GUIDING

PRINCIPLES

AND

RECOMMENDATIONS

Developing 

Cultural 

Competence 

in Disaster 

Mental Health 

Programs

Developing

Cultural

Competence 

in Disaster

Mental Health

Programs:

Guiding Principles 

and Recommendations

2003
i i

The document was written by Jean Athey, Ph.D., and Jean Moody-Williams, Ph.D., under Contract 

No. 99M00619401D with the Center for Mental Health Services (CMHS), Substance Abuse and Mental

Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (DHHS).

Portland Ridley was a contributing author and also served as the Government Project Officer. 

Susan R. Farrer, M.A., was the content editor of the guide. The SAMHSA Disaster Technical Assistance

Center operated by ESI, under contract with the Emergency Mental Health and Traumatic Stress

Services Branch (EMHTSSB)/CMHS, edited the document and designed the cover and layout for 

the publication. Numerous people contributed to the development of this document.

(See the textbox at the end of this page.)

Disclaimer

The views, opinions, and content of this publication are those of the authors and do not necessarily

reflect the views, opinions, or policies of SAMHSA or DHHS. The authors and the staff of CMHS 

acknowledge, appreciate, and respect the diverse terminology associated with cultural competence

and related issues, and regret any inadvertent omission of information or inclusion of statements 

that may be unfamiliar to our readers.

Public Domain Notice

All material appearing in this report is in the public domain and may be reproduced or copied without

permission from SAMHSA or CMHS. Citation of the source is appreciated. However, this publication

may not be reproduced or distributed for a fee without the specific, written authorization of the Office

of Communications, SAMHSA, DHHS.

Electronic Access and Copies of Publication

This publication may be accessed electronically through the following Internet World Wide Web

connection: www.samhsa.gov. For additional free copies of this document, please contact SAMHSA’s

National Mental Health Information Center at 1-800-789-2647 or 1-866-889-2647 (TDD).

Recommended Citation

U.S. Department of Health and Human Services. Developing Cultural Competence in Disaster Mental

Health Programs: Guiding Principles and Recommendations. DHHS Pub. No. SMA 3828. Rockville, MD:

Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2003.

Originating Office

Substance Abuse and Mental Health Services Administration

5600 Fishers Lane, Rockville, Maryland 20857

DHHS Publication No. SMA 3828

Printed 2003

Acknowledgments

Contributors and Reviewers: Lourdes Arellano-Carandang, Ph.D.; Robert Benedetto, D.P.A., L.C.S.W.; Marisa Brown,

M.S.N., R.N.; Nan Carle, Ph.D.; Deborah DeWolfe, Ph.D., M.S.P.H.; Kana Enomoto, M.A.; Linda Fain; Renee Georg;

Elzbieta Gozdziak, Ph.D.; Rachel Guerrero, L.C.S.W.; Robert Hammaker, Ed.D.; Angelia Hill; Joseph Hill; Carol Kardos,

M.S.S.W.; E’layne Koenigsberg; Harriet McCombs, Ph.D.; Patricia Mendoza, Ph.D.; Mary Elizabeth Nelson, M.S.W.; 

Wanetta Noconie; Gladys Padro, M.S.W.; Constance Peters, M.S.P.A.; Steven Shon, M.D.; Anthony Simms, Ph.D.; 

Karen Stengle; Suganya Sockalingam, Ph.D.; Cecilia Rivera-Casale, Ph.D.; and Katherine White, M.Div., R.N., C.C.C.
iii

FOREWORD ........................................................................................................................................ 1

INTRODUCTION................................................................................................................................ 4

Background and Overview ......................................................................................................... 4

ORGANIZATION OF THIS GUIDE ................................................................................................... 7

SECTION ONE: CULTURE AND DISASTER..................................................................................... 8

Understanding Culture............................................................................................................... 8

Diversity Among and Within Racial and Ethnic Minority Groups........................................ 10

Cultural Competence: Scope and Terminology...................................................................... 11

The Cultural Competence Continuum ................................................................................... 12

Cultural Competence and Disaster Mental Health Services ................................................. 14

Disaster Phases and Responses ............................................................................................... 17

Cultural Competence and Disaster Mental Health Planning................................................ 19

SECTION TWO: GUIDING PRINCIPLES AND RECOMMENDATIONS....................................... 22

Guiding Principles for Cultural Competence in Disaster Mental Health Programs ........... 22

Principle 1: Recognize the Importance of Culture and Respect Diversity .......................... 23

Principle 2: Maintain a Current Profile of the Cultural Composition 

of the Community ..................................................................................................................... 24

Principle 3: Recruit Disaster Workers Who Are Representative

of the Community or Service Area........................................................................................... 26

Principle 4: Provide Ongoing Cultural Competence Training 

to Disaster Mental Health Staff ................................................................................................ 27

Principle 5: Ensure That Services Are Accessible, Appropriate, and Equitable ................... 28

Principle 6: Recognize the Role of Help-Seeking Behaviors, Customs

and Traditions, and Natural Support Networks...................................................................... 29

Principle 7: Involve as “Cultural Brokers” Community Leaders and Organizations 

Representing Diverse Cultural Groups .................................................................................. 33

Principle 8: Ensure That Services and Information Are Culturally 

and Linguistically Competent.................................................................................................. 34

Principle 9: Assess and Evaluate the Program’s Level of Cultural Competence .................. 37

Table of Contents
i v

REFERENCES.................................................................................................................................... 40

APPENDICES .................................................................................................................................... 45

Appendix A: Cultural Competence Resources and Tools....................................................... 46

Appendix B: Disaster Mental Health Resources from the Center 

for Mental Health Services ....................................................................................................... 48

Appendix C: Sources of Demographic and Statistical Information...................................... 49

Appendix D: Sources of Assistance and Information ............................................................ 50

Appendix E: Glossary ................................................................................................................ 54

Appendix F: Cultural Competence Checklist 

for Disaster Crisis Counseling Programs................................................................................. 57

FIGURE

Figure 1-1: Cultural Competence Continuum........................................................................ 13

TABLES

Table 1-1: Percentage Distribution of the Population by Race and Hispanic Origin............ 9

Table 1-2: Federal Government Categories for Race and Ethnicity...................................... 11

Table 1-3: Characteristics of Disasters .................................................................................... 18

Table 1-4: Questions to Address in a Disaster Mental Health Plan....................................... 21

Table 2-1: Key Concepts of Disaster Mental Health ............................................................... 23

Table 2-2: Important Considerations When Interacting 

with People of Other Cultures.................................................................................................. 25

Table 2-3: Staff Attributes, Knowledge, and Skills Essential 

to Development of Cultural Competence............................................................................... 27

Table 2-4: Special Considerations When Working with Refugees ......................................... 30

Table 2-5: Guidelines for Using Interpreters........................................................................... 37

Table 2-6: A Cultural Competence Self-Assessment 

for Disaster Crisis Counseling Programs................................................................................. 38

Table of Contents CONTINUED
1

Disasters—earthquakes, hurricanes, chemical explosions, wars, school shootings, mass casualty

accidents, and acts of terrorism—can strike anyone, regardless of culture, ethnicity, or race.

No one who experiences or witnesses a disaster is untouched by it.

Peoples’ reactions to disaster and their coping skills, as well as their receptivity to crisis

counseling, differ significantly because of their individual beliefs, cultural traditions, and

economic and social status in the community. For this reason, workers in our Nation’s 

public health and human services systems increasingly recognize the importance of 

cultural competence in the development, planning, and delivery of effective disaster mental

health services. 

The increased focus on cultural competence also stems from the desire to better serve a 

U.S. population that is rapidly becoming more ethnically and culturally diverse. To respond 

effectively to the mental health needs of all disaster survivors, crisis counseling programs

must be sensitive to the unique experiences, beliefs, norms, values, traditions, customs, and

language of each individual, regardless of his or her racial, ethnic, or cultural background.

Disaster mental health services must be provided in a manner that recognizes, respects, 

and builds on the strengths and resources of survivors and their communities.

The Crisis Counseling Assistance and Training Program (CCP) is one of the Federal

Government’s major efforts to provide mental health services to people affected by disasters.

Created in 1974, this program is currently administered by the Center for Mental Health

Services (CMHS), Substance Abuse and Mental Health Services Administration (SAMSHA),

and the Federal Emergency Management Agency (FEMA). The Program provides

supplemental funding to States for short-term crisis counseling services to survivors 

of federally declared disasters. Crisis counseling services provided through the Program

include outreach, education, community networking and consultation, public information

and referral, and individual and group counseling. The CCP emphasizes specialized

interventions and strategies that meet the needs of special populations such as racial and

ethnic minority groups.

The purpose of this guide is to assist States and communities in planning, designing, and 

implementing culturally competent disaster mental health services for survivors of natural

and human-caused disasters of all scales. It complements information previously published

by FEMA and CMHS on disaster mental health response and recovery. FEMA provided the

funding for this guide as part of the agencies’ ongoing effort to address the needs of special

Foreword
2

populations in disaster mental health response and

recovery. Developing Cultural Competence in Disaster

Mental Health Programs: Guiding Principles and

Recommendations is part of a series of publications

developed by CMHS.

In developing this guide, CMHS recognized that cultural competence is a complex subject—

one that has varying terminologies, opinions, expectations, models, and paradigms. The

authors sought to identify common concepts and to suggest guiding principles and

recommendations for primary and behavioral health care providers working with disaster

survivors in multicultural communities. Although it is the hope of CMHS that readers will find

the guide useful, the authors also recognize that it is by no means intended to provide

comprehensive information on cultural competence.

The guiding principles are based on standards, guidelines, and recommendations established

by SAMHSA, the Office of Minority Health, and the Health Resources and Services

Administration in the U.S. Department of Health and Human Services (DHHS), although the

guiding principles do not necessarily represent these agencies’ specific views. Mental Health:

Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General 

(DHHS, 2001) informed our efforts to ensure consistency with fundamental practice 

and theory.

To produce this guide, the authors invited input from State and local disaster mental health

coordinators and consultants as well as from reviewers at the national, State, and community

levels. The publication also incorporates information gathered through an extensive literature

review. Vignettes from CMHS grant applications and grantee reports illustrate the range of

promising practices, experiences, and challenges of State and local disaster mental health

programs nationwide. As work on the guide continued, CMHS became increasingly aware

that the principles and values underlying cultural competence parallel those historically

espoused by disaster mental health service providers. 

This publication is a first step toward developing a framework for the design of culturally

competent disaster mental health programs. It also is the hope of CMHS that the information

it provides will improve understanding and increase the ability of State, local, and community

mental health and human service administrators, planners, trainers, and other staff to

respond sensitively and effectively to the needs of all disaster survivors.

No one who experiences 

or witnesses a disaster 

is untouched by it.

BACKGROUND AND

OVERVIEW 

Disasters affect hundreds of

thousands of people in the United

States annually. Between 1993 and

1998, the American Red Cross

responded to more than 322,000

disaster incidents in the United

States and provided financial

assistance to more than 600,000

families (American Red Cross,

2000). In 1997 alone, the Federal

Emergency Management Agency

(FEMA) responded to 43 major

disasters in 27 States and three

western Pacific Island territories

(FEMA, 2000). In recent years,

human-caused disasters have been

a major challenge. Such events

include the 1992 civil unrest in Los

Angeles, the 1995 bombing of the

Alfred P. Murrah Federal Building in

Oklahoma City, and the September

2001 terrorist attacks on the World

Trade Center in New York and the

Pentagon in Arlington.

Disaster crisis counseling is a

specialized service that involves

Introduction

4
5

rapid assignment and temporary

deployment of staff who must meet

multiple demands and work in

marginal conditions and in

unfamiliar settings such as shelters,

recovery service centers, and mass

care facilities. The major objective

of disaster mental health operations

is to mobilize staff to disaster sites

so that they can attend to the

emotional needs of survivors. In the

past, these responses tended to be

generic; little or no effort was made

to tailor resources to the

characteristics of a specific

population. With time and

experience, however, service

providers and funding

organizations have become

increasingly aware that race,

ethnicity, and culture may have a

profound effect on the way in which

an individual responds to and

copes with disaster. Today, those in

the field of disaster mental health

recognize that sensitivity to cultural

characteristics of individuals and

communities affected directly or

indirectly by a full range of natural

and human-made disasters. 

Designed to supplement

information already available

through CMHS, SAMHSA, and 

other sources, Developing Cultural

Competence in Disaster Mental

Health Programs highlights

important common issues relating

to cultural competence and to

disaster mental health. It provides

guidance for improving cultural

competence in support of disaster

mental health services. 

The following issues are key to 

the recommendations set forth in

this guide: 

■ Cultural competence requires

system-wide change. It must 

be manifested at every level 

of an organization, including policy

making, administration, and direct

service provision. Therefore, for

disaster mental health services to

Because of higher birth and 

immigration rates, the Hispanic 

population is growing faster than any

other ethnic minority group.

differences is essential in providing

mental health services to disaster

survivors. 

Integrating cultural competence in

the temporary structure and highintensity work environment of a

disaster relief operation is a

challenge. Increasing cultural

competence, not a one-time

activity, is a long-term process that

requires fundamental changes at

the institutional level. Because both

culture and the nature of disasters

are dynamic, these changes must 

be followed by ongoing efforts to

ensure that the needs of those

affected by disaster are met. 

The primary purpose of this guide

is to provide background

information, guiding principles,

recommendations, and resources

for developing culturally competent

disaster mental health services.

Disaster mental health providers

and workers can use and adapt the

guidelines set forth in this

document to meet the unique
6

be effective, cultural competence

must be reflected in disaster mental

health plans. For additional

information on building mental

health systems capacity for disaster

mental health response and

recovery, readers may wish to

review Disaster Response and

Recovery: A Strategic Guide (DHHS,

Rev. ed, in press). 

■ Cultural competence requires 

an understanding of the historical,

social, and political events that

affect the physical and mental

health of culturally diverse groups.

Issues such as racism,

discrimination, war, trauma,

immigration patterns, and poverty—

which reinforce cultural differences

and distinguish one cultural group 

from another—must be considered

(Hernandez and Isaacs, 1998). For 

a descriptive summary of historical

background, patterns, and events,

as well as detailed demographic

and other factors. This guide uses

the phrases “cultural groups” and

“racial and ethnic minority groups”1

to refer to the Nation’s diverse,

multicultural groups and

individuals.

■ The operational definition of 

cultural competence provided in

this guide is based on the principles 

of cultural competence described 

in Towards a Culturally Competent

System of Care (Cross et al., 1989).

Many Federal, State, and local 

public mental health systems, 

as well as organizations in the 

private sector, have adopted 

the principles presented in 

this document.

and health profiles of individual

cultural groups, readers may wish

to refer to Mental Health: Culture,

Race, and Ethnicity—A Supplement

to Mental Health: A Report of the

Surgeon General (DHHS, 2001) and

to Cultural Competence Standards

in Managed Care Mental Health

Services: Four Underserved/

Underrepresented Racial/Ethnic

Groups (DHHS, 2000b).

■ Precise definitions of the terms

“race,” “ethnicity,” and “culture” are

elusive. As social concepts, these

terms have many meanings, and

those meanings evolve over time

(DHHS, 2001). This guide espouses

a broad definition of culture that

includes not only race and ethnicity

but also gender, age, language,

socioeconomic status, sexual 

orientation, disability, literacy level,

spiritual and religious practices,

individual values and experiences,

1 The major racial and ethnic minority groups

referred to in this publication are African

Americans (blacks), American Indians and

Alaska Natives, Asian Americans, Native

Hawaiian and Other Pacific Islanders, and

Hispanic Americans (Latinos). The authors

recognize that opinions about which labels 

are appropriate differ and acknowledge that

heterogeneous subpopulations exist within each

of these populations. These categories, which

were established by the Office of Management

and Budget in 1997, are used because they are

widely accepted and used by service providers 

in the public and private sectors.

Precise definitions of the terms

“race,” “ethnicity,” and “culture”

are elusive.
7

The appendices provide additional information that

may be useful in developing cultural competence 

in disaster mental health. 

APPENDIX A is an annotated bibliography of cultural

competence resources and tools. Many of these

resources provide detailed information about

individual populations’ histories, immigration

patterns, and experiences with stress and trauma.

APPENDIX B lists disaster mental health technical

assistance resources and publications available

through CMHS. Some of these materials discuss 

the needs and provision of services for special

populations. 

APPENDIX C lists online resources that provide

community-specific demographic and 

statistical information. 

APPENDIX D lists Federal, private-sector, professional,

and other organizations with cultural competence

expertise. 

APPENDIX E is a glossary of terms associated with

disaster mental health and cultural competence. 

APPENDIX F is a Cultural Competence Checklist for

Disaster Crisis Counseling Programs. Based on

concepts discussed throughout this guide, the

checklist covers essential principles for ensuring 

a culturally competent disaster mental health

program.

SECTION ONE explores the nature of culture and

disaster. It begins by defining culturally related

terms, discussing diversity within racial and 

ethnic minority groups, and describing cultural

competence. It then discusses cultural competence

in the context of disaster mental health services.

Section One also presents the Cultural Competence

Continuum and a list of questions to address in a

disaster mental health plan. Readers seeking more

detail about crisis counseling or disaster response

and recovery may refer to other CMHS/FEMA

publications. For example, the Training Manual for

Mental Health and Human Service Workers in Major

Disasters (DHHS, 2000e) provides a comprehensive

overview of and essential information on training

concepts on crisis counseling, including a training

curriculum. Disaster Response and Recovery:

A Strategic Guide (DHHS, Rev. ed., in press) also 

is a useful resource.

