level less than half of the poverty threshold—and is also large when considering children and older persons (O’Hare, 1996). Although some Asian Americans are somewhat better off financially than other minority groups, they still are more than one and a half times more likely than whites to live in poverty. Poverty disproportionately affects minority women and their children (Miranda & Green, 1999). The effects of poverty are compounded by differences in total value of accumulated assets, or total wealth (O’Hare et al., 1991).

Lower socioeconomic status—in terms of income, education, and occupation—has been strongly linked to mental illness. It has been known for decades that people in the lowest socioeconomic strata are about two and a half times more likely than those in the highest strata to have a mental disorder (Holzer et al., 1986; Regier et al., 1993b). The reasons for the association between lower socioeconomic status and mental illness are not well understood. It may be that a combination of greater stress in the lives of the poor and greater vulnerability to a variety of stressors leads to some mental disorders, such as depression. Poor women, for example, experience more frequent, threatening, and uncontrollable life events than do members of the population at large (Belle, 1990). It also may be that the impairments associated with mental disorders lead to lower socioeconomic status (McLeod & Kessler, 1990; Dohrenwend, 1992; Regier et al., 1993b).

Cultural identity imparts distinct patterns of beliefs and practices that have implications for the willingness to seek, and the ability to respond to, mental health services. These include coping styles and ties to family and community, discussed below.

Coping Styles

Cultural differences can be reflected in differences in preferred styles of coping with day-to-day problems. Consistent with a cultural emphasis on restraint, certain Asian American groups, for example, encourage a tendency not to dwell on morbid or upsetting thoughts, believing that avoidance of troubling internal events is warranted more than recognition and outward expression (Leong & Lau, 1998). They have little willingness to behave in a fashion that might disrupt social harmony (Uba, 1994). Their emphasis on willpower is similar to the tendency documented among African Americans to minimize the significance of stress and, relatedly, to try to prevail in the face of adversity through increased striving (Broman, 1996).

Culturally rooted traditions of religious beliefs and practices carry important consequences for willingness to seek mental health services. In many traditional societies, mental health problems can be viewed as spiritual concerns and as occasions to renew one’s commitment to a religious or spiritual system of belief and to engage in prescribed religious or spiritual forms of practice. African Americans (Broman, 1996) and a number of ethnic groups (Lu et al., 1995), when faced with personal difficulties, have been shown to seek guidance from religious figures.

Many people of all racial and ethnic backgrounds believe that religion and spirituality favorably impact upon their lives and that well-being, good health, and religious commitment or faith are integrally intertwined (Taylor, 1986; Priest, 1991; Bacote, 1994; Pargament, 1997). Religion and spirituality are deemed important because they can provide comfort, joy, pleasure, and meaning to life as well as be means to deal with death, suffering, pain, injustice, tragedy, and stressful experiences in the life of an individual or family (Pargament, 1997). In the family/community-centered perception of mental illness held by Asians and Hispanics, religious organizations are viewed as an enhancement or substitute when the family is unable to cope or assist with the problem (Acosta et al., 1982; Comas-Diaz, 1989; Cook & Timberlake, 1989; Meadows, 1997).

Culture also imprints mental health by influencing whether and how individuals experience the discomfort associated with mental illness. When conveyed by tradition and sanctioned by cultural norms, characteristic modes of expressing suffering are sometimes called “idioms of distress” (Lu et al., 1995). Idioms of distress often reflect values and themes found in the societies in which they originate.

One of the most common idioms of distress is somatization, the expression of mental distress in terms of physical suffering. Somatization occurs widely and is believed to be especially prevalent among persons from a number of ethnic minority backgrounds (Lu et al., 1995). Epidemiological studies have confirmed that there are relatively high rates of somatization among African Americans (Zhang & Snowden, in press). Indeed, somatization resembles an African American folk disorder identified in ethnographic research and is linked to seeking treatment (Snowden, 1998).

