BASED ON TIP 59

Improving Cultural 

Competence

KAP KEYS

FOR CLINICIANS
KAP KEYS BASED ON TIP 59

Improving Cultural Competence

Introduction

KAP Keys were developed to accompany the Treatment 

Improvement Protocol (TIP) Series published by the 

Substance Abuse and Mental Health Services Administration 

(SAMHSA). These KAP Keys are based entirely on TIP 59 

and are designed to meet the needs of the busy clinician for 

concise, easily accessed “how-to” information.

For more information on the topics in these KAP Keys, see

TIP 59: Improving Cultural Competence

Other TIPs relevant to these KAP Keys:

TIP 57: Trauma-Informed Care in Behavioral Health 

Services

TIP 56: Addressing the Specific Behavioral Health 

Needs of Men

TIP 51: Substance Abuse Treatment: Addressing the 

Specific Needs of Women

TIP 42: Substance Abuse Treatment for Persons With 

Co-Occurring Disorders

TIP 39: Substance Abuse Treatment and Family 

Therapy

TIP 35: Enhancing Motivation for Change in 

Substance Abuse Treatment 
KAP KEYS BASED ON TIP 59

Improving Cultural Competence

Attitudes and Behaviors of 

Culturally Competent Counselors 

Attitude Behavior

Respect • Exploring, acknowledging, and validating 

the client’s worldview

• Approaching treatment as a 

collaborative process

• Investing time to understand the client’s 

expectations of treatment

• Using consultation, literature, and training 

to understand culturally specific behaviors 

that demonstrate respect for the client

• Communicating in the client’s 

preferred language

Acceptance • Maintaining a nonjudgmental attitude 

toward the client

• Considering what is important to the client

Sensitivity • Understanding the client’s experiences of 

racism, stereotyping, and discrimination

• Exploring the client’s cultural identity and 

what it means to her/him 

• Actively involving oneself with individuals 

from diverse backgrounds outside the 

counseling setting to foster a perspective 

that is more than academic or work related

• Adopting a broader view of family 

and, when appropriate, including other 

family or community members in the 

treatment process 

• Tailoring treatment to meet the cultural 

needs of the client (e.g., providing outside 

resources for traditional healing)

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Attitude Behavior

Commitment 

to equality

• Proactively addressing racism or bias as 

it occurs in treatment (e.g., processing 

derogatory comments made by another 

client in a group counseling session)

• Identifying the specific barriers to 

treatment engagement and retention 

among the populations being served

• Recognizing that equality of treatment 

does not translate to equity—that equity is 

defined as equality in opportunity, access, 

and outcome 

• Endorsing counseling strategies and 

treatment approaches that match the 

unmet needs of diverse populations to 

ensure treatment engagement, retention, 

and positive outcomes

Openness • Recognizing the value of traditional 

healing and help-seeking practices

• Developing alliances and relationships 

with traditional practitioners 

• Seeking consultation with traditional 

healers and religious and spiritual leaders 

when appropriate

• Understanding and accepting that people 

from diverse cultural groups can use 

different cognitive styles (e.g., placing 

more attention on reflecting and processing 

than on content; being task oriented)

Attitudes and Behaviors of Culturally 

Competent Counselors (continued)

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Attitudes and Behaviors of Culturally 

Competent Counselors (continued)

Attitude Behavior

Humility • Recognizing that the client’s trust is 

earned through consistent and competent 

behavior rather than the potential status 

and power that is ascribed to the role 

of counselor

• Acknowledging the limits of one’s 

competencies and expertise and referring 

clients to a more appropriate counselor or 

service when necessary

• Seeking consultation, clinical supervision, 

and training to expand cultural knowledge 

and cultural competence in counseling 

skills 

• Seeking to understand oneself as 

influenced by ethnicity and cultural groups 

and actively seeking a nonracist identity

• Being sensitive to the power differential 

between client and counselor

Flexibility • Using a variety of verbal and nonverbal 

responses, approaches, or styles to suit 

the cultural context of the client

• Accommodating different learning styles 

in treatment approaches (e.g., the use of 

role-plays or experiential activities to 

demonstrate coping skills or alcohol 

and drug refusal skills)

• Using cultural, socioeconomic, environmental, and political contextual factors 

in conducting evaluations (e.g., Alaska 

Native traditional practices, such as tundra 

walking or berry picking and other 

sustenance activities)
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Initial Interview and Assessment 

Questions 

When working with culturally diverse populations, explore:

• Number of generations in the United States.