SECTION TWO sets forth nine guiding principles for

culturally competent disaster mental health services

and related recommendations for developing these

services. It also presents the key concepts of disaster

mental health; important considerations when

working with people of other cultures; staff

attributes, knowledge, and skills essential to the

development of cultural competence; and a cultural 

competence self-assessment for disaster crisis

counseling programs. In addition, Section Two

provides suggestions for working with refugees 

and guidelines for using interpreters.

Organization of This Guide

This guide includes two sections and six appendices.
SECTION ONE

Culture

and

Disaster

been a nation of diversity. In the

years to come, fertility and mortality

rates, immigration patterns, and

age distributions within subgroups

of the population will contribute 

to an increasingly diverse national

population (Day, 1996). Data from

the 2000 U.S. Census reveal that

Hispanics have replaced African

Americans as the second largest

ethnic group after whites.2 Because

of higher birth and immigration

rates, the Hispanic population is

growing faster than any other ethnic

minority group (DHHS, 2001). The

population of Asian Americans is

also growing and is projected to

continue growth throughout the

first half of the 21st century, 

primarily because of immigration

(DHHS, 2001). As shown in 

Table 1-1, by 2010, Hispanic

Americans will comprise 

14.6 percent of the U.S. population,

African Americans will comprise

12.5 percent, Asian Americans will

comprise 4.8 percent, and Native

Americans will comprise less than

1 percent (U.S. Department of

Commerce, 2000).

These demographic changes have

given the United States the benefits

and richness of many cultures,

languages, and histories. At the

same time, the Nation’s growing

diversity has made it more

important than ever for health and

Since its founding, the United States has

8

human service providers—

including disaster mental health

service providers—to recognize,

understand, and respect the

diversity found among cultural

groups and subgroups. Service

providers must find ways to tailor

their services to individuals’ and

communities’ cultural identities,

languages, customs, traditions,

beliefs, values, and social support

systems. This recognition, understanding, respect, and tailoring of

services to various cultures is the

foundation of cultural competence.

UNDERSTANDING

CULTURE 

Culture influences many aspects 

of our lives—from how we

communicate and celebrate to how

we perceive the world around us.

Culture involves shared customs,

values, social rules of behavior,

rituals and traditions, and

perceptions of human nature and

natural events. Elements of culture

are learned from others and may 

be passed down from generation 

to generation.

Many people equate race and 

ethnicity with culture; however, 

the terms “race” and “ethnicity” 

do not fully define the scope and

breadth of culture. Race and

ethnicity are indeed prominent

elements of culture, but there are

important distinctions between

2 This publication uses the term “whites” to denote non-Hispanic white Americans.
TABLE 1-1

Percentage Distribution of the Population 

By Race and Hispanic Origin

(Includes foreign and native-born populations)

9

these terms. For example, many

people think of “race” as a biological

category and associate it with

visible physical characteristics 

such as hair and skin color. 

Physical features, however, do not

reliably differentiate people of 

different races (DHHS, 2001). For

this reason, race is widely used as 

a social category. Different cultures

classify people into racial groups on

the basis of a set of characteristics

that are socially important (DHHS,

2001). Often, members of certain

social or racial groups are treated 

as inferior or superior or given

unequal access to power and other

resources (DHHS, 2001). 

“Ethnicity” refers to a common 

heritage of a particular group.

Elements of this shared heritage

include history, language, rituals,

and preferences for music and

foods. Ethnicity may overlap 

with race when race is defined 

as a social category. For example,

because Hispanics are an ethnicity,

not a race, ethnic subgroups 

such as Cubans and Peruvians

include people of different races

(DHHS, 2001).

“Culture” refers to the shared 

attributes of a group of people. 

It is broadly defined as a common

heritage or learned set of beliefs,

norms, and values (DHHS, 2001).

Culture is as applicable to groups 

of whites, such as Irish Americans

or German Americans, as it is to

Race

Hispanic/

Latino 

Origin*

Black/ American Indian/ Asian and 

Year White African Alaska Pacific 

American Native** Islander

1995 73.6 12.0 0.7 3.3 10.2

2000 71.4 12.2 0.7 3.9 11.8

2010 67.3 12.5 0.8 4.8 14.6

2050 52.8 13.2 0.8 8.9 24.3

2100 40.3 13.0 0.7 12.6 33.3

* Persons of Hispanic/Latino origin may be of any race. Groups listed under “Race” 

are not of Hispanic origin.

** Includes American Indians, Alaska Natives, and Aleuts.

Source: U.S. Department of Commerce, Bureau of the Census. (2000). Projections of 

the resident population by race, Hispanic origin, and nativity: Middle series, 1999 to 2100.

Washington, DC: U.S. Department of Commerce.

racial and ethnic minorities (DHHS,

2001). People can share a culture,

regardless of their race or ethnicity.

For example, people who work for 

a particular organization, people

who have a particular physical or

mental limitation, or youth in a 

particular social group may share

cultural attributes.

A culture can be defined by 

characteristics such as:

■ National origin; 

■ Customs and traditions; 

■ Length of residency 

in the United States; 

■ Language; 

■ Age; 

■ Generation;

■ Gender;

■ Religious beliefs;

■ Political beliefs; 

■ Sexual orientation;

■ Perceptions of family 

and community;

■ Perceptions of health, 

well-being, and disability;

■ Physical ability or limitations;

■ Socioeconomic status;

■ Education level;

■ Geographic location; and

■ Family and household 

composition.
1 0

Culture changes continuously. For

example, immigrants to the United

States bring with them their own

beliefs, norms, and values, but

through the process of acculturation

gradually learn and adopt selected

elements of the dominant culture.

An immigrant group may develop

its own culture while becoming

acculturated. At the same time, 

the dominant culture may change

as a result of its interaction with 

the immigrant group (DHHS, 2001). 

DIVERSITY AMONG

AND WITHIN 

RACIAL AND ETHNIC

MINORITY GROUPS 

Four racial and ethnic minority

groups—African Americans,

American Indians and Alaska

Natives, Asian Americans and Pacific

Islanders, and Hispanic Americans—

accounted for approximately 

30 percent of the U.S. population in

the year 2000 and are expected to

account for nearly 40 percent of the

U.S. population by 2025 (DHHS,

2001). Although there are important

differences among these four

groups, there also is broad diversity

within each group. In other words,

people who find themselves in the

same racial or ethnic group—either 

by census category or through selfidentification—do not always have

the same culture. Examples follow:

■ American Indians and Alaska

Natives may belong to more than

500 tribes, each of which has a

different cultural tradition, language,

and ancestry (DHHS, 2001).

■ Asian Americans and Pacific

Islanders may identify with any 

of 43 subgroups and speak any 

of 100 languages and dialects

(DHHS, 2001).

Did You Know . . . 

Mental Health: Culture, Race, and Ethnicity— 

A Supplement to Mental Health: 

A Report of the Surgeon General 

(DHHS, 2001) notes that:

■ Approximately 12 percent of the U.S. population—34 million 

individuals—identify themselves as African American. 

■ Six percent of all blacks in the United States today are 

foreign-born. Most of those who are foreign-born come 

from the Caribbean.

■ Since 1983, more than 100,000 refugees have come to 

the United States from African nations.

■ The U.S. Census Bureau estimates that 4.1 million American Indians

and Alaska Natives (Indians, Eskimos, and Aleuts) lived in the 

United States in 2000, representing less than 1.5 percent of 

the total U.S. population.

■ Alaska Natives comprise approximately 4 percent of the 

combined American Indian and Alaska Native population.

■ By the year 2020, the combined Asian American and Pacific Islander

population will reach approximately 20 million, or about 6 percent 

of the total U.S. population.

■ Approximately 35 percent of Asian Americans and Pacific Islanders

live in linguistically isolated households. For some Asian American

ethnic groups—including Hmong, Cambodian, Laotian, Vietnamese,

Korean, and Chinese American households—the rate is much higher

than this percentage.

■ By the year 2050, Latinos will constitute nearly one-fourth of the 

U.S. population, and nearly one-third of persons under 19 years 

of age will be Hispanic.

■ Nearly two-thirds of Hispanic Americans were born in the 

United States.

■ Nearly two-thirds of Latinos are persons of Mexican origin, and 

the remaining one-third are primarily persons of Puerto Rican,

Cuban, or Central American origin.
1 1

■ Hispanics may be of Mexican,

Puerto Rican, Cuban, Central and

South American, or other heritage

(DHHS, 2001).

Furthermore, the broad category

labels are imprecise (DHHS, 2001).

For example, people who are

indigenous to the Americas may 

be called Hispanic if they are from

Mexico or American Indian if they

are from the United States (DHHS,

2001). In addition, many people in 

a particular racial or ethnic minority

group may identify more closely

with other social groups than 

with the group to which they are

assigned by definition (DHHS,

2001). Finally, many people identify

with multiple cultures that may be

associated with factors such as race,

ethnicity, country of origin, primary

language, immigration status, age,

religion, sexual orientation,

employment status, disability, 

geographic location, or

socioeconomic status. Table 1-2

identifies Federal Government

categories for race and ethnicity.

Recognizing the limitations of the

traditional broad groupings, the

U.S. Census Bureau revised the

categories used to report race and

ethnicity in the 2000 Census. For

the first time, individuals could

identify with more than one group

(U.S. Office of Management and

Budget, 2000). The U.S. Census

Bureau anticipated that this change

would result in approximately 63

categories of racial and ethnic

identifications (DHHS, 2001).

Appendix C lists additional resources

offering statistical and demographic

data on racial and ethnic

populations and subpopulations.

CULTURAL

COMPETENCE:

SCOPE AND

TERMINOLOGY

We use many terms to refer to

concepts associated with cultural

competence and with interactions

between and among people of 

different cultures including “cultural

diversity, cultural awareness, cultural

sensitivity, multiculturalism, and

transcultural services.” Although the 

differences in the meanings of 

these terms may be subtle, they are

extremely important. For example,

the term “cultural awareness”

suggests that it may be sufficient for

one to be cognizant, observant, 

and conscious of similarities and

differences among cultural groups

(Goode et al., 2001). 

“Cultural sensitivity,” on the other

hand, connotes the ability to

empathize with and understand 

the needs and emotions of persons

of one’s own culture as well as 

those of others and to identify with

emotional expressions and the

problems, struggles, and joys of

someone from another culture

(Hernandez and Isaacs, 1998). 

TABLE 1-2

Federal Government Categories 

for Race and Ethnicity

The U.S. Office of Management and Budget (1997) announced revised

standards for Federal data on race and ethnicity. The new categories 

for race are:

American Indian or Alaska Native refers to a person having origins 

in any of the original peoples of North and South America, including

Central America, and who maintains tribal affiliation or community

attachment.

Asian refers to a person having origins in any of the original peoples 

of the Far East, Southeast Asia, or the Indian subcontinent, including,

for example, Cambodia, China, India, Japan, Korea, Malaysia, 

Pakistan, the Philippine Islands, Thailand, and Vietnam. 

Black or African American refers to a person having origins 

in any of the black racial groups of Africa.

Hispanic or Latino refers to a person of Cuban, Mexican, 

Puerto Rican, South or Central American, or other Spanish culture 

or origin, regardless of race.

Native Hawaiian and Other Pacific Islander refers to a person 

having origins in any of the original peoples of Hawaii, Guam, 

Samoa, or other Pacific Islands.

White refers to a person having origins in any of the original peoples 

of Europe, the Middle East, or North Africa.

Some Other Race was included for those who identify with 

one or more races.
THE CULTURAL

COMPETENCE

CONTINUUM 

Cultural competence is not a matter

of being politically correct or 

of assigning one person to handle

diversity issues, nor does it mean

simply translating materials into

other languages. Rather, it is an

ongoing process of organizational

and individual development that

includes learning more about our

own and other cultures; altering our

thinking about culture on the basis

of what we learn; and changing 

the ways in which we interact with

others to reflect an awareness and

sensitivity to diverse cultures.

The Cultural Competence

Continuum depicted in Figure 1-1

was developed by Cross et al. (1989)

for mental health professionals.

Today, many other public health

practitioners and community-based

service providers also find it a useful

tool. The continuum assumes that

cultural competence is a dynamic

process with multiple levels of

achievement. It can be used to

assess an organization’s or

individual’s level of cultural

competence, to establish benchmarks, and to measure progress.

Cultural Destructiveness

The negative end of the continuum

is characterized by cultural

destructiveness. Organizations or

individuals in this stage view

cultural differences as a problem

and participate in activities that

purposely attempt to destroy a

culture. Examples of destructive

actions include denying people of

color access to their natural helpers

or healers, removing children of

color from their families on the

1 2

The term “cultural competence”

suggests a broader concept than

“cultural sensitivity” implies. As 

previously defined in this section,

the word “culture” refers to the

shared attributes—including beliefs,

norms, and values—of a group of

people (DHHS, 2001). The word

“competence” implies the capacity

to function effectively, both at the

individual and organizational levels.

“Competence” is associated with

“culture” to emphasize that being

aware of or sensitive to the

differences between cultures is not 

sufficient. Instead, service providers

must have the knowledge, skills,

attitudes, policies, and structures

needed to offer support and care

that is responsive and tailored to

the needs of culturally diverse 

population groups. 

Many people and organizations

have developed definitions of

cultural competence. The following

definition blends elements of

definitions used by SAMSHA 

(DHHS, 2001), the Health Resources

and Services Administration

(DHHS), the Office of Minority

Health (DHHS, 2000a), and

definitions found in the literature

(Bazron and Scallet, 1998; Cross et

al., 1989; Denboba, 1993; Evans,

1995; Roberts et al.,1990; Taylor et

al., 1998):

Cultural competence is a set of values,

behaviors, attitudes, and practices

within a system, organization,

program, or among individuals that

enables people to work effectively

across cultures. It refers to the ability

to honor and respect the beliefs,

language, interpersonal styles, and

behaviors of individuals and families

receiving services, as well as staff

who are providing such services.

Cultural competence is a dynamic,

ongoing, developmental process that

requires a long-term commitment

and is achieved over time.

Cross and colleagues (1989) 

note that culturally competent 

organizations and individuals:

■ Value diversity;

■ Have the capacity for cultural

assessment;

■ Are aware of cross-cultural

dynamics; 

■ Develop cultural knowledge; and

■ Adapt service delivery to reflect an

understanding of cultural diversity.

At the individual level, cultural

competence requires an understanding of one’s own culture and

worldview as well as those of others.

It involves an examination of one’s

attitudes, values, and beliefs, and

the ability to demonstrate values,

knowledge, skills, and attributes

needed to work sensitively and

effectively in cross-cultural

situations (Goode et al., 2001).

At the organizational and

programmatic levels, cultural

competence requires a

comprehensive, coordinated plan

that cuts across policymaking,

infrastructure building, program

administration and evaluation, and

service delivery. Culturally

competent organizations and

programs acknowledge and

incorporate the importance of

culture, assess cross-cultural

relations, are aware of dynamics

that can result from cultural

differences and ethnocentric

attitudes, expand cultural

knowledge, and adopt services 

that meet unique cultural needs

(DHHS, 2000d).
1 3

of organizations in this stage of the

continuum are discriminatory.

Cultural Blindness

Cultural blindness is the midpoint

of the continuum. Organizations

and individuals at this stage believe

that color or culture makes no

difference and that all people are

the same. Individuals at this stage

may view themselves as unbiased

and believe that they address

cultural needs. In fact, people who

are culturally blind do not perceive,

and therefore cannot benefit from,

the valuable differences among

diverse groups. Services or programs

created by organizations at this stage

are virtually useless to address the

needs of diverse groups.

Cultural Pre-competence

Culturally pre-competent

organizations and individuals begin

to move toward the positive end 

of the continuum. They realize

weaknesses in their attempts to

serve various cultures and make

some efforts to improve the services

offered to diverse populations. Precompetent organizations hire staff

from the cultures they serve, involve

people of different cultures on their

boards of directors or advisory

committees, and provide at least

rudimentary training in cultural

differences. However, organizations

at this stage run the risk of

becoming complacent, especially

when members believe that the

accomplishment of one goal or

activity fulfills the obligation to the

community. Tokenism is another

danger. Organizations sometimes

hire one or more workers from a

racial or ethnic group and feel that

they have done all that is necessary.

Cultural Competence

Culturally competent organizations

and individuals accept and respect

differences, and they participate in

continuing self-assessment

regarding culture. Such

organizations continuously expand

their cultural knowledge and

resources and adopt service models

that better meet the needs of

minority populations. In addition,

they strive to hire unbiased

employees, and seek advice and

consultation from representatives

of the cultures served. They also

support their staff members’

comfort levels when working in

cross-cultural situations and in

understanding the interplay

between policy and practice.

Cultural Proficiency

Culturally proficient organizations

hold diversity of culture in high

basis of race, and risking the wellbeing of minority individuals by

involving them in social or 

medical experiments without their

knowledge or consent. Organizations

and individuals at this extreme

operate on the assumption that one

race is superior and that it should

eradicate “lesser” cultures.

Cultural Incapacity

Organizations and individuals in

the cultural incapacity stage lack

the ability to help cultures from

diverse communities. Although 

they do not intentionally seek to

cause harm, they believe in the

superiority of their own racial 

or ethnic group and assume a

paternalistic posture toward “lesser”

groups. They may act as agents 

of oppression by enforcing racist

policies and maintaining

stereotypes. Employment practices

The continuum includes six stages: cultural destructiveness, cultural incapacity, cultural

blindness, cultural pre-competence, cultural competence, and cultural proficiency 

(Cross et al., 1989).