A number of idioms of distress are well recognized as culture-bound syndromes and have been included in an appendix to DSM-IV. Among culture-bound syndromes found among some Latino psychiatric patients is ataque de nervios, a syndrome of “uncontrollable shouting, crying, trembling, and aggression typically triggered by a stressful event involving family. . . ” (Lu et al., 1995, p. 489). A Japanese culture-bound syndrome has appeared in that country’s clinical modification of ICD-10 (WHO International Classification of Diseases, 10th edition, 1993). Taijin kyofusho is an intense fear that one’s body or bodily functions give offense to others. Culture-bound syndromes sometimes reflect comprehensive systems of belief, typically emphasizing a need for a balance between opposing forces (e.g., yin/yang, “hot-cold” theory) or the power of supernatural forces (Cheung & Snowden, 1990). Belief in indigenous disorders and adherence to culturally rooted coping practices are more common among older adults and among persons who are less acculturated. It is not well known how applicable DSM-IV diagnostic criteria are to culturally specific symptom expression and culture-bound syndromes.

Family and Community as Resources

Ties to family and community, especially strong in African, Latino, Asian, and Native American communities, are forged by cultural tradition and by the current and historical need to assist arriving immigrants, to provide a sanctuary against discrimination practiced by the larger society, and to provide a sense of belonging and affirming a centrally held cultural or ethnic identity.

Among Mexican-Americans (del Pinal & Singer, 1997) and Asian Americans (Lee, 1998) relatively high rates of marriage and low rates of divorce, along with a greater tendency to live in extended family households, indicate an orientation toward family. Family solidarity has been invoked to explain relatively low rates among minority groups of placing older people in nursing homes (Short et al., 1994).

The relative economic success of Chinese, Japanese, and Korean Americans has been attributed to family and communal bonds of association (Fukuyama, 1995). Community organizations and networks established in the United States include rotating credit associations based on lineage, surname, or region of origin. These organizations and networks facilitate the startup of small businesses.

There is evidence of an African American tradition of voluntary organizations and clubs often having political, economic, and social functions and affiliation with religious organizations (Milburn & Bowman, 1991). African Americans and other racial and ethnic minority groups have drawn upon an extended family tradition in which material and emotional resources are brought to bear from a number of linked households. According to this literature, there is “(a) a high degree of geographical propinquity; (b) a strong sense of family and familial obligation; (c) fluidity of household boundaries, with greater willingness to absorb relatives, both real and fictive, adult and minor, if need arises; (d) frequent interaction with relatives; (e) frequent extended family get-togethers for special occasions and holidays; and (f) a system of mutual aid” (Hatchett & Jackson, 1993, p. 92).

Families play an important role in providing support to individuals with mental health problems. A strong sense of family loyalty means that, despite feelings of stigma and shame, families are an early and important source of assistance in efforts to cope, and that minority families may expect to continue to be involved in the treatment of a mentally ill member (Uba, 1994). Among Mexican American families, researchers have found lower levels of expressed emotion and lower levels of relapse (Karno et al., 1987). Other investigators have demonstrated an association between family warmth and a reduced likelihood of relapse (Lopez et al., in press).

Epidemiology and Utilization of Services

One of the best ways to identify whether a minority group has problems accessing mental health services is to examine their utilization of services in relation to their need for services. As noted previously, a limitation of contemporary mental health knowledge is the lack of standard measures of “need for treatment” and culturally appropriate assessment tools. Minority group members’ needs, as measured indirectly by their prevalence of mental illness in relation to the U.S. population, should be proportional to their utilization, as measured by their representation in the treatment population. These comparisons turn out to be exceedingly complicated by inadequate understanding of the prevalence of mental disorders among minority groups in the United States.  Nationwide studies conducted many years ago overlooked institutional populations, which are disproportionately represented by minority groups. Treatment utilization information on minority groups in relation to whites is more plentiful, yet, a clear understanding of health seeking behavior in various cultures is lacking.

The following paragraphs reveal that disparities abound in treatment utilization: some minority groups are underrepresented in the outpatient treatment population while, at the same time, overrepresented in the inpatient population. Possible explanations for the differences in utilization are discussed in a later section.