• Number of years in the United States.

• Fluency in English (or literacy).

• Extent (or lack) of family support.

• Community resources.

• Level of education.

• Change in social status due to immigration (for 

immigrant or refugee).

• Extent of personal relationships with people from diverse 

cultural backgrounds.

Source: 

American Psychological Association. (1990). APA guidelines for providers of psychological services to ethnic, linguistic, and culturally diverse populations. Washington, DC: 

Author.
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Questions Related to Health, 

Illness, and Healing

The following questions highlight many of the culturally 

related issues that are prevalent in and pertinent to 

assessment, treatment planning, and case management. 

This list of considerations can help facilitate discussions in 

counseling and clinical supervision contexts.

• Does the cultural group in question consider 

psychological, physical, and spiritual health or 

well-being as separate entities or as unified aspects 

of the whole person? 

• How are illnesses and healing practices defined 

and conceptualized? 

• What are acceptable behaviors for managing stress? 

• How do people who belong to the culture in question 

typically express emotions and emotional distress? 

• What behaviors, practices, or customs do members of 

this culture consider to be preventive? 

• What words do people from this cultural group use to 

describe a particular problem? 

• How do members of the group explain the origins or 

causes of a particular condition? 

• Are there culturally specific conditions or cultural 

concepts of distress? 

• Where do people from this cultural group typically seek 

help for psychological concerns and substance misuse? 

• What traditional healing practices and treatments for 

psychological concerns and substance misuse are endorsed 

by members of this group? 

• Are there biomedical treatments or procedures that would 

typically be unacceptable?

• Are there specific counseling approaches more congruent 

with the beliefs of most members?

• What are common health inequities for this population?

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• What are acceptable caregiving practices? 

• Do members of this group attach honor to caring for 

family members with specific diseases? 

• Are individuals with specific conditions shunned from 

the community? 

• What are the roles of family members in providing health 

care and in making decisions? 

• Is discussing consequences of and prognosis for behaviors, 

conditions, or diseases acceptable? 

• Is it customary for family members to withhold prognosis 

from the client?

Questions Related to Health, 

Illness, and Healing (continued)
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Behaviors for Counselors To Avoid

• Addressing clients or their families informally, which 

may be perceived as disrespectful; counselors should not 

assume familiarity until they grasp cultural expectations 

and client preferences.

• Failing to monitor and adjust to the client’s verbal 

pacing (e.g., not allowing time for the client to respond 

to questions).

• Using counseling jargon and treatment language (e.g., 

“I am going to send you to our primary stabilization 

program to obtain a biopsychosocial and then, afterwards, 

to partial”).

• Using statements based on stereotypes or other preconceived ideas generated from experiences with other clients 

from the same culture.

• Using gestures without understanding their meaning and 

appropriate context within the given culture.

• Ignoring the relevance of cultural identity in the client–

counselor relationship.

• Neglecting the client’s history (i.e., not understanding the 

client’s individual and cultural background).

• Ignoring cultural context by providing an explanation 

of how current difficulties can be resolved without first 

obtaining the client’s own explanations of the problems 

and how he or she thinks these problems should 

be addressed.

• Downplaying the importance of traditional practices and 

failing to coordinate these services as needed.

Sources: 

Fontes, L. A. (2008). Interviewing clients across cultures: A practitioner’s guide. New 

York: Guilford Press.

Lynch, E. W., & Hanson, M. J. (2011). Steps in the right direction: Implications for 

service providers. In E. W. Lynch & M. J. Hanson (Eds.), Developing cross-cultural 

competence: A guide for working with children and their families (4th ed., pp. 472–489). 

Baltimore: Brookes.

Pack-Brown, S. P., & Williams, C. B. (2003). Ethics in a multicultural context. In P. 