FIGURE 1-1

Cultural Competence Continuum
CULTURAL

COMPETENCE AND

DISASTER MENTAL

HEALTH SERVICES 

Culture as a source of knowledge,

information, and support provides

continuity and a process for healing

during times of tragedy (DeVries,

1996). Survivors react to and

recover from disaster within 

the context of their individual racial

and ethnic backgrounds, cultural

viewpoints, life experiences, and

values. Culture offers a protective

system that is comfortable and

reassuring. It defines appropriate

behavior and furnishes social

support, identity, and a shared

vision for recovery. For example,

stories, rituals, and legends that are

part of a culture’s fabric help people

adjust to catastrophic losses by

highlighting the mastery of

communal trauma and explaining

the relationship of individuals to

the spiritual. Despite the strengths

that culture can provide, responses

to disaster also fall on a continuum.

Persons from disadvantaged racial

and ethnic communities may be

more vulnerable to problems

associated with preparing for and

recovering from disaster than

persons of higher socioeconomic

status (Fothergill et al., 1999).

Because of the strong role that 

culture plays in disaster response,

disaster mental health services 

are most effective when survivors

receive assistance that is in accord

with their cultural beliefs and

consistent with their needs

(Hernandez and Isaacs, 1998). 

As disaster mental health service

providers seek to become more

culturally competent, they must

recognize three important social

and historical influences that can

1 4

esteem. They seek to add to the

knowledge base of culturally 

competent practice by conducting

research, developing new

therapeutic approaches based on

culture, and publishing and

disseminating the results of

demonstration projects. Culturally

proficient organizations hire staff

members who are specialists in

culturally competent practice.

Achieving cultural competence and

progressing along the continuum

do not happen by chance. Policies

and procedures, hiring practices,

service delivery, and community

outreach must all include the 

principles of cultural competence.

For these reasons, a commitment 

to cultural competence must 

permeate an organization before 

a disaster strikes. If the concepts 

of cultural competence and 

proficiency have been integrated

into the philosophy, policies, and

day-to-day practices of the mental

health provider agency, they will 

be much easier to incorporate into

disaster recovery efforts. 

Cultural Competence Necessary 

from Project Initiation

After the Great Flood of 1993 devastated the economy of 

rural Minnesota, the State developed a program of supportive

services, including crisis counseling for rural residents. Ethnic

populations affected by the flood included Hispanics, African

Americans, Southeast Asians (Vietnamese, Hmong, Laotians),

and Somalians. Some of these populations were relatively 

new to rural Minnesota, and they were not well integrated 

into the communities. Trust between cultures was tenuous 

at best, and many of the minority groups were somewhat

socially isolated. 

The crisis counseling project faced barriers of language, culture,

and mistrust that had to be overcome in order to provide

services. The challenge was difficult. Virtually all coordinators 

and outreach workers initially hired were white and middle class.

While a concerted effort was made to provide culturally

competent services once the program got underway, the final

project report, with great candor, concluded that success in

providing services to the various ethnic populations was spotty.

It stated that the project might have been more effective had 

a focus on cultural competence been integrated into the

program from the beginning.

Minnesota Final Report, 1994

REPORT
community may provide especially

strong social support functions for

its members, particularly when it is

surrounded by a hostile society.

However, its smaller size may

render it more fragile and more

subject to dispersion and

destruction after a disaster.

Members of some racial and ethnic

minority groups, such as refugees,

previously have experienced

destruction of their social support

systems, and the destruction of a

second support system may be

particularly difficult (Beiser, 1990;

Van der Veer, 1995).

Racism and

Discrimination

Many racial and ethnic minority

groups, including African Americans,

American Indians, and Chinese 

and Japanese Americans, have

experienced racism, discrimination,

or persecution for many years. 

Both legally sanctioned and more

subtle forms of discrimination and

racism are an undeniable part of

our Nation’s historical fabric.

Despite improvements in recent

decades, evidence exists that racial

1 5

affect the success of their efforts.

These three influences are the

importance of community, racism

and discrimination, and social and

economic inequality.

The Importance 

of Community 

Disasters affect both individuals

and communities. Following a

disaster, there may be individual

trauma, characterized as “a blow 

to the psyche that breaks through

one’s defenses so suddenly and with

such brutal force that one cannot

react to it effectively” (DHHS, 

Rev. ed. in press). There also may 

be collective trauma—“a blow to

the basic tissues of social life that

damages the bonds attaching

people together and impairs the

prevailing sense of community”

(DHHS, Rev. ed., in press). Cultural

and socioeconomic factors

contribute to both individual and

community responses to the

trauma caused by disaster.

The culture of the community 

provides the lens through which 

its members view and interpret 

the disaster, and the community’s

degree of cohesion helps determine

the level of social support available

to survivors. In other words, a

community that is disrupted and

fragmented will be able to provide 

less support than a cohesive 

community.

A classic example is presented by

sociologist Kai Erikson, who studied

the impact of the devastating 1972

flood in Buffalo Creek, West Virginia

(Erikson, 1976). The flood led to

relocation of the entire community.

Erikson describes a “loss of

community,” in which people lost

not only their sense of connection

with the locale but also the support

of people and institutions. Results

of this community’s fragmentation

included fear, anger, anxiety, 

and depression.

Other studies have emphasized

positive effects that can result from

disaster experiences in communities

that perform a protective role and

cushion the stress of the disaster

(Dynes et al., 1994). Compared with

nondisaster-related suffering, which

is isolating and private, the suffering

of disaster survivors can be

collective and public (Dynes et al.,

1994). However, devastating

disasters can have positive

outcomes. They can bring a

community closer or reorient its

members to new priorities or values

(Ursano, Fullerton et al., 1994).

Individuals may exhibit courage,

selflessness, gratitude, and hope

that they may not have shown or

felt before the disaster.

Community often is extremely

important for racial and ethnic

minority groups, and it may

dramatically affect their ability to

recover from disaster. For example,

a racial or ethnic minority

Disaster Projects Confront Distrust

Several disaster crisis counseling projects supported by the 

Federal Government have had to address the distrust of ethnic

minority groups and their reluctance to use available resources. 

For example, following the 1994 California earthquake, the disaster

crisis counseling project found that many immigrants’ distrust of

government posed a barrier to their use of disaster services.

Likewise, some of the survivors of a hurricane in Alabama were

immigrants from Asian Communist countries who did not trust 

any government and were not accustomed to receiving

Government assistance.

California Final Report, 1995 • Alabama Final Report, 1999

REPORT
help (Bolin and Stanford, 1998).

Low-income individuals and

families typically lose a much larger

part of their material assets and

suffer more lasting negative effects

from disaster than do those with

higher incomes (Wisner, 1993).

Often, disadvantaged persons live

in the least desirable and most

hazardous areas of a community,

and their homes may be older and

not as sound as those in higher

income areas. For example, many

low-income people live in

apartment buildings that contain

unreinforced masonry, which is

susceptible to damage in a disaster

(Bolton et al., 1993).

Although disaster relief activities

can help ameliorate some of the

damage rendered by a disaster,

some groups cannot readily access

such services. Negative perceptions

derived from pre-disaster

experiences may serve as a barrier

to seeking care. Lack of familiarity

with sources of community support

or lack of transportation are

common barriers for many

immigrants and unwillingness to

disclose their immigration status is

a major barrier.

Middle-class disaster survivors are

more likely than lower-income

people—including those from other

cultures—to know how to complete

forms, communicate adequately,

talk to the “right” people, or

otherwise maneuver within the

system. Thus, they may be more

likely to receive aid than survivors

with fewer means or those from

different cultures (Aptekar, 1990).

On the other hand, affluent groups

may find it difficult to accept

assistance from mental health and

1 6

discrimination persists in housing

rentals and sales, hiring practices,

and medical care. Racism also takes

the form of demeaning comments,

hate crimes, and other violence by

institutions or individuals, either

intentionally or unintentionally

(DHHS, 2001).

As a result of past or present

experiences with racism and

discrimination, racial and ethnic

minority groups may distrust offers

of outside assistance at any time,

even following a disaster. They may

not be accustomed to receiving

support and assistance from persons

outside of their own group in nondisaster circumstances. Therefore,

they may be unfamiliar with the

social and cultural mechanisms of

receiving assistance and remain

outside the network of aid.

Particularly during the

“disillusionment phase” of the

disaster, when intragroup tensions

are typically high, racial and ethnic

minority groups can face the brunt

of anger and even blame from

members of the larger culture. 

Such psychological assaults and

experiences with racism and

discrimination can result in

increased stress for individuals 

and groups.

Social and Economic

Inequality

Poverty disproportionately affects

racial and ethnic minority groups.

For example, in 1999, 8 percent of

whites, 11 percent of Asian

Americans and Pacific Islanders, 

23 percent of Hispanic Americans,

24 percent of African Americans,

and 26 percent of American Indians

and Alaska Natives lived in poverty

(DHHS, 2001). Significant

socioeconomic differences also

exist within racial and ethnic

minority groups. For example,

although some subgroups of Asian

Americans have prospered, others

remain at low socioeconomic levels

(O’Hare and Felt, 1991).

Social and economic inequality also

leads to reduced access to resources,

including employment; financial

credit; legal rights; and education,

health, and mental health services

(Blaikie et al., 1994). Poor

neighborhoods also have high rates

of homelessness, substance abuse,

and crime (DHHS, 2001).

Poverty makes people more

susceptible than others to harm

from disaster and less able to access

Damage from Mississippi 

Tornadoes Unequal

In the late 1950s, several tornadoes struck rural Mississippi. 

The only persons killed were black. A subsequent study found

that many people in the black community had great difficulty 

in coming to terms with this disaster. They did not understand

how a just God could discriminate in such a fashion between

white and black. 

Perry and Perry, 1959

REPORT
necessarily move forward in linear

fashion; instead, they often overlap

and blend together. Furthermore,

individuals may experience a 

given phase in different ways

(DHHS, 1999), and different 

cultural groups may respond 

differently during these phases.

Below are brief descriptions of 

each phase, including examples 

of responses of different cultural

groups during each phase.

For further information about 

disaster characteristics and phases,

refer to the Training Manual for

Mental Health and Human Service

Workers in Major Disasters

(DHHS, 2000e).

1 7

social service agencies. They may

fear a loss of control and find it

humiliating to accept emergency

assistance such as clothing, food,

loans, and emotional support from

disaster workers. 

In some instances, people of lower

socioeconomic status exhibit strong

coping skills in disaster situations

because they have seen difficult

times before and have survived. 

In other instances, the loss of 

what little one had may leave an

individual feeling completely

hopeless.

DISASTER PHASES 

AND RESPONSES 

Survivors’ reactions to and recovery

from a disaster are influenced by a

number of factors, including:

■ The disaster’s unique

characteristics, such as its size and

scope, and whether it was caused

by human or natural factors (see

Table 1-3);

■ The affected community’s unique

characteristics, including its

demographic and cultural make-up

and the presence of pre-existing

structures for social support and

resources for recovery; and

■ The individual’s personal assets

and vulnerabilities that either

reduce or exacerbate stress 

(DHHS, 2000e).

Despite the differences in disasters,

communities, and individuals, 

survivors’ emotional responses to

disaster tend to follow a pattern of

seven “disaster phases” (National

Institute of Mental Health, 1983;

DHHS, 2000e):

■ Warning or threat;

■ Impact;

■ Rescue or heroic;

■ Remedy or honeymoon;

■ Inventory;

■ Disillusionment; and

■ Reconstruction or recovery.

The characteristics of the disaster,

as well as those of the community

and its individual residents, affect

the duration and nature of the

seven phases. The phases do not

Tornadoes 

Destroy Homes 

in Sioux Nation

In 1999, tornadoes ravaged

the Oglala Sioux Nation in

South Dakota. Housing units

are scattered throughout this

vast reservation; one home

may be 10 to 20 miles from

the nearest neighbor or

community. Many roads 

on the reservation are

unimproved. Only 10 percent

to 15 percent of the homes

have telephone service.

Because of the lack of

adequate housing, multiple

family units reside in one

dwelling. In some situations,

20 family members live in a

two-bedroom home with no 

running water or sewage

system. Outhouses are

commonplace. 

South Dakota Application, 1999

Disaster Resurfaces

Emotional Reactions 

to Prior Stressors 

Flooding occurred in Clovis,

California, in 1995, when 

a canal and ponding basins

overflowed. Many families,

mostly Hmong, who lived 

near the canal were displaced.

The Hmong population is a 

low-income community with

immigrants from Southeast

Asia who have a history of war

and severe losses. Many were

suffering from Post-Traumatic

Stress Syndrome prior to the

flood. The flood increased

financial stress and anxiety, 

and exacerbated their 

existing symptoms.

California Final Report, 1995

REPORT

REPORT
about risks and in the credence they

place on such information. For

example, Hispanics are more likely

than non-Hispanics to use social

networks for disaster information

(Blanchard-Boehm, 1997; Perry and

Mushkatel, 1986) and to believe

information obtained through these

networks (Perry and Lindell, 1991)

than are members of other groups.

Furthermore, some marginalized

communities do not have adequate

or functioning warning systems.

When disaster warning information

is not provided in multiple

languages or is not closedcaptioned, people who do not

understand English or who are 

deaf or hard of hearing may not

receive adequate warning.

Impact Phase

The impact phase occurs when the

disaster actually strikes. This phase

can vary from the slow, low-threat

buildup associated with some 

types of floods to the violent and

destructive outcomes associated

with tornadoes and explosions.

Depending on the characteristics 

of the disaster, reactions range from

confusion, disbelief, and anxiety

(particularly if family members 

are separated) to shock or hysteria. 

Rescue or Heroic Phase

In the rescue or heroic phase,

individuals’ activity levels are

typically high and oriented toward

rescue operations, survival, and

perhaps evacuation. People

generally work together to save lives

and property; pre-existing tensions

between racial and ethnic or

cultural groups are set aside.

However, if family members are

separated, anxiety may be

heightened.

1 8

Warning or Threat Phase

The warning or threat phase occurs

with hurricanes, floods, and other

disasters for which there is warning

hours or days in advance. Lack of

warning can make survivors feel

vulnerable, unsafe, and fearful of

future unpredicted tragedies. The

perception that they had no control

over protecting themselves or their

loved ones can be deeply distressing.

Racial and ethnic groups

sometimes differ in the ways in

which they receive information

TABLE 1-3

Characteristics of Disasters

Researchers have identified several common characteristics of disasters

that are particularly important when discussing emotional distress 

and recovery (Bolin, 1985: DHHS, 2000a, p. 6). These characteristics 

are as follows:

■Intensity of the impact: Disasters that wreak intense destruction

within a short period of time are more likely to cause emotional

distress among survivors than are disasters that work their effects

more slowly.

■Impact ratio (i.e., the proportion of the community sustaining

personal losses): When a disaster affects a significant proportion of 

a community’s population, few individuals may be available to 

provide material and emotional support to survivors.

■Potential for recurrence of other hazards: The real or perceived

threat of recurrence of the disaster or of associated hazards can 

lead to anxiety and heightened stress among survivors.

■Cultural and symbolic aspects: Changes in survivors’ social and

cultural lives and routine activities can be profoundly disturbing.

Both natural and human-caused disasters can have symbolic

implications.

■Extent and types of loss sustained by survivors: Property damage

or loss, deaths of loved ones, injury, and job loss all affect 

emotional recovery.
1 9

Remedy or 

Honeymoon Phase

During this phase, optimism may

reign as the community pulls

together and government and 

volunteer assistance become 

available. The interactions between

relief workers and survivors from

different cultures can be very

important and can influence 

people’s long-term perceptions of

the disaster relief effort. Perceptions

and beliefs about how healing

occurs also may influence recovery.

Frequently, however, disaster

workers who have had no

orientation to local cultures and

lack sensitivity to them are brought

in to help out during this phase.

Such workers may exacerbate,

rather than mitigate, cultural

differences. 

Inventory Phase

During the inventory phase,

survivors recognize the limits of

help and begin to assess their

futures. They become exhausted

because of multiple demands,

financial pressures, and the stress 

of relocation or living in a damaged

home. Initial optimism may give

way to discouragement and fatigue.

This also is a time characterized by

high levels of grief and loss.

Families who lose loved ones will

grieve and cope in different ways.

Disillusionment Phase

The disillusionment phase occurs

when survivors recognize the reality

of loss and the limits of outside

relief. This phase is characterized 

by a high level of stress that may be

manifested in personally

destructive behavior, family

discord, and community

fragmentation. Obtaining

assistance from relief agencies can

be extremely difficult, and survivors

may feel helpless and angry.

Hostility between neighbors and

among groups is common, and

tensions may erupt among different

cultural, racial, and ethnic groups.

Reconstruction or

Recovery Phase

The final phase, reconstruction or

recovery, may last for years. This

phase involves the structural

rebuilding of the community as well

as the integration of changes

occasioned by the disaster into

one’s community and one’s life. 

A common problem is a lack of

housing, particularly if the disaster

destroyed much of the low-income

housing stock. In such situations,

the private market typically hinders

rebuilding of low- and moderateincome rental units (Fothergill 

et al., 1999). Therefore, housing

shortages and rent increases disproportionately affect racial and

ethnic minority groups (Bolin and

Stanford, 1991; Peacock and Girard,

1997). It is not unusual for local

political issues to create friction 

and fragmentation in the impacted

community during the disparate

reconstruction progress and

buyouts between neighboring

counties.

CULTURAL

COMPETENCE AND

DISASTER MENTAL

HEALTH PLANNING 

Providing culturally competent

mental health services to survivors

requires action before, during, and

after a disaster. The disaster mental

health plan, which should be part of

a State or community emergency

management plan, can help ensure 

an efficient, coordinated response

to the mental health needs of the

affected population (DHHS, 

Rev. ed., in press). These plans

specify roles, responsibilities, and

relationships among agencies 

and organizations in responding 

to a community’s mental health

needs following a disaster (DHHS,

Rev. ed., in press).