African Americans

The prevalence of mental disorders is estimated to be higher among African Americans than among whites (Regier et al., 1993a). This difference does not appear to be due to intrinsic differences between the races; rather, it appears to be due to socioeconomic differences. When socioeconomic factors are taken into account, the prevalence difference disappears. That is, the socioeconomic status-adjusted rates of mental disorder among African Americans turn out to be the same as those of whites. In other words, it is the lower socioeconomic status of African Americans that places them at higher risk for mental disorders (Regier et al., 1993a).

African Americans are underrepresented in some outpatient treatment populations, but overrepresented in public inpatient psychiatric care in relation to whites (Snowden & Cheung, 1990; Snowden, in press-b). Their underrepresentation in outpatient treatment varies according to setting, type of provider, and source of payment. The racial gap between African Americans and whites in utilization is smallest, if not nonexistent, in community-based programs and in treatment financed by public sources, especially Medicaid (Snowden, 1998) and among older people (Padgett et al., 1995). The underrepresentation is largest in privately financed care, especially individual outpatient practice, paid for either by fee-for-service arrangements or managed care. As a result, underrepresentation in the outpatient setting occurs more among working and middle-class African Americans, who are privately insured, than among the poor. This suggests that socioeconomic standing alone cannot explain the problem of underutilization (Snowden, 1998).

African Americans are, as noted above, overrepresented in inpatient psychiatric care (Snowden, in press-b). Their rate of utilization of psychiatric inpatient care is about double that of whites (Snowden & Cheung, 1990). This difference is even higher than would be expected on the basis of prevalence estimates. Overrepresentation is found in hospitals of all types except private psychiatric hospitals.  While difficult to explain definitively, the problem of overrepresentation in psychiatric hospitals appears more rooted in poverty, attitudes about seeking help, and a lack of community support than in clinician bias in diagnosis and overt racism, which also have been implicated (Snowden, in press-b). This line of reasoning posits that poverty, disinclination to seek help, and lack of health and mental health services deemed appropriate, and responsive, as well as community support, are major contributors to delays by African Americans in seeking treatment until symptoms become so severe that they warrant inpatient care.

Finally, African Americans are more likely than whites to use the emergency room for mental health problems (Snowden, in press-a). Their overreliance on emergency care for mental health problems is an extension of their overreliance on emergency care for other health problems. The practice of using the emergency room for routine care is generally attributed to a lack of health care providers in the community willing to offer routine treatment to people without insurance (Snowden, in press-a).

Asian Americans/Pacific Islanders

The prevalence of mental illness among Asian Americans is difficult to determine for methodological reasons (i.e., population sampling). Although some studies suggest higher rates of mental illness, there is wide variance across different groups of Asian Americans (Takeuchi & Uehara, 1996). It is not well known how applicable DSM-IV diagnostic criteria are to culturally specific symptom expression and culture-bound syndromes. With respect to treatment-seeking behavior, Asian Americans are distinguished by extremely low levels at which specialty treatment is sought for mental health problems (Leong & Lau, 1998). Asian Americans have proven less likely than whites, African Americans, and Hispanic Americans to seek care. One national sample revealed that Asian Americans were only a quarter as likely as whites, and half as likely as African Americans and Hispanic Americans, to have sought outpatient treatment (Snowden, in press-a). Asian Americans/Pacific Islanders are less likely than whites to be psychiatric inpatients (Snowden & Cheung, 1990). The reasons for the underutilization of services include the stigma and loss of face over mental health problems, limited English proficiency among some Asian immigrants, different cultural explanations for the problems, and the inability to find culturally competent services. These phenomena are more pronounced for recent immigrants (Sue et al., 1994).

Hispanic Americans

Several epidemiological studies revealed few differences between Hispanic Americans and whites in lifetime rates of mental illness (Robins & Regier, 1991; Vega & Kolody, 1998). A recent study of Mexican Americans in Fresno County, California, found that Mexican Americans born in the United States had rates of mental disorders similar to those of other U.S. citizens, whereas immigrants born in Mexico had lower rates (Vega et al., 1998a). A large study conducted in Puerto Rico reported similar rates of mental disorders among residents of that island, compared with those of citizens of the mainland United States (Canino et al., 1987).