Pedersen (Series Ed.), Multicultural Aspects of Counseling Series: Vol. 19. Thousand 

Oaks, CA: Sage.

Srivastava, R. (2007). Understanding cultural competence in health care. In 

R. Srivastava (Ed.), The healthcare professional’s guide to clinical cultural competence

(pp. 3–27). Toronto, Canada: Mosby.
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Tips for Cross-Cultural 

Communication

• Slow down.

• Use plain, nonpsychiatric language.

• Show or draw pictures.

• Limit the amount of information provided at one time.

• Use the “teach-back” method. Ask the client, in a nonthreatening way, to explain or show what he or she has 

been told.

• Create a shame-free environment that encourages 

questions and participation.

Source: 

Weiss, B. D. (2007). Removing barriers to better, safer care: Health literacy and patient 

safety; Help patients understand. Manual for clinicians. Chicago: American Medical 

Association Foundation.
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Client Strengths and Supports

Initial interviews and evaluations can overemphasize 

presenting problems and concerns while underplaying client 

strengths and supports. This list, although not exhaustive, 

reminds clinicians to conduct interviews that acknowledge 

client strengths and supports from the outset. 

• Pride and participation in one’s culture

• Social skills, traditions, knowledge, and practical skills 

specific to the client’s culture 

• Bilingual or multilingual skills

• Traditional, religious, or spiritual practices, beliefs, 

and faith

• Generational wisdom

• Extended families and nonblood kinships

• Ability to maintain cultural heritage and practices

• Perseverance in coping with racism and oppression 

• Culturally specific ways of coping

• Community involvement and support

Source: 

Hays, P. A. (2008). Addressing cultural complexities in practice: Assessment, 

diagnosis, and therapy (2nd ed.). Washington, DC: American Psychological Association. 
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Questions About Culture and 

Acculturation

Counselors can adapt the wording in the questions below to 

suit clients’ cultural contexts and styles of communication; 

the questions are only examples. Ask the questions tactfully 

so they do not sound like an interrogation. Try to integrate 

the questions naturally into a conversation rather than

asking one after another. Not all questions are relevant in 

all settings. 

• Where were you born?

• Whom do you consider family?

• What was the first language you learned?

• Which other language(s) do you speak?

• What language or languages are spoken in your home?

• What is your religion? How observant are you in 

practicing that religion?

• What activities do you enjoy when you are not working?

• How do you identify yourself culturally?

• What aspects of being ________ are most important to 

you? (Use the same term for the identified culture as the 

client.)

• How would you describe your home and neighborhood?

• Whom do you usually turn to for help when facing 

a problem?

Source: 

Fontes, L. A. (2008). Interviewing clients across cultures: A practitioner’s guide. New 

York: Guilford Press.
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Questions To Elicit Client Views on 

Presenting Problems

Some clients do not see their presenting physical, 

psychological, and/or behavioral difficulties as problems. 

Instead, they may view their presenting difficulties as the 

result of stress or another issue, thus defining or labeling the 

presenting problem as something other than a physical or 

mental disorder. In such cases, word the following questions 

using the clients’ terminology rather than using the word 

“problem.” These questions help explore how clients view 

their behavioral health concerns:

• I know that clients and counselors sometimes have 

different ideas about illness and diseases, so can you 

tell me more about your idea of your problem?

• Do you consider your use of alcohol and/or drugs 

a problem?

• How do you label your problem? Do you think it 

is a serious problem?

• What do you think caused your problem?

• Why do you think it started when it did?

• What is going on in your body as a result of 

this problem?

• How has this problem affected your life?

• What frightens or concerns you most about this 

problem and its treatment?

• How is your problem viewed in your family? 

Is it acceptable? 

• How is your problem viewed in your community? 

Is it acceptable? Is it considered a disease?

• Do you know others who have had this problem? 

How did they treat the problem?

• How does your problem affect your stature in 

the community?

• What kinds of treatment do you think will help or 

heal you?

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• How have you treated your drug and/or alcohol problem 

or emotional distress?

• What has been your experience with treatment programs?