Civil Unrest Causes

Emotional Problems

for Refugees

The civil unrest and fires 

in Los Angeles that came 

in the wake of the Rodney

King verdict affected a 

community inhabited by 

many refugees from 

Central America and Asia. 

For immigrants who came 

from war-torn countries, 

the Los Angeles disturbances

reactivated fears and 

emotions associated 

with their homeland. Many 

experienced increased 

agitation, depression, 

confusion, and recollections

of prior bereavements.

California Final Report, 1994

REPORT
2 0

Well-designed disaster mental

health plans enhance coordination

and minimize chaos, thereby

helping to ensure that survivors

receive assistance in a timely,

helpful, and culturally sensitive

manner should a disaster occur.

Disaster mental health plans that

identify and address diverse needs

within a community can save

valuable time and avert many

problems. In the absence of such

planning, disaster relief is

disorganized, especially in the

immediate aftermath. Confusion

and inefficiency can prevail when

survivors attempt to gain access 

to services.

Successful program planners

recognize that creating culturally

competent environments requires

more than recruiting bilingual and

bicultural mental health workers,

sponsoring a single diversity

management class, sending a few

employees to a cultural competence

workshop, or hiring a “token” racial

or ethnic minority group

representative. Rather, cultural

competence must be a part of the

program values; included in the

program’s mission statement; and

encouraged in attitudes, policies,

and practices at every level.

To develop a culturally competent

disaster mental health plan, 

planners must:

■ Assess and understand the

community’s composition;

■ Identify culture-related needs of

the community;

■ Be knowledgeable about formal

and informal community

institutions that can help meet

diverse mental health needs;

■ Gather information from and

establish working relationships with

trusted organizations, service

providers, and cultural group

leaders and gatekeepers; and

■ Anticipate and identify solutions

to cultural problems that may arise

in the event of a disaster.

Table 1-4 presents questions that

should be addressed in the mental

health plan. For further information

about disaster mental health

planning, refer to Disaster Response

and Recovery: A Strategic Guide

(DHHS, Rev. ed., in press).

Disaster Strikes 

a Highly Diverse Community

On January 17, 1994, a major earthquake struck Los Angeles 

and Ventura Counties. The Northridge earthquake was the largest

and most violent to hit an urban area in the United States since 

the 1906 San Francisco quake. The post-disaster recovery effort

provided mental health services to 1.9 million persons, representing

myriad ethnic groups, special populations, and lifestyles.

The size and scope of the two affected counties, as well as 

the ethnic diversity of their residents, constituted a challenge to

disaster mental health providers. For example, Ventura County 

is home to many undocumented migrant farm workers, the

majority of whom do not speak English and are mistrustful of

government at any level. Language and cultural barriers had to 

be overcome for persons from several Asian cultures as well. 

The diverse population in the affected areas also included 

other special populations, such as physically challenged 

persons and runaway youth, two groups that required 

special outreach strategies. 

The disaster mental health program staff recognized from 

the beginning of the project the need to develop and provide 

culturally relevant and linguistically appropriate services, 

covering a multitude of cultures and languages.

California Final Report, 1995

REPORT
2 1

TABLE 1-4

Questions to Address in a Disaster Mental Health Plan

Community demographic 

characteristics 

■Who are the most vulnerable

persons in the community?

Where do they live? 

■What is the range of family

composition (i.e., single-parent

households)?

■How could individuals be

identified and reached in a

disaster? 

■Are policies and procedures in

place to collect, maintain, and

review current demographic

data for any area that might be

affected by a disaster?

Cultural groups

■What cultural groups (ethnic,

racial, and religious) live in the

community? 

■Where do they live, and what are

their special needs? 

■What are their values, beliefs,

and primary languages? 

■Who are the cultural brokers in

the community?

Socioeconomic factors 

■Does the community have any

special economic considerations

that might affect people’s

vulnerability to disaster? 

■Are there recognizable

socioeconomic groups with

special needs? 

■How many live in rental

property? How many own 

their own homes? 

Mental health resources 

■What mental health service

providers serve the community? 

■What skills and services does

each provider offer? 

■What gaps, including lack of

cultural competence, might

affect disaster services? 

■How could the community’s

mental health resources be used

in response to different types of

disasters?

Government roles and

responsibilities in disaster 

■What are the Federal, State, and

local roles in disaster response? 

■How do Federal, State, and local

agencies relate to one another? 

■Who would lead the response

during different phases of 

a disaster?

■How can mental health services

be integrated into the

government agencies’ disaster

response? 

■What mutual aid agreements

exist? 

■Do any subgroups in the

community harbor any historical

or political concerns that affect

their trust of government?

Nongovernmental

organizations’ roles in disaster 

■What are the roles of the

American Red Cross, interfaith

organizations, and other disaster

relief organizations? 

■What resources do nongovernment agencies offer, 

and how can local mental 

health services be integrated

into their efforts? 

■What mutual aid agreements

exist?

■How can mental health

providers collaborate with 

private disaster relief efforts?

Community partnerships

■What resources and supports

would community and

cultural/ethnic groups provide

during or following a disaster? 

■Do the groups hold pre-existing

mutual aid agreements with any

State or county agencies? 

■Who are the key informants/

gatekeepers of the impacted

community? 

■Has a directory of cultural

resource groups, natural helpers,

and community informants who

have knowledge about diverse

groups been developed? 

■Are the community partners

involved in all phases of disaster

preparedness, response, and

recovery operations?
SECTION TWO

Guiding 

Principles and

Recommendations

2 2

GUIDING

PRINCIPLES FOR

CULTURAL

COMPETENCE IN

DISASTER MENTAL

HEALTH PROGRAMS

Principle 1: Recognize the

importance of culture and respect

diversity.

Principle 2: Maintain a current

profile of the cultural composition

of the community.

Principle 3: Recruit disaster

workers who are representative of

the community or service area.

Principle 4: Provide ongoing

cultural competence training to

disaster mental health staff.

Principle 5: Ensure that services 

are accessible, appropriate, and

equitable. 

Principle 6: Recognize the role of

help-seeking behaviors, customs

and traditions, and natural support

networks.

Principle 7: Involve as “cultural

brokers” community leaders and

organizations representing diverse

cultural groups.

Principle 8: Ensure that services

and information are culturally and

linguistically competent.

Principle 9: Assess and evaluate 

the program’s level of cultural

competence.

requires a concerted effort by

disaster mental health planners 

and front-line workers. Successful

programs share common practices

that are defined by nine guiding

principles. These principles, listed

here, have been identified by

CMHS.

This section discusses each of 

the nine guiding principles and

suggests ways to integrate them

into disaster mental health

planning and crisis counseling

programs. The guiding principles, 

in many ways, overlay the Key

Concepts of Disaster Mental Health

(DHHS, 2000e), presented in 

Table 2-1. The Cultural Competence

Checklist for Disaster Crisis

Counseling Programs, presented 

in Appendix F, summarizes key

content in a convenient form for

use in program planning.

Developing cultural competence 
2 3

PRINCIPLE 1:

RECOGNIZE THE

IMPORTANCE OF

CULTURE AND

RESPECT DIVERSITY 

Culture is one medium through

which people develop the resilience

that is needed to overcome

adversity. Following a disaster,

culture provides validation and

influences rehabilitation. However,

when daily rituals, physical and

social environments, and

relationships are disrupted, life

becomes unpredictable for survivors.

Disaster mental health workers can

help reestablish customs, rituals,

and social relationships and thereby

help survivors cope with the impact

of a disaster. When doing so, these

workers need to recognize that

diversity exists within as well as

across cultures (Cross et al.,1989).

In disasters, individuals within a

given cultural group may respond

in very different ways; some will be

receptive to disaster relief efforts,

while others will not. Older adults

and young people within a

particular culture may react to

losses or seek help in different ways,

depending on their degree of

acculturation. Disaster mental

health workers also must be aware

of and sensitive to issues stemming

from biculturalism; these issues

include conflict and ambivalence

related to identity and the need 

to function in cross-cultural

environments (Hernandez and

Isaacs, 1998).

Recognizing the importance of

culture and respecting diversity

require an institution-wide

commitment. To meet this

commitment, disaster mental health

workers must understand their own

TABLE 2-1

Key Concepts of Disaster Mental Health

The following concepts should be adopted by all disaster mental 

health providers, including those serving culturally diverse survivors.

The concepts can also help administrators and service providers set

program priorities. The concepts deviate in some ways from those on

which mental health work has traditionally been based. However, their

validity has been confirmed again and again in disasters of various

types that have affected a broad range of populations (DHHS, 2000a).

■No one who sees a disaster is untouched by it.

■There are two types of disaster trauma—individual and community.

■Most people pull together and function adequately during and 

after a disaster, but their effectiveness is diminished by the 

effects of the event.

■Stress and grief in disasters are normal reactions to abnormal

situations.

■Many emotional reactions of disaster survivors stem from 

problems of daily living brought about by the disaster.

■Disaster relief assistance may be confusing to some survivors. They

may experience frustration, anger, and feelings of helplessness related

to Federal, State, and private-sector disaster assistance programs.

■Most people do not see themselves as needing mental health services

following a disaster and will not seek such services.

■Survivors may reject disaster assistance of all types.

■Disaster mental health assistance is often more practical than

psychological in nature.

■Disaster mental health services must be tailored to the culture of

communities where they are provided.

■Mental health workers should set aside traditional methods, avoid

mental health labels, and use an active outreach approach to

intervene successfully in disaster.

■Survivors respond to active, genuine interest, and concern.

■Interventions must be appropriate to the phase of the disaster.

■Social support systems are crucial to recovery.
PRINCIPLE 2:

MAINTAIN A

CURRENT PROFILE

OF THE CULTURAL

COMPOSITION OF

THE COMMUNITY 

No one knows when or where

disaster will strike. For this reason, 

a predisaster assessment of a

community’s composition and

familiarity with cultural traditions

and customs during times of loss,

trauma, and grief can provide

invaluable knowledge in the event

of a disaster. The range of cultural

diversity—ethnic, religious, racial,

and language differences among

subgroups—should be assessed 

and described in a comprehensive

profile of the community. A

comprehensive community profile

describes the community’s

composition in terms of:

■ Race and ethnicity; 

■ Age; 

■ Gender; 

■ Religion; 

■ Refugee and immigrant status;

■ Housing status (i.e., number of

single-parent households, type of

housing, rental versus ownership,

number of persons per household); 

■ Income and poverty levels; 

■ Percentage of residents living in

rural versus urban areas;

■ Unemployment rate; 

■ Languages and dialects spoken;

■ Literacy level;

■ Number of schools; and

■ Number and types of businesses.

2 4

cultures and world views; examine

their own attitudes, values, and

beliefs about culture; acknowledge

cultural differences; and work to

understand how cultural differences

affect the values, attitudes, and

beliefs of others. Table 2-2 examines

important considerations mental

health workers should keep in mind

when dealing with people from

other cultures. 

Concerns About Child Care 

Heightened by Bombing

REPORT

Following the 1995 bombing of the Alfred P. Murrah Federal Building

in Oklahoma City, local mental health agencies mobilized to provide

services to the survivors. One Latino child perished in the Murrah

Building and several Latino children were wounded at the YMCA

day care center. Mental health workers realized that they would

have to address the concerns and guilt of Latino parents regarding

child care because in this culture individuals generally resist using

babysitters or placing their children in day care.

Oklahoma Application, 1995

Indigenous Outreach Workers Provide

Community-Appropriate Services in Guam

REPORT

In the aftermath of the 1997 super-typhoon, Paka, the Territory 

of Guam partnered with the University of Guam College of Life

Sciences to provide culturally appropriate crisis counseling services.

Strategies such as paying special attention to racial tensions,

matching workers to the population served, and providing training

on culturally respectful interactions helped the outreach workers

gain entry to the island’s diverse population. 

The demographics of the staff mirrored that of the community, and

the mental health providers were an integral part of the community.

Culture-specific training provided a forum for interacting with

representatives of helping agencies on the island and from

neighboring Saipan. Outreach tools and strategies included a

monkey hand puppet used to engage children, a program for hotel

workers, and a program for seniors that used symbolism and

activities to encourage recovery. Broadcast and print media, as well

as personal conversations, were used to educate the public about

the project and the emotional effects of disaster.

Guam Site Visit Report, 1998
2 5

TABLE 2-2

Important Considerations 

When Interacting with People of Other Cultures

Giger and Davidhizar’s “transcultural assessment and intervention model” was developed to assist in the

provision of transcultural nursing care. It is currently used by several other health and human services

professions. The model identifies five issues that can affect the interactions of providers and service recipients.

These issues, adapted below to apply to disaster crisis counseling, illustrate the importance of acknowledging

culture and of respecting diversity. A complete description of the model can be found in Transcultural Nursing:

Assessment and Intervention (Giger and Davidhizar, 1999).

Communication: Both verbal and nonverbal communication can be barriers to providing effective disaster

crisis counseling when survivors and workers are from different cultures. Culture influences how people

express their feelings, as well as what feelings are appropriate to express, in a given situation. The inability to

communicate can make both parties feel alienated and helpless. 

Personal Space: “Personal space” is the area that immediately surrounds a person, including the objects

within that space. Although spatial requirements may vary from person to person, they tend to be similar

among people in a given cultural group (Watson, 1980). A person from one subculture might touch or move

closer to another as a friendly gesture, whereas someone from a different culture might consider such behavior

invasive. Disaster crisis counselors must look for clues to a survivor’s need for space. Such clues may include,

for example, moving the chair back or stepping closer.

Social Organization: Beliefs, values, and attitudes are learned and reinforced through social organizations,

such as family, kinships, tribes, and political, economic, and religious groups. Understanding these influences

will enable the disaster crisis counselor to more accurately assess a survivor’s reaction to disaster. A survivor’s

answers to seemingly trivial questions about hobbies and social activities can lead to insight into his or her life

before the disaster.

Time: An understanding of how people from different cultures view time can help avoid misunderstandings

and miscommunication. In addition to having different interpretations of the overall concept of time,

members of different cultures view “clock time”—that is, intervals and specific durations—differently. Social

time may be measured in terms of “dinner time,” “worship time,” and “harvest time.” Time perceptions may be

altered during a disaster. Crisis counselors acting with a sense of urgency may be tempted to set timeframes

that are not meaningful or realistic to a survivor. The result may be frustration for both parties.

Environmental Control: A belief that events occur because of some external factor—luck, chance, fate, will of

God, or the control of others—may affect the way in which a survivor responds to disaster and the types of

assistance needed. Survivors who feel that events and recovery are out of their control may be pessimistic

regarding counseling efforts. In contrast, individuals who perceive that their own behavior can affect events

may be more willing to act (Rotter, 1966). Disaster crisis counselors need to understand beliefs related to

environmental control because such beliefs will affect survivors’ behavior.
to serve as counselors or in some

other capacity. The community

profile can be reviewed when

recruiting disaster crisis counseling

workers to ensure that they are

representative of the community 

or service area.

If indigenous workers are not

immediately available, coordinators

can attempt to recruit staff with 

the required racial or ethnic

background and language skills

from other community agencies 

or jurisdictions (DHHS, Rev. ed. 

in press).

Recruitment based solely on race,

ethnicity, or language, however,

may not be sufficient to ensure 

an effective response. People 

who are racially and ethnically

representative of the community

are not necessarily culturally or

linguistically competent. The ability

to speak a particular language is not

necessarily associated with cultural

competence. For example, a welleducated, Spanish-speaking

Hispanic professional may not

understand the problems and

cultural nuances of an immigrant

community whose members are

living in poverty (DHHS, 2000d).

Table 2-3 highlights the attributes,

knowledge, and skills essential 

to development of cultural

competence that should be

considered when recruiting 

disaster mental health staff.

2 6

Information about the values,

beliefs, social and family norms,

traditions, practices, and politics 

of local cultural groups, as well as

the history of racial relations or

ethnic issues in the community,

should be included in the

community profile, because these

cultural characteristics may take 

on additional significance in times 

of stress (DeVries, 1996). This

information should be gathered

with the assistance of and in

consultation with community

cultural leaders (“key informants”)

who represent and understand 

local cultural groups.

Other sources of data incorporated

in the community profile include

the city hall or the county

commissioner’s office, as well as 

the resources listed in Appendix C.

Finally, information included in 

the community profile should be

updated frequently, because such

data can change rapidly. 

PRINCIPLE 3: 

RECRUIT DISASTER

WORKERS WHO ARE

REPRESENTATIVE OF

THE COMMUNITY OR

SERVICE AREA 

Disaster mental health programs

are most effective when individuals

from the community and its various

cultural groups are involved in

service delivery as well as in

program planning, policy, and

administration and management.

Recruiting staff whose cultural,

racial, and ethnic backgrounds are

similar to those of the survivors

helps ensure a better understanding

of both the survivors and the

community and increases the

likelihood that survivors will be

willing to accept assistance. For

example, if American Indian or

Alaska Native populations have

experienced a disaster, tribal

leaders, elders, medicine persons,

or holy persons might be recruited

Migrant Farm Workers 

Employed as Outreach Workers

REPORT

In 1998, El Niño caused a series of storms that devastated many

California communities. The storms affected a large number of

migrant farm workers, including many in Ventura County. The

migrant workers were unwilling to seek help because of cultural

proscriptions and language barriers. Some were illiterate.

To improve its ability to assist the migrant workers, Ventura County’s

disaster crisis counseling project hired peer farm laborers. 

These workers, who had contacts and credibility within the 

migrant community, enabled the project to establish a unique

communication model to reach farm laborers. The peer 

counselors went into labor camps and met with the victims 

of the rains and their indigenous leaders. Local residents noted 

that these were the first “government” workers in recent memory

to be allowed in the farm workers’ camp.