Although rates of mental illness may be similar to whites in general, the prevalence of particular mental health problems, the manifestation of symptoms, and help-seeking behaviors within Hispanic subgroups need attention and further research. For instance, the prevalence of depressive symptomatology is higher in Hispanic women (46%) than men (almost 20%); yet, the known risk factors do not totally explain the gender difference (Vega et al., 1998a; Zunzunegui et al., 1998). Several studies indicate that Puerto Rican and Mexican American women with depressive symptomatology are underrepresented in mental health services and overrepresented in general medical services (Hough et al., 1987; Sue et al., 1991, 1994; Duran, 1995; Jimenez et al., 1997).

Native Americans

American Indians/Alaska Natives have, like Asian Americans and Pacific Islanders, been studied in few epidemiological surveys of mental health and mental disorders. The indications are that depression is a significant problem in many American Indian/Alaska Native communities (Nelson et al., 1992). One study of a Northwest Indian village found rates of DSM-III-R affective disorder that were notably higher than rates reported from national epidemiological studies (Kinzie et al., 1992). Alcohol abuse and dependence appear also to be especially problematic, occurring at perhaps twice the rate of occurrence found in any other population group. Relatedly, suicide occurs at alarmingly high levels. (Indian Health Service, 1997). Among Native American veterans, post-traumatic stress disorder has been identified as especially prevalent in relation to whites (Manson, 1998). In terms of patterns of utilization, Native Americans are overrepresented in psychiatric inpatient care in relation to whites, with the exception of private psychiatric hospitals (Snowden & Cheung, 1990; Snowden, in press-b).

Barriers to the Receipt of Treatment

The underrepresentation in outpatient treatment of racial and ethnic minority groups appears to be the result of cultural differences as well as financial, organizational, and diagnostic factors. The service system has not been designed to respond to the cultural and linguistic needs presented by many racial and ethnic minorities. What is unresolved are the relative contribution and significance of each factor for distinct minority groups.

Help-Seeking Behavior

Among adults, the evidence is considerable that persons from minority backgrounds are less likely than are whites to seek outpatient treatment in the specialty mental health sector (Sussman et al., 1987; Gallo et al., 1995; Leong & Lau, 1998; Snowden, 1998; Vega et al., 1998a, 1998b; Zhang et al., 1998). This is not the case for emergency department care, from which African Americans are more likely than whites to seek care for mental health problems, as noted above. Language, like economic and accessibility differences, can play an important role in why people from other cultures do not seek treatment (Hunt, 1984; Comas-Diaz, 1989; Cook & Timberlake, 1989; Taylor, 1989).


The reasons why racial and ethnic minority groups are less apt to seek help appear to be best studied among African Americans. By comparison with whites, African Americans are more likely to give the following reasons for not seeking professional help in the face of depression: lack of time, fear of hospitalization, and fear of treatment (Sussman et al., 1987). Mistrust among African Americans may stem from their experiences of segregation, racism, and discrimination (Primm et al., 1996; Priest, 1991). African Americans have experienced racist slights in their contacts with the mental health system, called “microinsults” by Pierce (1992). Some of these concerns are justified on the basis of research, cited below, revealing clinician bias in overdiagnosis of schizophrenia and underdiagnosis of depression among African Americans.

Lack of trust is likely to operate among other minority groups, according to research about their attitudes toward government-operated institutions rather than toward mental health treatment per se. This is particularly pronounced for immigrant families with relatives who may be undocumented, and hence they are less likely to trust authorities for fear of being reported and having the family member deported. People from El Salvador and Argentina who have experienced imprisonment or watched the government murder family members and engage in other atrocities may have an especially strong mistrust of any governmental authority (Garcia & Rodriguez, 1989). Within the Asian community, previous refugee experiences of groups such as Vietnamese, Indochinese, and Cambodian immigrants parallel those experienced by Salvadoran and Argentine immigrants. They, too, experienced imprisonment, death of family members or friends, physical abuse, and assault, as well as new stresses upon arriving in the United States (Cook & Timberlake, 1989; Mollica, 1989).