Sources: 

Lynch, E. W., & Hanson, M. J. (2011). Steps in the right direction: 

Implications for service providers. In E. W. Lynch & M. J. Hanson (Eds.), 

Developing cross-cultural competence: A guide for working with children and their families

(4th ed., pp. 472–489). Baltimore: Brookes.

Tang, W. W. H., & Bigby, J. (1996). Cultural perspectives on substance abuse. In L. 

Friedman, N. Fleming, D. Roberts, & S. E. Hyman (Eds.), Source book of substance 

abuse and addiction (pp. 41–56). Baltimore: Williams & Wilkins.

Taylor, T. (2002). Effective cross-cultural communication in drug abuse intervention 

among ethnic minority populations. In G. X. Ma & G. Henderson (Eds.), Ethnicity 

and substance abuse: Prevention and intervention (pp. 19–37). Springfield, IL: Charles 

C. Thomas. 

Questions To Elicit Client Views on 

Presenting Problems (continued)
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Multicultural Intake Checklist 

Ask questions on the following topics to explore a client’s 

views of his or her behavioral health concerns:

 Immigration history

 Relocations (current migration patterns)

 Losses associated with immigration and 

relocation history

 English-language fluency

 Bilingual or multilingual fluency

 Individualistic/collectivistic orientation

 Racial, ethnic, and cultural identities 

 Tribal affiliation, if appropriate

 Geographic location

 Family and extended family concerns (including 

nonblood kinships)

 Acculturation level (e.g., traditional, bicultural)

 Acculturation stress

 History of discrimination/racism

 Trauma history

 Historical trauma

 Intergenerational family history and concerns

 Gender roles and expectations 

 Birth order roles and expectations

 Relationship and dating concerns

 Sexual and gender orientation

 Health concerns

 Traditional healing practices

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 Help-seeking patterns

 Beliefs about wellness 

 Beliefs about mental illness and treatment for 

mental illness

 Beliefs about substance use, misuse, and dependence

 Beliefs about substance use treatment

 Family views on substance use and substance 

use treatment

 Treatment concerns related to cultural differences

 Cultural approaches to healing or treatment of substance 

use and mental disorders

 Education history and concerns

 Work history and concerns

 Socioeconomic status and financial concerns

 Cultural group affiliation 

 Current network of support

 Community concerns

 Review of confidentiality parameters and concerns

 Cultural concepts of distress (Diagnostic and Statistical 

Manual of Mental Disorders, Fifth Edition, American 

Psychiatric Association, 2013; DSM-5)

 DSM-5 culturally related V-codes 

Sources: 

Comas-Díaz, L. (2012). Multicultural care: A clinician’s guide to cultural competence. 

Washington, DC: American Psychological Association.

Constantine, M. G., & Sue, D. W. (2005). Strategies for building multicultural 

competence in mental health and educational settings. Hoboken, NJ: Wiley.

Sussman, L. K. (2004). The role of culture in definitions, interpretations, and 

management of illness. In U. P. Gielen, J. M. Fish, & J. G. Draguns (Eds.), 

Handbook of culture, therapy, and healing (pp. 37–65). Mahwah, NJ: Erlbaum.

Multicultural Intake Checklist 

(continued)
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Culturally Responsive Screening 

and Assessment 

• Assess the client’s primary language and language 

proficiency prior to the administration of any evaluation 

or use of testing instruments.

• Determine whether the assessment materials were 

translated using specific terms, including idioms that 

correspond to the client’s literacy level, culture, and 

language. Do not assume that translation into a stated 

language exactly matches the specific language of the 

client. Specifically, the client may not understand the 

translated language if it does not match his or her ways of 

thinking or speaking.

• Educate the client on the purpose of the assessment and 

its application to the development of the treatment plan. 

Remember that testing can generate many emotional 

reactions.

• Know how the test was developed. Is normative data 

available for the population being served? Test results 

can be inflated, underestimated, or inaccurate due to 

differences within the client’s population.

• Consider the role of acculturation in testing, including 

the influence of the client’s worldview on responses. 

Unfamiliarity with mainstream U.S. culture can 

affect interpretation of questions, the client–evaluator 

relationship, and behavior, including participation level 

during evaluation and verbal and behavioral responses.