California Final Report, 1998
2 7

PRINCIPLE 4:

PROVIDE ONGOING

CULTURAL

COMPETENCE

TRAINING TO

DISASTER MENTAL

HEALTH STAFF

Cultural competence is an essential

component of disaster mental

health training programs. Training

should be provided to help mental

health workers acquire the values,

knowledge, skills, and attributes

needed to communicate and work

in a sensitive, nonjudgmental, and

respectful way in cross-cultural

situations. Such training should be

provided to direct services staff,

administrative and management

staff, language and sign-language

interpreters, and temporary staff.

Cultural competence training

programs work particularly well

when they are provided in

collaboration with communitybased groups that offer expertise or

technical assistance in cultural

competence or in the needs of a

particular culture. Involving such

groups not only enables program

staff to gain firsthand knowledge of

various cultures, but also opens the

door for long-term partnerships

(Hernandez and Isaacs, 1998).

Training should cover basic cultural

competence principles, concepts,

terminology, and frameworks. For

example, training should include

discussion of:

■ Cultural values and traditions; 

■ Family values; 

■ Linguistics and literacy; 

TABLE 2-3

Staff Attributes, Knowledge, and 

Skills Essential to Development 

of Cultural Competence

Personal Attributes

■ Genuineness, empathy, and a capacity to respond flexibly 

to a range of possible solutions

■ Acceptance and awareness of cultural differences and 

cross-cultural dynamics 

■ Willingness to work with survivors of different cultures 

■ Ability to articulate one’s own values, stereotypes, and biases 

and to identify how they may accommodate or conflict with 

the needs of culturally diverse disaster survivors

■ Openness to learning about the cultures of diverse groups

Knowledge

■ History, tradition, values, and artistic expressions of culturally

diverse disaster survivors

■ Help-seeking behaviors, informal helping supports, and natural

healing practices of survivors of various cultures

■ Role of language, speech patterns, and communication styles 

in culturally distinct communities

■ Psychosocial stressors relevant to diverse groups (e.g., migration,

acculturation stress, legal and illegal discriminatory patterns, racism,

and socioeconomic status)

■ Community resources (e.g., agencies, informal helping networks)

and their availability to special populations 

Skills

■ Ability to discuss cultural issues and to respond to culturallybased cues

■ Ability to assess the meaning of culture for the disaster survivor 

■ Ability to interview and assess survivors on the basis 

of their personal, psychological, social, cultural, political, 

or spiritual models

(Adapted from: Benedetto, 1998; DHHS, 1998)
more affluent neighborhoods had

more community volunteers than

survivors. The mayor visited the

disaster site in these areas. Less

affluent neighborhoods had fewer

volunteers, and some volunteers

made remarks that the survivors felt

were offensive. The mayor did not

visit these areas (Dhesi, 1991).

Moreover, food and meal

preparation in shelters was not

culturally appropriate following 

the earthquake, and many Latinos

reported that they became sick

from eating the food prepared 

by the Anglo relief workers 

(Phillips, 1993).

In studies of Hurricane Andrew’s

aftermath, racial and ethnic minority

group survivors were less likely to

have insurance than were white

survivors because of practices that

exclude certain communities from

insurance coverage at affordable

rates. Survivors from minority

groups were also more likely to

receive insufficient settlement

amounts (Peacock and Girard, 1997).

Concerns related to gender also were

investigated after Hurricane Andrew.

Many non-English-speaking women

of color, especially single women,

were subjected to dishonest

practices of construction contractors

(Enarson and Morrow, 1997).

The delivery of appropriate services

is a frequent problem. Racial and

ethnic discrimination, language

barriers, and stigma associated with

counseling services have a negative

effect on many individuals’ access

to and utilization of health and

mental health services (Denboba 

et al.,1998). Families who

participated in focus groups

reported problems with cultural

2 8

■ Immigration experiences 

and status; 

■ Help-seeking behaviors;

■ Cross-cultural outreach

techniques and strategies; and

■ Avoidance of stereotypes 

and labels (DHHS, 2000e).

Even if the initial training period is

of limited duration, participants

should have an opportunity to

examine and assess values,

attitudes, and beliefs about their

own and other cultures. Selfassessment helps identify areas

where skills need to be developed

(DHHS, 1998). Training should

stress that people of a given cultural

group may react quite differently to

disaster, depending on their level of

acculturation. 

Cultural competence training is a

developmental process. Ongoing

education—through in-service

training and regularly scheduled

meetings with project staff to

discuss cultural competence

issues—is essential (Hernandez 

and Isaacs, 1998).

PRINCIPLE 5:

ENSURE THAT

SERVICES 

ARE ACCESSIBLE,

APPROPRIATE, 

AND EQUITABLE 

Survivors are not always receptive

to offers of support. For example,

some members of cultural groups

may be reluctant to take advantage

of services because of negative past

experiences. Undocumented

immigrants may not seek services

because they fear deportation. 

Such individuals may be reluctant

or refuse to move to temporary

shelters, to accept State or Federal

assistance, or to discuss

information that they think could

be used against them.

Inequitable treatment following

disasters may reinforce mistrust 

of the public services and disaster

assistance systems. Following the

1989 Loma Prieta earthquake in

California, shelter services in the

Innovative Program Developed for Seniors

REPORT

Following civil unrest in Los Angeles in 1993, a crisis counseling

program was developed to assist the community. One element 

of this program was peer counseling with senior adults, including

a group of elderly Samoans. No mental health professionals from

the Samoan population could be found to help address the needs

of these monolingual older adults in South Bay. Project staff

worked with the head of the Samoan Council of Chiefs to offer a

first-of-its-kind peer counselor training delivered via simultaneous

translation. It worked beautifully. Twenty Samoans became deeply

committed to counseling seniors in their community.

California Final Report, 1994
2 9

and ethnic biases and stereotypes,

offensive communication and

interactions based on such biases

and stereotypes, lack of crosscultural knowledge, and lack of

understanding of the values 

of various cultural groups (Malach

et al., 1996).

Disaster mental health programs

must take special care to exercise

culturally competent practices.

They should make efforts to ensure

that staff members speak the

language and understand the values

of the community. Providing food

that has cultural significance can be

important. Involving cultural group

representatives in disaster recovery

committees and program decision

making (for example, as members

of planning boards or other policysetting bodies) can help ensure that

disaster services are accessible,

appropriate, and equitable.

Culturally sensitive outreach

techniques also can help ensure

that services are accessible and

appropriate to all survivors. For

example, outreach workers should:

■ Allow time for and devote energy

to gaining acceptance, take

advantage of associations with

trusted organizations, and be wary

of aligning their efforts with those

of agencies and organizations that

are mistrusted by cultural groups; 

■ Determine the most appropriate

ways to introduce themselves;

■ Recognize cultural variations in

expression of emotion,

manifestation and description of

psychological symptoms, and views

about counseling; and 

■ Assist in eliminating barriers by

carefully interpreting facts, policies,

and procedures.

Table 2-4 addresses special

considerations that should be 

taken into account when

counseling refugees.

PRINCIPLE 6:

RECOGNIZE 

THE ROLE OF 

HELP-SEEKING

BEHAVIORS,

CUSTOMS AND

TRADITIONS, AND

NATURAL SUPPORT

NETWORKS 

Culturally competent disaster

mental health services proactively

respond to the culturally defined

needs of the community.

Disruption of many aspects of life

and the need to adapt to difficult

circumstances cause stress and

anxiety in many survivors. In some

cases, these problems can be as

difficult as the disaster itself.

Effective response requires

familiarity with help-seeking

behaviors; customs and traditions

related to healing, trauma, and loss;

and use of natural support networks

of various cultural groups.

Help-Seeking Behaviors

Different cultures exhibit different

help-seeking behaviors. In many

cultures, people turn to family

members, friends, or cultural

community leaders for help before

reaching out to government and

private-sector service systems. They

may prefer to receive assistance

from familiar cultural community

leaders or groups rather than

unfamiliar service systems. In most

communities, churches and other

places of worship play a role similar

to that of an extended family, and

Hurricane Response 

Designed to Be Culturally Competent

REPORT

Hurricane Hortense struck Puerto Rico in 1996 with devastating

impact. The disaster crisis counseling program was designed to

be particularly sensitive to the Puerto Rican culture. For example,

recognizing that this culture encourages strong ties with friends

and neighbors, the program provided group debriefing sessions. 

The project also used cultural celebrations to advance its goals.

For example, the festival of the Three Kings Day, which occurs 

in early January, was used as an opportunity for special outreach 

in which project staff went door to door “giving asaltos”—a

tradition of singing Christmas carols and giving donated gifts—as a

way to identify needs and provide information and social support. 

The project also used dramatization to inform persons in the

community about disaster phases and disaster planning. 

Puerto Rico Final Report, 1997
3 0

TABLE 2-4

Special Considerations When Working with Refugees

Refugees may differ from each other and from native populations on several dimensions, including:

Language: Refugees frequently do not speak English

well, if at all. This issue presents communication

challenges throughout all phases of a disaster.

Culture: Refugees have their own cultures. Because

they are new to the United States, they usually are less

well-versed in Western culture than are immigrants,

who have had more time to understand it. 

Economic marginalization and differences: When

they arrive in the United States, many refugees can

barely manage economically. Many are supporting

relatives left at home. On the other hand, some

refugees—especially those with education and highly

sought skills—find well paying jobs quickly. Thus,

although poverty is common among refugees, not all

refugees are poor.

Fractured social relations: The communities of

origin of many refugees have failed to provide

needed security. In addition, many refugees have

experienced personal attacks by representatives of

their community or the larger society. Some become

so disillusioned by this experience that they are

reluctant to form new community bonds. In addition,

refugees often face within-group schisms. Preexisting

ethnic, religious, and political divisions of the society

of origin are frequently reinstituted in refugee

communities formed in the new country.

Some refugees solve the problem by restricting new

relationships to the safest ones, for example, by

forming or joining small groups of people who

emigrated from the same geographic area. When a

disaster forces relocation, it can break up this small

community and make recovery more problematic

(Athey and Ahearn, 1991).

The negative experiences of many refugees also 

make them suspicious of government. They may 

be reluctant to seek out or accept assistance

following a disaster. Undocumented migrants may

fear deportation, but even refugees who have

achieved legal status may fear that accepting

assistance following a disaster will put them at risk of

deportation. Thus, refugees often are the last group

to obtain assistance following disaster.

Experience of traumatic stressors and of loss:

Refugees often have experienced horrific events that

cause symptoms of Post-Traumatic Stress Disorder.

They may have lost family members, their homes,

and their possessions, and some have been deprived

of sufficient food or water, lacked medical care, or

lived in inadequate housing for long periods of time.

A disaster can lead to the emotional re-experiencing

of these events (Van der Veer, 1995). On the other

hand, some refugees may have gained strength and

resilience from their previous experiences and bring

that strength to the new disaster.

Family dynamics and role changes: Another

challenge for many refugee families is that of new

family dynamics upon resettlement. Children may

have seen their parents fearful, helpless, and stressed

during the flight and—upon resettlement—anxious,

powerless, and exhausted. Children may come to

believe that adults are not to be trusted because 

they have not seen adults playing a protective and

nurturing role.

Intergenerational conflict resulting from differing

rates of acculturation presents another family

problem. Finally, parents may feel deprived of their

role as family heads when they find they must

depend on children as language translators or

navigators within the new culture (de Monchy, 1991).

De Monchy (1991) identifies three principles for

effective service delivery with refugees:

1. Trauma experiences need to be acknowledged. 

2. Refugees need to be recognized as successful

survivors, and their wisdom and strengths

affirmed. 

3. Empowerment and the recovery of control need 

to be encouraged, especially for refugees who are

reestablishing parental roles with their children.
3 1

survivors turn to them first for

assistance.

Many survivors may be reluctant to

seek help or may reject disaster

assistance of all types. Some people

feel shame in accepting assistance

from others, including the

government, and equate

government assistance with

“welfare.” Members of racial and

ethnic minority groups, including

refugees and immigrants, also may

be reluctant or afraid to seek help

and information from service

systems because of historical

mistrust of the health, mental

health, and human services systems

or because of fear of deportation

(Aponte, Rivers, and Wohl, 1995).

Other groups may prefer to suffer 

or even perish rather than seek 

help from people they mistrust.

Therefore, building trusting

relationships and rapport with

disaster survivors is essential to

effective crisis counseling.

Those who do seek help may find

relief procedures confusing.

Feelings of anger and helplessness

and loss of self-esteem can result

from survivors’ encounters with

relief agencies. These feelings result

from the survivors’ lack of understanding of the disaster relief

system as well as government and

private agencies’ often bureaucratic

procedures.

Customs and Traditions

in Trauma and Loss 

Religious and cultural beliefs are

important to survivors as they try to

sort through their emotions in the

aftermath of traumatic events.

Beliefs may influence their

perceptions of the causes of

traumatic experiences. For example,

in many cultures, people believe

that traumatic events have spiritual

causes. These beliefs can affect their

receptivity to assistance and

influence the type of assistance that

they will find most effective.

Different populations may

elaborate on the cultural meaning

of suffering in different ways, but

suffering itself is a defining

characteristic of the human

condition in all societies. In most

major religions, including

Christianity, Judaism, Islam,

Hinduism, and Buddhism, the

experience of human misery—

resulting from sickness, natural

disasters, accidents, violent death,

and atrocity—also is a defining

feature of the human condition.

Different cultural groups also

handle grief in different ways.

Family customs, beliefs, and degree

of acculturation affect expressions

of grief. Disaster mental health

workers must recognize that grief

rituals, although diverse in nature,

can help people return to a

reasonable level of functioning. 

For example, Western tradition

holds that grief should be “worked

through.” This process includes

acceptance of the loss; extinction 

of behaviors that are no longer

adaptive; acquisition of new ways 

of dealing with others; and

resolution of guilt, anger, and 

other disruptive emotions.

If a community remains intact 

after a disaster, cultural norms,

traditions, and values determine 

the strategies that the survivors use

to deal with the effects. When the

entire community is affected,

however, cultural mechanisms may

be overwhelmed and unable to

fulfill their customary functions 

of regulating emotions and

Shamans Counter Bad Luck

REPORT

In 1995, northern California experienced a series of storms that led

to flooding, landslides, and mud debris flow. The State

implemented a FEMA-funded crisis counseling program for the

victims of the storms. One group affected were Hmong

immigrants, persons with a history of war and severe losses. In

serving the Hmong population, the program utilized the color red

in many printed materials and supplies because Hmong culture

includes a belief that red symbolically wards off evil spirits. Another

consideration involved the Hmong belief that floods are an omen

of doom and that shaman cleansing rituals are needed to counter

the bad luck that this omen portends. As a way of acknowledging

and respecting this belief, the staff developed and provided a

referral list of shamans in the local area.

California Final Report, 1996
3 2

providing identity, support, and

resources (DeVries, 1996). Disaster

mental health workers can support

the healing process by helping

rebuild the community’s cultural

support system. Workers will be

most effective when they recognize

and understand the importance 

of culture in the lives of disaster

survivors and the beliefs, rituals,

and level of acculturation of the

community in which they work.

Customs and Traditions 

for Healing

Many cultural groups hold beliefs

about illness and healing that differ

sharply from those held by Western

society. People in every culture share

beliefs about the causes of illness

and ideas about how suffering can

be mitigated. For example, members

of some cultures believe that

physical and emotional problems

result from spiritual wrongdoings 

in this life or a previous one. 

They believe that healing requires

forgiveness from ancestors or

higher spirits. Some people 

believe that suffering cannot be

ameliorated (DeVries, 1996). Others

demonstrate stress and emotional

conflict through complaints about

their physical health.

Traditional healers, such as local

herbalists, faith healers, and

acupuncturists, play important

roles in recovery of mental and

physical health within some

cultures. In general, the work of

healers is based on the principle

that the body cannot be isolated

from the mind, and the mind

cannot be removed from its social

context. Disaster mental health

workers who interact with cultures

in which healers play a key role in

health must understand the

concepts of integration of body,

mind, and spirit when they provide

disaster crisis counseling services to

diverse populations. They must be

able to integrate traditional

methods of healing into service

delivery (de Monchy, 1991).

Although the crisis counselor may

not subscribe to certain cultural

healing beliefs, he or she must

acknowledge their existence and

recognize their importance to some

disaster survivors. At the same time,

the worker must be alert for any use

of dangerous healing practices,

such as ingestion of harmful

mixtures containing lead or other

toxic substances, and take

corrective measures. Reestablishing

Alaska Villagers Helped by Tribal Elders

REPORT

In 1994, severe rains in Alaska resulted in extensive flooding of 

the Koyukuk River. Three native villages experienced tremendous

damage and residents had to be temporarily evacuated. With

FEMA funding, the State of Alaska developed a disaster crisis

counseling project that included among its staff professionals 

and paraprofessionals, Alaska Native and non-native staff, and

tribal elders. Among the counselors were individuals with cultural

sensitivity and respect for the wisdom of the elders. The project

organized sewing circles and birchbark basket-making circles 

in order to use the mechanisms of the culture’s social life 

to assist in its recovery.

Alaska Final Report, 1995

Importance of Culturally Competent 

Ethnic Workers

REPORT

Flooding in Florida displaced many residents in 1998. One area

that was flooded included a community with a high percentage 

of African Americans, a majority of whom were living in rental

property. Unfortunately, the landlords were less than prompt,

thorough, or enthusiastic in making repairs. 

The disaster crisis counseling program that was developed 

in response to the flood employed an African American team

leader from the county where most of the affected people lived.

She was especially important in accessing community leaders 

and gatekeepers, helping identify needs of the community, 

and providing services.

Florida Final Report, 1999
3 3

rituals in appropriate locations is

another way to help survivors in 

the recovery process. Symbolic

gathering places, such as churches,

mosques, trees, and safe places 

for meeting after sundown are

important in some cultures and are

required for certain rituals. After a

disaster, survivors may lose access

to symbolic places, and this loss

may limit their ability to mobilize

healing resources. Identifying new

locations for rituals can foster social

support and facilitate coping

mechanisms following disaster

(DeVries, 1996).

Disaster mental health workers also

may help organize culturally

appropriate anniversary activities

and commemorations as a way to

help survivors mark a milestone in

the healing process. Cultural and

religious traditions, including

special ways of both celebrating

and mourning, can be incorporated

into such events and may enrich

their symbolic meaning and healing

potential. Any attempts to facilitate

activities involving customs and

traditions must be undertaken

carefully and only after consultation

with members of the involved

cultural groups.

Natural Support

Networks

In many cultures, the family or kin

group is chiefly responsible for its

members, and support from kin

may be essential in helping

individuals overcome grief and

trauma. However, when disaster

strikes, all members of the extended

family may be affected, leaving

many people without this

customary support network.

Traditions concerning the role of

the family, who is included in the

family, and who makes decisions

vary across cultures (DHHS, 2000e).

Elders and extended family play a

significant role in some cultures,

whereas in other cultures, isolated

nuclear families are the decision

makers (DHHS, 2000e). Households

in racial and ethnic communities

are, on average, larger than white

households (O’Hare, 1992); they

also are more likely to be

multigenerational. Asians, for

example, are more than twice as

likely as whites to live in extended

families (O’Hare and Felt, 1991).

Disaster mental health workers

must recognize that family support

may not be available when entire

kin groups are affected. Helping

families and friends reunite is one

way to ensure mutual support.

Likewise, formal support groups

can help assure those with limited

access to relatives and acquaintances

that they are not alone. Individuals

who do not relate to support groups

because of cultural and linguistic

differences may need more

individualized services.

Disaster mental health workers also

must recognize that in many

cultures, the individual cannot be

separated from the family and

community (Reichenberg and

Friedman, 1996). In such cultures,

unlike those of Western society, the

individual does not exist apart from

the group; outreach efforts focused

on individuals are, therefore,

neither comprehensible nor

effective. For example, among some

Asian American and Pacific Islander

populations, intervention strategies

that diffuse the power of family

relationships are especially

inappropriate. Mental health

workers can assess who is

significant in a survivor’s family

structure by asking the survivor to

describe his or her home, family,

and community (Managua, 1998). 

PRINCIPLE 7:

INVOLVE AS 

“CULTURAL

BROKERS”

COMMUNITY

LEADERS AND

ORGANIZATIONS

REPRESENTING

DIVERSE CULTURAL

GROUPS 

Involving “cultural brokers”—

community leaders and groups that

represent diverse groups—is vital 

to the success of disaster mental

health efforts. Collaborating with

organizations and leaders who are

knowledgeable about the

community is the most effective

way of gaining information about

the community. Collaboration can

assist in assessing needs, creating

community profiles, making

contact with and gaining the trust

of survivors, establishing program

credibility, integrating cultural

competence in training, and

ensuring that strategies and

services are culturally competent

(DHHS, 1998).

In most communities, and in

diverse communities in particular,

some of the most influential

individuals are cultural group
3 4

leaders who possess “insider”

knowledge of the community and

are willing and able to articulate

that knowledge (Hernandez and

Isaacs, 1998). These individuals,

who may not be immediately

visible, can include spiritual

leaders, members of the clergy,

teachers, civic leaders, local officials,

or long-term residents who have

the respect and confidence of their

neighbors. They often can provide

outsiders with the best insights into

a local culture’s values, norms,

customs, conventions, traditions,

and expectations (Hernandez and

Isaacs, 1998).

Organizations representing various

cultural groups and other special

interest groups in the community

should be invited to participate in

disaster mental health programs.

These organizations can provide

valuable insight during the planning

process, serve as a point of entry 

to the survivor community, and

enhance cultural relevance of

service delivery. Including

individuals from various cultures 

on planning task forces and

committees will help ensure that

they concur with the selected

strategies. 

Should a disaster occur,

community-based organizations

can provide an important

communication link with the

cultural groups they represent. For

example, churches do much more

than serve the spiritual needs of the

African American community. They

are also the center of political,

social, educational, and cultural

activities. Therefore, African

American ministers may play an

important part in mental health

outreach and recovery efforts.

Informal, culture-specific groups

such as sewing circles and youth

sports teams can also be sources of

support to disaster survivors. The

crisis counseling program staff

should identify the most effective

ways to work with such groups.

Community-based organizations

that should be involved include:

■ Civic associations;

■ Social clubs; 

■ Neighborhood groups; 

■ Faith-based organizations;

■ Interfaith groups; 

■ Mutual aid societies; 

■ Voluntary organizations; 

■ Health care and social service

providers; and 

■ Nonprofit advocacy organizations

(Hernandez and Isaacs, 1998).

To ensure effective use of resources,

crisis counselors should coordinate

their work with that of other public

and private agencies responding to

the disaster. The coordinating

agency should recognize unique

jurisdictional situations that may

arise when working with various

American Indian and Alaska Native

cultures. American Indian and

Alaska Native tribes are federally

recognized sovereign nations.

Disaster mental health agencies

should acknowledge the need for a

partnership that includes various

agencies within tribes, different

levels of government, and many

tribes working together to improve

access to disaster assistance.

Although under the Stafford Act, 

a State government must request 

a Presidential disaster declaration 

on behalf of a tribe, agencies subsequently can work directly with the

tribe and with existing authorities

and resources to tailor disaster

plans to the tribe’s unique needs

and jurisdictional requirements.

PRINCIPLE 8:

ENSURE THAT

SERVICES AND

INFORMATION ARE

CULTURALLY AND

LINGUISTICALLY

COMPETENT 

Language can be a major barrier to

service delivery. Survivors who are

monolingual, limited in their

English, or deaf or hard of hearing

Did You Know . . . 

According to 1990 census data, nearly 14 percent of 

the Nation’s population—32 million people—speak a language

other than English in their homes. More than 300 languages are

spoken in the United States (Goode et al., 2001).
3 5

may be at a particular disadvantage.

Emergency response programs

generally have few or no staff

trained to work with bilingual

populations (Phillips and

Ephraim,1992). For example, most

of the information provided

immediately after Hurricane

Andrew in Florida was available

only in English (Yelvington, 1997).

As a result, many Latinos and

Haitians did not receive needed

food, medical supplies, and disaster

mental health assistance

information. 

“Linguistic competence” ensures

accurate communication of

information in languages other

than English. This capability

enables an organization and its

personnel to communicate

effectively with persons of limited

English proficiency, those who are

illiterate or have low literacy skills,

and individuals who are deaf or

hard of hearing (Goode et al., 2001).

Elements of linguistic competence

include the availability of trained

bilingual and bicultural staff,

translations of educational

materials and documents, and 

sign-language and language

interpretation services. Although

linguistic competence and cultural

competence involve distinct skills,

they are intrinsically connected

(DHHS, 1999).

Availability of 

Trained Bilingual 

and Bicultural Staff

Ideally, disaster mental health

workers should be bilingual,

bicultural, and from the affected

community. However, in many

circumstances, workers who are

bilingual but not from the affected

culture and community must 

be hired. In such situations,

communication challenges may

arise, even though the disaster

worker or interpreter speaks the

same language as the survivors. 

Examples or related issues follow. 

■ Disaster mental health workers

may be responsible for assisting

survivors who have a language

pattern that is different from their

own. Dialects, in addition to

colloquialisms and accents, can be

difficult to understand and

communication barriers can result. 

■ Words may have different

meanings even among people who

share a language. Rogers (1992)

noted difficulty in communicating

disaster information between

members of the United States Army

and people in a native Polynesian

culture because, although they both 

spoke English, the two groups 

did not assign a common meaning

to certain words and phrases. 

The language differences led 

to frustration and a breakdown 

of credibility. 

■ Bilingual disaster survivors who

primarily speak Spanish may be

more withdrawn when interviewed

in English rather than in Spanish.

An individual’s speech pattern 

may be halting or disrupted and

expression of affect may be reduced

when the person is required to

speak in a language other than his

or her primary language. In such

situations, the disaster worker’s

assessment of the survivor’s issues

and needs can be distorted. Ideally,

the preferred or primary language

of bilingual disaster survivors

should be used in delivering

outreach and other services 

(Aponte et al., 1995).

Multiple Methods Employed 

to Communicate with Asian Groups

REPORT

Hurricane George caused extensive damage in Alabama in 1998,

leaving many people homeless and others with major losses to

their homes and businesses. Included among the disaster

survivors was an Asian population. The disaster crisis counseling

program used several methods to reach and serve them. For

example, it developed leaflets in the Cambodian, Laotian, and

Vietnamese languages and distributed them to churches serving

large numbers of Asian immigrants. The crisis counseling project

also employed interpreters, a strategy that was viewed as highly

effective in disseminating information to these groups. Finally, the

project provided screening and information services to Asian

adolescents in a church group.

Alabama Final Report, 1999
3 6

Program managers must be

cautious in selecting bilingual 

staff members and interpreters.

Those who are bilingual also 

must understand nonverbal and

cultural patterns to communicate

effectively. Bilingual staff members

should demonstrate bilingual

proficiency and undergo cultural

competence training (DHHS, 2000a).

Dissemination of

Educational Information

Written information should be

translated3 into multiple languages,

as appropriate for the community

to be served. The literacy level of 

the target population must be

considered when developing

written materials. Any written

materials should be supplemented

with other forms of information

(DHHS, 2000a). For example,

messages may be conveyed by radio

or through announcements at

churches and other community

centers. Most localities now have

television stations that broadcast in

the languages of various cultural

groups. Although these communications media should be used, it is

important to note that some people

do not have access to television and

may depend on radio broadcasts 

for information.

Crisis support programs should

establish relationships with multicultural television stations, radio

stations, and newspapers before a

disaster occurs. In addition, program

staff should invite television and

radio station personnel to participate

in the development of a disaster

communications plan. 

The information needs of people

who are deaf or hard of hearing 

also must be considered. Closedcaptioned television, for example, 

is a critical communication tool 

for this population. The Federal

Communications Commission

requires that all emergency

information presented on television

be accessible to persons who are

deaf or hard of hearing.

Language and SignLanguage Interpretation

Language interpretation may be

used when the language barrier is

so great that communication

between mental health workers and

survivors is not possible or when no

bilingual staff can be hired. Signlanguage interpretation also must

be considered when developing

communication strategies.

Although language interpreters may

be the only viable option in some

situations, hiring bilingual staff

members remains the preferred

solution. Van der Veer (1995) notes

that an interpreter’s behavior may

evoke certain feelings in the

disaster survivor. Factors such as

the interpreter’s gender, age, or level

of acculturation may affect the

survivor’s willingness to speak

openly. Disaster survivors may be

ashamed of mental health problems

that are considered a sign of

madness or a cause for contempt in

their cultures. They also may

distrust interpreters who are from

the same country and speak the

same language, but who have

different political or religious

backgrounds (Van der Veer, 1995). 

Interpreters should be trained to

accurately convey the tone, level,

and meaning of the information

presented in the original language.

Without adequate training,

interpreters may interpret

information inaccurately or

incompletely. The most common

problems include changing openended questions into leading

questions, altering the content of

questions, and adding comments.

Problems in interpreting answers

include leaving out part of the

answer, adding something to the

answer, and making mistakes

because of limited understanding 

of English (Van der Veer, 1995).

When working with refugees,

mental health workers should be

aware that interpreters might have

experienced traumatic events

similar to those experienced by 

the refugees. In such situations, 

the interpreter may want to avoid

reliving unhappy or traumatic

memories. Thus, the interpreter

may present information

inaccurately, evade certain topics,

change the subject, or tell the

mental health worker that the

interview is too stressful for the

disaster survivor (Westermeyer,

1989). Table 2-5 provides useful

guidelines for using interpreters.

3 Interpretation is the oral restating in one

language of what has been said in another

language. Translation typically refers to the

conversion of written materials from one

language to another (Goode et al., 2001). 
3 7

PRINCIPLE 9:

ASSESS AND

EVALUATE THE

PROGRAM’S LEVEL 

OF CULTURAL

COMPETENCE

Self-assessment and process

evaluation are keys to ensuring that

disaster mental health services are

as effective as possible and to

making maximum use of resources.

Self-assessment helps programs

identify organizational problems

that may impede the delivery of

culturally competent services. The

self-assessment tool presented in

Table 2-6 may be used in

conjunction with the Cultural

Competence Checklist for Disaster

Crisis Counseling Programs,

presented in Appendix F. The

Cultural Competence Continuum

(Figure 1-1) is another useful tool 

for assessing a program’s level of

cultural competence.

Process evaluation helps ensure

that the disaster mental health

program stays on course. It also 

can identify problems or gaps in

providing culturally competent

services. Involving representatives

from as many cultural groups as

possible in process evaluation

ensures that diverse cultural 

groups or group perspectives 

are heard and understood.

The program can use a variety 

of techniques for collecting

information for process evaluations.

For example, staff might create 

an evaluation task force or advisory

group or a discussion or focus

group that includes representatives

of different cultural groups. A 

group that includes a disaster

survivor perspective, as well as

TABLE 2-5

Guidelines for Using Interpreters 

The following guidelines should be considered when using 

language interpreters (Bamford, 1991; Gaw, 1993; Paniagua, 1998;

Westermeyer, 1989):

■ Before hiring interpreters, attempt to identify mental health workers

who speak the language spoken by survivors and who identify with

the survivors’ culture.

■ Hire certified, qualified interpreters who share the survivor’s racial

and ethnic background.

■ Determine the survivor’s dialect before asking for an interpreter.

■ Compare the level of acculturation of the interpreter with that 

of the survivor. If it is not similar, effective communication may 

not be possible because Western values may be reflected in the

interpreter’s comments.

■ Introduce the interpreter to the disaster survivor, and allow time 

for them to build trust through informal conversation.

■ Take time for translation. Use a sequential mode of interpretation—

that is, the disaster survivor speaks, the interpreter interprets what 

has been said into English, the disaster mental health worker

speaks, and the interpreter speaks again.

■ Do not use survivors’ friends and relatives, including their children,

as interpreters. The survivor may not feel comfortable expressing

concerns of a personal nature to relatives and friends. Using

children can reverse the hierarchical role of parents and place

burdens on children. Moreover, such responsibility may require

skills beyond the child’s current stage of development and be too

stressful for the child (DHHS, 2000c).
3 8

TABLE 2-6

A Cultural Competence Self-Assessment 

for Disaster Crisis Counseling Programs

Leadership

■ Are the leaders of the program committed to

cultural competence? 

■ Does the project manager hold staff accountable

for knowledge of the provision of appropriate

services to all disaster survivors?

Understanding of cultural competence 

■ Has the program staff developed a common

understanding of cultural competence and 

do they clearly and frequently communicate 

that understanding to others?

Organizational culture

■ Does the crisis counseling program promote 

and encourage cultural competence? 

■ Is the program administered by an organization

with a strong commitment to and history of

working toward cultural competence? 

■ Are policies, procedures, and systems in place 

for delivering interpretation, bilingual, or

translation services?

Training 

■ Have all crisis counseling staff members been

trained in cultural competence, and are they

familiar with the diverse cultural and ethnic 

groups in the community? 

■ Are training programs ongoing? 

Six elements are needed to ensure cultural competence of mental health agencies (Bernard, 1998). 

Programs can use these elements to assess their level of cultural competence as well.

■ Are regular meetings convened and educational

opportunities offered for staff members to discuss

cultural competence issues and concerns, build

cross-cultural skills, and develop strategies?

Cultural competence plan 

■ Has the program identified goals designed to

address the mental health needs of the community

in a culturally competent manner? 

■ Has the program explored various methods of

working with disaster survivors in a way that

respects and is sensitive to the needs of all groups

in the community? 

■ Has the program established partnerships with

community-based agencies that serve cultural and

ethnic groups for input on needs assessment,

program planning, and evaluation? 

■ Has the program developed a mechanism to

acquire knowledge about the customs, values, 

and beliefs of special populations?

Managing the plan 

■ Has a person or group been identified to evaluate

the success of the program in addressing cultural

competency issues? 

■ Have methods been instituted to recognize

innovations in serving culturally distinct groups

and implement those innovations project-wide?
3 9

representatives of partner agencies,

can provide qualitative information

and innovative ideas that can help

the crisis counseling program more

effectively address the community’s

cultural needs. Evaluation methods

should be consistent with the

cultural norms of the groups being

served. Evaluators should be

sensitive to the culture and familiar

with the culture whenever possible 

and practical (DHHS, 2001).

Program staff should regularly

communicate process evaluation

findings to key informants and

cultural groups engaged in the

project and in the evaluation 

in order to ensure their ongoing

support.

Developing a culturally competent

disaster crisis counseling program

requires commitment and

diligence. The rewards of such

dedication are at the heart of the

program—effective and appropriate

services to help disaster survivors

recover and heal.

Bilingual and Bicultural Staff 

Assist in Assuring Cultural Competence 

REPORT

Late winter storms in California in 1995 affected several ethnic

groups in Fresno County. The county crisis counseling project

sought to deliver services in a bilingual, bicultural manner. Staff

members were assigned to match the ethnic and cultural

attributes of each community; for example, Spanish-English

speakers primarily concentrated in one area of the county, 

while Hmong-English speakers were deployed to another area.

Brochures and other forms of written information were translated

into both Hmong and Spanish. Interpreters were used to reach

persons who spoke Punjabi, Armenian, and Chinese. The project

also arranged to provide oral translations of handouts for those

who were illiterate.

California Final Report, 1995

Information Dissemination for Deaf and

Hard-of-Hearing Populations Improved

REPORT

In September 1999, Hurricane Floyd arrived in North Carolina,

causing the most devastating flooding the State had ever

experienced. Outreach efforts organized through the “Hope After

Floyd” program helped thousands of residents to deal with the

hurricane’s aftermath.

Outreach workers reported particular success in providing crisis

counseling services to individuals who were deaf and hard of

hearing, many of whom experienced fear and stress associated

with the lack of access to information provided through television

or radio. Following the disaster, project staff provided in-service

training and consultation to emergency management agency

officials on the needs of the deaf and hard-of-hearing populations,

and worked to ensure that the Federal Communications

Commission required broadcast stations to provide closedcaptioned emergency information.

North Carolina Site Visit Report, 2000
4 0

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4 3

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Ursano, R. J., Fullerton, C. S., and McCaughey, B. G. (1994).

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4 4

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Department of Health and Human Services. Substance

Abuse and Mental Health Services Administration,

Center for Mental Health Services.

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Psychosocial Issues for Children and Adolescents in

Disasters (2nd ed.) (Pub. No. ADM 86-1070R). Rockville,

MD: U.S. Department of Health and Human Services.

Substance Abuse and Mental Health Services

Administration, Center for Mental Health Services.

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Health Services Administration.

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Response and Recovery: A Strategic Guide (Pub. No. 

SMA 94-3010R). Rockville, MD: U.S. Department of

Health and Human Services, Substance Abuse and

Mental Health Services Administration, Center for 

Mental Health Services. (Rev. ed. in press.)

U.S. Department of Health and Human Services (2000e).

Training Manual for Mental Health and Human Service

Workers in Major Disasters (2nd ed.) (Pub. No. 

ADM 90-538). Rockville, MD: U.S. Department of 

Health and Human Services. Substance Abuse and

Mental Health Services Administration, Center for 

Mental Health Services.

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Sociology of Disasters. New York: Routledge.

CRISIS COUNSELING 

PROGRAM REPORTS

The Emergency Mental Health and Traumatic Stress

Services Branch reviews reports from States that 

have received funding under the Robert T. Stafford

Disaster Relief and Emergency Assistance Act. The

following reports were reviewed for this publication:

Alabama, Hurricane George, 1998 

FEMA-1250-DR

Alaska, Storms and Floods, 1994 

FEMA-1039-DR

California, Civil Unrest, 1994 

FEMA-942-DR

California, Northridge Earthquake, 1994 

FEMA-1008-DR

California, Late Winter Storms, 1995 

FEMA-1046-DR

California, Flooding, 1998 

FEMA-1203-DR

California, El Nino Storms, 1998 

FEMA-1203-DR

Florida, Severe Storms, 1999 

FEMA-1204-DR

Guam, Super Typhoon, 1997 

FEMA-1193-DR

Minnesota, Storms and Floods, 1993 

FEMA-995-DR

North Carolina, Hurricane Floyd, 1999 

FEMA-1292-DR

Oklahoma, Oklahoma City Bombing, 1995 

FEMA-1048-DR

Puerto Rico, Hurricane Hortense, 1997 

FEMA-1136-DR

South Dakota, Severe Storms, 1997 

FEMA-1156-DR
4 5

Appendices
4 6

■ American Psychological Association (1990). 

APA Guidelines for Providers of Psychological Services 

to Ethnic, Linguistic, and Culturally Diverse Populations.

Washington, DC: American Psychological Association.

Offers recommendations on working with ethnic 

and culturally diverse populations to providers of

psychological services. 

■ Child Welfare League of America (1993). 

Cultural Competence Self-assessment Instrument.

Washington, DC: Child Welfare League of America.

A tool designed to help organizations providing

family services identify, improve, and enhance

cultural competence in staff relations and client

service functions. The instrument, which has been

field-tested, provides a practical, easy-to-use

approach to addressing the major issues associated

with delivering culturally competent services.

■ Cohen, R. (1992). Training mental health professionals 

to work with families in diverse cultural contexts.

Responding to Disaster: A Guide for Mental Health

Professionals. Washington, DC: American Psychiatric

Press, Inc.

Explores cultural considerations for mental health

workers and disaster survivors in the immediate 

and longer-term aftermath of a disaster. Examines

issues of loss, mourning, separation, coping, and

adaptation as they relate to disaster survivors from

various cultures.

■ Cross, T. L. (1989). Towards a Culturally Competent

System of Care. Vol. I: A Monograph of Effective Services 

for Minority Children who are Severely Emotionally

Disturbed. Washington, DC: CASSP Technical

Assistance Center, Georgetown University Child

Development Center.

One of the first documents to provide practical

information on operationalizing cultural

competence. Provides definitions for competence,

introduces the concept of a cultural competence

continuum, and provides information that can be

used at individual and organizational levels. 

■ Giger, J., and Davidhizar, R. (1999). Transcultural

Nursing: Assessment and Intervention. St. Louis, MO:

Mosby, Inc.

Provides tools that can be used to evaluate cultures’

perceptions and needs related to communication,

space, social organization, time, environmental

control, and biological variations. Giger and

Davidhizar were among the first to develop the

concept of cultural competence in the nursing

profession. Now in its third printing, the publication 

is used by a number of other disciplines.

■ Goode, T. D. (1999). Getting Started: Planning,

Implementing and Evaluating Culturally Competent

Service Delivery Systems in Primary Health Care Settings,

Implications for Policy Makers and Administrators.

Washington, DC: Georgetown University, National

Center for Cultural Competence.

A checklist that can assist programs and

organizations in initiating strategic development 

of policies, structures, procedures, and practices 

that support cultural and linguistic competence.

■ Health Resources and Services Administration (1998).

Health Care Rx: Access for All. Washington, DC: Health

Resources and Services Administration.

A chart book that provides a picture of the health 

of racial and ethnic minority Americans and the

cascade of factors that limit access to health care,

hamper workforce diversity, and limit culturally

competent services.

■ Hernandez, M., and Isaacs, M. (1998). Promoting

Cultural Competence in Children’s Mental Health Services.

Baltimore, MD: Paul H. Brookes Publishing.

Provides an excellent framework for developing a

culturally competent mental health system. Focuses

on the need to develop organizational infrastructures

that support and further cultural competence and the

need to ensure that programs are meaningful at the

community and neighborhood levels. Also addresses

special issues related to serving culturally diverse

populations. Designed for planners, program

Appendix A:

Cultural Competence Resources and Tools
4 7

managers, policy makers, practitioners, parents,

teachers, researchers, and others who are interested

in improving mental health services for families.

■ Hicks, Noboa-Rios (1998). Cultural Competence in

Mental Health: A Study of Nine Mental Health Programs 

in Ohio. Columbus, OH: Outcomes Management

Group, Ltd.

Provides an assessment of nine culturally competent

programs that were funded to encourage the

provision of cultural sensitivity training to the mental

health community and to develop nontraditional,

culturally sensitive methods of delivering services 

to persons of color. Prepared for the Multi-Ethnic

Behavioral Consortium of the Ohio Department 

of Mental Health.

■ Nader, K., Dubrow, N., and Stamm, H. (1999).

Honoring Differences: Cultural Issues in the Treatment of

Trauma and Loss. Ann Arbor, MI: Brunner/Mazel.

Discusses the treatment of trauma and loss while

recognizing the importance of understanding the

cultural context in which the mental health

professional provides assistance.

■ Perkins, J., Simon, H., Cheng, F., et al. (1998). 

Ensuring Linguistic Access in Health Care Settings:

Legal Rights and Responsibilities. Los Angeles, CA:

National Health Law Program.

An informative discussion on linguistic issues that 

can impede effective service delivery. Covers the

importance of language access, use of community

volunteers, limitations of interpretation, linguistic

barriers in mental health, and effective use of 

written materials. 

■ Substance Abuse and Mental Health Services

Administration (2000). Cultural Competence 

Standards in Managed Mental Health Care for

Underserved/Underrepresented Racial/Ethnic Groups.

Washington, DC: Western Interstate Commission 

for Higher Education and Center for Mental Health

Services, Substance Abuse and Mental Health

Services Administration, U.S. Department of Health

and Human Services.

Provides information on cultural competence

guidelines, performance indicators, and potential

outcomes in the areas of triage and assessment, 

care planning, treatment plans, treatment services,

communication styles, and cross-cultural linguistic

and communication support.

■ Substance Abuse and Mental Health Services

Administration (2000). Cultural strengths and

challenges in implementing a system of care model 

in American Indian communities. Systems of Care:

Promising Practices in Children’s Mental Health

(2000 Series, Vol. 1). Washington, DC: Center for

Effective Collaboration and Practice, American

Institutes for Research. 

Examines promising practices of five American

Indian children’s mental health projects that integrate

traditional American Indian helping and healing

methods with the systems of care model.

■ U.S. Department of Health and Human Services 

(1992-1999). Cultural Competence Series.

Monograph series sponsored by Bureau of 

Primary Health Care, Health Resources and 

Services Administration; Center for Substance 

Abuse Prevention, Substance Abuse and Mental

Health Services Administration; and Office of 

Minority Health.

■ Van der Veer, G. (1995). Psychotherapeutic Work 

with Refugees. New York: Plenum Press.

Suggests that the trauma that a refugee experiences 

in a disaster may not be an isolated incident, but 

part of a series of ongoing traumatic events. 

Stresses that overcoming cultural difference is

essential in working with traumatized refugees 

and that such work requires creatively adjusting 

a variety of existing techniques.
4 8

PUBLICATIONS

ADM 86-1070R Psychosocial Issues for Children 

and Adolescents in Disasters

ADM 90-538 Training Manual for Mental Health 

and Human Service Workers in 

Major Disasters, Second Edition

SMA 94-3010R Disaster Mental Health Response 

and Recovery: A Strategic Guide

(May not be available;

revised edition in press)

SMA 95-3022 Psychosocial Issues for Children 

and Families: A Guide for the 

Primary Care Physician 

SMA 96-3077 Responding to the Needs of People 

with Serious and Persistent Mental 

Illness in Times of Major Disaster

SMA 99-3323 Psychosocial Issues for Older Adults 

in Disasters

SMA 99-3378 Crisis Counseling Programs 

for the Rural Community

VIDEOS

ESDRB-2 Children and Trauma: 

The School’s Response

OM 00-4070 Voices of Wisdom: 

Seniors Cope with Disaster

OM 00-4070S Voices of Wisdom: 

Seniors Cope with Disaster 

(Spanish Version)

OM 00-4071 Hurricane Andrew: 

The Fellowship House Experience

GENERAL MATERIALS

CMHS Program Guidance Series

Appendix B:

Disaster Mental Health Resources 

from the Center for Mental Health Services (CMHS)

The following publications and videos on disaster response and recovery planning for special populations were

developed by the Emergency Mental Health and Traumatic Stress Services Branch of CMHS. To download these

documents or order copies, please visit the Substance Abuse and Mental Health Services Administration

(SAMHSA) Web site at www.samhsa.gov.
4 9

STATISTICS ABOUT 

IMMIGRATION PATTERNS

Immigration and Naturalization Service, 

U.S. Department of Justice:

http://uscis.gov/graphics/shared/aboutus/

statistics/index.htm

NATIONAL, STATE, AND COUNTY

STATISTICS AND DEMOGRAPHIC

DATA BY AGE, RACIAL, ETHNIC, 

AND LINGUISTIC SUBGROUPS

U.S. Bureau of the Census:

www.census.gov/population/www/index.html

UNEMPLOYMENT INFORMATION 

BY GENDER, RACE, AND AGE

Bureau of Labor Statistics:

http://stats.bls.gov/

DEMOGRAPHIC INFORMATION 

BY ZIP CODE

PeopleSpot:

http://peoplespot.com/statistics/

demographics.htm

GENERAL INFORMATION

Government Information Sharing Project, 

Oregon State University:

http://govinfo.kerr.orst.edu/index.html

National Center for Health Statistics, 

Centers for Disease Control and Prevention:

www.cdc.gov/nchs/

Federal Healthfinder®: 

www.healthfinder.gov/

Appendix C:

Sources of Demographic and Statistical Information

The following World Wide Web resources offer demographic and statistical information useful for developing

disaster mental health community profiles:
5 0

FEDERAL GOVERNMENT 

ORGANIZATIONS AND

RESOURCES

Federal Emergency Management Agency (FEMA)

FEMA coordinates with other State and Federal agencies

to respond to presidentially declared disasters. It

provides disaster assistance for individuals, businesses

(through the Small Business Administration), and

communities (through the Robert T. Stafford Disaster

Relief and Emergency Assistance Act).

Federal Emergency Management Agency

Human Services Division

500 C Street, SW

Washington, DC 20472

Phone: 202-566-1600

www.fema.gov

Center for Mental Health Services (CMHS),

Substance Abuse and Mental Health Services

Administration (SAMHSA)

Through an interagency agreement with FEMA, CMHS

provides consultation and technical assistance for the

Crisis Counseling Assistance and Training Program.

Publications and videotapes on disaster human

response are available through SAMHSA’s National

Mental Health Information Center.

Center for Mental Health Services

Emergency Mental Health and Traumatic Stress

Services Branch

5600 Fishers Lane

Room 17C-20

Rockville, MD 20857

Phone: 301-443-4735

Fax: 301-443-8040

www.samhsa.gov

SAMHSA’s National Mental Health 

Information Center

P.O. Box 42557

Washington, DC 20015

Phone: 1-800-789-2647

Fax: 301-984-8796

TDD: 1-866-889-2647

www.mentalhealth.samhsa.gov/

Federal Communications Commission (FCC)

445 12th Street, SW

Washington, DC 20554

Phone: 202-418-1771 or 1-888-225-5322

TTY: 202-418-2520 or 1-888-835-5322

Fax: 202-418-0710 or 1-866-418-0232

www.fcc.gov

Health Resources and Services Administration (HRSA)

Office of Minority Health

5600 Fishers Lane

Room 14-48

Rockville, MD 20857

Phone: 301-443-3376 or 1-888-275-4772

www.hrsa.gov

Indian Health Service (IHS)

Office of Public Health

The Reyes Building

801 Thompson Avenue

Suite 400

Rockville, MD 20852-1627

Phone: 301-443-3024

www.ihs.gov

National Institute on Deafness and 

Other Communication Disorders (NIDCD)

31 Center Drive

MSC 2320

Bethesda, MD 20892

Phone: 301-496-7243

www.nidcd.nih.gov

NIDCD Information Clearinghouse

1 Communication Avenue

Bethesda, MD 20892

Phone: 1-800-241-1044 

TTY: 1-800-241-1055

www.nidcd.nih.gov

Appendix D:

Sources of Assistance and Information 
5 1

Office for Civil Rights

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F

Hubert H. Humphrey Building

Washington, DC 20201

Phone: 202-619-0257 or 1-877-696-6775

www.hhs.gov/ocr

Office of Public Health and Science

U.S. Office of Minority Health Resource Center

U.S. Department of Health and Human Services

P.O. Box 37337

Washington, DC 20013-7337

Phone: 301-443-5084 or 1-800-444-6472

Fax: 301-251-2160

www.omhrc.gov

Rural Information Center Health Service

National Agricultural Library

10301 Baltimore Avenue

Room 304

Beltsville, MD 20705-2351

Phone: 301-504-5547 or 1-800-633-7701

Fax: 301-504-5181

TDD/TTY: 301-504-6856

www.nal.usda.gov/ric

NATIONAL ORGANIZATIONS

American Red Cross (ARC)

ARC has chapters in most large cities and a State chapter

in each capital city. Every local Red Cross chapter is

charged with readiness and response responsibilities in

collaboration with its disaster partners. Disaster services

include preparedness training, community education,

mitigation, and response. ARC chapters help families

with immediate basic needs (food, clothing, and shelter)

and provide supportive services and longer-term

interventions. Contact the local chapter for assistance

or the chapter in your State capital.

American Red Cross National Headquarters

2025 E Street, NW

Washington, DC 20006

Phone: 202-737-8300 General Information

Phone: 202-303-4498 Public Inquiry

Phone: 703-206-7460 Disaster Services

www.redcross.org

PROFESSIONAL PRIVATESECTOR ORGANIZATIONS 

AND RESOURCES

African American Mental Health Research Center

Institute for Social Research

University of Michigan

426 Thompson

Room 5118

Ann Arbor, MI 48106

Phone: 734-763-0045

Fax: 734-763-0044

http://rcgd.isr.umich.edu/prba

American Psychological Association

750 First Street, NE

Washington, DC 20002-4242

Phone: 202-336-5510 or 1-800-374-2721

TDD/TTY: 202-336-6123

www.apa.org

Cross Cultural Health Care Program

270 S. Hanford Street

Suite 100

Seattle, WA 98134

Phone: 206-860-0329

Fax: 206-860-0334

www.xculture.org

National Alliance for Hispanic Health

1501 16th Street, NW

Washington, DC 20036

Phone: 202-387-5000

www.hispanichealth.org

National Asian American and Pacific Islander 

Mental Health Association

1215 19th Street

Suite A

Denver, CO 80202

Phone: 303-298-7910

Fax: 303-298-8180

www.naapimha.org

National Association for Rural Mental Health

3700 W. Division Street

Suite 105

St. Cloud, MN 56301

Phone: 320-202-1820

Fax: 320-202-1833

www.narmh.org
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National Association of Social Workers

750 First Street, NE

Suite 700

Washington, DC 20002-4241

Phone: 202-408-8600 or 1-800-638-8799

www.naswdc.org

National Center for American Indian and Alaska

Native Mental Health Research

University of Colorado Health Sciences Center

Department of Psychiatry, North Pavilion

4455 E. 12th Avenue

Campus Box A011-13

Denver, CO 80220

Phone: 303-724-1414

Fax: 303-724-1474

www.uchsc.edu/sm/ncaianmhr

National Center for Cultural Competence

Georgetown University Center for 

Child and Human Development

3307 M Street, NW

Suite 401

Washington, DC 20007-3935

Phone: 202-687-8635 or 1-800-788-2066

Fax: 202-687-8899

TTY: 202-687-5503

http://gucchd.georgetown.edu

National Indian Health Board

101 Constitution Avenue, NW

Suite 8-B09

Washington, DC 20001

Phone: 202-742-4262

Fax: 202-742-4285

www.nihb.org

National MultiCultural Institute

3000 Connecticut Avenue, NW

Suite 438

Washington, DC 20008-2556

Phone: 202-483-0700

Fax: 202-483-5233

www.nmci.org

National Rural Health Association

One West Armour Boulevard

Suite 203

Kansas City, MO 64111-2087

Phone: 816-756-3140

www.nrharural.org

STATE AND LOCAL 

GOVERNMENT AGENCIES

Departments of Mental Health

Contact the State agency responsible for mental

health services. A State disaster mental health

coordinator may be designated to manage the Crisis

Counseling Program. The main office will be located

in your State’s capital city.

Emergency Services

The emergency services agency is the lead agency

delegated by the State’s governor to carry out 

day-to-day emergency management responsibilities.

Contact the Office of Emergency Services in your

capital city.

UNIVERSITY AND 

MEDICAL UNIVERSITIES

Academic practitioners with general training in

stress, coping, and counseling often express interest

in offering assistance to communities that have

experienced a disaster. Undergraduate and graduate

students are usually very interested in serving as

crisis counselors. Caution is advised to ensure that

survivors are treated appropriately and not enlisted

into research studies or given treatments designed

for traditional psychiatric disorders. Contact your

local university’s departments of psychiatry,

psychology, or social work.

RELIGIOUS ORGANIZATIONS

Churches, synagogues, other faith-based

organizations, and interfaith organizations are

valuable resources for identifying and serving

disaster survivors. Often, they are the most

productive and rapid responders for immediate 

basic needs. Most denominations have some kind 

of disaster relief program. Contact the district office

for major denominations in your area.

MEDIA

Television, radio, and newspapers can provide a list

of resources and supports in major disasters.
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VOLUNTARY ORGANIZATIONS

The National Voluntary Organizations Active 

in Disasters (NVOAD) has made disaster response 

a priority. Member organizations provide 

effective services and avoid service duplication 

by coordinating response efforts. Member

organizations include:

■ Adventist Community Services (ACS)

■ American Red Cross (ARC)

■ American Relay League, Inc. (ARL)

■ AMURT (Ananda Marga Universal Relief Team)

■ Catholic Charities USA (CC)

■ Christian Disaster Response, AECCGC

■ Christian Reformed World Relief Committee

(CRWRC)

■ Church of the Brethren (CB)

■ Church World Service (CWS)

■ The Episcopal Church (EC)

■ Friends Disaster Service (FDS)

■ Inter-Lutheran Disaster Response (ILDR)

■ Mennonite Disaster Service (MDS)

■ Nazarene Disaster Response (NDR)

■ The Phoenix Society (PS)

■ The Points of Light Foundation (PLF)

■ Presbyterian Church, USA (PC)

■ REACT International, Inc. (REACT)

■ The Salvation Army (SA)

■ Second Harvest National Network of Food Banks

(SHNNFB)

■ Society of St. Vincent de Paul (SSVP)

■ Southern Baptist Convention (SBC)

■ United Methodist Church Committee of Relief

(UMCOR)

■ Volunteers of America (VOA)

■ World Vision (WV)

ADDITIONAL RESOURCES

Building Cultural Competence:

A Blueprint for Action

Washington State Department of Health 

Maternal and Child Health Community 

and Family Health

New Market Industrial Campus, Building #7

P.O. Box 47880

Olympia, WA 98504-7880

Phone: 360-236-3504 or 206-389-3052

Fax: 360-586-7868

The Diversity Journal

Harvard Pilgrim Health Care

Office of Diversity

Brookline, MA 02146-7229

Phone: 617-730-7710

Fax: 617-730-4695

A Practical Guide for the Assessment of Cultural

Competence in Children’s Mental Health

Organizations

The Technical Assistance Center for the

Evaluation of Children’s Mental Health System

Judge Baker Children’s Center

295 Longwood Avenue

Boston, MA 02115

Phone: 617-232-8390

Fax: 617-232-4125
Acculturation

The process by which an individual or group 

adopts the identity, customs, and values 

of another culture. 

Center for Mental Health Services (CMHS) 

A center within the Substance Abuse and Mental

Health Services Administration (SAMHSA).

CMHS advises the Federal Emergency

Management Agency (FEMA) on disaster 

mental health issues. SAMHSA is part of the 

U.S. Department of Health and Human Services

(DHHS).

Competence 

The capacity to function effectively.

Crisis Counseling Assistance and Training Program

(commonly referred to as the Crisis Counseling Program)

A program funded by the Federal Emergency

Management Agency through the Robert T.

Stafford Disaster Relief and Emergency

Assistance Act (Public Law 93-288 as amended 

by Public Law 100-707). The Crisis Counseling

Program supports the provision of crisis

counseling to individuals and groups who have

been affected by a major disaster or its aftermath,

educational activities and public information on

disaster mental health issues, and disaster

mental health consultation and training. 

Crisis Counselor (Outreach Worker)

An individual who provides crisis counseling

services and ideally is from the community,

cultural, or ethnic group that is to receive those

services. Crisis counselors are members of,

familiar to, and recognized by their own

communities. They may be spouses of

community leaders, natural leaders in their 

own right, or individuals who have a nurturing

role in their communities. Crisis counselors 

may include retired persons, students, and

community volunteers. They may or may not

have formal training in counseling or related

professions, and they may be paraprofessionals

or professionals.

Cultural Competence

A set of values, behaviors, attitudes, and 

practices that enables an organization or

individual to work effectively across cultures; 

the ability to honor and respect the beliefs,

language, interpersonal styles, and behaviors 

of individuals and families receiving services as

well as of staff who are providing such services.

Culture 

The shared attributes of a group of people; 

a common heritage or learned set of beliefs,

norms, and values. 

Emergency Mental Health and Traumatic Stress

Services Branch

The branch within the Division of Program

Development, Special Populations and Projects,

CMHS, that provides disaster mental health

technical assistance to FEMA and the State

Mental Health Authority on the Crisis Counseling

Assistance and Training Program. 

Ethnicity 

The common heritage of a particular group of

people; includes shared history, language, rituals,

and preferences for music and foods.

Federal Emergency Management Agency 

The lead Federal agency in disaster response and

recovery; provides funding for crisis counseling

grants to State mental health authorities

following presidentially declared disasters.

Formative Evaluation

Data-based description of the trends of

the program over time.

Appendix E:

Glossary

This glossary defines terms often used in the disaster mental health response field and terms that may be useful in

understanding cultural competence. The definitions for cultural competence terms are based on standards used by

the Federal Government and by national and community-based systems of care.

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Healers

Persons who have cultural knowledge and

training to relieve people of their physical and

emotional afflictions according to their cultural

beliefs. Healers may use physical approaches,

spirituality, herbs, and other techniques.

Interpretation

The oral restating in one language of information

that has been stated in another language (Goode

et al., 2001). An interpretation should convey the

tone, level, and meaning of the information on

which it is based.

Key Stakeholder

One who has a primary interest in the success of

the program.

Linguistic Competence

The capacity of an organization or individual to

communicate effectively with persons of limited

English proficiency, those who are illiterate or

have low literacy skills, and individuals who are

deaf or hard of hearing. 

Major Disaster 

According to Section 102 of the Robert T. Stafford

Disaster Relief and Emergency Assistance Act, 

“any natural catastrophe (including any hurricane,

tornado, storm, high water, wind-driven water,

tidal wave, tsunami, earthquake, volcanic

eruption, landslide, mudslide, snowstorm, or

drought) that in the determination of the

President causes damage of sufficient severity

and magnitude to warrant major disaster

assistance under this Act to supplement the

efforts and available resources of States, local

governments, and disaster relief organizations 

in alleviating the damage, loss, hardship, or

suffering caused thereby.” 

National Voluntary Organizations Active in Disaster

(NVOAD) 

A group of voluntary organizations that have

made disaster response a priority. State VOADs

perform a similar function at the State level by

directing local organizations and governments 

to area resources.

Outreach 

A method for delivering crisis counseling services

to disaster survivors; consists primarily of direct

contact with survivors in their natural

environments. 

Paraprofessional

A person who works as a crisis counselor and has

a bachelor’s degree or less in a specialty that may

or may not be related to counseling.

Paraprofessionals have strong intuitive skills,

know how to relate well to others, possess good

judgment and common sense, and are good

listeners. They may or may not be indigenous

workers. In times of disaster, they provide

outreach, counseling, education, information,

and referral services. They work with individuals,

families, and groups. Effective crisis counseling

programs train paraprofessionals in how to work

with people who are experiencing the

psychological sequelae of disasters.

Process Evaluation

Changes in the program based on findings/reports

from program date.

Professional 

A person who has an advanced degree (master’s

level or higher) in psychology, social work,

counseling, or a related profession. Professionals

have experience in the mental health or

counseling fields as well as the expertise needed

to provide clinical supervision and training to

crisis counselors. Typically, a professional

coordinates and supervises the local outreach

team associated with a crisis counseling

program. He or she may provide crisis services

directly or offer consultation and support to

crisis counselors. Professionals clinically evaluate

clients to determine whether their needs exceed

the scope of the crisis counseling program. They

may work directly with individuals, families, and

groups whose problems are unusually

challenging or complex.

Professionals often need training on the ways in

which crisis counseling for disaster survivors

differs from traditional mental health or

counseling practice.
Race 

A category describing people according to a set of

characteristics that are socially important but

that are not necessarily defined by visible

physical features (DHHS, 2001).

Racial and Ethnic Minority Group

A collective, heterogeneous group of people who

identify as African American, American Indian

and Alaska Native, Asian American and Pacific

Islander, or Hispanic American (DHHS, 2001, p. 5).

Refugee

A person who, because of fear of being

persecuted for reasons of race, religion,

nationality, or political opinion, is residing

outside the country of his or her nationality and

is unable or unwilling to avail himself or herself of

the protection of that country; also, a person who,

not having a nationality and being outside the

country of his or her former habitual residence, 

is unable or unwilling to return to that country. 

Special Population 

A targeted group in a disaster-impacted

community or area with needs that require

specific attention by the crisis counseling

program. Special populations include children,

adolescents, older adults, elderly persons,

members of ethnic and cultural groups, migrant

workers, disaster relief workers, persons who are

severely mentally ill, persons with disabilities,

and homeless persons. Other special populations

may be unique to the area being served by the

crisis counseling program.

Stafford Act (Robert T. Stafford Disaster Relief and

Emergency Assistance Act)

The legislation (Public Law 93-288 as amended

by Public Law 100-707) that enables Federal

emergency response and services to be provided

following a disaster. Section 416 authorizes the

President to provide crisis counseling assistance

and training for disaster survivors following

presidentially declared disasters. 

State Mental Health Authority (SMHA) 

The lead State government organization for

providing mental health services. Because this

organization may be a department, division, or

branch, depending on the State government

system, CMHS and FEMA use the abbreviation

“SMHA” to denote the lead mental health

organization. 

Substance Abuse and Mental Health Services

Administration 

A component of DHHS. SAMHSA comprises

three centers: CMHS, the Center for Substance

Abuse Prevention, and the Center for Substance

Abuse Treatment. CMHS provides technical

assistance to FEMA for the Crisis Counseling

Assistance and Training Program.

Translation

Written conversion of written materials from one

language to another (Goode et al., 2001).

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Recognize the importance of culture and respect diversity.

■Complete a self-assessment to determine your own

beliefs about culture.

■Encourage staff to complete self-assessments in order

to understand their own cultures and worldviews;

examine their own attitudes, values, and beliefs about

culture; and acknowledge cultural differences.

■Assess capabilities of the counselors to understand

and respect the values, customs, beliefs, language, and

interpersonal style of the disaster survivor.

■Seek evidence that you/staff respect the importance of

verbal and nonverbal communication, space, social

organization, time, and environment control within

various cultures.

Maintain a current profile of the cultural composition of

the community.

■ Develop and periodically update a community profile

that describes the community’s composition in terms

of race and ethnicity, age, gender, religion, refugee and

immigrant status, housing status, income and poverty

levels, percentage of residents living in rural versus

urban areas, unemployment rate, language and

dialects, literacy level, and number of schools and

businesses.

■Include in the profile information about the values,

beliefs, social and family norms, traditions, practices,

and politics of local cultural groups, and historical

racial relations or ethnic issues.

■Gather information in consultation with community

cultural leaders who represent and understand 

local cultural groups.

Recruit disaster workers who are representative 

of the community or service area.

■Review the community profile when recruiting disaster

crisis counseling workers and attempt to recruit

workers from the ethnic and cultural groups included

among the survivors.

■If workers from the community or service area are not

available, recruit others with backgrounds and

language skills similar to those of local residents.

■Assess disaster workers’ personal attributes,

knowledge, and skills as they relate to cultural

competence.

Provide ongoing cultural competence training 

to disaster mental health staff.

■ Offer ongoing cultural competence training 

(e.g., in-service training and regularly scheduled

meetings) to service providers, administrators 

and managers, language and sign interpreters, 

and temporary staff.

■Involve community-based groups with expertise in

cultural competence or in the needs of specific cultures.

■Allot time for training participants to examine and

assess their values, attitudes, and beliefs about their

own and other cultures.

Ensure that services are accessible, appropriate,

and equitable.

■Identify and take steps to overcome reluctance of

ethnic groups to use services because of mistrust of

the system or previous inequitable treatment.

■Identify and take steps to eliminate service barriers

that occur as a result of racial and ethnic discrimination,

language barriers, transportation issues, and the

stigma associated with counseling services.

Appendix F:

Cultural Competence Checklist for Disaster Crisis Counseling Programs

Cultural competence should be integrated into a community emergency mental health management plan before a

disaster actually occurs.When disaster strikes, certain principles must be followed to ensure a culturally competent

disaster crisis counseling program. The following checklist can assist in developing cultural competence in disaster crisis

counseling programs.You also can use this checklist as an informal program assessment tool. For this purpose, use the

check boxes to insert a numerical ranking from 1 to 3, with 1 reflecting the cultural pre-competence stage of development

(good intentions, no actions yet); 2 representing the cultural competence stage (importance recognized, some actions

underway); and 3 denoting the cultural proficiency stage (effective program in place). The terminology used to describe

these phases was drawn from the Cultural Competence Continuum developed by Cross and colleagues (1989).
■Involve representatives of diverse cultural groups in

program committees, planning boards, and policysetting bodies and in decision making.

■Identify and use strategies to address specific concerns

of refugees who had negative experiences that make

them suspicious of government intervention.

Recognize the role of help-seeking behaviors, customs and

traditions, and natural support networks. Identify and use

strategies to:

■Identify cultural patterns that may influence 

help-seeking behaviors. 

■Build trusting relationships and rapport with disaster

survivors.

■Recognize that survivors may find traditional relief

procedures confusing or difficult. 

■Recognize individual cultures’ customs and traditions

related to healing, trauma, and loss, and identify how

these customs and traditions influence an individual’s

receptivity to and need for assistance.

■Acknowledge cultural beliefs about healing and

recognize their importance to some disaster survivors.

■ Help survivors reestablish rituals; organize culturally

appropriate anniversary activities and

commemorations.

■Recognize that outreach efforts focused only on the

individual may not be effective for people whose

cultures are centered around family and community. 

■ Determine who is significant in survivors’ families and

social spheres by listening to their descriptions of the

home, family, and community.

Involve community leaders and organizations

representing diverse cultural groups as 

cultural brokers.

■Collaborate with trusted leaders (e.g., spiritual leaders,

clergy members, and teachers) who know the

community.

■Invite organizations representing cultural groups and

other special interest groups in the community to

participate in disaster mental health program planning

and service delivery.

■Collaborate with community-based organizations to

communicate with the cultural groups they represent. 

■Identify effective ways to work with informal culturespecific groups.

■Coordinate with other public and private agencies in

responding to the disaster.

Ensure that services and information are culturally and

linguistically competent.

■Identify indigenous workers who speak the language of

the survivors; use interpreters only when necessary.

■Identify trained interpreters who share the disaster

survivors’ cultural backgrounds.

■ Determine the dialect of the disaster survivor before

asking for an interpreter.

■Assess the level of acculturation of the interpreter 

in relation to that of the disaster survivors.

■Establish a plan for providing written materials in

languages other than English and at the literacy level

of the target population.

■Provide means to reach people who are deaf or 

hard of hearing.

■Consult with cultural groups in the community to

determine the most effective outreach activities.

■ Use existing community resources (e.g., multicultural

television and radio stations) to enhance outreach

efforts.

Assess and evaluate the program’s level of cultural

competence.

■Continuously assess the program to identify and

correct problems that may impede the delivery of

culturally competent services.

■Incorporate process evaluation into the crisis

counseling program.

■Involve representatives of various cultural groups in

process evaluation.

■Communicate process evaluation findings to key

informants and cultural groups engaged in the

program.

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U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration

Center for Mental Health Services

5600 Fishers Lane

Rockville, MD 20857

DHHS Publication No. SMA 3828

Printed 2003