American Indians’ past experience in this country also imparted lack of trust of government. Those living on Indian reservations are particularly fearful of sharing any information with white clinicians employed by the government. As with African Americans, the historical relationship of forced control, segregation, racism, and discrimination has affected their ability to trust a white majority population (Herring, 1994; Thompson, 1997).


The stigma of mental illness is another factor preventing African Americans from seeking treatment, but not at a rate significantly different from that of whites. Both African American and white groups report that embarrassment hinders them from seeking treatment (Sussman et al., 1987). In general, African Americans tend to deny the threat of mental illness and strive to overcome mental health problems through self-reliance and determination (Snowden, 1998). Stigma, denial, and self-reliance are likely explanations why other minority groups do not seek treatment, but their contribution has not been evaluated empirically, owing in part to the difficulty of conducting this type of research. One of the few studies of Asian Americans identified the barriers of stigma, suspiciousness, and a lack of awareness about the availability of services (Uba, 1994). Cultural factors tend to encourage the use of family, traditional healers, and informal sources of care rather than treatment-seeking behavior, as noted earlier.


Cost is yet another factor discouraging utilization of mental health services (Chapter 6). Minority persons are less likely than whites to have private health insurance, but this factor alone may have little bearing on access. Public sources of insurance and publicly supported treatment programs fill some of the gap. Even among working class and middle-class African Americans who have private health insurance, there is underrepresentation of African Americans in outpatient treatment (Snowden, 1998). Yet studies focusing only on poor women, most of whom were members of minority groups, have found cost and lack of insurance to be barriers to treatment (Miranda & Green, 1999). The discrepancies in findings suggest that much research remains to be performed on the relative importance of cost, cultural, and organizational barriers, and poverty and income limitations across the spectrum of racial and ethnic and minority groups.

Clinician Bias

Advocates and experts alike have asserted that bias in clinician judgment is one of the reasons for overutilization of inpatient treatment by African Americans. Bias in clinician judgment is thought to be reflected in overdiagnosis or misdiagnosis of mental disorders. Since diagnosis is heavily reliant on behavioral signs and patients’ reporting of the symptoms, rather than on laboratory tests, clinician judgment plays an enormous role in the diagnosis of mental disorders. The strongest evidence of clinician bias is apparent for African Americans with schizophrenia and depression. Several studies found that African Americans were more likely than were whites to be diagnosed with schizophrenia, yet less likely to be diagnosed with depression (Snowden & Cheung, 1990; Hu et al., 1991; Lawson et al., 1994).

In addition to problems of overdiagnosis or misdiagnosis, there may well be a problem of underdiagnosis among minority groups, such as Asian Americans, who are seen as “problem-free” (Takeuchi & Uehara, 1996). The presence and extent of this type of clinician bias are not known and need to be investigated.

Improving Treatment for Minority Groups

The previous paragraphs have documented underutilization of treatment, less help-seeking behavior, inappropriate diagnosis, and other problems that have beset racial and ethnic minority groups with respect to mental health treatment. This kind of evidence has fueled the widespread perception of mental health treatment as being uninviting, inappropriate, or not as effective for minority groups as for whites. The Schizophrenia Patient Outcome Research Team demonstrated that African Americans were less likely than others to have received treatment that conformed to recommended practices (Lehman & Steinwachs, 1998). Inferior treatment outcomes are widely assumed but are difficult to prove, especially because of sampling, questionnaire, and other design issues, as well as problems in studying patients who drop out of treatment after one session or who otherwise terminate prematurely. In a classic study, 50 percent of Asian Americans versus 30 percent of whites dropped out of treatment early (Sue & McKinney, 1975). However, the disparity in dropout rates may have abated more recently (O’Sullivan et al., 1989; Snowden et al., 1989). One of the few studies of clinical outcomes, a pre- versus post-treatment study, found that African Americans fared more poorly than did other minority groups treated as outpatients in the Los Angeles area (Sue et al., 1991). Earlier studies from the 1970s and 1980s had given inconsistent results (Sue et al., 1991).


There is mounting awareness that ethnic and cultural influences can alter an individual’s responses to medications (pharmacotherapies). The relatively new field of ethnopsychopharmacology investigates cultural variations and differences that influence the effectiveness of pharmacotherapies used in the mental health field. These differences are both genetic and psychosocial in nature. They range from genetic variations in drug metabolism to cultural practices that affect diet, medication adherence, placebo effect, and simultaneous use of traditional and alternative healing methods (Lin et al., 1997). Just a few examples are provided to illustrate ethnic and racial differences.

Pharmacotherapies given by mouth usually enter the circulation after absorption from the stomach. From the circulation they are distributed throughout the body (including the brain for psychoactive drugs) and then metabolized, usually in the liver, before they are cleared and eliminated from the body (Brody, 1994). The rate of metabolism affects the amount of the drug in the circulation. A slow rate of metabolism leaves more drug in the circulation. Too much drug in the circulation typically leads to heightened side effects. A fast rate of metabolism, on the other hand, leaves less drug in the circulation. Too little drug in the circulation reduces its effectiveness.

There is wide racial and ethnic variation in drug metabolism. This is due to genetic variations in drug-metabolizing enzymes (which are responsible for breaking down drugs in the liver). These genetic variations alter the activity of several drug-metabolizing enzymes. Each drug-metabolizing enzyme normally breaks down not just one type of pharmacotherapy, but usually several types. Since most of the ethnic variation comes in the form of inactivation or reduction in activity in the enzymes, the result is higher amounts of medication in the blood, triggering untoward side effects.

For example, 33 percent of African Americans and 37 percent of Asians are slow metabolizers of several antipsychotic medications and antidepressants (such as tricyclic antidepressants and selective serotonin reuptake inhibitors) (Lin et al., 1997). This awareness should lead to more cautious prescribing practices, which usually entail starting patients at lower doses in the beginning of treatment. Unfortunately, just the opposite typically had been the case with African American patients and antipsychotic drugs. Clinicians in psychiatric emergency services prescribed more oral doses and more injections of antipsychotic medications to African American patients (Segel et al., 1996). The combination of slow metabolism and overmedication of antipsychotic drugs in African Americans can yield very uncomfortable extrapyramidal  side effects (Lin et al., 1997). These are the kinds of experiences that likely contribute to the mistrust of mental health services reported among African Americans (Sussman et al., 1987).

Psychosocial factors also can play an important role in ethnic variation. Compliance with dosing may be hindered by communication difficulties; side effects can be misinterpreted or carry different connotations; some groups may be more responsive to placebo treatment; and reliance on psychoactive traditional and alternative healing methods (such as medicinal plants and herbs) may result in interactions with prescribed pharmacotherapies. The result could be greater side effects and enhanced or reduced effectiveness of the pharmacotherapy, depending on the agents involved and their concentrations (Lin et al., 1997). Greater awareness of ethnopsychopharmacology is expected to improve treatment effectiveness for racial and ethnic minorities. More research is needed on this topic across racial and ethnic groups.

20 The term “Latino(a)” refers to all persons of Mexican, Puerto Rican, Cuban, or other Central and South American or Spanish origin (CMHS, 1998).

21 Acculturation refers to the “social distance” separating members of an ethnic or racial group from the wider society in areas of beliefs and values and primary group relations (work, social clubs, family, friends) (Gordon, 1964). Greater acculturation thus reflects greater adoption of mainstream beliefs and practices and entry into primary group relations.

22 Research is emerging on the importance of tailoring services to the special needs of gay, lesbian, and bisexual mental health service users (Cabaj & Stein, 1996).

23 Of the 15 percent of the U.S. population that use mental health services in a given year, about 2.8 percent receive care only from members of the clergy (Larson et al., 1988).

24 In spring 2000, survey field work begins on an NIMH-funded study of the prevalence of mental disorders, mental health symptoms, and related functional impairments in African Americans, Caribbean blacks, and non-Hispanic whites. The study will examine the effects of psychosocial factors and race-associated stress on mental health, and how coping resources and strategies influence that impact. The study will provide a database on mental health, mental disorders, and ethnicity and race. James Jackson, Ph.D., University of Michigan, is principal investigator.

25 African Americans are overrepresented among persons undergoing involuntary civil commitment (Snowden, in press-b).

26 Dystonia (brief or prolonged contraction of muscles), akathisia (an urge to move about constantly), or parkinsonism (tremor and rigidity) (Perry et al., 1997).

 Continuing disparities in the diagnosis and effective treatment of depression persist. Many of these contributing factors can be grouped into three broad categories.

First, larger societal issues such as poverty, racism and discrimination, unemployment and underemployment, and inadequate housing have an impact on health/mental health status of diverse racial and ethnic groups.

Second, differential access to services has been demonstrated to be a factor in disparities. Access involves more than availability and affordability of services. Access also refers to an active connection with the patient. Thus, acceptability of services—how they are offered, where they are offered and by whom—is a significant factor in access.

Third, cultural and linguistic factors have been identified as contributing to disparities including language barriers, diverse belief systems related to health, mental health, healing and well-being, culturally influenced help-seeking behaviors, attitudes toward care providers, and individual preferences and approaches to care.

While continuing medical education (CME) can not address all of these issues, all may be positively impacted in the long run by health and mental health care providers who are aware of disparities and societal issues that contribute to them, and who have the knowledge and skills necessary to diagnose and treat depression effectively in culturally and linguistically diverse patient populations.

One of the five essential elements of cultural and linguistic competence is the capacity for self-assessment at both the organizational and individual levels. This continuing education activity will help you to assess yourself on cultural and linguistic competence in relation to the diagnosis and treatment of depression.

This continuing education activity allows you to assess your awareness, knowledge and/or skills in six domains:

  • Values and Belief Systems -- perspectives on health, illness, mental health, well-being, care-seeking behaviors, traditional health practices, and spirituality of your patients and their communities as well as family/community dynamics.

  • Cultural Influences on Illness and Related Problems -- health and mental health disparities and risk factors for culturally and linguistically diverse groups and communities.

  • Depression and Health -- awareness of the relationship between illness and the risk for depression and the impact of depression on treatment and clinical course of diabetes, cardiovascular disease and HIV/AIDS

  • Clinical Management -- screening, assessment/diagnosis, treatment/discharge planning, and use of community-based resources.

  • Cross-Cultural Communication -- cross-cultural communication, utilization of different modes of communication, and the provision of interpretation/translation services.

  • Promotion of Cultural and Linguistic Competence in Systems of Care and Communities -- the practitioners’ role in providing information that enables individuals to intervene on their own behalf, advocate and build community capacity for improved health, mental health, and well being.

Multicultural Issues

The term "culture" can be reasonably applied to various population categories. There are cultures or subcultures, for example, that reflect differences of age, gender, sexual orientation, religion, and geographic region. Each of these groups employ particular ways of viewing and meeting the challenges, traumas, and triumphs of life. For this discussion, however, culture represents race and ethnicity. It is this diversity that both enriches and obstructs much of our involvement and interaction with others.

Across America, racial and ethnic heritages are being dramatically interwoven. An array of languages, religions, customs, and traditions is infusing our nation with both vibrancy and challenge. Molefi Asante, chair of African American Studies at Temple University has stated:

"Once America was a microcosm of European nationalities,
today America is a microcosm of the world."

Such an occurrence is not necessarily the harbinger of chaos. Inevitably and even enthusiastically, this emergence must be accepted and endorsed.

The criminal justice system is not exempt from the consequences of these demographic changes that are generating a new definition of "American." As the European American population continues to decrease in relative percentage, there is a corresponding and accelerating increase of Latino, Asian, and African Americans. This raises the following concerns or questions for victim service providers:

  • How does the criminal justice system adhere to equal justice for this diversity of people?

  • How can victim assistance programs fashion priorities and ensure competence in order to serve the widening spectrum, rather than exclusive number, of people?

There are two eternal truths about human beings:

  • People differ from one another.

  • People are similar to one another.

When the distinctiveness of others is considered, there can be a tendency to over-generalize in order to highlight the commonalties within cultural identities. The variety within cultural groups, however, may be obscured by the emphasis placed in distinguish-ing between them. Any aggregate labeling of people is, in other words, part logic and part insult.

The term "Indian," for example, was a misnomer foisted upon the Arawak tribe of the southeastern United States by an errant Italian navigator who had set sail for India. It is now (mistakenly) used to describe all the native populations of the Western Hemisphere.

  • "American Indians," perhaps preferably called "Native Americans," are now acknowledged by the Bureau of the Census to be over 500 separate nations and tribes with 187 different languages.

The term "Hispanic" refers to those who share a common language, i.e. Spanish. But not everyone who is from Mexico speaks Spanish, e.g. the native peoples from the central mountains.

  • There are also noticeable class differences between destitute Guatemalan refugees who have fled violent political upheaval in their homeland and relatively prosperous Costa Ricans who enjoyed some measure of social and economic stability.

Just as it is presumptuous to consider a Bostonian Irishman, an Anglo-California yuppie, a Jewish Greenwich Village artist, a Texas rodeo star, and a New Age Santa Fe vegetarian as all the same because they are coincidentally "white," it is just as unwise to render all "Latinos" (or Asians or African Americans) as inherently alike. As Ross, Millen, and Martinez have pointed out, "There are some ways in which any particular Chicano is like all other Chicanos, and there are some ways in which a particular Chicano is like no other Chicano."

Points to Reflect Upon in Providing Services

  • No one is just what we label or classify them.

  • Who we are is inseparable from our racial and ethnic backgrounds but not strictly determined by them.

  • All crime victims deserve to be treated as individuals even as the nuances of race and culture (and the degrees of acculturation) are recognized.

  • Victim counselors must be aware of the cultural context of the victims with whom they are working, continually assess the adequacy of their communication styles and counseling methods, and be flexible enough to make adjustments on a case-by-case basis.

What "Culturally-Sensitive Service" is Not

Color Blindness

I haven't noticed that you are different. We are all humans. We all have the same feelings. I don't care if you are pink, green or purple.

Presumably with good intentions to treat everyone equally, such overtures are sometimes made by victim counselors. There is, however, no universal response to suffering. The role of racial experience and cultural history cannot be readily dissolved into some melting pot of generic humanity. As Tello states:

"What it (color blindness) does demonstrate is the service provider's inability to understand and articulate these differences. When this occurs, the service provider may attempt to justify his or her own position by mini-mizing the role of culture."

Individual experiences in culture, language and identity serve to filter and shape how a person perceives events and reacts to both small and life-altering events. As Parsons writes:

"Ethnic identification is an irreducible entity, central to how persons organize experience."

Memorizing Cultural Idiosyncrasies

Service to culturally diverse crime victims is not primarily a command of every minute custom or memorization of an encyclopedia of rigid "do's and don'ts." This would be an impossible task.

  • A stereotypic approach to any victim is obviously simplistic and harmful.

  • An attempt should instead be made to learn the significance behind several major cultural forms, for example, the meaning to the persons practicing those traditions.

This will help one gain a personal feel for the culture, and to know people from the perspective they see themselves rather than focus upon their isolated behaviors and "unusual thinking."

Case Example of Multi-cultural Healing in the Aftermath of Victimization:

In the aftermath of Patrick Purdy's deadly rifle assault on the schoolchildren of Cleveland Elementary School in Stockton, California in 1989, for example, there was an outpouring of concern and support from across the nation. Five children had been killed and 29 children and one teacher wounded. Two of the central events in the healing process for the Cambodian and Vietnamese surviving family members were the Buddhist funeral service and a subsequent ceremonial purification of the school grounds for the purpose of "releasing" the children's spirits.
These rituals were strange for the local district attorney's victim assistance staff, but their involvement in facilitating and participating in these events, their willingness to depend upon the Buddhist monks for leadership, and their efforts to quickly learn (only) the most important Southeast Asian mourning customs were keys to being helpful.