Sources: 

Association for Assessment in Counseling and Education. (2012). Standards for 

multicultural assessment (4th ed.). Alexandria, VA: Author.

Saldaña, D. (2001). Cultural competency: A practical guide for mental health service 

providers. Austin, TX: Hogg Foundation for Mental Health.
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National Standards for Culturally and 

Linguistically Appropriate Services (CLAS) 

in Health and Health Care 

Principal Standard:

1. Provide effective, equitable, understandable, and respectful 

quality care and services that are responsive to diverse 

cultural health beliefs and practices, preferred languages, 

health literacy, and other communication needs. 

Governance, Leadership, and Workforce:

2. Advance and sustain organizational governance and 

leadership that promotes CLAS and health equity 

through policy, practices, and allocated resources. 

3. Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that 

are responsive to the population in the service area. 

4. Educate and train governance, leadership, and workforce 

in culturally and linguistically appropriate policies and 

practices on an ongoing basis. 

Communication and Language Assistance:

5. Offer language assistance to individuals who have limited 

English proficiency and/or other communication needs, 

at no cost to them, to facilitate timely access to all health 

care and services. 

6. Inform all individuals of the availability of language 

assistance services clearly and in their preferred language, 

verbally and in writing. 

7. Ensure the competence of individuals providing language 

assistance, recognizing that the use of untrained individuals 

and/or minors as interpreters should be avoided. 

8. Provide easy-to-understand print and multimedia 

materials and signage in the languages commonly used 

by the populations in the service area. 

Engagement, Continuous Improvement, and 

Accountability:

9. Establish culturally and linguistically appropriate goals, 

policies, and management accountability, and infuse them 

throughout the organization’s planning and operations. 
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10. Conduct ongoing assessments of the organization’s 

CLAS-related activities and integrate CLAS-related 

measures into measurement and continuous quality 

improvement activities. 

11. Collect and maintain accurate and reliable demographic 

data to monitor and evaluate the impact of CLAS on 

health equity and outcomes and to inform service delivery. 

12. Conduct regular assessments of community health assets 

and needs and use the results to plan and implement 

services that respond to the cultural and linguistic 

diversity of populations in the service area. 

13. Partner with the community to design, implement, and 

evaluate policies, practices, and services to ensure cultural 

and linguistic appropriateness. 

14. Create conflict and grievance resolution processes that 

are culturally and linguistically appropriate to identify, 

prevent, and resolve conflicts or complaints. 

15. Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, 

and the general public.

Source: Office of Minority Health. (2013). National Standards for Culturally and 

Linguistically Appropriate Services (CLAS) in Health and Health Care. Washington, 

DC: U.S. Department of Health and Human Services. For more information, visit 

www.ThinkCulturalHealth.hhs.gov.

National Standards for Culturally and 

Linguistically Appropriate Services (CLAS) 

in Health and Health Care (continued)

Note

A 2014 report, Improving Cultural Competence to Reduce 

Health Disparities for Priority Populations, extends the 

findings of TIP 59. This report is a systematic review of 

system-, clinic-, and individual-level interventions to 

improve culturally appropriate health care for people with 

disabilities, gender and sexual minority populations, and 

racial/ethnic minority populations. The report encourages 

consideration of diversity competence, to encompass all 

populations that experience health disparities. The report 

also highlights the need for “structural equity-focused 

interventions.” The report, which is a product of the 

Agency for Healthcare Research and Quality, can be 

accessed through www.effectivehealthcare.ahrq.gov.
Ordering Information

TIP 59

Improving Cultural 

Competence

TIP 59-Related Products:

Quick Guide for Administrators

Based on TIP 59

Quick Guide for Clinicians

Based on TIP 59

Publications may be ordered or downloaded 

from SAMHSA’s Publications Ordering Web 

page at http://store.samhsa.gov. Or, please call 

SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) 

(English and Español).

Do not reproduce or distribute this publication for a fee without 

specific, written authorization from the Office of Communications, 

Substance Abuse and Mental Health Services Administration, 

U.S. Department of Health and Human Services.

HHS Publication No. (SMA) 16-4933

Printed 2016

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment