TIP 59

A TreATmenT ImprovemenT proTocol

Improving Cultural 

Competence
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment

1 Choke Cherry Road 

Rockville, MD 20857

TIP 59

Improving Cultural 

Competence

A TreATmenT ImprovemenT proTocol
Improving Cultural Competence

Acknowledgments

This publication was produced by The CDM Group, Inc., under the Knowledge Application 

Program (KAP) contract numbers 270-99-7072, 270-04-7049, and 270-09-0307 with the 

Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of 

Health and Human Services (HHS). Andrea Kopstein, Ph.D., M.P.H., Karl D. White, Ed.D., 

and Christina Currier served as the Contracting Officer’s Representatives. 

Disclaimer 

The views, opinions, and content expressed herein are those of the consensus panel and do not 

necessarily reflect the views, opinions, or policies of SAMHSA or HHS. No official support of 

or endorsement by SAMHSA or HHS for these opinions or for particular instruments, software, 

or resources is intended or should be inferred.

Public Domain Notice 

All materials appearing in this volume except those taken directly from copyrighted sources are 

in the public domain and may be reproduced or copied without permission from SAMHSA or 

the authors. 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, HHS. 

Electronic Access and Copies of Publication

This publication 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).

Recommended Citation

Substance Abuse and Mental Health Services Administration. Improving Cultural Competence. 

Treatment Improvement Protocol (TIP) Series No. 59. HHS Publication No. (SMA) 14-4849. 

Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

Originating Office

Quality Improvement and Workforce Development Branch, Division of Services Improvement, 

Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services 

Administration, 1 Choke Cherry Road, Rockville, MD 20857. 

HHS Publication No. (SMA) 14-4849

First Printed 2014

ii
Contents

Consensus Panel ............................................................................................................. vii

KAP Expert Panel and Federal Government Participants ...................................................ix 

What Is a TIP? .................................................................................................................xi 

Foreword ....................................................................................................................... xiii 

Executive Summary ......................................................................................................... xv 

Chapter 1—Introduction to Cultural Competence ............................................................. 1 

Purpose and Objectives of the TIP........................................................................................... 2 

Core Assumptions..................................................................................................................... 4 

What Is Cultural Competence? ................................................................................................ 5 

Why Is Cultural Competence Important? .............................................................................. 7 

How Is Cultural Competence Achieved?................................................................................. 9 

What Is Culture?.................................................................................................................... 11 

What Is Race?......................................................................................................................... 13 

What Is Ethnicity? ................................................................................................................. 15 

What Is Cultural Identity? .................................................................................................... 16 

What Are the Cross-Cutting Factors in Race, Ethnicity, and Culture? ................................ 16 

As You Proceed ....................................................................................................................... 33 

Chapter 2—Core Competencies for Counselors and Other Clinical Staff ...........................35 

Core Counselor Competencies............................................................................................... 36 

Self-Assessment for Individual Cultural Competence ........................................................... 55 

Chapter 3—Culturally Responsive Evaluation and Treatment Planning .............................57 

Step 1: Engage Clients............................................................................................................ 59 

Step 2: Familiarize Clients and Their Families With Treatment and Evaluation Processes . 59 

Step 3: Endorse Collaboration in Interviews, Assessments, and Treatment Planning........... 60 

Step 4: Integrate Culturally Relevant Information and Themes............................................ 61 

Step 5: Gather Culturally Relevant Collateral Information .................................................. 64 

Step 6: Select Culturally Appropriate Screening and Assessment Tools................................ 65 

Step 7: Determine Readiness and Motivation for Change .................................................... 69 

Step 8: Provide Culturally Responsive Case Management .................................................... 70 

Step 9: Integrate Cultural Factors Into Treatment Planning ................................................. 71 

iii
Improving Cultural Competence

Chapter 4—Pursuing Organizational Cultural Competence ..............................................73 

Cultural Competence at the Organizational Level ................................................................ 74 

Organizational Values............................................................................................................. 76 

Governance ............................................................................................................................. 78 

Planning.................................................................................................................................. 80 

Evaluation and Monitoring .................................................................................................... 84 

Language Services................................................................................................................... 88 

Workforce and Staff Development......................................................................................... 90 

Organizational Infrastructure ................................................................................................. 96 

Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups ................ 101 

Introduction .......................................................................................................................... 102 

Counseling for African and Black Americans...................................................................... 103 

Counseling for Asian Americans, Native Hawaiians, and Other Pacific Islanders.............. 116 

Counseling for Hispanics and Latinos ................................................................................. 128 

Counseling for Native Americans......................................................................................... 138 

Counseling for White Americans......................................................................................... 150 

Chapter 6—Drug Cultures and the Culture of Recovery .................................................. 159 

What Are Drug Cultures?.................................................................................................... 161 

The Role of Drug Cultures in Substance Abuse Treatment ................................................ 171 

Appendix A: Bibliography ............................................................................................. 177 

Appendix B: Instruments To Measure Identity and Acculturation .................................... 253 

Appendix C: Tools for Assessing Cultural Competence ................................................... 259 

Appendix D: Screening and Assessment Instruments ...................................................... 277 

Appendix E: Cultural Formulation in Diagnosis and Cultural Concepts of Distress .......... 283 

Appendix F: Cultural Resources ..................................................................................... 287 

Appendix G: Glossary .................................................................................................... 295 

Appendix H: Resource Panel .......................................................................................... 299 

Appendix I: Cultural Competence and Diversity Network Participants ............................ 301 

Appendix J: Field Reviewers ........................................................................................... 303 

Appendix K: Acknowledgments ...................................................................................... 307 

List of Exhibits 

Exhibit 1-1: Multidimensional Model for Developing Cultural Competence ........................ 6 

Exhibit 1-2: The Continuum of Cultural Competence ......................................................... 10 

Exhibit 1-3: Common Characteristics of Culture.................................................................. 12 

Exhibit 1-4: Education and Culture....................................................................................... 22 

iv
Contents

Exhibit 1-5: Cultural Identification and Cultural Change Terminology............................... 24 

Exhibit 1-6: Five Levels of Acculturation .............................................................................. 25 

Exhibit 1-7: Measuring Acculturation ................................................................................... 27 

Exhibit 2-1: Stages of Racial and Cultural Identity Development ........................................ 40 

Exhibit 2-2: Counselor Worldview......................................................................................... 43 

Exhibit 2-3: ACA Counselor Competencies: Counselor s' Awareness of Their 

Own Cultural Values and Biases....................................................................................... 46 

Exhibit 2-4: ACA Counselor Competencies: Awareness of Clients' Worldviews ................. 47 

Exhibit 2-5: Attitudes and Behaviors of Culturally Competent Counselors......................... 49 

Exhibit 2-6: ACA Counselor Competencies: Culturally Appropriate Intervention 

Strategies........................................................................................................................... 56 

Exhibit 3-1: Client–Counselor Matching .............................................................................. 71 

Exhibit 4-1: Requirements for Organizational Cultural Competence................................... 75 

Exhibit 4-2: Creating Culturally Responsive Treatment Environments................................ 75 

Exhibit 4-3: Hands Across Cultures Mission Statement....................................................... 78 

Exhibit 4-4: Critical Treatment Issues To Consider in Providing Culturally Responsive 

Services ............................................................................................................................. 80 

Exhibit 4-5: Qualities of Effective Cultural Competence Training....................................... 92 

Exhibit 4-6: OMH Staff Education and Training Guidelines............................................... 94 

Exhibit 4-7: Cultural Competence Initiative Across Time in One Organization ................. 99 

Exhibit 5-1: Core Culturally Responsive Principles in Counseling African Americans ..... 110 

Exhibit 5-2: Lifetime Prevalence of Substance Use Disorders According to Ethnic 

Subgroup and Immigration Status ................................................................................. 130 

Exhibit 5-3: Native Americans and Community ................................................................. 143 

Exhibit 5-4: The Lakota Version of the 12 Steps................................................................. 147 

Exhibit 6-1: How Drug Cultures Differ .............................................................................. 162 

Exhibit 6-2: The Language of a Drug Culture .................................................................... 164 

Exhibit 6-3: The Values and Beliefs of a Heroin Culture .................................................... 166 

Exhibit 6-4: Music and Drug Cultures ................................................................................ 166 

Exhibit 6-5: The Rituals of Drug Cultures .......................................................................... 168 

Exhibit 6-6: Questions Regarding Knowledge and Skill Demands of Heroin Use............. 168 

Exhibit 6-7: 12-Step Group Values and the Culture of Recovery ....................................... 174 

v 
Consensus Panel

Note: Information given indicates each participant’s affiliation during the time the panel was 

convened and may no longer reflect the individual’s current affiliation.

Chair

Felipe González Castro, M.S.W., Ph.D. 

Professor

Department of Psychology

Arizona State University

Tempe, AZ

Co-Chairs

Loretta J. Bradley, M.A., Ph.D. 

Professor

Department of Educational Psychology

Texas Tech University

Lubbock, TX

Jacqueline P. Butler, M.S.W., CCDC, 

LISW 

Professor of Clinical Psychiatry

Substance Abuse Division

College of Medicine

University of Cincinnati

Cincinnati, OH

Flanders Byford, M.S.W., LCSW 

Oklahoma City-County Health Department

Oklahoma City, OK

Ting-Fun May Lai, M.S.W., CSW, 

CASAC 

Director

Chinatown Alcoholism Center

Hamilton-Madison House

New York, NY

Workgroup Leaders

Virgil A. Gooding, Sr., M.A., M.S.W., 

LISC 

Clinical Director 

Foundation II, Inc. 

Cedar Rapids, IA

Ford H. Kuramoto, D.S.W. 

President 

National Asian Pacific American Families 

Against Substance Abuse

Los Angeles, CA

Harry Montoya, M.A. 

President/Chief Executive Officer 

Hands Across Cultures 

Española, NM

Onaje M. Salim, M.A., NCAC-II, CCS 

Director 

Cork Institute Southeast Addiction 

Technology Transfer Center

Morehouse School of Medicine 

Atlanta, GA

Panelists

Barbara Lee Aragon, M.S.W. 

Academic Fellow

Department of Health Services

North Highlands, CA

vii 
Improving Cultural Competence

Debra A. Claymore, M.Ed.Adm. 

D. Claymore & Associates, Inc.

Loveland, CO

E. Daniel Edwards, D.S.W. 

Director

Ethnic Studies Program

University of Utah

Salt Lake City, UT

Tonda L. Hughes, M.S.N., Ph.D., FAAN 

Associate Professor

College of Nursing

University of Illinois at Chicago

Chicago, IL

David Mathews, M.A., Ph.D. 

Director of Adult Services

Kentucky River Community Care, Inc.

Jackson, KY

Anthony (Tony) Taiwai Ng, M.D. 

Consultant

Washington, DC

Barry Pilson, Ph.D.

Adjunct Professor

School of Social Work 

Tulane University

Metairie, LA

Rafaela R. Robles, Ed.D. 

Director

Technology Transfer Center

Caribbean Basin/Hispanic Addiction

Centro de Estudios en Adicción

Universidad Central del Caribe

Bayamon, PR

Gloria M. Rodriguez, D.S.W. 

Research Scientist

Division of Addiction Services

New Jersey Department of Health and Senior 

Services

Trenton, NJ

Ann S. Yabusaki, M.Ed., M.A., Ph.D. 

Director

Coalition for a Drug-Free Hawaii

Honolulu, HI

viii
KAP Expert Panel and Federal 

Government Participants

Note: Information given indicates each participant’s affiliation during the time the panel was 

convened and may no longer reflect the individual’s current affiliation.

Barry S. Brown, Ph.D. 

Adjunct Professor

University of North Carolina at Wilmington

Carolina Beach, NC

Jacqueline Butler, M.S.W., LISW, LPCC, 

CCDC III, CJS 

Professor of Clinical Psychiatry

College of Medicine

University of Cincinnati

Cincinnati, OH

Deion Cash 

Executive Director

Community Treatment and Correction

Center, Inc.

Canton, OH

Debra A. Claymore, M.Ed.Adm. 

D. Claymore & Associates, Inc.

Loveland, CO

Carlo C. DiClemente, Ph.D. 

Chair

Department of Psychology

University of Maryland Baltimore County

Baltimore, MD

Catherine E. Dube, Ed.D. 

Independent Consultant

Brown University

Providence, RI

Jerry P. Flanzer, D.S.W., LCSW, CAC 

Chief of Services

Division of Clinical and Services Research

National Institute on Drug Abuse

National Institutes of Health

Bethesda, MD

Michael Galer, D.B.A. 

Independent Consultant

Westminster, MA

Renata J. Henry, M.Ed. 

Director

Division of Alcoholism, Drug Abuse and 

Mental Health

Delaware Department of Health and Social 

Services

New Castle, DE

Joel Hochberg, M.A.

President

Asher & Partners

Los Angeles, CA

Jack Hollis, Ph.D. 

Associate Director

Center for Health Research

Kaiser Permanente

Portland, OR 

ix
Improving Cultural Competence

Mary Beth Johnson, M.S.W. 

Director

Addiction Technology Transfer Center

University of Missouri—Kansas City

Kansas City, MO 

Eduardo Lopez, B.S. 

Executive Producer

EVS Communications

Washington, DC

Holly A. Massett, Ph.D. 

Academy for Educational Development

Washington, DC

Diane Miller, Ph.D. 

Chief

Scientific Communications Branch

National Institute on Alcohol Abuse

and Alcoholism

National Institutes of Health

Bethesda, MD

Harry B. Montoya, M.A. 

President/Chief Executive Officer

Hands Across Cultures

Española, NM

Richard K. Ries, M.D. 

Director/Professor

Outpatient Mental Health Services

Dual Disorder Programs

Seattle, WA

Gloria M. Rodriguez, D.S.W. 

Research Scientist

Division of Addiction Services

New Jersey Department of Health and Senior 

Services

Trenton, NJ 

Everett Rogers, Ph.D. 

Center for Communications Programs

Johns Hopkins University

Baltimore, MD

Jean R. Slutsky, P.A., M.S.P.H. 

Director

Center for Outcomes and Evidence

Agency for Healthcare Research and Quality

Rockville, MD

Nedra Klein Weinreich, M.S. 

President

Weinreich Communications

Canoga Park, CA

Clarissa Wittenberg 

Director

Office of Communications and

Public Liaison

National Institute of Mental Health

National Institutes of Health

Bethesda, MD

Consulting Members of the KAP 

Expert Panel

Paul Purnell, M.A 

Social Solutions, L.L.C.

Potomac, MD

Scott Ratzan, M.D., M.P.A., M.A. 

Academy for Educational Development

Washington, DC

Thomas W. Valente, Ph.D. 

Director, Master of Public Health Program

Department of Preventive Medicine

School of Medicine

University of Southern California

Alhambra, CA

Patricia A. Wright, Ed.D. 

Independent Consultant

Baltimore, MD

x
What Is a TIP?

Treatment Improvement Protocols (TIPs) are developed by the Substance Abuse and Mental 

Health Services Administration (SAMHSA) within the U.S. Department of Health and Human 

Services (HHS). TIPs are best practice guidelines for the treatment of substance use disorders. 

TIPs draw on the experience and knowledge of clinical, research, and administrative experts to 

evaluate the quality and appropriateness of various forms of treatment. TIPs are distributed to 

facilities and individuals across the country. Published TIPs can be accessed via the Internet at 

http://store.samhsa.gov.

Although each TIP strives to include an evidence base for the practices it recommends, 

SAMHSA recognizes that the field of substance abuse treatment is continually evolving, and 

research frequently lags behind the innovations pioneered in the field. A major goal of each TIP 

is to convey front-line information quickly but responsibly. If research supports a particular 

approach, citations are provided.

xi
Foreword

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency 

within the U.S. Department of Health and Human Services that leads public health efforts to 

advance the behavioral health of the nation. SAMHSA’s mission is to reduce the impact of 

substance abuse and mental illness on America’s communities.

The Treatment Improvement Protocol (TIP) series fulfills SAMHSA’s mission to reduce the 

impact of substance abuse and mental illness on America’s communities by providing evidencebased and best practice guidance to clinicians, program administrators, and payers. TIPs are the 

result of careful consideration of all relevant clinical and health services research findings, 

demonstration experience, and implementation requirements. A panel of non-federal clinical 

researchers, clinicians, program administrators, and patient advocates debates and discusses their 

particular area of expertise until they reach a consensus on best practices. This panel’s work is 

then reviewed and critiqued by field reviewers.

The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly 

participatory process have helped bridge the gap between the promise of research and the needs 

of practicing clinicians and administrators to serve, in the most scientifically sound and effective 

ways, people in need of behavioral health services. We are grateful to all who have joined with us 

to contribute to advances in the behavioral health field.

Pamela S. Hyde, J.D. 

Administrator

Substance Abuse and Mental Health Services Administration

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM 

Director

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services Administration

xiii
Executive Summary

The development of culturally responsive 

clinical skills is vital to the effectiveness of 

behavioral health services. According to the 

U.S. Department of Health and Human 

Services (HHS), cultural competence “refers to 

the ability to honor and respect the beliefs, 

languages, interpersonal styles, and behaviors of 

individuals and families receiving services, as 

well as staff members who are providing such 

services. Cultural competence is a dynamic, 

ongoing developmental process that requires a 

long-term commitment and is achieved over 

time”(HHS 2003a, p. 12). It has also been 

called “a set of behaviors, attitudes, and policies 

that . . . enable a system, agency, or group of 

professionals to work effectively in crosscultural situations”(Cross et al. 1989, p. 13).

This Treatment Improvement Protocol (TIP) 

uses Sue’s (2001) multidimensional model for 

developing cultural competence. Adapted to 

address cultural competence across behavioral 

health settings, this model serves as a framework for targeting three organizational levels 

of treatment: individual counselor and staff, 

clinical and programmatic, and organizational 

and administrative. The chapters target specific racial, ethnic, and cultural considerations 

along with the core elements of cultural competence highlighted in the model. These core 

elements include cultural awareness, general 

cultural knowledge, cultural knowledge of 

behavioral health, and cultural skill development. The primary objective of this TIP is to 

assist readers in understanding the role of 

culture in the delivery of behavioral health 

services (both generally and with reference to 

specific cultural groups). This TIP is organized 

into six chapters and begins with an introduction to cultural competence. The following 

subheadings provide a summary of each chapter and an overview of this publication. 

Introduction to Cultural 

Competence

Why is the development of cultural competence and culturally responsive services 

important in the behavioral health field?

Culturally responsive skills can improve client 

engagement in services, therapeutic relationships between clients and providers, and 

treatment retention and outcomes. Cultural 

competence is an essential ingredient in decreasing disparities in behavioral health. 

The development of cultural competence can 

have far-reaching effects not only for clients, 

but also for providers and communities. Cultural competence improves an organization’s 

sustainability by reinforcing the value of diversity, flexibility, and responsiveness in addressing the current and changing needs of clients, 

communities, and the healthcare environment. 

Culturally responsive organizational strategies 

and clinical services can help mitigate organizational risk and provide cost-effective treatment, in part by matching services to client 

xv
Improving Cultural Competence

needs more appropriately from the outset. So 

too, culturally responsive organizational policies and procedures support staff engagement 

in culturally responsive care by establishing 

access to training, supervision, and congruent 

policies and procedures that enable staff to 

respond in a culturally appropriate manner to

clients’ psychological, linguistic, and physical 

needs. 

What is the process of becoming culturally 

competent as a counselor or culturally 

responsive as an organization? Cultural 

competence is not acquired in a limited 

timeframe or by learning a set of facts about 

specific populations; cultures are diverse and 

continuously evolving. Developing cultural 

competence is an ongoing process that begins 

with cultural awareness and a commitment to 

understanding the role that culture plays in 

behavioral health services. For counselors, the 

first step is to understand their own cultures as 

a basis for understanding others. Next, they 

must cultivate the willingness and ability to 

acquire knowledge of their clients’ cultures. 

This involves learning about and respecting 

client worldviews, beliefs, values, and attitudes 

toward mental health, help-seeking behavior, 

substance use, and behavioral health services.

Behavioral health counselors should incorporate culturally appropriate knowledge, understanding, and attitudes into their actions (e.g., 

communication style, verbal messages, treatment policies, services offered), thereby conveying their cultural competence and their 

organizations’ cultural responsiveness during 

assessment, treatment planning, and the 

treatment process.

What is culture? Culture is the conceptual 

system developed by a community or society 

to structure the way people view the world. It 

involves a particular set of beliefs, norms, and 

values that influence ideas about relationships,

how people live their lives, and the way people 

organize their world. Culture is not a definable 

entity to which people belong or do not belong. Within a nation, race, or community, 

people belong to multiple cultural groups and 

negotiate multiple cultural expectations on a 

daily basis. These expectations, or cultural 

norms, are the spoken or unspoken rules or 

standards for a given group that indicate 

whether a certain social event or behavior is 

appropriate or inappropriate. The word “culture”is sometimes applied to groups formed 

on the basis of age, socioeconomic status, 

disability, sexual orientation, recovery status, 

common interest, or proximity. Counselors 

and administrators should understand that 

each client embraces his or her culture(s) in a 

unique way and that there is considerable 

diversity within and across races, ethnicities, 

and culture heritages. Other cultures and

subcultures often exist within larger cultures. 

What are race and ethnicity? Race is often 

referred to as a biological category based on 

genetic traits like skin color (HHS 2001), but 

there are no reliable means of identifying race 

through biological criteria. Despite its limitations, the concept of race is important to 

discussions of cultural competence. Race—

when defined as a social construct to describe 

people with shared physical characteristics—

can have tremendous social significance. The 

term ethnicity is often used interchangeably 

with race, although by definition, ethnicity—

unlike race—implies a certain sense of belonging. It is generally based on shared values, 

beliefs, and origins rather than shared physical 

characteristics. With the exception of its final 

chapter, which examines drug cultures, this 

TIP focuses on the major racial and ethnic 

groups identified by the U. S. Census Bureau 

within the United States: African and Black

Americans, Asian Americans (including Native Hawaiians and other Pacific Islanders), 

Hispanics and Latinos, Native Americans, and 

White Americans.

xvi
Executive Summary

What constitutes cultural identity? Cultural 

identity, in the simplest terms, involves an 

affiliation or identification with a particular 

group or groups. An individual’s cultural 

identity reflects the values, norms, and 

worldview of the larger culture, but it is defined by more than these factors. Cultural

identity includes individual traits and attributes shaped by race, ethnicity, language, life 

experiences, historical events, acculturation, 

geographic and other environmental influences, and other forces. Thus, no two individuals will possess exactly the same cultural 

identity even if they identify with the same 

cultural group(s). Cultural identities are not 

static; they develop, evolve, and change across 

the life cycle. 

This TIP explores cultural identity and its 

influence on assessment, treatment planning, 

and therapeutic and healing practices. The 

introduction it provides to the cross-cutting 

factors of race, ethnicity, and culture will help 

counselors gain knowledge about the many 

forces that shape cultures, communities, and 

the lives of clients, including, but not limited 

to, families and kinships, gender roles, socioeconomic status, religion, education, immigration, and migration.

What core assumptions serve as the foundation of this TIP? The consensus panel 

developed several core assumptions upon 

which to structure the content of this TIP:

• An understanding of race, ethnicity, and 

culture (including one’s own) is necessary 

to appreciate the diversity of human dynamics and to treat clients effectively.

• Incorporating cultural competence into 

treatment improves therapeutic decisionmaking and offers alternative ways to 

define and plan a treatment program firmly directed toward progress and recovery.

• Organizational commitment to supporting

culturally responsive treatment services, 

including adequate allocation of resources, 

reinforces the importance of sustaining

cultural competence in counselors and 

other clinical staff.

• Advocating culturally responsive practices 

increases trust within the community, 

agency, and staff.

• Achieving cultural competence requires 

the participation of racially and ethnically 

diverse groups and underserved populations in the development and implementation of treatment approaches and training 

activities.

• Consideration of culture is important at all 

levels of operation and in all stages of 

treatment and recovery.

Core Competencies for 

Counselors and Other 

Clinical Staff

Cultural competence has come to mean more 

than a discrete skill set or knowledge base; 

cultural competence also requires selfevaluation on the part of the practitioner.

Culturally competent counselors are aware of 

their own culture and values, and they 

acknowledge their own assumptions and 

biases about other cultures. Moreover, culturally competent counselors strive to understand 

how these assumptions affect their ability to 

provide culturally responsive services to clients 

from similar or diverse cultures. 

Counselors should begin the process of becoming culturally competent by identifying 

and exploring their cultural heritage and 

worldview along with their clinical worldview, 

uncovering how these views shape their perceptions of and during the counseling process. 

In addition to understanding themselves and 

how their culture and values can affect the 

therapeutic process, culturally competent 

counselors possess a general understanding of 

xvii
Improving Cultural Competence

the cultures of the specific clients with whom 

they work. Counselors should also understand 

how individual cultural differences affect 

substance abuse, health beliefs, help-seeking 

behavior, and perceptions of behavioral health 

services. Culturally competent counselors: 

• Frame issues in culturally relevant ways.

• Allow for complexity of issues based on 

cultural context. 

• Make allowances for variations in the use 

of personal space. 

• Are respectful of culturally specific meanings of touch (e.g., hugging). 

• Explore culturally based experiences of 

power and powerlessness.

• Adjust communication styles to the client’s culture. 

• Interpret emotional expressions in light of 

the client’s culture.

• Expand roles and practices as needed.

Chapter 2 addresses counselors’ core cultural 

competencies and presents clinical activities, 

including clinical supervision tools. The key 

areas explored include cultural awareness and 

cultural identity development, the cultural lens 

of counseling, key components of cultural 

knowledge for behavioral health counselors, 

and specific counseling skills that support 

culturally responsive services. 

Culturally Responsive 

Evaluation and Treatment 

Planning

The role of culture should be considered 

during initial intakes and interviews, in 

screening and assessment processes, and in the 

development of treatment planning. Culturally 

responsive treatment can only occur when the 

making of clinical and programmatic decisions 

includes culturally relevant information and 

practices and is endorsed and supported by 

clinical staff, clinical supervisors, and the 

organization as a whole. Chapter 3 presents 

culturally responsive evaluation and treatment 

planning as a series of nine steps.

Step 1: Engage clients. Because the intake 

meeting is often the first encounter clients 

have with the behavioral health system, it is 

vital that they leave the meeting feeling understood and hopeful. Counselors should try 

to establish rapport with clients before launching into a series of questions.

Step 2: Familiarize clients and family 

members with the evaluation and treatment 

process. Often, clients and family members 

are not familiar with treatment jargon, the 

treatment program, the facility, or the expectations of treatment; furthermore, not all clients 

will have had an opportunity to express their 

own expectations or apprehension. Clinical 

and other treatment staff must not assume 

that clients already understand the treatment 

process. Instead, they need to take sufficient 

time to talk with clients (and their families, as 

appropriate) about how treatment works and 

what to expect from treatment providers.

Step 3: Endorse a collaborative approach in 

facilitating interviews, conducting assessments, and planning treatment. Counselors 

should educate clients about their role in 

interview, assessment, and treatment planning 

processes. From first contact, they should 

encourage clients and their families to participate actively by asking questions, voicing 

specific treatment needs, and being involved in 

treatment planning. Counselors should allow

clients and family members to give feedback 

on the cultural relevance of the treatment plan. 

Step 4: Obtain and integrate culturally 

relevant information and themes. By exploring culturally relevant themes, counselors will 

better understand each client and will be 

better equipped to develop a culturally informed evaluation and treatment plan. Areas 

xviii
Executive Summary

to explore include immigration and migration 

history, cultural identity, acculturation status, 

health beliefs, healing practices, and other 

information culturally relevant to the client.

Step 5: Gather culturally relevant collateral 

information. Such information is a powerful 

tool in assessing clients’ presenting problems, 

understanding the influence of cultural factors 

on clients, and gathering resources to support 

treatment endeavors. By involving others in the 

early phases of treatment, providers will likely 

obtain more external support for each client’s 

engagement in treatment services. Counselors 

can obtain supplemental information (with 

client permission) from family members, medical and court records, probation and parole 

officers, community members, and so on. 

Step 6: Select culturally appropriate screening and assessment tools. In selecting evaluation tools, counselors should note the 

availability of normative data for the populations to which their clients belong, the incidence of test item bias, the role of 

acculturation in understanding test items, and 

the adaptation of testing materials to each

client’s culture and language.

Step 7: Determine readiness and motivation for change. Although few studies focus

on the use of motivational interviewing with 

specific cultural groups, its theories and strategies may be more culturally appropriate for

most clients than other approaches. Through 

reflective listening, motivational interviewing 

focuses on helping clients explore ambivalence 

toward change, decisions, and subsequent 

treatment.It is a nonconfrontational, clientcentered approach that reinforces clients as the 

experts on what will work and supports the 

key idea that change is a process. 

Step 8: Provide culturally responsive case 

management. Many core competencies for 

counselors are also relevant to case managers. 

Like counselors, case managers should possess 

cultural self-knowledge and a basic knowledge 

of other cultures. They should possess traits 

conducive to working well with diverse groups 

and the ability to apply cultural competence in 

practical ways. Case management includes the 

use, as necessary, of interpreters who can 

communicate well in the specific dialects

spoken by each client and who are familiar 

with behavioral health vocabulary relevant to 

the specific behavioral health setting in which 

service provision will occur. Case managers 

should acquire cultural and community 

knowledge to assist with the coordination of 

social, health, and other essential services and 

to secure culturally relevant services in and 

outside the treatment facility. Case managers 

should also keep a list of culturally appropriate 

referral resources to help meet client needs.

Step 9: Integrate cultural factors into 

treatment planning. Counselors should be 

flexible in designing a treatment plan to meet 

the cultural needs of clients and should integrate traditional healing practices into treatment plans when appropriate, using resources 

available in the clients’ cultural communities. 

Treatment goals and objectives need to be 

culturally relevant, and the treatment environment must be conducive to client participation in treatment planning and to the 

gathering of client feedback on the cultural 

relevance of the treatment being provided. 

Pursuing Organizational 

Cultural Competence

Organizational cultural competence is a dynamic, ongoing process that begins with 

awareness and commitment and evolves into 

culturally responsive organizational policies 

and procedures. A commitment to improving 

cultural competence must include resources to 

help support ongoing fidelity to these policies 

and procedures along with an ongoing process 

xix
Improving Cultural Competence

of reassessment and adaptation as client and 

community needs evolve. Chapter 4 presents 

20 organizational tasks that support counselors’ development of cultural competence and 

improve organizational development of culturally responsive treatment services. 

Beginning with the organization’s vision and 

mission statement, administrators and governing boards need to develop, implement, and 

support a strategic planning process that 

demonstrates commitment to cultural competence. Key staff members assigned to oversee 

the development of culturally responsive 

services act as liaisons and facilitators in establishing a cultural competence committee and

conducting an organizational self-assessment 

of cultural competence. With the involvement 

of community members, staff, clients and their 

families, board members, and other invested 

individuals, the cultural competence committee supports and oversees organizational selfassessment, using it to identify strengths and 

specific areas for improvement in cultural 

responsiveness. Based on the results of the 

self-assessment, the committee develops and 

implements a cultural competence plan. 

An organizational self-assessment helps the 

committee prioritize the steps needed to 

improve culturally responsive services. The 

plan should address strategies for recruiting, 

hiring, retaining, and promoting qualified, 

diverse staff members; the use of interpreters 

or bilingual staff members; staff training, 

professional development, and education; 

fostering community involvement; facilities 

design and operation; development of culturally appropriate program materials; how to 

incorporate culturally relevant treatment 

approaches; and development and implementation of supporting policies and procedures,

including reassessment processes. An organization’s commitment to and support of culturally responsive services, including congruent 

policies and procedures, will enable counselors 

to respond more consistently to clients in a 

culturally competent manner. 

Behavioral Health 

Treatment for Major Racial 

and Ethnic Groups 

Knowledge of a culture’s attitudes toward 

mental illness, substance use, healing, and 

help-seeking patterns, practices, and beliefs is 

essential in understanding clients’ presenting 

problems, developing culturally competent 

counseling skills, and formulating culturally 

relevant agency policies and procedures. 

Treatment providers need to learn and understand how identification with one or more 

cultural groups influences each client’s 

worldview, beliefs, and traditions surrounding 

initiation of use, healing, and treatment. 

Chapter 5 provides a review of the literature as 

it pertains to specific racial and ethnic groups 

identified by the U.S. Census Bureau. After a 

brief introduction, the chapter explores each 

major racial and ethnic group’s specific patterns of substance use and substance use disorders, help-seeking patterns, beliefs about 

and traditions involving substance use, beliefs 

and attitudes about treatment, assessment and 

treatment considerations (including cooccurring disorders and culturally specific 

disorders), and theoretical approaches and 

treatment interventions (including evidencebased and best practices as well as traditional 

healing practices). 

Chapter 5 also offers assistance in providing 

treatment to African and Black Americans, 

Asian Americans (including Native Hawaiian 

and other Pacific Islanders), Latinos, Native 

Americans, and White Americans. Counselors, clinical supervisors, and administrators 

are encouraged to use the information in this 

chapter as a starting point for learning about 

xx
Executive Summary

the major cultural groups of their clients. 

Nonetheless, many forces shape how an individual identifies with, is influenced by, or 

portrays his/her culture, and numerous subcultures can exist within any culture; thus, generalizations about various population groups 

should be avoided.

Drug Cultures and the 

Culture of Recovery

This TIP emphasizes the concept that many 

subcultures exist within and across diverse 

ethnic and racial populations and cultures. 

Drug cultures are a formidable example—they 

can influence the presentation of mental, 

substance use, and co-occurring disorders 

while also affecting prevention and treatment 

strategies and outcomes. Drug cultures differ 

from the types of cultures discussed in the rest 

of this TIP, but they do share some common 

features. For instance, there is not a single 

drug culture in the United States today, but 

rather, a number of distinct (although sometimes related) drug cultures that differ according to substances used, geographic location, 

socioeconomic status, and other factors. Drug 

cultures focusing on illicit substances may be 

of greater importance in the lives of people 

who use substances, but people who use legal 

substances, such as alcohol, can also participate in a drug culture. For example, people 

who drink heavily at a bar or fraternity/sorority house can develop their own drug 

culture that works to encourage new people to 

use, supports high levels of continued use or 

binge use, and reinforces denial.

Understanding the role that drug cultures play 

in clients’ lives is particularly important because these cultures, more than any other 

cultural connections, influence clients’substance use or abuse and the behaviors in which 

they engage to manage mental disorders. 

Through drug cultures, people new to using

learn to experience “getting high” as a pleasurable activity; they also learn the skills needed 

to procure and use drugs effectively and to 

avoid the pitfalls of the drug-using lifestyle 

(e.g., getting arrested, running out of money to 

buy drugs). Perhaps most importantly, the 

person who uses gains acceptance from a 

group of peers even as mainstream society 

increasingly discriminates against him or her

because of his or her substance use or mental 

illness. Prejudice from mainstream society may 

make ties with the drug culture even stronger; 

he or she may feel as if there is no other place 

to turn for social and cultural support.

Within a treatment program, an understanding of drug cultures will help providers engage 

new clients and recognize the social and cultural bonds that might lead them back to 

substance use or other high-risk behaviors that 

are contraindicated for individuals who are 

being treated for psychological symptoms 

and/or mental illness. However, unlike other 

types of cultural affiliations, the treatment 

provider’s relationship to the drug culture does 

not just involve understanding; the provider 

must actively work to weaken that connection 

and replace it with other experiences that meet 

the client’s social and cultural needs. In many 

cases, this involves helping the client connect 

with a “culture of recovery”to meet those 

needs over the long course of recovery. 

In sum, this TIP was written to help counselors and organizations provide culturally responsive services. Practices and procedures 

that improve one’s cultural competence will 

likely result in better outcomes for clients in 

treatment for mental and substance use disorders. Culturally competent counseling can 

improve counselor credibility, client satisfaction, and client self-disclosure while increasing 

clients’willingness to continue in treatment.

xxi
 IN THIS CHAPTER

• Purpose and Objectives 

of the TIP

• Core Assumptions

• What Is Cultural 

Competence?

• Why Is Cultural 

Competence Important?

• How Is Cultural 

Competence Achieved? 

• What Is Culture?

• What Is Race?

• What Is Ethnicity?

• What Is Cultural Identity?

• What Are the CrossCutting Factors in Race, 

Ethnicity, and Culture?

• As You Proceed

Introduction to Cultural 

Competence 

Hoshi was born and grew up in Japan. He has been living in the 

United States for nearly 20 years, going to graduate school and 

working as a systems analyst, while his family has remained in 

Japan. Hoshi entered a residential treatment center for alcohol 

dependence where the treatment program expected every client to

notify his or her family members about being in treatment. This 

had proven to be a positive step for many other clients and their 

families in this treatment program, where the belief was that contact with family helped clients become honest about their substance abuse, reconnect with possibly estranged relatives, and take 

responsibility for the decision to seek treatment. 

He was reluctant, but staff members persuaded Hoshi to comply 

with program expectations. He wrote to his family, describing his 

current life and explaining his need for treatment. It was not until 

weeks later, after he had been discharged from residential treatment and was participating in the program’s continuing care program, that he received a reply. Staff members were shocked to learn

that Hoshi’s parents had disowned him because he had “shamed” 

the family by disclosing the details of his life to the program staff, 

publicly admitting that he had a drinking problem.

As Hoshi’s story demonstrates, a well-meaning but culturally inappropriate intervention can be counterproductive to recovery. The 

program applied a “one size fits all” model without being sensitive 

to the possibility that such an approach might harm the client. 

Fortunately, Hoshi eventually reconciled with his family, and the

program administration and staff began to develop initiatives to 

improve their cultural awareness and competence.

Counselors and other behavioral health service providers who are

equipped with a general understanding of how culture affects their

1

1 
Improving Cultural Competence

own worldviews as well as those of their clients will be able to work more effectively with 

clients who have substance use and mental 

disorders. Even when culture is not a conscious consideration in providing interventions 

and services, it is a dynamic force that often 

influences client responses to treatment and 

subsequent outcomes. Although outcome 

research is limited, culturally responsive behavioral health counseling results in greater 

counselor credibility, better client satisfaction, 

more client self-disclosure, and greater willingness among clients to continue with counseling (Goode et al. 2006; Lie et al. 2011; 

Ponterotto et al. 2000). This Treatment 

Improvement Protocol (TIP) examines the 

significance of culture in substance abuse 

patterns, mental health, treatment-seeking 

behaviors, assessment and counseling processes, program development, and organizational 

practices in behavioral health services.

Purpose and Objectives of 

the TIP

This TIP is intended to help counselors and 

behavioral health organizations make progress 

toward cultural competence. Gaining cultural 

competence, like any important counseling 

skill, is an ongoing process that is never completed; such skills cannot be taught in any 

single book or training session. Nevertheless, 

this TIP provides a framework to help practitioners and administrators integrate cultural 

factors into their evaluation and treatment of 

clients with behavioral health disorders. It also 

seeks to motivate professionals and organizations to examine and broaden their cultural 

awareness, embrace diversity, and develop a 

heightened respect for people of all cultural 

groups. This TIP places significant importance on the role of program management 

and organizational commitment in the development of cultural competence. Organizational

support allows counselors, case managers, and 

administrators to begin to integrate culturally 

congruent and responsive services more consistently across the continuum of care—

including outreach and early intervention, 

assessment, treatment planning and intervention, and recovery services.

The key objectives of this TIP are helping 

readers understand:

• Why it is important for behavioral health 

organizations and counselors who provide 

prevention and treatment services to consider culture.

• The role culture plays in the treatment 

process, both generally and with reference 

to specific cultural groups.

Intended Audience

The primary audiences for this TIP are prevention professionals, substance abuse counselors, mental health clinicians, and other 

behavioral health service providers and administrators. Those who work with culturally 

diverse populations will find it particularly 

useful, though all behavioral health workers—

regardless of their client populations—can 

benefit from an awareness of the importance 

of culture in shaping their own perceptions as 

well as those of their clients. Secondary audiences include educators, researchers, policymakers for treatment and related services, 

consumers, and other healthcare and social 

service professionals who work with clients 

who have behavioral health disorders.

Structure of the TIP

This TIP focuses on the essential ingredients 

for developing cultural competence as a counselor and for providing culturally responsive 

services in clinical settings as an organization. 

Chapter 1 defines cultural competence, presents a rationale for pursuing it, and describes 

the process of becoming culturally competent 

and responsive to client needs. The chapter 

2
Chapter 1—Introduction to Cultural Competence

highlights the consensus panel’s core assumptions. It introduces a framework, adapting 

Sue’s (2001) multidimensional model of cultural competence as the guiding model across 

chapters. The initial chapter ends with a broad 

overview of the concepts integral to an understanding of race, ethnicity, and culture.

Chapter 2 addresses the development of cultural awareness and describes core competencies for counselors and other clinical staff, 

beginning with self-knowledge and ending 

with skill development. It covers behaviors and 

skills for cultivating cultural competence as 

well as attitudes conducive to working effectively with diverse client populations.

Chapter 3 provides guidelines for culturally 

responsive clinical services, including interviewing skills, assessment practices, and treatment planning.

Chapter 4 provides organizational strategies to 

promote the development and implementation 

of culturally responsive practices from the top 

down, beginning with organizational selfassessment of current services and continuing 

through implementation and oversight of an 

organizational plan targeting initiatives to 

improve culturally responsive services.

Chapter 5 provides a general introduction for 

each major racial and ethnic group, providing 

specific cultural knowledge related to substance use patterns, beliefs and attitudes toward help-seeking behavior and treatment, 

and an overview of research- and practicebased treatment approaches and interventions.

Chapter 6 closes the TIP with an exploration 

of the concept of “drug culture”—the relationship between the drug culture and mainstream 

culture, the values and rituals of drug cultures, 

how people “benefit”from participation in 

drug cultures, and the role of the drug culture 

in substance abuse treatment.

Terminology

Throughout the TIP, the term substance abuse

is used to refer to both substance abuse and 

substance dependence. This term was chosen 

partly because substance abuse treatment 

professionals commonly use the term substance abuse to describe any excessive use of 

addictive substances. In this TIP, the term 

refers to use of alcohol as well as other substances of abuse. Readers should attend to the 

context in which the term occurs to determine 

what possible range of meanings it covers; in 

most cases, however, the term will refer to all 

varieties of substance use disorders described 

by the Diagnostic and Statistical Manual of 

Mental Disorders, Fifth Edition (DSM-5; 

American Psychiatric Association, 2013).

Throughout the TIP, the term behavioral 

health refers to a state of mental/emotional 

being and/or choices and actions that affect 

wellness. Behavioral health problems include 

substance abuse or misuse, alcohol and drug 

addiction, psychological distress, suicide, and 

mental and substance use disorders. This 

includes a range of problems, from unhealthy 

stress to diagnosable and treatable diseases like 

serious mental illness and substance use disorders, which are often chronic in nature but 

from which people can and do recover. The 

term is also used in this TIP to describe the 

service systems encompassing the promotion 

of emotional health, the prevention of mental 

and substance use disorders, substance use and 

related problems, treatments and services for 

mental and substance use disorders, and recovery support. Behavioral health conditions, 

taken together, are the leading causes of disability burden in North America; efforts to 

improve their prevention and treatment will 

benefit society as a whole. Efforts to reduce 

the impact of mental and substance use disorders on communities in the United States, 

such as those described in this TIP, will help 

achieve nationwide improvements in health.

3
Improving Cultural Competence

Core Assumptions

The consensus panel developed assumptions 

that serve as the fundamental platform of this 

TIP. Assumptions were derived from clinical 

and administrative experiences, available 

empirical evidence, conceptual writings, and 

program and treatment service models.

Assumption 1: The focus of cultural competence, in practice, has historically been on 

individual providers. However, counselors will 

not be able to sustain culturally responsive 

treatment without the organization’s commitment to support and allocate resources to 

promote these practices. Organizations that 

value diversity and reflect cultural competence 

through congruent policies and procedures are 

more likely to be successful in the everchanging landscape of communities, treatment 

services, and individual client needs.

Assumption 2: An understanding of race, 

ethnicity, and culture (including one’s own) is 

necessary to appreciate the diversity of human 

dynamics and to treat all clients effectively. 

Before counselors begin to probe the cultures, 

races, and ethnicities of their clients and use 

this information to improve client treatment, 

the consensus panel recommends first that 

counselors examine and understand their own 

cultural histories, racial and ethnic heritages, 

and cultural values and beliefs. This applies to 

all practitioners regardless of race, ethnicity, or 

cultural identity. Beyond that, clinicians 

should clearly identify the influences of their 

own cultural experiences on the counseling 

relationship. In other words, each counselor 

must understand, embrace, and, if warranted, 

reexamine and adjust his or her own worldview to practice in a culturally competent 

manner. So too, all support staff, clinicians, 

administrators, and policymakers—including 

those not from the mainstream culture— 

must become educated and convinced of the 

importance of cultural competence in the 

delivery of effective behavioral health services.

Assumption 3: Incorporating cultural competence into treatment improves therapeutic 

decision-making and offers alternate ways to 

define and plan a treatment program that is 

firmly directed toward progress and recovery—as defined by both the counselor and 

client. Using culturally responsive practices is 

essential and provides many benefits for organizations, staff, communities, and clients.

Assumption 4: Consideration of culture is 

important at all levels of operation—

individual, programmatic, and organizational—across behavioral health treatment settings. It is also important in all activities and 

at every treatment phase: outreach, initial 

contact, screening, assessment, placement, 

treatment, continuing care and recovery services, research, and education. Because organizations and systems have their own internal 

cultures, it is vital that treatment facilities, 

training and educational programs on 

substance-related and mental disorders and 

treatment processes, and licensing agencies 

and accrediting bodies incorporate culturally 

responsive practices into their curricula, standards, criteria, and requirements.

Assumption 5: Achieving cultural competence in an organization requires the participation of racially and ethnically diverse groups 

and underserved populations in the development and implementation of culturally responsive practices, program structure and 

design, treatment strategies and approaches, 

and staff professional development. Culturally 

congruent interventions cannot be successfully 

applied when generated outside a community 

or without community participation. Clients, 

potential clients, their families, and their communities should be invited to participate in the 

development of a cultural competence plan (an

4
Chapter 1—Introduction to Cultural Competence

organization’s plan to improve cultural competence and to provide culturally responsive 

services) and, subsequently, the design of 

culturally relevant treatment services and 

organizational policies and procedures.

Assumption 6: Public advocacy of culturally 

responsive practices can increase trust among 

the community, agency, and staff. The community is thus empowered with a voice in 

organizational operations. Advocacy can 

further function as a secondary form of public 

education and awareness as well as outreach. 

High collective participation allows treatment 

to be viewed as of and for the community. 

What Is Cultural 

Competence?

In 1989, Cross et al. provided one of the more 

universally accepted definitions of cultural 

competence in clinical practice: “A set of 

congruent behaviors, attitudes, and policies 

that come together in a system, agency, or 

among professionals and enable the system, 

agency, or professionals to work effectively in 

cross-cultural situations” (p. 13).

Since then, others have interpreted this definition in terms of a particular field or attempted 

to refine, expand, or elaborate on earlier conceptions of cultural competence. At the root 

of this concept is the idea that cultural competence is demonstrated through practical 

means—that is, the ability to provide effective 

services. Bazron and Scallet (1998) defined 

culturally responsive services as those that are 

“responsive to the unique cultural needs of 

bicultural/bilingual and culturally distinct 

populations” (p. 2). The Office of Minority 

Health (OMH 2000) merged several existing 

definitions to conclude that:

Cultural and linguistic competence is a set of 

congruent behaviors, attitudes, and policies 

that come together in a system, agency, or 

among professionals that enables effective 

work in cross-cultural situations. ‘Culture’ refers to integrated patterns of human behavior 

that include the language, thoughts, communications, actions, customs, beliefs, values, and 

institutions of racial, ethnic, religious, or social 

groups. ‘Competence’ implies having the capacity to function effectively as an individual 

and an organization within the context of the 

cultural beliefs, behaviors, and needs presented 

by consumers and their communities. (p. 28)

Numerous evolving definitions and models of 

cultural competence reflect an increasingly 

complex and multidimensional view of how 

race, ethnicity, and culture shape individuals—their beliefs, values, behaviors, and ways 

of being (see Bhui et al. 2007 for a systemic 

review of cultural competence models in 

mental health). In this TIP, Sue’s (2001) 

multidimensional model of cultural competence guides its overall organization and the 

specific content of each chapter. The model 

was adapted to fit the unique topic areas 

addressed by this TIP (Exhibit 1-1) and to 

target essential elements of cultural competence in providing behavioral health services 

across three main dimensions, as shown in the 

cube. (Note: Each subsequent chapter displays 

a version of this cube shaded to emphasize the 

focus of that chapter.)

Dimension 1: Racially and 

Culturally Specific Attributes

Exhibit 1-1 and this TIP focus on main population groups as identified by the U.S. Census 

Bureau (Humes et al. 2011), but this dimension is inclusive of other multiracial and culturally diverse groups and can also include 

sexual orientation, gender orientation, socioeconomic status, and geographic location. There 

are often many cultural groups within a given 

population or ethnic heritage. For simplicity, 

these groups are not represented on the actual 

model, and it is assumed that the reader 

acknowledges the vast inter- and intragroup 

variations that exist in all population, ethnic, 

5 
Improving Cultural Competence

and cultural groups. Refer to Chapters 5 and 6 

to gain further clinical knowledge about specific racial, ethnic, and cultural groups.

Dimension 2: Core Elements of 

Cultural Competence

This dimension includes cultural awareness, 

cultural knowledge, and cultural skill development. To provide culturally responsive 

treatment services, counselors, other clinical 

staff, and organizations need to become aware 

of their own attitudes, beliefs, biases, and 

assumptions about others. Providers need to 

invest in gaining cultural knowledge of the 

populations that they serve and obtaining

specific cultural knowledge as it relates to 

help-seeking, treatment, and recovery. This 

dimension also involves competence in clinical 

skills that ensure delivery of culturally appropriate treatment interventions. Several chapters capture the ingredients of this dimension. 

Chapter 1 provides an overview of cultural 

competence and concepts, Chapter 2 provides 

an indepth look at the role and effects of the 

counselor’s cultural awareness and identity 

within the counseling process, Chapter 3 

provides an overview of cultural considerations 

and essential clinical skills in the assessment 

and treatment planning process, and Chapter 

5 specifically addresses the role of culture 

across specific treatment interventions.

Dimension 3: Foci of Culturally 

Responsive Services

This dimension targets key levels of treatment 

services: the individual staff member level, the 

Exhibit 1-1: Multidimensional Model for Developing Cultural Competence

6 
Chapter 1—Introduction to Cultural Competence

clinical and programmatic level, and the organizational and administrative level. Interventions need to occur at each of these levels 

to endorse and provide culturally responsive 

treatment services, and such interventions are 

addressed in the following chapters. Chapter 2 

focuses on core counselor competencies; 

Chapter 3 centers on clinical/program attributes in interviewing, assessment, and treatment planning that promote culturally 

responsive interventions; and Chapter 4 addresses the elements necessary to improve 

culturally responsive services within treatment 

programs and behavioral health organizations.

Why Is Cultural 

Competence Important?

Foremost, cultural competence provides clients 

with more opportunities to access services that 

reflect a cultural perspective on and alternative, 

culturally congruent approaches to their presenting problems. Culturally responsive services will likely provide a greater sense of 

safety from the client’s perspective, supporting 

the belief that culture is essential to healing. 

Even though not all clients identify with or 

desire to connect with their cultures, culturally 

responsive services offer clients a chance to 

explore the impact of culture (including historical and generational events), acculturation, 

discrimination, and bias, and such services also 

allow them to examine how these impacts 

relate to or affect their mental and physical 

health. Culturally responsive practice recognizes the fundamental importance of language 

and the right to language accessibility, including translation and interpreter services. For 

clients, culturally responsive services honor the 

beliefs that culture is embedded in the clients’ 

language and their implicit and explicit communication styles and that languageaccommodating services can have a positive 

effect on clients’ responses to treatment and 

subsequent engagement in recovery services. 

The Affordable Care Act, along with growing 

recognition of racial and ethnic health disparities and implementation of national initiatives 

to reduce them (HHS 2011b), necessitates 

enhanced culturally responsive services and 

cultural competence among providers. Most 

behavioral health studies have found disparities in access, utilization, and quality in behavioral health services among diverse ethnic and 

racial groups in the United States (Alegria et 

al. 2008b; Alegria et al. 2011; HHS 2011b; Le 

Cook and Alegria 2011; Satre et al. 2010). 

The lack of cultural knowledge among providers, culturally responsive environments, and 

diversity in the workforce contribute to disparities in healthcare. Even limited cultural 

competence is a significant barrier that can 

translate to ineffective provider–consumer 

communication, delays in appropriate treatment and level of care, misdiagnosis, lower 

rates of consumer compliance with treatment, 

and poorer outcome (Barr 2008; CarpenterSong et al. 2011; Dixon et al. 2011). Increasing the cultural competence of the healthcare 

workforce and across healthcare settings is 

crucial to increasing behavioral health equity.

Additionally, adopting and integrating culturally responsive policies and practices into 

What Are Health Disparities?

A health disparity is a particular type of health difference closely linked with social, economic, and/or 

environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual or gender 

orientation; geographic location; or other characteristics historically tied to discrimination or exclusion.

Source: U.S. Department of Health and Human Services (HHS) 2011a. 

7 
Improving Cultural Competence

behavioral health services provides many 

benefits not only for the client, but also for the 

organization and its staff. Foremost, it increases the likelihood of sustainability. Cultural 

competence supports the viability of services 

by bringing to the forefront the value of diversity, flexibility, and responsiveness in organizations and among practitioners. Beyond the 

necessity of adopting culturally responsive 

practices to meet funding, state licensing, 

and/or national accreditation requirements, 

cultural competence essential in organizational 

risk management (the process of making and 

implementing decisions that will optimize 

therapeutic outcomes and minimize adverse 

effects upon clients and, ultimately, the organization). For instance, implementing culturally 

responsive services is likely to increase access 

to care and improve assessment, treatment 

planning, and placement. So too, it is likely to 

enhance effective communication between 

clients and treatment providers, thus decreasing risks associated with misunderstanding the 

clients’ presenting problems or the needs of 

clients with regard to appropriate referrals for 

evaluation or treatment.

Organizational investment in improving 

cultural competence and increasing culturally 

responsive services will likely increase use and 

cost effectiveness because services are more 

appropriately matched to clients from the 

beginning. A key principle in culturally responsive practices is engagement of the community, clients, and staff. As organizations 

establish community involvement in the ongoing implementation of culturally responsive 

services, the community will be more aware of 

available treatment services and thus will 

become more likely to use them as its involvement with and trust for the organization 

grows. Likewise, clients and staff are more apt 

to be empowered and invested if they are 

involved in the ongoing development and 

delivery of culturally responsive services. Client and staff satisfaction can increase if organizations provide culturally congruent 

treatment services and clinical supervision. 

An organization also benefits from culturally 

responsive practices through planning for, 

attracting, and retaining a diverse workforce 

that reflects the multiracial and multiethnic 

heritages and cultural groups of its client base 

and community. Developing culturally responsive organizational policies includes hiring and 

promotional practices that support staff diversity at all levels of the organization, including 

board appointments. Increasing diversity does 

not guarantee culturally responsive practices, 

but it is more likely that doing so will lead to 

broader, varied treatment services to meet 

client and community needs. Organizations 

are less able to ignore the roles of race, ethnicity, and culture in the delivery of behavioral 

health services if staff composition at each 

level of the organization reflects this diversity.

Culturally responsive practice reinforces the 

counselor’s need for self-exploration of cultural identity and awareness and the importance 

of acquiring knowledge and skills to meet 

clients’ specific cultural needs. Cultural competence requires an understanding of the 

client’s worldview and the interactions between that worldview and the cultural identities of the counselor and the client in the 

therapeutic process. Culturally responsive 

practice reminds counselors that a client’s 

worldview shapes his or her perspectives, 

The Enhanced National Standards for 

Culturally and Linguistically Appropriate 

Services in Health and Health Care (OMH 

2013) are meant to reduce and eliminate 

disparities, improve quality of care, and 

promote health equality by establishing a 

blueprint for health and the organization 

of health care (see Appendix C or visit

http://www.thinkculturalhealth.hhs.gov).

8 
Chapter 1—Introduction to Cultural Competence

beliefs, and behaviors surrounding substance 

use and dependence, illness and health, seeking help, treatment engagement, counseling 

expectations, communication, and so on. 

Cultural competence includes addressing the 

client individually rather than applying general treatment approaches based on assumptions and biases. It also can counteract a 

potentially omnipotent stance on the part of 

counselors that they know what clients need 

more than the clients themselves do. Cultural 

competence highlights the need for counselors 

to take time to build a relationship with each

of their clients, to understand their clients, and 

to assess for and access services that will meet 

each client’s individual needs.

The importance and benefit of cultural competence does not end with changes in organizational policies and procedures, increases in 

program accessibility and tailored treatment 

services, or enhancement of staff training. In 

programs that prioritize and endorse cultural 

competence at all levels of service, clients, too, 

will have more exposure to psychoeducational 

and clinical experiences that explore the roles 

of race, ethnicity, culture, and diversity in the 

treatment process. Treatment will help clients 

address their own biases, which can affect 

their perspectives and subsequent relationships 

with other clients, staff members, and individuals outside of the program, including other 

people in recovery. Culturally responsive 

services prepare clients not only to embrace 

their own cultural groups and life experiences, 

but to acknowledge and respect the experiences, perspectives, and diversity of others.

How Is Cultural 

Competence Achieved? 

Cultural groups are diverse and continuously 

evolving, defying precise definitions. Cultural 

competence is not acquired merely by learning 

a given set of facts about specific populations, 

changing an organization’s mission statement, 

or attending a training on cultural competence. Becoming culturally competent is a 

developmental process that begins with 

awareness and commitment and evolves into 

skill building and culturally responsive behavior within organizations and among providers.

Cultural competence is the ability to recognize 

the importance of race, ethnicity, and culture 

in the provision of behavioral health services. 

Specifically, it is awareness and acknowledgment that people from other cultural groups 

do not necessarily share the same beliefs and 

practices or perceive, interpret, or encounter 

similar experiences in the same way. Thus, 

cultural competence is more than speaking 

another language or being able to recognize 

the basic features of a cultural group. Cultural 

competence means recognizing that each of 

us, by virtue of our culture, has at least some 

ethnocentric views that are provided by that 

culture and shaped by our individual interpretation of it. Cultural competence is rooted in 

respect, validation, and openness toward 

someone whose social and cultural background is different from one’s own (Center for 

Substance Abuse Treatment [CSAT] 1999b). 

Nonetheless, cultural competence literature 

highlights how difficult it is to appreciate 

cultural differences and to address these differences effectively, because many people tend 

to see things solely from their own culturebound perspectives. For counselors, specific 

cognitions, attitudes, and behaviors characterize the path to culturally competent counseling and culturally responsive services. Exhibit 

1-2 depicts the continuum of thoughts and 

behaviors that lead to cultural competence in 

the provision of treatment. The “stages” are 

not necessarily linear, and not all people begin 

with a negative impression of other cultural 

groups—they may simply fail to recognize 

differences and diverse ways of being. For

9 
Improving Cultural Competence

Exhibit 1-2: The Continuum of Cultural Competence

Stage 1: Cultural Destructiveness

Organizational Level: At best, the behavioral health organization negates the relevance of culture in 

the delivery of behavioral health services. Agencies expect individuals from diverse ethnic and cultural 

backgrounds to fit into the existing treatment program rather than adapting the program to each 

client to provide culturally congruent services. Driving this expectation is the attitude that mainstream 

culture and current services are superior and that other approaches (e.g., Native American traditional 

healing practices) need not be considered. Organizations can also take a more adversarial role at this 

level—failing to provide basic services, creating an uncomfortable environment to covertly discourage 

the use of services, or expecting the individual to leave culture at the door.

Individual Level: Counselors can also operate from this stance, holding a myopic view of “effective” 

treatment. However, it would likely be difficult to operate at this level as a counselor without organizational endorsement. Counselors can project superiority by stating with authority and conviction in 

sessions that their approach is the best and expressing directly to clients that they should be grateful 

to receive these services. At the same time, these counselors filter interactions through a biased lens 

without engaging in self-reflection or examination of the impact of their prejudice.

Stage 2: Cultural Incapacity

Organizational Level: Due to lack of organizational responsiveness, services and organizational culture 

may be biased, and clients may view them as oppressive. An agency functioning at cultural incapacity 

expects clients from diverse backgrounds to conform to services rather than the agency being flexible 

and adapting services to meet client needs. Treatment of diverse individuals is often paternalistic, 

limiting their active participation in treatment planning or minimizing the need for culturally congruent 

treatment services. 

Individual Level: Counselors ignore the relevance of culture while using the dominant client population and/or culture as the norm for assessment, treatment planning, and determination of services. At 

this level, counselors can be aware of the need to approach treatment differently but likely believe that 

they are powerless over circumstances or the organizational system.

Stage 3: Cultural Blindness

Organizational Level: The core belief that perpetuates cultural blindness is the assumption that all 

cultural groups are alike and have similar experiences. Taking the position that individuals across 

cultural groups are more alike than different, organizations can rationalize that “good” treatment 

services will suffice for all clients regardless of ethnicity, race, religion, sexual orientation, national 

origin, or class. Consequently, organizations that operate at this level will continue developing and 

implementing policies and procedures that propagate discrimination.

Individual Level: At this stage, counselors uphold the belief that there are no essential differences 

among individuals across cultural groups—that everyone experiences discrimination and is subject to 

the biases of others. Counselors rationalize that approaching all clients as individuals negates the need 

to focus specifically on cultural competence. For example, some counselors may believe that there is

(Continued on the next page.)

10
Chapter 1—Introduction to Cultural Competence

most people, the process of becoming culturally competent is complex, with movement back 

and forth along the continuum and with

feelings and thoughts from more than one 

stage sometimes existing concurrently. 

What Is Culture?

Culture is defined by a community or society. 

It structures the way people view the world. It 

involves the particular set of beliefs, norms, 

and values concerning the nature of relationships, the way people live their lives, and the 

way people organize their environments. 

Culture is a complex and rich concept. Understanding it requires a willingness to examine 

and grasp its many elements and to comprehend how they come together. Castro (1998) 

identified the elements generally agreed to 

constitute a culture as: 

• A common heritage and history that is 

passed from one generation to the next. 

Exhibit 1-2: The Continuum of Cultural Competence (continued)

too much focus on cultural competence and that training in this area has become the “pop culture” in 

the counseling field, or they may feel that too much time is spent on cultural issues when a good 

assessment addressing individual issues and needs would suffice.

Stage 4: Cultural Precompetence

Organizational Level: Organizations at this stage begin to develop a basic understanding of and 

appreciation for the importance of sociocultural factors in the delivery of care. Similar to the preparation stage identified in the stages of change model (Prochaska et al. 1992; Miller and Rollnick 2013), 

this level involves recognition of the need for more culturally responsive services, further exploration of 

steps toward creating more appropriate services for culturally diverse populations, and a general 

commitment characterized by small organizational changes. Despite having incomplete knowledge, 

agencies at this stage can evolve toward organizational cultural competence with support, planning, 

and commitment from the governing and advisory boards, community, and administrators.

Individual Level: Counselors acknowledge a need for more training specific to the populations they 

serve at this level of development. They acknowledge the need to attend more to ethnicity, race, and 

culture in the provision of services, but they probably lack the information and skills necessary to 

translate their recognition into behavioral change. Even so, they are open to training, recognize the 

importance of developing cultural competence, and have taken small steps to improve their clinical 

knowledge.

Stage 5: Cultural Competence and Proficiency

Organizational Level: Organizations are aware of the importance of integrating services that are 

congruent with diverse populations. Organizations understand that a commitment to cultural competence begins with strategic planning to conduct an organizational self-assessment and adopt a cultural 

competence plan. There is a willingness to be more transparent in evaluating current services and 

practices and in developing policies and practices that meet the diverse needs of the treatment population and the community at large. Proficiency on an organizational level is characterized by an ongoing commitment to workforce development, training, and evaluation; development of culturally 

specific and congruent services; and continual performance evaluation and improvement.

Individual Level: Recognition of the vital need to adopt culturally responsive practices is present. 

Counselors acknowledge significant differences across and within races, ethnicities, and cultural 

groups, and they know that these differences need to be integrated into assessment, treatment planning, and services. At this stage, counselors are committed to an ongoing process of becoming culturally competent.

Sources: Comas-Diaz 2012; Cross et al. 1989; Sue and Constantine 2005. 

11
Improving Cultural Competence

• Shared values, beliefs, customs, behaviors, 

traditions, institutions, arts, folklore, and 

lifestyle.

• Similar relationship and socialization 

patterns.

• A common pattern or style of communication or language.

• Geographic location of residence (e.g., 

country; community; urban, suburban, or 

rural location).

• Patterns of dress and diet.

Although these criteria cannot be strictly 

applied to every cultural group, they do sufficiently define cultures so that groups are 

distinguishable to their members and to others 

(Castro 1998). Note that these criteria apply 

more or less equally well to cultural groups 

based on nationality, ethnicity, region (e.g., 

Southern, Midwestern), profession, and social 

interests (Exhibit 1-3 reviews common characteristics of culture). 

However, culture is not a definable entity to 

which people belong or do not belong. Within 

a nation, race, or community, people belong to 

multiple cultural groups, each with its own set 

of cultural norms (i.e., spoken or unspoken 

rules or standards that indicate whether a 

certain behavior, attitude, or belief is appropriate or inappropriate).

The word “culture” can be applied to describe 

the ways of life of groups formed on the bases 

Exhibit 1-3: Common Characteristics of Culture

The following list provides examples of common elements that distinguish one culture from another. 

Not every cultural group will define or endorse every item on this list, but most cultural groups will 

uphold the most common characteristics, which include:

• Identity development (multiple identities and self-concept).

• Rites of passage (rituals and rites that mark specific developmental milestones).

• Broad role of sex and sexuality.

• Images, symbols, and myths.

• Religion and spirituality.

• View, use, and sources of power and authority.

• Role and use of language (direct or implied).

• Ceremonies, celebrations, and traditions.

• Learning modalities, acquisition of knowledge and skills.

• Patterns of interpersonal interaction (culturally idiosyncratic behaviors).

• Assumptions, prejudices, stereotypes, and expectations of others.

• Reward or status systems (meaning of success, role models, or heroes).

• Migration patterns and geographic location.

• Concepts of sanction and punishment.

• Social groupings (support networks, external relationships, and organizational structures).

• Perspectives on the role and status of children and families.

• Patterns and perspectives on gender roles and relationships.

• Means of establishing trust, credibility, and legitimacy (appropriate protocols).

• Coping behaviors and strategies for mediating conflict or solving problems.

• Sources for acquiring and validating information, attitudes, and beliefs.

• View of the past and future, and the group’s or individual’s sense of place in society and the 

world.

• History and other past circumstances that have contributed to a group’s current economic, 

social, and political status within the broader culture as well as the experiences associated with 

developing certain beliefs, norms, and values.

Sources: American Psychological Association (APA) 1990; Center for Substance Abuse Prevention 

1994; Charon 2004; Dogra and Karim 2010. 

12
Chapter 1—Introduction to Cultural Competence

of age, profession, socioeconomic status, disability, sexual orientation, geographic location, 

membership in self-help support groups, and 

so forth. In this TIP, with the exception of the 

drug culture, the focus is on cultural groups 

that are shaped by a dynamic interplay among 

specific factors that shape a person’s identity, 

including race, ethnicity, religion, socioeconomic status, and others. 

What Is Race? 

Race is often thought to be based on genetic 

traits (e.g., skin color), but there is no reliable 

means of identifying race based on genetic 

information (HHS 2001). Indeed, 85 percent 

of human genetic diversity is found within any 

“racial” group (Barbujani et al. 1997). Thus, 

what we perceive as diverse races (based largely

on selective physical characteristics, such as 

skin color) are much more genetically similar 

than they are different. Moreover, physical 

characteristics ascribed to a particular racial 

group can also appear in people who are not in 

that group. Asians, for example, often have an 

epicanthic eye fold, but this characteristic is 

also shared by the Kung San bushmen, an 

African nomadic Tribe (HHS 2001).

Although it lacks a genetic basis, the concept 

of race is important in discussing cultural 

competence. Race is a social construct that 

describes people with shared physical characteristics. It can have tremendous social significance in terms of behavioral health services, 

social opportunities, status, wealth, and so on. 

The perception that people who share physical 

characteristics also share beliefs, values, attitudes, and ways of being can have a profound 

impact on people’s lives regardless of whether 

they identify with the race to which they are 

ascribed by themselves or others. The major 

racial groupings designated by the U.S. Census 

Bureau—African American or Black, White 

American or Caucasian, Asian American, 

American Indian/Alaska Native, and Native 

Hawaiian/Pacific Islander—are limiting in 

that they are categories developed to describe 

identifiable populations that exist currently 

within the United States. The U.S. Census 

defines Hispanics/Latinos as an ethnic group 

rather than a racial group (see the “What Is 

Ethnicity?” section later in this chapter). 

Racial labels do not always have clear meaning 

in other parts of the world; how one’s race is 

defined can change according to one’s current 

environment or society. A person viewed as 

Black in the United States can possibly be 

viewed as White in Africa. Racial categories 

also do not easily account for the complexity 

of multiracial identities. An estimated 3 percent of United States residents (9 million 

individuals) indicated in the 2010 Census that 

they are of more than one race (Humes et al.

2011). The percentage of the total United 

States population who identify as being of 

mixed race is expected to grow significantly in 

coming years, and some estimate that it will 

rise as high as one in five individuals by 2050 

(Lee and Bean 2004).

White Americans constitute the largest racial 

group in the United States. In the 2010 

Census, 72 percent of the United States population consisted of non-Hispanic Whites, a 

classification that has been used by the Census 

Bureau and others to refer to non-Hispanic 

people of European, North African, or Middle 

Eastern descent (Humes et al. 2011). The U.S. 

Census Bureau predicts, however, that White 

Americans will be outnumbered by persons of 

color sometime between the years 2030 and 

2050. The primary reasons for the decreasing 

proportion of White Americans are immigration patterns and lower birth rates among 

Whites relative to Americans of other racial 

backgrounds (Sue and Sue 2003b). 

Whites are often referred to collectively as 

Caucasians, although technically, the term 

13
Improving Cultural Competence

refers to a subgroup of White people from the 

Caucasus region of Eastern Europe and West 

Asia. To complicate matters, some Caucasian 

people—notably some Asian Indians—are 

typically counted as Asian (U.S. Census 

Bureau 2001a). Many subgroups of White 

Americans (of European, Middle Eastern, or 

North African descent) have had very different experiences when immigrating to the 

United States. 

African Americans, or Blacks, are the second 

largest racial group in the United States, making up about 13 percent of the United States 

population in 2010 (Humes et al. 2011). 

Although most African Americans trace their 

roots to Africans brought to the Americas as 

slaves centuries ago, an increasing number are 

new immigrants from Africa and the Caribbean. The terms African American and Black

are used synonymously at times in literature 

and research, but some recent immigrants do 

not consider themselves to be African 

Americans, assuming that the designation 

only applies to people of African descent born 

in the United States. The racial designation 

Black, however, encompasses a multitude of 

cultural and ethnic variations and identities 

(e.g., African Caribbean, African Bermudian, 

West African, etc.). The history and experience of African Americans has varied considerably in different parts of the United States, 

and the experience of Black people in this 

country varies even more when the culture and 

history of more recent immigrants is considered. Today, African American culture embodies elements of Caribbean, Latin American, 

European, and African cultural groups. Noting this diversity, Brisbane (1998) observed 

that “these cultures are so unique that practices 

of some African Americans may not be understood by other African Americans...there 

is no one culture to which all African 

Americans...belong”(p. 2).

The racial category of Asian is defined by the 

U.S. Census Bureau (2001a) as people “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”

(p. A-3). In the 2010 census, Asian Americans 

accounted for 4.8 percent of the total United 

States population, or 5.6 percent when biracial 

or multiracial Asians were included (Hoeffel

et al. 2012). For those who identified with 

only one Asian group, 23 percent of Asian 

Americans were Chinese; 19 percent, Asian 

Indian; 17 percent, Filipino; 11 percent,

Vietnamese; 10 percent, Korean; and 5 percent, Japanese. Asian Americans comprised 

about 43 ethnic subgroups, speaking more 

than 100 languages and dialects (HHS 2001). 

The tremendous cultural differences among 

these groups make generalizations difficult.

Until recently, Asian Americans were often 

grouped with Pacific Islanders (collectively 

called Asians and Pacific Islanders, or APIs) 

for data collection and analysis. Beginning 

with the 2000 Census, however, the Federal 

Government recognized Pacific Islanders as a 

distinct racial group. As a result, this TIP does 

not combine Asians with Pacific Islanders. 

Nonetheless, remnants of the old classification 

system are evident in research based on the 

API grouping. Where possible, the TIP uses 

data solely for Asians; however, in some cases,

the only research available is for the combined 

API grouping.

Native American is a term that describes both 

American Indians and Alaska Natives. Racially,

Native Americans are related to Asian peoples 

(notably, those from Siberia in Russia), but 

they are considered a distinct racial category 

by the U.S. Census Bureau, which further 

stipulates that people categorized in this 

fashion have to have a “Tribal affiliation

14
Chapter 1—Introduction to Cultural Competence

or community attachment” (U.S. Census Bureau 2001a, p. A-3). There are 566 federally 

recognized American Indian or Alaska Native 

Tribal entities (U.S. Department of the Interior, 

Indian Affairs 2013a), but there are numerous

other Tribes recognized only by States and still 

others that go unrecognized by any government agency. These Tribes, despite sharing a 

racial background, represent a widely diverse 

group of cultures with diverse languages, 

religions, histories, beliefs, and practices.

What Is Ethnicity?

The term ethnicity is sometimes used interchangeably with “race,” although it is important to draw distinctions between the two. 

According to Yang (2000), ethnicity refers to 

the social identity and mutual sense of belonging that defines a group of people through 

common historical or family origins, beliefs, 

and standards of behavior (i.e., culture). In 

some cases, ethnicity also refers to identification with a clan or group whose identity can 

be based on race as well as culture. Some 

Latinos, for example, self-identify in terms of 

both their ethnicity (e.g., their Cuban heritage) and their race (e.g., whether they are dark 

or light skinned).

Because Latinos can belong to a number of 

races, the Census Bureau defines them as an 

ethnic group rather than a race. In 2010, 

Latinos comprised 16 percent of the United 

States population (Ennis et al. 2011). They are 

the fastest growing ethnic group in the United 

States; between 2000 and 2010, the number of 

Latinos in the country increased 43 percent, a 

rate nearly four times higher than that for the 

total population (Ennis et al. 2011). By 2050, 

Latinos are expected to make up 29 percent of 

the total population (Passel and Cohn 2008). 

Nearly 60 percent of Latino Americans were 

born in the United States, but Latinos also 

account for more than half of the nation’s 

foreign-born population (Larsen 2004; 

Ramirez and de la Cruz 2003). Foreign-born 

Latinos include legal immigrants, some of 

whom have succeeded in becoming naturalized American citizens, as well as undocumented or illegal immigrants to the United 

States. Approximately three-quarters (74 

percent) of the Nation’s unauthorized immigrant population are Hispanics, mostly from 

Mexico (Passel and Cohn 2008).

The terms “Hispanic” and “Latino” refer to 

people whose cultural origins are in Spain or 

Portugal or the countries of the Western 

Hemisphere whose culture is significantly 

influenced by Spanish or Portuguese colonization. Regional and political differences exist 

among various groups as to whether they 

prefer one term over the other. The literature 

currently uses both terms interchangeably, as 

both terms are widely used and refer generally 

to the same Latin-heritage population of the 

United States. That said, a distinction can 

technically be drawn between Hispanic (literally meaning people from Spain or its former 

colonies) and Latino (which refers to persons 

whose origins lie in countries ranging from 

Mexico to Central and South America and 

the Caribbean, which were colonized by 

Spain, and including Portugal and its former 

colonies as well). For that reason, this TIP uses 

the more inclusive term Latino, except when 

research specifically indicates the other. The 

term Latinas is used to refer specifically to 

women who are a part of this cultural group. 

Ethnicity differs from race in that groups of 

people can share a common racial ancestry 

yet have very different ethnic identities. 

Thus, by definition, ethnicity—unlike race—

is an explicitly cultural phenomenon. It is 

based on a shared cultural or family heritage as well as shared values and beliefs 

rather than shared physical characteristics.

15
Improving Cultural Competence

Within a racial group (e.g., Asian, White, 

Black, Native American), there are many 

diverse ethnicities, and these diverse ethnicities often reflect vast differences in cultural 

histories. The White Anglo-Saxon Protestant 

peoples of England and Northern Europe 

have, for example, many differing cultural 

attributes and a very different history in the 

United States than the Mediterranean peoples 

of Southern Europe (e.g., Italians, Greeks).

What Is Cultural Identity?

Cultural identity describes an individual’s 

affiliation or identification with a particular 

group or groups. Cultural identity arises 

through the interaction of individuals and 

culture(s) over the life cycle. Cultural identities 

are not static; they develop and change across 

stages of the life cycle. People reevaluate their 

cultural identities and sometimes resist, rebel, 

or reformulate them over time. All people, 

regardless of race or ethnicity, develop a cultural identity (Helms 1995). Cultural identity 

is not consistent even among people who 

identify with the same culture. Two Korean 

immigrants could both identify strongly with 

Korean culture but embrace or reject different 

elements of that culture based on their particular life experiences (e.g., being raised in an 

urban or rural community, belonging to a 

lower- or upper-class family). Cultural groups 

may also place different levels of importance 

on various aspects of cultural identities. In 

addition, individuals can hold two or more 

cultural identities simultaneously.

Some of the factors that are likely to vary 

among members of the same culture include 

socioeconomic status, geographic location,

gender, education level, occupational status, 

sexuality, and political and religious affiliation.

For individuals whose families are highly 

acculturated, some of these characteristics 

(e.g., geographic location, occupation, religion) 

can be more important than ethnic culture in 

defining their sense of identity. The section 

that follows provides more detailed information on the most important cross-cutting 

factors involved in the creation of a person’s 

cultural identity.

What Are the CrossCutting Factors in Race, 

Ethnicity, and Culture?

Language and Communication

Language is a key element of culture, but 

speaking the same language does not necessarily mean that people share the same cultural 

beliefs. For example, English is spoken in 

Australia, Canada, Jamaica, India, Belize, and 

Nigeria, among other countries. Even within 

the United States, people from different regions can have diverse cultural identities even 

though they speak the same language. Conversely, those who share an ethnicity do not 

automatically share a language. Families who 

immigrated to this country several generations 

earlier may identify with their culture of origin 

but no longer be able to speak its language. 

English is the most common language in the 

United States, but 18 percent of the total 

population report speaking a language other 

than English at home (Shin and Bruno 2003). 

Styles of communication and nonverbal methods of communication are also important 

aspects of cultural groups. Issues such as the 

use of direct versus indirect communication, 

appropriate personal space, social parameters 

for and displays of physical contact, use of 

silence, preferred ways of moving, meaning of 

gestures, degree to which arguments and 

verbal confrontations are acceptable, degree of 

formality expected in communication, and 

amount of eye contact expected are all culturally defined and reflect very basic ethnic and 

cultural differences (Comas-Diaz 2012; 

16
Chapter 1—Introduction to Cultural Competence

Franks 2000; Sue 2001). More specifically, the 

relative importance of nonverbal messages 

varies greatly from culture to culture; highcontext cultural groups place greater importance on nonverbal cues and the context of 

verbal messages than do low-context cultural 

groups (Hall 1976). For example, most Asian 

Americans come from high-context cultural 

groups in which sensitive messages are encoded carefully to avoid giving offense. 

A behavioral health service provider who listens only to the literal meaning of words can 

miss clients’ actual messages. What is left unsaid, or the way in which something is said, 

can be more important than the words used to 

convey the message. African Americans have 

a relatively high-context culture compared 

with White Americans but a somewhat 

lower-context culture compared with Asian 

Americans (Franks 2000). Thus, African 

Americans typically rely to a greater degree 

than White Americans on nonverbal cues in 

communicating. Conversely, White American 

culture is low context (as are some European 

cultural groups, such as German and British); 

communication is expected to be explicit, and 

formal information is conveyed primarily 

through the literal content of spoken or written messages. 

Geographic Location

Cultural groups form within communities and 

among people who interact meaningfully with 

each other. Although one can speak of a national culture, the fact is that any culture is 

subject to local adaptations. Local norms or 

community rules can significantly affect a 

culture. Thus, it is important for providers to 

be familiar with the local cultural groups they 

Advice to Counselors: Cultural Differences in Communication

The following examples provide broad descriptions that do not necessarily fit all cultural groups from 

a specific racial or ethnic group. Counselors should avoid assuming that a client has a particular 

expectation or expression of nonverbal and verbal communication based solely on race, ethnicity, or 

cultural heritage. For example, a counselor could make an assumption during an interview that a 

Native American client prefers a nondirective counseling style coupled with long periods of silence, 

whereas the client expects a more direct, active, goal-oriented approach. Counselors should be 

knowledgeable and remain open to differences in communication patterns that can be present when 

counseling others from diverse backgrounds. The following are some examples of general differences among cultural groups:

• Individuals from many White/European cultural groups can be uncomfortable with extended 

silences and can believe them to indicate that nothing is being accomplished (Franks et al. 2000), 

whereas Native Americans, who often place great emphasis on the value of listening, can find 

extended silences appropriate for gathering thoughts or showing that they are open to another’s 

words (Coyhis 2000).

• Latinos often value personalismo (i.e., warm, genuine communication) in interpersonal relations 

and value personal rapport in business dealings; they prefer personal relationships to formal 

ones (Barón 2000; Castro et al. 1999a). Many Latinos also initially engage in plática (small talk) to 

evaluate the relationship and often use plática prior to disclosing more personal information or 

addressing serious issues (Comas-Diaz 2012). On the other hand, Asian Americans can be put off 

by a communication style that is too personal or emotional, and some may lack confidence in a 

professional whose communication style is too personal (Lee and Mock 2005a). 

• Some cultural groups are more comfortable with a high degree of verbal confrontation and 

argument; others stress balance and harmony in relationships and shun confrontation. For some, 

forceful, direct communication can seem rude or disrespectful. In many Native American and 

Latino cultural groups, cooperation and agreeableness (simpatía) is valued. Members often avoid 

disagreement, contradiction, and disharmony within the group (Sue and Sue 2013a).

17
Improving Cultural Competence

encounter—to not think, for example, in terms 

of a homogeneous Mexican culture so much as 

the Mexican culture of Los Angeles, CA, or 

the Mexican culture of El Paso, TX.

Geographical factors can also have a significant effect on a client’s culture. For example, 

clients coming from a rural area—even if they 

come from different ethnicities—can have a 

great deal in common, whereas individuals 

from the same ethnicity who were raised in 

different geographic locales can have very 

different experiences and, consequently, attitudes. For example, although the vast majority 

of Asian Americans live in urban areas (95 

percent in 2002; Reeves and Bennett 2003), a 

particular Asian American client may have 

been born in a rural community or come from 

a culture (e.g., the Hmong) that developed in 

remote areas; the client may retain cultural 

values and interests that reflect those origins. 

Other clients who currently live in cities may 

still consider a rural locale as their home and 

regularly return to it. Many Native Americans 

who live in urban areas or in communities 

adjacent to reservations, for example, travel 

regularly back to their home reservations 

(Cornell and Kalt 2010; Lobo 2003).

In addition to its potential influence upon 

culture, geography can strongly affect substance use and abuse, mental health and wellbeing, and access to and use of health services 

(Baicker et al. 2005). In the Substance Abuse 

and Mental Health Services Administration’s 

(SAMHSA’s) 2012 National Survey on Drug 

Use and Health (NSDUH), past-month illicit 

drug use rates among individuals ages 12 and 

older were 9.9 percent in large metropolitan 

areas, 8.3 percent in nonmetropolitan urbanized areas, 5.9 percent in less urbanized nonmetropolitan areas, and 4.8 percent in rural 

areas (SAMHSA 2013d). In very rural or 

remote areas, illicit drug use is likely to be 

even less common than in rural areas 

(Schoeneberger et al. 2006). Even among 

members of the same culture, less substance 

use is observed in those who live in more rural 

regions. For example, O’Connell and associates (2005) found that alcohol consumption 

was lower for American Indians living on 

reservations than for those who were geographically dispersed (and typically living in 

urban areas). Likewise, individuals born or 

living in urban areas may be at greater risk for 

serious mental illness. In one systematic study, 

higher distribution rates of schizophrenia were 

found in urban areas, particularly among 

people who were born in metropolitan areas 

(McGrath et al. 2004). 

Worldview, Values, and Traditions

There are many ways of conceptualizing how 

culture influences an individual. Culture can 

be seen as a frame through which one looks at 

the world, as a repertoire of beliefs and practices that can be used as needed, as a narrative 

or story explaining who people are and why 

they do what they do, as a set of institutions 

defining different aspects of values and traditions, as a series of boundaries that use values 

and traditions to delineate one group of people 

from another, and so on. According to Lamont

and Small (2008), such schemata recognize 

that culture shapes what people believe (i.e., 

their values and worldviews) and what they do 

to demonstrate their beliefs (i.e., their traditions and practices). Cultural groups define 

the values, worldviews, and traditions of their 

members—from food preferences to appropriate leisure activities—including use of alcohol 

and/or drugs (Bhugra and Becker 2005). Thus, 

it is impossible to review and summarize the 

variety of cultural values, traditions, and 

worldviews found in the United States in this 

publication. Providers are encouraged to 

speak with their clients to learn about their 

worldviews, values, and traditions and to seek 

training and consultation to gain specific 

18
Chapter 1—Introduction to Cultural Competence

knowledge about clients’ cultural beliefs and 

practices.

Family and Kinship

Although families are important in all cultural 

groups, concepts of and attitudes toward 

family are culturally defined and can vary in a 

number of ways, including the relative importance of particular family ties, the family’s 

inclusiveness, how hierarchical the family is, 

and how family roles and behaviors are defined (McGoldrick et al. 2005). In some cultural groups (e.g., White Americans of Western 

European descent, such as German, English), 

family is limited to the nuclear family, whereas in other groups (e.g., African Americans; 

Asian Americans; Native Americans; White

Americans of Southern European descent, such 

as Italian, Greek), the idea of family typically 

includes many other blood or marital relations 

(Almeida 2005; Hines and Boyd-Franklin 

2005; Marinangeli 2001; McGill and Pearce 

2005; McGoldrick et al. 2005). Some cultural 

groups clearly define roles for different family 

members and carefully prescribe methods of 

behaving toward one another based on specific 

relationships. For example, in Korean culture, 

wives are expected to defer to their in-laws 

about many decisions (Kim and Ryu 2005).

Even in cultural groups with carefully defined 

roles and rules for family members, family 

dynamics may change as the result of internal 

or external forces. The process of acculturation, for instance, can significantly affect 

family roles and dynamics among immigrant 

families, causing the dissolution of longstanding cultural hierarchies and traditions within 

the family and resulting in conflict between 

spouses or different generations of the family 

(Hernandez 2005; Juang et al. 2012; Lee and 

Mock 2005a). Information on family therapy 

with major ethnic/racial groups is provided in 

Chapter 5 of this TIP. Details of the role of 

family in treatment and the provision of family

therapy appear in TIP 39, Substance Abuse 

Treatment and Family Therapy (CSAT 2004b).

Gender Roles

Gender roles are largely cultural constructs; 

diverse cultural groups have different understandings of the proper roles, attitudes, and 

behaviors for men and women. Even within 

modern American society, there are variations 

in how cultural groups respond to gender 

norms. For example, after controlling for 

income and education, African American

women are less accepting than White 

American women of traditional American 

gender stereotypes regarding public behavior 

but more accepting of traditional domestic 

gender roles (Dugger 1991; Haynes 2000).

Culturally defined gender roles also appear to 

have a strong effect on substance use and 

abuse. This can perhaps be seen most clearly 

in international research indicating that, in 

societies with more egalitarian relationships 

between men and women, women typically 

consume more alcohol and have drinking 

patterns more closely resembling those of men 

in the society (Bloomfield et al. 2006). A 

similar effect can be seen in research conducted in the United States with Latino men and 

women with varying levels of acculturation to 

mainstream American society (Markides et al. 

2012; Zemore 2005).

The terms for and definitions of gender roles 

can also vary. For example, in Latino cultural 

groups, importance is placed on machismo (the 

belief that men must be strong and protect 

their families), caballerismo (men’s emotional 

connectedness), and marianismo (the idea that 

women should be self-sacrificing, endure 

suffering for the sake of their families, and 

defer to their husbands) (Arciniega et al. 2008; 

Torres et al. 2002). These strong gender roles 

have benefits in Latino culture, such as simplifying and clarifying roles and responsibilities, 

19
Improving Cultural Competence

but they are also sources of potential problems, 

such as limiting help-seeking behavior or the 

identification of difficulties. For example, 

because of the need to appear in control, a 

Latino man can have difficulty admitting that 

his substance use is out of control or that he is 

experiencing psychological distress (Castro et 

al. 1999a). For Latinas, the difficulties of 

negotiating traditional gender roles while 

encountering new values through acculturation can lead to increased substance use/abuse 

and mental distress (Gil and Vazquez 1996; 

Gloria and Peregoy 1996; Mora 2002).

Negotiating gender roles in a treatment setting is often difficult; providers should not

assume that a client’s traditional culture-based 

gender roles are best for him or her or that 

mainstream American ideas about gender are 

most appropriate. The client’s degree of acculturation and adherence to traditional values 

must be taken into consideration and respected. Two TIPs explore the relationship of 

gender to substance abuse and substance 

abuse treatment: TIP 51, Substance Abuse 

Treatment: Addressing the Specific Needs of 

Women (CSAT 2009c), and TIP 56, Addressing 

the Specific Behavioral Health Needs of Men

(SAMHSA 2013a). TIP 42, Substance Abuse 

Treatment for Persons With Co-Occurring 

Disorders, addresses the relationships among 

gender, mental illness, and substance use 

disorders (CSAT 2005d). 

Socioeconomic Status and 

Education

Sociologists often discuss social class as an 

important aspect in defining an individual’s 

cultural background. In this TIP, socioeconomic status (SES) is used as a category similar to class—the difference being that 

socioeconomic status is a more flexible and 

less hierarchically defined concept. SES in the 

United States is related to many factors, including occupational prestige and education, 

yet it is primarily associated with income level. 

Thus, SES affects culture in several ways, 

namely through a person’s ability to accumulate material wealth, access opportunities, and 

What Causes Health Disparities?

The National Institutes of Health (NIH; 2012, Overview, p. 1) define health disparities as “differences 

in the incidence, prevalence, morbidity, and burden of diseases and other adverse health conditions 

that exist among specific population groups.” Numerous studies have found longstanding health 

disparities among racial/ethnic groups in the United States (Smedly et al. 2003), and the Agency for 

Healthcare Research and Quality (AHRQ) issues yearly reports that provide updates on this topic 

(AHRQ 2012). An Institute of Medicine report on disparities (Smedly et al. 2003) found multiple 

causes for these disparities, including historical inequalities that have influenced the healthcare 

system, persistent racial and ethnic discrimination, and distrust of the healthcare system among 

certain ethnic and racial groups. However, the most persistent and prominent cause appears to be 

disparities in SES, which affect insurance coverage and access to quality care (Russell 2011). These 

economic disparities account for significantly higher death rates, particularly among African 

Americans compared with non-Hispanic Whites (Arias 2010), as well as greater lack of insurance 

coverage or worse coverage for people of color (Smedly et al. 2003).

Evidence-based interventions to reduce health disparities are limited (Beach et al. 2006; CarpenterSong et al. 2011). Current strategies generally focus on reducing risk factors that affect groups who 

experience a greater burden from poor health (Murray et al. 2006). The Federal Government has 

recognized the need to address health disparities and has made this issue a priority for agencies that 

deal with health care (HHS 2011b). As part of this effort, it has created the National Institute on 

Minority Health and Health Disparities (see http://ncmhd.nih.gov/). More specific information on 

mental health and substance abuse treatment disparities is provided in Chapter 5 of this TIP.

20
Chapter 1—Introduction to Cultural Competence

use resources. Discrimination and historical 

racism have led to lasting inequalities in SES 

(Weller et al. 2012; Williams and WilliamsMorris 2000). SES affects mental health and 

substance use. From 2005 to 2010, adults 45 

through 64 years of age were five times more 

likely to have depression if they were poor 

(National Center for Health Statistics 2012). 

Serious mental illness among adults living in 

poverty has a prevalence rate of 9.1 percent

(SAMHSA 2010). Some research demonstrates higher risk for schizophrenia from 

lower socioeconomic levels, but other studies 

draw no definite conclusion (Murali and 

Oyebode 2010). Most literature suggests that 

poverty and its consequences, including limited access to resources, increase stress and 

vulnerability among individuals who may 

already be predisposed to mental illness. Often, theoretical discussions explaining a significant relationship between mental illness and 

SES suggest a bidirectional relationship in 

which stress from poverty leads to mental 

illness vulnerability and/or mental illness leads 

to difficulty in maintaining employment and 

sufficient income. 

Studies have had conflicting results as to 

whether people with high or low SES are 

more likely to abuse substances ( Jones-Webb 

et al. 1995). In international studies, increases 

in wealth on a societal level have been associated with increases in alcohol consumption 

(Bergmark and Kuendig 2008; Kuntsche et al. 

2006; Room et al. 2003). However, other 

factors, such as the availability of social support systems and education, as well as the 

individual’s acculturation level, can also play a 

role. Karriker-Jaffe and Zemore (2009) found 

that, in immigrants, a greater level of acculturation was associated with increased heavy 

drinking for those with above-average SES 

but not for those with lower SES. Besides 

lower socioeconomic status, neighborhood 

poverty (defined as having a high [≥20 percent] proportion of residents living in poverty) 

was associated with binge drinking and higher 

rates of substance-related problems, particularly for men (McKinney et al. 2012). 

Education is also an important factor related 

to SES (Exhibit 1-4). Higher levels of education are associated with increased income, 

although the degree to which education increases income varies among diverse racial/ethnic groups (Crissey 2009). Research in 

the United States has found that problems 

with alcohol are often associated with lower 

SES and lower levels of education (Crum 

2003; Mulia et al. 2008). However, other 

studies have shown that greater frequency of 

drinking and number of drinks consumed are 

generally associated with higher levels of 

education and higher SES (Casswell et al.

2003; van Oers et al. 1999). For example, the 

2012 NSDUH showed that adult rates of 

past-month alcohol use increased with increasing levels of education; among those with 

Social Determinants of Health 

Per Healthy People 2020 (http://www.healthypeople.gov), a federal prevention agenda involving a 

multiagency effort to identify preventable threats to health and set goals for reducing them, “social 

determinants of health are conditions in the environments in which people are born, live, learn, work, 

play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and 

risks.” Social determinants include access to educational, economic, and vocational training; job opportunities; transportation; healthcare services; emerging healthcare technologies; availability of community-based resources, basic resources to meet daily living needs, language services, and social support; 

exposure to crime; social disorder; community and concentrated poverty; and residential segregation.

Source: Office of Disease Prevention and Health Promotion, HHS 2013.

21
Improving Cultural Competence

less than a high school education, 36.6 percent 

were current drinkers, whereas 68.6 percent of 

college graduates were current drinkers. 

(SAMHSA 2013d). Education can also affect 

substance use independently of SES. For 

example, lower education levels seem to relate

to heavy drinking independently of socioeconomic status (Kuntsche et al. 2006).

The desperation associated with poverty and a 

lack of opportunity—as well as the increased 

exposure to illicit drugs that comes from living 

in a more impoverished environment—can 

also increase drug use (Bourgois 2003). Lower 

SES and the concurrent lack of either money 

or insurance to pay for treatment are associated with less access to substance abuse treatment and mental health services (Chow et al. 

2003). For example, compared with Medicare 

coverage, private insurance coverage increases 

the odds twofold that someone who has a 

substance use disorder will enter treatment 

(Schmidt and Weisner 2005). Thus, lower 

SES can have a dramatic effect on recovery. 

Immigration and Migration

With the exception of American Indians, 

Alaska Natives, Native Hawaiians, and other 

Pacific Islanders, the United States is a country of immigrants. Recent immigrants, even 

when they come from diverse ethnic/racial 

backgrounds, typically share certain experiences and expectations in common. Often, they 

encounter a difficult process of acculturation 

(as discussed throughout this chapter). They 

can also share concerns surrounding the renewal of visas, obtainment of citizenship, or 

fears of possible deportation depending on 

their legal status. Immigration itself is stressful 

for immigrants, though the reasons for migrating and the legal status of the immigrant 

affect the degree of stress. For documented 

residents, the process of adaptation tends to be 

smoother than for those who are undocumented. Undocumented persons may be wary 

of deportation, are less likely to seek social 

services, and frequently encounter hostility 

(Padilla and Salgado de Snyder 1992). 

Nonetheless, there are numerous variables that 

contribute to or influence well-being, quality 

of life, cultural adaptation, and the development of resilience (e.g., the capacity to mobilize social supports and bicultural integration; 

Castro and Murray 2010). Research suggests 

that immigrants may not experience higher 

rates of mental illness than nonimmigrants 

(Alegria et al. 2006), yet immigration nearly 

always includes separation from one’s family 

and culture and can involve a grieving process 

Exhibit 1-4: Education and Culture 

Culture has an effect on an individual’s attitudes toward education; for instance, a lack of cultural 

understanding on the part of educational institutions affects student goals and achievements (Sue 

2001). A number of factors besides culture also appear to affect educational attainment, including 

immigration status and longstanding systemic biases. For example, 88 percent of the native-born 

United States population ages 25 and older had at least a high school degree in 2007, but only 68 

percent who were foreign-born were high school graduates (Crissey 2009). Research also highlights 

large within-group differences in educational attainment. For example, among Asian Americans, who 

overall have high levels of education, some groups had very low rates—only 16 percent of Vietnamese

Americans and 5 percent of other Southeast Asian Americans had a college degree in 2000 (Reeves 

and Bennett 2003).

Immigration status does not always affect education status in the same way. For non-Latino Whites 

and Blacks, being born outside the United States is associated with a greater likelihood of obtaining 

at least a bachelor’s degree. African immigrants have the highest level of education of any immigrant 

group, higher than White or Asian immigrants (African Immigrant 2000).

22
Chapter 1—Introduction to Cultural Competence

as a result of these losses as well as other 

changes, including changes in socioeconomic 

status, physical environment, social support, 

and cultural practices.

Immigrants who are refugees from war, famine, oppression, and other dangerous environments are more vulnerable to psychological 

distress (APA 2010). They are likely to have 

left behind painful and often life-threatening 

situations in their countries of origin and can 

still bear the scars of these experiences. Some 

refugees come to the United States with high 

expectations for improved living conditions, 

only to find significant barriers to their full 

participation in American society (e.g., language barriers, discrimination, poverty). Experiencing such traumatic conditions can also 

increase substance use/abuse among some 

groups of immigrants (see TIP 57, TraumaInformed Care in Behavioral Health Services

[SAMHSA 2014]). Behavioral health services 

must assess the needs of refugee populations, 

as the clinical issues for these populations may 

be considerably different than for immigrant 

groups (Kaczorowski et al. 2011). 

For immigrant families, disruption of roles 

and norms often occurs upon arrival in the 

United States (for review, see Falicov 2012). 

Generally, youth adopt American customs, 

values, and behaviors much more easily and at 

higher rates than their parents or older members of the extended family. Parental frustration may occur if traditional standards of 

behavior conflict with mainstream norms 

acquired by their children. The differences in 

parents’ values and expectations and adolescents’ behavior can lead to distress in closeknit immigrant families. This disruption, 

known as the acculturation gap, can result in 

increased parent–child conflicts (APA 2012; 

Falicov 2012; Telzer 2010). For some youth, it 

may contribute to experimentation with alcohol and/or illicit drugs—increased acculturation is typically associated with increased 

substance use and substance use disorders. 

Overall, “old country” or traditional behavioral 

norms and expectations for appropriate behavior become increasingly devalued in American 

majority culture for members of various immigrant groups (Padilla and Salgado de Snyder 

1992; Sandhu and Malik 2001). Research 

shows that family cohesion and adaptability 

decrease with time spent in the United States, 

regardless of the amount of involvement in 

mainstream culture. This suggests that other 

factors may confound the relationship between 

family conflict and increased exposure to 

American culture (Smokowski et al. 2008). 

Advice to Counselors and Clinical 

Supervisors: Initial Interview and 

Assessment Questions 

When working with clients who are recent 

immigrants or have immigrated to United States 

during their lifetime, the APA (1990) recommends exploring:

• 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.

• Extent of personal relationships with people 

from diverse cultural backgrounds.

Stress due to migration and acculturation.

The Cultural Orientation Resource 

Center

The Cultural Orientation Resource Center, 

funded by the U.S. Department of State’s 

Bureau of Population, Refugees, and Migration, 

is a useful resource for clinicians to gain information about topics including culture, resettlement experiences, and historical and refugee

background information. This site is also quite 

useful for refugees. It provides refugee orientation materials and guidance in establishing 

housing, language, transportation, education, 

and community services, among other pressing 

refugee concerns. 

23
Improving Cultural Competence

Exhibit 1-5: Cultural Identification and Cultural 

Change Terminology 

Acculturation is the process whereby an individual from one 

cultural group learns and adopts elements of another cultural 

group, integrating them into his or her original culture. Although 

it can refer to any process of cultural integration, it is typically 

used to describe the ways in which an immigrant or nonmajority 

individual or group adopts cultural elements from the majority or 

mainstream culture, as the incentive is typically greater for acculturation to occur in this direction (see Lopez-Class et al. 2011 for 

a historical review of acculturation concepts). 

Assimilation is one outcome of acculturation. It involves the 

complete adoption of the ways of life of the new cultural group, 

resulting in the assimilated group losing nearly all of its original or 

native culture.

Segmented assimilation describes a more complicated process 

of assimilation whereby an immigrant group does not assimilate 

entirely with mainstream culture but adopts aspects of other 

diverse cultural groups that are themselves outside mainstream 

culture (e.g., involvement in the drug culture; see Chapter 6 of 

this TIP and Portes et al. 2005).

Biculturalism occurs when an individual acquires the knowledge, 

skills, and identity of both his or her culture of origin and the 

mainstream/majority culture and is equally (or nearly equally) 

capable of social and cultural interaction in both societies.

Enculturation can denote a process whereby an individual adopts 

the culture that surrounds him or her (similar to acculturation), 

but the term has more recently been used to describe the process by which individuals come to value their native cultures and 

begin to learn about and adopt their native cultural lifeways.

Sources: LaFromboise et al. 1993; Paniagua 1998; Portes et al. 

2005; Smokowski et al. 2008; Stone et al. 2006.

Clients who are migrants (e.g., seasonal workers) pose a particular set of challenges for 

treatment providers because of the difficulties 

involved in connecting clients to treatment 

programs and recovery communities. In the 

United States, migrant workers are considered 

one of most marginalized and underserved 

populations (Bail et al. 2012). Migrants face 

many logistical obstacles to treatment-seeking, 

such as lack of childcare, insurance, access to 

regular health care, and transportation (Hovey 

2001; Rosenbaum and Shin 2005). Current 

data are limited but suggest high rates of 

alcohol use, alcohol use disorders, and binge drinking, often 

occurring as a response to 

stress or boredom associated 

with the migrant lifestyle

(Hovey 2001; Worby and 

Organista 2007). In addition, 

limited data on migrant mental health reflect mixed findings regarding increased risk 

for mental illness or psychological distress (Alderete et al.

2000). One factor associated 

with mental health status is 

the set of circumstances leading up to the migrant worker’s 

decision to migrate for employment (Grzywacz et al. 

2006). 

Acculturation and 

Cultural Identification

Many factors contribute to an 

individual’s cultural identity, 

and that identity is not a static 

attribute. There are many 

forces at work that pressure a 

person to alter his or her 

cultural identity to conform to 

the mainstream culture’s 

concept of a “proper” identity. 

As a result, people may feel conflicted about 

their identities—wanting to fit in with the 

mainstream culture while also wanting to 

retain the values of their culture of origin. For 

clients, sorting through these conflicting 

cultural expectations and forging a comfortable identity can be an important part of the 

recovery process. Some of the more commonly 

used terms related to cultural identity are 

defined in Exhibit 1-5. 

All immigrants undergo some acculturation 

over time, but the rate of change varies from 

group to group, among individuals, and across 

24
Chapter 1—Introduction to Cultural Competence

different periods of history. Earlier theories 

suggested that immigrants generally assimilated within three generations from the time of 

immigration and that assimilation was associated with socioeconomic gains. More recent 

scholarship suggests that this is changing 

among some cultural groups who may lack the 

financial or human capital necessary to succeed in mainstream society or who may find 

that continued involvement in their native or 

traditional culture has benefits that outweigh 

those associated with acculturation (Portes et 

al. 2005; Portes and Rumbaut 2005).

Acculturation typically occurs at varying speeds 

for different generations, even within the same 

family. Acculturation can thus be a source of 

conflict within families, especially when parents 

and children have different levels of acculturation (Exhibit 1-6) (Castro and Murray 2010; 

Farver et al. 2002; Hernandez 2005). Others 

have suggested that acculturation can negatively affect mental health because it erodes traditional family networks and/or because it results 

in the loss of traditional culture, which otherwise would have a protective function (Escobar 

and Vega 2000; Sandhu and Malik 2001). 

Many studies have found that increased acculturation or factors related to acculturation are 

associated with increased alcohol and drug use 

and with higher rates of substance use disorders among White, Asian, and Latino immigrants (Alegria et al. 2006; Grant et al. 2004a; 

Grant et al. 2004b; Vega et al. 2004). Place of 

birth is most strongly associated with higher 

rates of substance use and disorders thereof. 

For example, research suggests a rate of substance use disorders about three times higher 

for Mexican Americans born in the United 

States than for those born in Mexico (Alegria 

et al. 2008a; Escobar and Vega 2000). Asian 

adolescents born in the United States present 

a higher rate of past-month alcohol use than 

Asian adolescents not born in the United 

States (8.7 versus 4.7 percent); however, the 

rate of nonmedical use of prescription drugs is 

higher among Asian adolescents not born in 

the United States than among those born in 

the United States (2.7 versus 1.4 percent; 

SAMHSA, Center for Behavioral Health 

Statistics and Quality 2012). 

Acculturation can increase substance 

use/abuse, in part because the process of acculturation is itself stressful (Berry 1998; Vega et

al. 2004). Mora (2002) asserts that the stress 

associated with acculturation has a significant 

effect on increasing substance use and abuse 

among Latinas; this can be observed most 

clearly in the increases in substance use associated with being a second- or third-generation 

Exhibit 1-6: Five Levels of Acculturation 

Numerous models have been developed to explain the process of acculturation. Choney et al. (1995) 

proposed a model, applicable to a number of different contexts, that features five levels:

1. A traditional orientation: The individual is entirely oriented toward his or her native culture. 

2. A transitional orientation: The individual is more oriented toward traditional culture but has some 

familiarity with mainstream culture.

3. A bicultural orientation: The individual is equally comfortable with and knowledgeable of both 

traditional and mainstream culture.

4. An assimilated orientation: The individual is mostly oriented toward mainstream culture but has 

some familiarity with the traditional/native culture. 

5. A marginal orientation: The individual is not comfortable with either culture.

Note: This is not a stage model in which a person naturally moves from one orientation to the next, 

nor does this model place greater value on one level versus another. The authors emphasize that 

each level of acculturation has strengths.

25
Improving Cultural Competence

Latina from an immigrant family. The stress 

associated with acculturation could also contribute to rates of mental disorders and cooccurring disorders (CODs), which are higher 

among more acculturated groups of immigrants (Cherpitel et al. 2007; Escobar and 

Vega 2000; Grant et al. 2004a; Organista et al.

2003; Vega et al. 2009; Ward 2008). In fact, 

American-born Latinos who have used substances are three times more likely to have 

CODs than foreign-born Latinos who have 

used substances (Vega et al. 2009). Research 

also suggests that acculturation could interact 

with factors such as culture or stress in increasing mental disorders.

Rates of substance use/abuse in the United 

States are among the highest in the world 

(United Nations, Office on Drugs and Crime 

2008, 2012), so for many immigrants, adopting mainstream American cultural values and 

lifestyles can also entail changing attitudes 

toward substance use. As an example, Marin 

(1998) found that, compared with Whites,

Mexican Americans expected significantly 

more negative consequences and fewer positive ones from drinking, but Marin also found

that the more acculturated the Mexican 

American participants were, the more closely 

their expectations resembled those of Whites.

Other factors that can contribute to increased 

substance use among more acculturated clients 

include changes in traditional gender roles, 

exposure to socially and physically challenging 

inner-city environments (Amaro and Aguiar 

1995), and employment outside the home 

(often a role-transforming change that can 

contribute to increased risk of alcohol dependence). Although much of the research has 

focused on the relationship of acculturation to 

male substance use/abuse patterns, women can 

be even more affected by acculturation. Multiple studies using international samples have 

found that the greater the amount of gender 

equality in a society, the more similar alcohol 

consumption patterns are for men and women 

(Bloomfield et al. 2006). Many immigrants to 

the United States (where gender equality is 

relatively strong) come from societies with less 

gender equality and thus with greater prohibitions against alcohol use for women. 

Karriker-Jaffe and Zemore (2009) found that 

higher levels of acculturation are associated 

with increased alcohol consumption only 

when combined with above-average SES (and 

not with lower SES), suggesting that income 

is another factor to consider when evaluating 

the effect of acculturation on alcohol use. 

There are exceptions to the idea that acculturation increases substance use/abuse. Most 

notably, immigrants coming from countries 

with unusually high levels of drinking do not 

necessarily experience a change in their use, 

and they may even consume less alcohol and 

fewer drugs that they did in their native countries. Even among those born in the United 

States, however, data suggest that greater 

identification with one’s traditional culture has 

a protective function. For example, in the 

National Latino and Asian American Study, 

the largest national survey specifically targeting these population groups to date, greater 

ethnic identification was associated with 

significantly lower rates of alcohol use disorders among Asian Americans (Chae et al. 

2008), and the use of Spanish with one’s 

family was linked with significantly lower 

rates of alcohol use disorders in Latinos 

(Canino et al. 2008).

Less research is available on the relationship of 

acculturation to substance use and substance 

use disorders among nonimmigrants, but some 

data suggest that a lower level of identification 

with one’s native culture is linked with heavier,

lengthier substance use among American 

Indians living on reservations (Herman-Stahl 

et al. 2003). For some American Indians, more

26
Chapter 1—Introduction to Cultural Competence

involvement in Tribal culture and traditional 

spiritual activities is associated with better 

posttreatment outcomes for alcohol use disorders (Stone et al. 2006). American Indians 

who drink heavily but live a traditional lifestyle have better recovery outcomes than those 

who do not live a traditional lifestyle (Kunitz 

et al. 1994). Likewise, African Americans may 

have greater motivation for treatment if they 

recognize that they have a drug problem and 

also have a strong Afrocentric identity 

(Longshore et al. 1998b). Strong cultural or 

racial/ethnic identity can have protective 

features, whereas acculturation can lead to a 

loss of cultural identity that increases substance abuse and contributes to poorer recovery outcomes for both Native Americans and 

African Americans.

Overall, acculturation and cultural identification have tremendous implications for behavioral health services. Research has shown an 

association between low levels of acculturation 

and low usage rates of mainstream healthcare

services. Individuals can feel conflicted about 

their identities—wanting to both fit in with 

the mainstream culture and retain the traditions and beliefs of their cultures of origin. For 

such clients, sorting through these conflicting 

cultural expectations and forging a comfortable identity can be an important part of the 

recovery process. Familiarity with cultural 

identity formation models and theories of 

acculturation (including acculturation measurement methods; see Exhibit 1-7) can help 

behavioral health workers provide services

with greater flexibility and sensitivity (see

Appendix B for instruments that measure 

aspects of cultural identity and acculturation).

Heritage and History

A culture’s history and heritage explain the 

culture’s development through the actions of

members of that culture and also through the 

actions of others toward the specific culture. 

Providers should be knowledgeable about the 

many positive aspects of each culture’s history 

and heritage and resourceful in learning how 

to integrate these into clinical practice. 

Nearly all immigrant groups have experienced 

some degree of trauma in leaving behind 

Exhibit 1-7: Measuring Acculturation

Acculturation is a construct that includes factors relating to behavior, knowledge, values, selfidentification, and language use (Zea et al. 2003). One of the biggest problems in analyzing the 

effects of acculturation is determining how to define and evaluate it. In research literature, acculturation is inconsistently defined and measured. In some large-scale surveys, it is not defined at all, but 

only implied in other factors, such as length of stay in the United States, English language use, or 

place of birth. Overall, instruments that assess acculturation do not ask the same questions or address the same factors, thus making it unclear whether acculturation is truly being evaluated (Zane 

and Mak 2003). More research is warranted on how to conceptualize and evaluate acculturation and 

cultural identity.

Many acculturation tools focus on specific racial or ethnic groups (for example, see Wallace et al. 

2010). Acculturation and cultural identity instruments typically ask questions about language use and 

preference (e.g., whether English is used at home), media preferences (e.g., preference for foreign 

language programming), social interactions (e.g., friendships with persons from other ethnicities/cultural groups), cultural knowledge (e.g., knowledge of beliefs, traditions, and ceremonies 

specific to a cultural or ethnic group), and cultural values (Zea et al. 2003). Others evaluate acculturation simply by asking which culture a person identifies with most. Organista et al. (2003) and Zane 

and Mak (2003) reviewed measures designed to evaluate acculturation and cultural identity. 

Appendix B provides a sample of acculturation and cultural identity instruments.

27
Improving Cultural Competence

family members, friends, and/or familiar 

places. Their eagerness to assimilate or remain 

separate depends greatly on the circumstances 

of their immigration (Castro and Murray

2010). Additionally, some immigrants are 

refugees from war, famine, natural disasters, 

and/or persecution. The depths of suffering 

that some clients have endured can result in 

multiple or confusing symptoms. For example, 

a traumatized Congolese woman could speak 

of hearing voices, and it could be unclear 

whether these voices suggest an issue requiring 

spiritual healing within a cultural framework, 

a traumatic stress reaction, or a mental disorder involving the onset of auditory hallucinations. Those who have watched close family 

members die violently can have “survivor guilt”

as well as agonizing memories. Amodeo et al.

(1997) report that “somatic complaints, including trouble sleeping, loss of appetite, 

stomach pains, other bodily pains, headaches, 

fatigue or lack of energy, memory problems, 

mood swings and social withdrawal have been 

reported to be among the refugees’most frequent presenting problems”(p. 70). For an 

overview of the impact of trauma, see TIP 57, 

Trauma-Informed Care in Behavioral Health 

Services (SAMHSA 2014).

Abueg and Chun (1998) caution, however, 

that “traumatic experience is not homogenous”

(p. 292). Experiences before, during, and after 

migration and/or encampment vary depending 

on the country of origin as well as the time 

and motivation for migration. Within the 

United States, cultural groups such as African 

Americans and Native Americans have long 

histories of traumatic events, which have had 

lasting effects on the descendants of those 

who experienced the original trauma. Consequently, past as well as present discrimination 

and racism are related to a number of negative 

consequences across diverse populations, including lower SES, health disparities, and fewer 

employment and educational opportunities (see 

review in Williams and Williams-Morris 

2000).

According to theories of historical trauma, the 

traumas of the past continue to affect later 

generations of a group of people. This concept 

was first developed to explain how the trauma 

of the Holocaust continued to affect the descendants of survivors (Duran et al. 1998; 

Sotero 2006). In the United States, it has 

perhaps been best explored in relation to the 

traumas endured by Native American peoples 

during the colonization and expansion of the 

United States. One can extend this concept 

to other groups (e.g., African Americans, 

Cambodians, Rwandans) who suffered traumatic events like slavery or genocide.

Among Native Americans in treatment for 

substance use and/or mental disorders, historical trauma is an important clinical issue (Brave 

Heart et al. 2011; Duran et al. 1998; EvansCampbell 2008). Some research indicates that 

thinking about historical loss or displaying 

symptoms associated with historical trauma 

plays into increases in alcohol use disorders, 

other substance use, and lower family cohesion 

(Whitbeck et al. 2004; Wiechelt et al. 2012). 

Brave Heart (1999) theorizes that historical 

traumas perpetuate their effects among Native 

Americans by harming parenting skills and 

increasing abuse of children, which creates a 

cyclical pattern—greater levels of mental and 

substance use disorders in the next generation 

along with continued poor parenting skills.

Specifically, Libby et al. (2008) found that 

substance use was involved in the intergenerational transmission of trauma. Additional 

research highlights a relationship between 

elevated chronic trauma exposure and prevalence of both mental and substance use disorders among large samples of American Indian 

adults living on reservations (Beals et al. 2005; 

Manson et al. 2005).

28
Chapter 1—Introduction to Cultural Competence

Sotero (2006) reviews research on historical 

trauma across diverse populations and proposes a similar explanation of how deliberately 

perpetrated, large-scale traumatic events continue affecting communities years after they 

occur. She argues that the generation that 

directly experiences the trauma suffers material

(e.g., displacement), psychological (e.g., posttraumatic stress disorder), economic (e.g., loss 

of sources of income/sustenance), and cultural 

(e.g., lost knowledge of traditions and beliefs) 

effects. These lasting sequelae of trauma then 

affect the next generation, who can suffer in 

many similar ways, resulting in poorer coping 

skills or in attempts to self-medicate distress 

through substance abuse.

Sexuality

Attitudes toward sexuality in general and 

toward sexual identity or orientation are culturally defined. Each culture determines how 

to conceptualize specific sexual behaviors, the 

degree to which they accept same-sex relationships, and the types of sexual behaviors considered acceptable or not (Ahmad and Bhugra

2010). In any cultural group, diverse views and 

attitudes about appropriate gender norms and 

behavior can exist. For example, in some Latino 

cultural groups, homosexual behavior, especially among men, is not seen as an identity but 

as a curable illness or immoral behavior (Kusnir 

2005). In some Latino cultural groups, selfidentifying as other than heterosexual may

provoke a more negative response than engaging in some homosexual behaviors (de Korin 

and Petry 2005; Greene 1997; Kusnir 2005).

For individuals from various ethnic/racial 

groups in United States, having a sexual identity different from the norm can result in 

increased substance use/abuse, in part because 

of increased stress. Additionally, alcohol and 

drug use can be more acceptable within some 

segments of gay/lesbian/bisexual cultures 

(Balsam et al. 2004; CSAT 2001; Mays et al. 

2002). As a result of a lack of acceptance 

within both mainstream and diverse ethnic/racial communities, various gay cultures 

have developed in the United States. For some 

individuals, gay culture provides an alternative 

to their culture of origin, but unfortunately, 

cultural pressures can make the individual feel 

like he or she has to select which identity is 

most important (Greene 1997). However, a 

person can be, for example, both gay and 

Latino without experiencing any conflicts 

about claiming both identities at the same 

time. For more information on substance 

abuse treatment for persons who identify as 

gay, lesbian, or bisexual, refer to the CSAT 

(2001) publication, A Provider’s Introduction to 

Substance Abuse Treatment for Lesbian, Gay, 

Bisexual, and Transgender Individuals.

Heterosexual behaviors are carefully prescribed 

by a culture. Typically, these prescriptions are 

determined based on gender; behaviors considered acceptable for men can be considered 

unacceptable for women and vice versa. In 

addition, cultures define the role of alcohol or 

other substances in courtship, sexual behaviors, 

and relationships (Room 1996). Other factors 

that can vary across cultural groups include the 

appropriate age for sexual activity, the rituals 

and actions surrounding sexual activity, the use 

of birth control, the level of secrecy or openness related to sexual acts, the role of sex 

workers, attitudes toward sexual dysfunction, 

and the level of sexual freedom in choosing 

partners.

Perspectives on Health, Illness, 

and Healing

Beliefs, attitudes, and behaviors related to 

health, illness, and healing vary across racial, 

ethnic, and cultural groups. Many cultural 

groups hold views that differ significantly 

from those of Western medical practice and 

thus can affect treatment (Sussman 2004). The 

field of medical anthropology was developed, 

29
Improving Cultural Competence

in part, to analyze these differences, and much 

has been written about the range of cultural 

beliefs concerning health and healing. In 

general, cultural groups differ in how they 

define and determine health and illness; who 

is able to diagnosis and treat an illness; their 

beliefs about the causes of illness; and their 

remedies (including the use of Western medicines), treatments, and healing practices for 

illness (Bhugra and Gupta 2010; Comas-Diaz

2012). In addition, there are complex rules 

about which members of a community or 

family can make decisions about health care 

across cultural groups (Sussman 2004).

In mainstream American society, healthcare

professionals are typically viewed as the only 

ones who have real expertise about health and 

illness. However, other societies have different 

views. For instance, among the Subanun people of the Philippines, all members of the 

community learn about healing and diagnosis; 

when an individual is sick, the diagnosis of his 

or her problem is an activity that involves the 

whole community (Frake 1961). Cultural 

groups also differ in their understanding of the 

causes of illness, and many cultural groups 

recognize a spiritual element in physical illness. The Hmong, for example, believe that 

illness has a spiritual cause and that healing 

may require shamans who communicate with 

spirits to diagnose and treat an illness 

(Fadiman 1997; Gensheimer 2006).

With respect to mental health, providers 

should be aware that any mental disorder or 

symptom is only considered a disorder or 

problem by comparison with a socially defined 

norm. For instance, in some societies, someone 

who hears voices can be considered to have 

greater access to the spirit world and to be 

blessed in some way. Furthermore, there are 

mental disorders that only present in a specific 

cultural group or locality; these are called 

cultural concepts of distress. Appendix E

describes cultural concepts of distress recognized by the DSM-5. Other specific examples 

of cultural differences relating to the use of 

health care and alternative approaches to 

medical diagnosis and treatment are also 

presented in Chapter 5.

Religion and Spirituality

Religious traditions or spiritual beliefs are 

often very important factors for defining an 

individual’s cultural background. In turn, 

attention to religion and spirituality during 

the course of treatment is one facet of culturally competent services (Whitley 2012). 

Christians, Muslims, Jews, and Buddhists 

(among others) can be members of any racial 

or ethnic group; in the same vein, people of 

the same ethnicity who belong to different 

religions sometimes have less in common than 

people of the same religion but different 

ethnicities. In some cases, religious affiliation 

is an especially important factor in defining a

person’s culture. For instance, the American 

Religious Identification Survey reported that 

47 percent of the respondents who identified 

culturally as Jewish were not practicing Jews 

(Kosmin et al. 2001).

According to the American Religious Identification Survey (Kosmin and Keysar 2009), only 

15 percent of Americans identified as not

having a religion; of those, less than 2 percent 

identified as atheist or agnostic. In another 

survey from the Pew Forum on Religion and 

Public Life (2008), 1.6 percent of respondents

stated that they were atheist; 2.4 percent, 

agnostic; and 6.3 percent, secular and unaffiliated with a religion. Many religions are practiced in the United States today. This TIP

cannot cover them all in detail in. However, 

this TIP does briefly describe the four most 

common (by size of self-identified membership) religious traditions. 

30
Chapter 1—Introduction to Cultural Competence

Christianity 

Christianity, in its various forms, remains the 

predominant religion in the United States 

today. According to Kosmin and Keysar 

(2009), 76 percent of the population in 2008 

identified as Christian, with the largest denomination being Catholics (25.1 percent), followed by Baptists (15.8 percent). Christianity

encompasses a variety of denominations with 

different beliefs and attitudes toward issues 

such as alcohol and/or other substance use. 

Most mainstream Christian religions support 

behavioral health treatment, and many churches serve as sites for self-help groups or for 

Christian recovery programs. Some Christian 

sects, however, are not as amenable to substance abuse and mental health treatment as 

others.

Judaism 

Judaism is the second most common religion 

in the United States (1.2 percent of the population as of 2008; Kosmin and Keysar 2009). 

Most Jews believe that they share a common 

ancient background. However, the population 

has dispersed over time and now exists in 

various geographic regions. The majority of 

Jews in the United States would be considered 

White, but Ethiopian Jews (the Beta Israel) 

and members of other African-Jewish communities would likely be seen as African 

Americans; the Jewish community from India 

(Bene Israel), as Asian Americans; and Jews 

who immigrated to the United States from 

Latin America, as Latinos. In 2001, approximately 5 percent of people who identified as 

adherents to Judaism (the religion, as opposed 

to people who identify as culturally Jewish) 

were Latinos, and approximately 1 percent 

were African Americans (Kosmin et al. 2001).

Regarding beliefs about and practices surrounding substance use, there are no prohibitions against alcohol use (or other substance 

use) in Judaism, but rates of alcohol abuse and 

dependence are significantly lower for Jews 

than for other populations (Bainwol and 

Gressard 1985; Straussner 2001). This could 

be partially attributable to genetics, yet there is 

also a definite cultural component (Hasin et al. 

2002). Conversely, rates of use and abuse of 

Advice to Counselors: Spirituality, Religion, Substance Abuse, and Mental Illness 

For people in treatment and recovery, it can be especially important to distinguish between spirituality and religion. For example, some clients are willing to think of themselves as spiritual but not 

necessarily religious. Religion is organized, with each religion having its own set of beliefs and practices designed to organize and further its members’ spirituality. Spirituality, on the other hand, is 

typically conceived of as a personal matter involving an individual’s search for meaning; it does not 

require an affiliation with any religious group (Cook 2004). People can have spiritual experiences or 

develop their own spirituality outside of the context of an organized religion.

Spirituality often plays an important role in recovery from mental illness and substance abuse, and 

higher ratings of spirituality (using a variety of scales) have been associated with increased rates of 

abstinence (Laudet et al. 2006; Zemore and Kaskutas 2004). If substance abuse represents a lack of 

personal control, discipline, and order, then spirituality and religion can help counter this by providing a sense of purpose, order, self-discipline, humility, serenity, and acceptance. In addition, spirituality can help a person with mental illness gain a sense of meaning or purpose, develop inner strength, 

and learn acceptance and tolerance. Chappel (1998) maintains that the development of spirituality 

requires a concerted and consistent effort through such activities as prayer, meditation, discussion 

with others, reading, and participation in other spiritual activities. Counselors, he says, have an obligation to understand the role that spirituality can play in promoting and supporting recovery. The 

first step in this process is for counselors to learn about and respect clients’ beliefs; understanding 

the roles of religion and spirituality is one form of cultural competence (Whitley 2012).

31
Improving Cultural Competence

other substances are about the same or slightly 

higher for Jews in the United States compared 

with other populations (Straussner 2001). 

Because some Jewish people will feel uncomfortable in 12-Step groups that meet in 

churches and are largely Christian in composition, mutual-help groups designed specifically 

for Jewish people have been developed. The 

largest of these is Jewish Alcoholics, Chemically Dependent Persons and Significant 

Others (see http://www.jbfcs.org/programsservices/jewish-community-services-2/jacs/

for more information). Other Jewish people in 

recovery may prefer participating in secular 

self-help programs (Straussner 2001). Most 

Jewish people support behavioral health 

treatment. 

Islam

In 2008, roughly 1.3 million people identified 

as Muslims in the United States, making it the 

third most common religion (Kosmin and 

Keysar 2009). Many Americans assume that 

all Arabs are Muslim, but the majority of Arab 

Americans are Christian; Muslims can come 

from any ethnic background (Abudabbeh and 

Hamid 2001). Islam is the most ethnically 

diverse religion in America, with a membership that is 15 percent White, 27 percent 

Black, 34 percent Asian, and 10 percent 

Latino (Kosmin et al. 2001).

Attitudes of Muslims toward mental illness 

and seeking formal mental health services are

likely to be affected by cultural and religious 

beliefs about mental health problems, 

knowledge and familiarity with formal services, perceived societal prejudice, and the use 

of informal indigenous resources (Aloud

2004). Attitudes toward substance use, abuse, 

and treatment will likely be shaped by Islam’s 

prohibition of the use of alcohol and other 

intoxicants. Many Muslim countries have 

harsh penalties for the use of alcohol and 

other drugs. For these reasons, Muslims 

appear to have low rates of substance use 

disorders. Despite there being no current data 

regarding levels of alcohol and other substance 

use among Muslim immigrants in the United 

States, Cochrane and Bal (1990) found that, in 

a comparison of Sikh, Hindu, Muslim, and 

White (probably Christian) men in a British 

community, Muslims by far drank the least, yet 

those Muslims who consumed the most alcohol experienced a greater number of alcoholrelated problems on average. High levels of 

alcohol consumption among Muslims who do

drink could be related to feelings of guilt and 

shame about their behavior, thus potentially 

leading to further abuse and avoidance of 

seeking substance abuse treatment when 

problems arise (Abudabbeh and Hamid 2001). 

Buddhism

In 2008, about 1.2 million Buddhists were 

living in the United States (Kosmin and 

Keysar 2009). In 2001, according to Kosmin et 

al (2001), the majority of Buddhists were 

Asian Americans (61 percent), but a significant number of White Americans have embraced the religion (they make up 32 percent 

of Buddhists in the United States), as have 

African Americans (4 percent) and Latinos (2 

percent). In China and Japan, Buddhism is 

often combined with other religious traditions, such as Taoism or Shintoism, and some 

immigrants from those countries combine the 

beliefs and practices of those religions with 

Buddhism.

Buddhists believe that the choices made in 

each life create karma that influences the next 

life and can affect behavior (McLaughlin and 

Braun 1998). The Fifth Precept of Buddhism 

is not to use intoxicating substances, and thus,

the expectation for devout believers is that 

they will not use alcohol or other substances of 

abuse (Assanangkornchai et al. 2002). In the 

United States, no specific substance abuse 

treatment programs specialize in treating 

32
Chapter 1—Introduction to Cultural Competence

Buddhist clients. Buddhist substance abuse 

and mental health treatment programs do 

exist in other countries (e.g., Thailand) and 

report high outcome rates (70 percent) using 

culturally specific practices (e.g., herbal saunas) and religious practices (Barrett 1997).

As You Proceed

This chapter has established the foundation 

and rationale of this TIP; reviewed the core 

concepts, models, and terminology of cultural 

competence; and provided an overview of 

factors that are common among diverse racial, 

ethnic, and cultural groups. As you proceed, be 

aware that diversity occurs not only across 

racially and ethnically diverse groups, but

within each group as well—there are cultures

within cultures. Clinicians and organizations 

need to develop skills to create an environment that is responsive to the unique attributes and experiences of each client, as outlined 

earlier in this chapter in the “What Are the 

Cross-Cutting Factors in Race, Ethnicity, and 

Culture?”section. As you read this TIP, remember that many cross-cutting factors influence the counselor–client relationship, the 

client’s presentation and identification of 

problems, the selection and interpretation of 

screening and assessment tools, the client’s 

responsiveness to specific clinical services, and 

the effectiveness of program delivery and 

organizational structure and planning.

33
 IN THIS CHAPTER

• Core Counselor 

Competencies

• Self-Assessment for 

Individual Cultural 

Competence

. 

Core Competencies for 

Counselors and Other 

Clinical Staff

Gil, a 40-year-old Mexican American man, lives in an upper middle class neighborhood. He has been married for more than 15 

years to his high school sweetheart, a White American woman, and 

they have two children. Gil owns a fleet of street-sweeping 

trucks—a business started by his father-in-law that Gil has expanded considerably. Of late, Gil has been spending more time at 

work. He has also been drinking more than usual and dabbling in 

illicit drugs. As his drinking has increased, tensions between Gil 

and his wife have escalated. From Gil’s perspective and that of 

some family members and friends, Gil is just a hard-working guy 

who deserves to have a beer as a reward for a hard day’s work. 

Many people in his Mexican American community do not consider Gil’s low-level daily drinking a problem, especially because he 

drinks primarily at home. 

Recently, Gil had an accident while working on one of his trucks. 

The treating physician identified alcohol abuse as one of several 

health problems and referred him to a substance abuse treatment 

center. Gil attended, but argued all the while that he was not a 

borracho (drunkard) and did not need treatment. He distrusted the 

counselors, stating that seeking help from professionals for a mental disorder was something that only gabachos (Whites) did. Gil was

proud of his capacity to “hold his liquor” and felt anger and hostility toward those who encouraged him to reduce his drinking. Gil’s 

feelings and attitudes were valid; they stemmed from and were influenced by the Mexican American culture and community in 

which he had been raised from infancy. Gil dropped out of treatment. When his wife threatened to divorce him if he did not take 

immediate action to deal with his drinking problem, he reluctantly 

2

35
Improving Cultural Competence

enrolled in an outpatient treatment program. 

Gil, like all people, is a product of his environment—an environment that has provided 

him with a rich cultural and spiritual background, a strong male identity, a deep attachment to family and community, a strong work 

ethic, and a sense of pride in being able to 

support his family. In many Mexican American

cultural groups, illness disrupts family life, 

work, and the ability to earn a living. Illness 

has psychological costs as well, including 

threats to a man’s self-identity and sense of 

manhood (Sobralske 2006). Given this background, Gil would understandably be reluctant 

to enter treatment, to accept the fact that his 

drinking was a problem or an illness, and to 

jeopardize his ability to care for his family and 

his company. A culturally competent counselor 

would recognize, legitimize, and validate Gil’s 

reluctance to enter and continue in treatment. 

In an ideal situation, the treatment counselor 

would have experience working with people 

with similar backgrounds and beliefs, and the 

treatment program would be structured to 

change Gil’s behavior and attitudes in a manner that was in keeping with his culture and 

community. His initial treatment might have 

succeeded if the counselor had been culturally 

competent and the treatment program had 

been culturally responsive. 

Like Gil, all clients enter treatment carrying 

beliefs, attitudes, conflicts, and problems 

shaped by their cultural roots as well as their 

present-day realities. As with Gil, many clients 

enter treatment with some reluctance and 

denial. Research shows that if clients such as 

Gil are greeted by a culturally competent 

counselor, they are more likely to respond 

positively to treatment (Damashek et al. 2012; 

Griner and Smith 2006; Kopelowicz et al.

2012; Whaley and Davis 2007). The presence 

of counselors of any race or gender who are 

culturally competent in responding to the 

needs and issues of their clients can greatly 

assist client recovery. Gaining regard, respect, 

and trust from clients is crucial for successful 

counseling outcomes (Ackerman and Hilsenroth 2003; Sue and Sue 2003a). 

Effective therapy is an ongoing process of 

building relational bridges that engender trust 

and confidence. Sensitivity to the client’s 

cultural and personal perspectives, genuine 

empathy, warmth, humility, respect, and acceptance are the tenets of all sound therapy. 

This chapter expands on these concepts and 

provides a general overview of the core competencies needed so that counselors may 

provide effective treatment to diverse racial 

and ethnic groups. Using Sue’s (2001) multidimensional model for developing cultural 

competence, the content focuses on the counselor’s need to engage in and develop cultural 

awareness; cultural knowledge in general; and 

culturally specific skills and knowledge of 

wellness, mental illness, substance use, treatments, and skill development.

Core Counselor 

Competencies

Since Sue et al. introduced the phrase “multicultural counseling competencies”in 1992, 

researchers and academics have elaborated on 

the core skill sets that enable counselors to 

work with diverse populations (American 

Psychological Association [APA] 2002; 

Council of National Psychological 

Associations for the Advancement of Ethnic 

Minority Interests 2009; Pack-Brown and 

Williams 2003; Tseng and Streltzer 2004). 

Cultural competence has evolved into more 

than a discrete skill set or knowledge base; it 

also requires ongoing self-evaluation on the 

part of the practitioner. Culturally competent 

counselors are aware of their own cultural 

groups and of their values, assumptions, and 

biases regarding other cultural groups. Moreover, culturally competent counselors strive to 

36
Chapter 2—Core Competencies for Counselors and Other Clinical Staff

understand how these factors affect their 

ability to provide culturally effective services 

to clients. 

Given the complex definition of culture and 

the fact that racially and ethnically diverse 

clients represent a growing portion of the 

client population, the need to update and 

expand guidelines for cultural competence is 

increasing. The consensus panel thus adapted 

existing guidelines from the Association of 

Multicultural Counseling for culturally responsive behavioral health services; some of 

their key suggestions for counselors and other 

clinical staff are outlined in this chapter.

Self-Knowledge

Counselors with a strong belief in evidencebased treatment methods can find it hard to 

relate to clients who prefer traditional healing 

methods. Conversely, counselors with strong 

trust in traditional healers and culturally accepted methods can fail to understand clients 

who seek scientific explanations of, and solutions to, their substance abuse and mental 

health problems. To become culturally competent, counselors should begin by exploring 

their own cultural heritage and identifying 

how it shapes their perceptions of normality, 

abnormality, and the counseling process. 

Multidimensional Model for Developing Cultural Competence: Individual Staff 

Level 

37
Improving Cultural Competence

Counselors who understand themselves and 

their own cultural groups and perceptions are

better equipped to respect clients with diverse 

belief systems. In gaining an awareness of their 

cultures, attitudes, beliefs, and assumptions 

through self-examination, training, and clinical supervision, counselors should consider the 

factors described in the following sections. 

Cultural awareness 

Counselors who are aware of their own cultural

backgrounds are more likely to acknowledge 

and explore how culture affects their client–

counselor relationships. Without cultural 

awareness, counselors may provide counseling 

that ignores or does not address obvious issues 

that specifically relate to race, ethnic heritage, 

and culture. Lack of awareness can discount

the importance of how counselors’ cultural 

backgrounds—including beliefs, values, and 

attitudes—influence their initial and diagnostic impressions of clients. Without cultural 

awareness, counselors can unwittingly use 

their own cultural experiences as a template to 

prejudge and assess client experiences and 

clinical presentations. They may struggle to 

see the cultural uniqueness of each client, 

assuming that they understand the client’s life 

experiences and background better than they 

really do. With cultural awareness, counselors 

examine how their own beliefs, experiences, 

and biases affect their definitions of normal 

and abnormal behavior. By valuing this awareness, counselors are more likely to take the 

time to understand the client’s cultural groups 

and their role in the therapeutic process, the 

client’s relationships, and his or her substancerelated and other presenting clinical problems. 

Cultural awareness is the first step toward 

becoming a culturally competent counselor. 

Racial, ethnic, and cultural identities 

A key step in attaining cultural competence is 

for counselors to become aware of their own 

racial, ethnic, and cultural identities. Although 

the constructs of these identities are complex 

and difficult to define briefly, what follows is

an overview. Racial identity “refers to a sense 

of group or collective identity based on one’s 

perception that he or she shares a common 

heritage with a particular racial group” (Helms 

1990, p. 3). Ethnic and cultural identity is 

“often the frame in which individuals identify 

consciously or unconsciously with those with 

whom they feel a common bond because of 

similar traditions, behaviors, values, and beliefs” (Chavez and Guido-DiBrito 1999, p. 

41). Culture includes, but is not limited to, 

spirituality and religion, rituals and rites of 

passage, language, dietary habits (e.g., attitudes 

toward food/food preparation, symbolism of 

food, religious taboos of food), and leisure 

activities (Bhugra and Becker 2005). 

Aspects of racial, ethnic, and cultural identities 

are not always apparent and do not always

factor into conscious processes for the counselor or client, but these factors still play a role 

in the therapeutic relationship. Identity development and formation help people make sense 

of themselves and the world around them. If 

Models of Racial Identity 

Models of racial identity, often structured in 

stages, highlight the process that individuals 

undertake in becoming aware of their sense of 

self in relation to race and ethnicity within the 

context of their families, communities, societies, and cultural histories. Influenced by the 

Civil Rights Movement, earlier racial identity 

models in the United States focused on White 

and Black racial identity development (Cross 

1995; Helms 1990; Helms and Carter 1991). 

Since then, models have been created to 

incorporate other races, ethnicities, and 

cultures. 

Although this chapter highlights two formative 

racial identity models (see next page), additional resources highlight racial identity models 

that incorporate other diverse groups, including those individuals who identify as multiracial 

(e.g., see Wijeyesinghe and Jackson 2012).

38
Chapter 2—Core Competencies for Counselors and Other Clinical Staff

positive racial, ethnic, and cultural messages 

are not available or supported in behavioral 

health services, counselors and clients can lack

affirmative views of their own identities and 

may internalize negative messages or feel 

disconnected from their racial and cultural 

heritages. Counselors from mainstream society 

are less likely to be actively aware of their own 

ethnic and cultural identities; in particular, 

White Americans are not naturally drawn into 

examining their cultural identities, as they 

typically experience no dissonance when 

engaging in cultural activities. 

In working to attain cultural competence, 

counselors must explore their own racial and 

cultural heritages and identities to gain a 

deeper understanding of personal development. Many models and theories of racial, 

ethnic, and cultural development are available; 

two common processes are presented below. 

Exhibit 2-1 highlights the racial/cultural 

identity development (R/CID) model (Sue 

and Sue 1999b) and the White racial identity 

development (WRID) model (Sue 2001). 

Although earlier work focused on a linear 

developmental process using stages, current 

thought centers on a more flexible process 

whereby identification status can loop back to 

an earlier process or move to a later phase. 

Using either model, counselors can explore 

relational and clinical challenges associated 

with a given phase. Without an understanding 

of the cultural identity development process, 

counselors—regardless of race or ethnicity—

can unwittingly minimize the importance of 

racial and ethnic experiences. They may fail to 

identify cultural needs and secure appropriate 

treatment services, unconsciously operate from 

a superior perspective (e.g., judging a specific 

behavior as ineffectual, a sign of resistance, or a 

symptom of pathology), internalize a client’s 

reaction (e.g., an African American counselor 

feeling betrayed or inadequate when a client of 

the same race requests a White American 

counselor for therapy during an initial interview), or view a client’s behavior through a veil 

of societal biases or stereotypes. By acknowledging and endorsing the active process of 

racial and cultural identity development, counselors from diverse groups can normalize their 

own development processes and increase their 

awareness of clients’ parallel processes of 

identity development. In counseling, racial, 

ethnic, and cultural identities can be pivotal to

the treatment process in the relationships not 

only between the counselor and client, but 

among everyone involved in the delivery of the 

client’s behavioral health and primary care 

services (e.g., referral sources, family members, 

medical personnel, administrators). The case 

study on page 41 uses stages from the two 

models in Exhibit 2-1 to show the interactive 

process of racial and cultural identity development in the treatment context.

Cultural and racial identities are not static 

factors that simply mediate individual identity; 

they are dynamic, interactive developmental 

processes that influence one’s willingness to 

acknowledge the effects of race, ethnicity, and 

culture and to act against racism and disparity 

across relationships, situations, and environments (for a review of racial and cultural 

identity development, see Sue and Sue 2013c). 

For counselors and clinical supervisors, it is 

essential to understand the dynamic nature of 

cultural identity in all exchanges. Starting with 

a personal appraisal, clinical staff members can 

begin to reflect—without judgment—on how 

their own racial and cultural identities influence their decisions, treatment planning, case 

presentation, supervision, and interactions

with other staff members. Clinicians can map 

the interactive influences of cultural identity 

development among clients, the clients’families, staff members, the organization, other 

agencies, and any other entities involved in the 

client’s treatment. Using mapping (see the

39
Improving Cultural Competence

Exhibit 2-1: Stages of Racial and Cultural Identity Development 

R/CID Model WRID Model

Conformity: Has a positive attitude toward 

and preference for dominant cultural values; 

places considerable value on characteristics 

that represent dominant cultural groups; may 

devalue or hold negative views of own race or 

other racial/ethnic groups. 

Dissonance and Appreciating: Begins to 

question identity; recognizes conflicting messages and observations that challenge beliefs/stereotypes of own cultural groups and 

value of mainstream cultural groups; develops 

growing sense of one’s own cultural heritage 

and the existence of racism; moves away from 

seeing dominant cultural groups as all good. 

Resistance and Immersion: Embraces and 

holds a positive attitude toward and preference for his or her own race and cultural 

heritage; rejects dominant values of society 

and culture; focuses on eliminating oppression 

within own racial/cultural group; likely to 

possess considerable feelings—including 

distrust and anger—toward dominant cultural 

groups and anything that may represent them; 

places considerable value on characteristics 

that represent one’s own cultural groups 

without question; develops a growing appreciation for others from racially and culturally 

diverse groups. 

Introspection: Begins to question the psychological cost of projecting strong feelings 

toward dominant cultural groups; desires to 

refocus more energy on personal identity 

while respecting own cultural groups; realigns 

perspective to note that not all aspects of 

dominant cultural groups—one’s own racial/cultural group or other diverse groups—

are good or bad; may struggle with and experience conflicts of loyalty as perspective 

broadens. 

Integrative Awareness: Has developed a 

secure, confident sense of racial/cultural 

identity; becomes multicultural; maintains 

pride in racial identity and cultural heritage; 

commits to supporting and appreciating all 

oppressed and diverse groups; tends to 

recognize racism as a societal illness by which 

all can be victimized.

Naiveté: Had an early childhood developmental 

phase of curiosity or minimal awareness of race; 

may or may not receive overt or covert messages 

about other racial/cultural groups; possesses an

ethnocentric view of culture. 

Conformity: Has minimal awareness of self as a 

racial person; believes strongly in the universality 

of values and norms; perceives White American 

cultural groups as more highly developed; may 

justify disparity of treatment; may be unaware of 

beliefs that reflect this.

Dissonance: Experiences an opportunity to 

examine own prejudices and biases; moves 

toward the realization that dominant society 

oppresses racially and culturally diverse groups; 

may feel shame, anger, and depression about 

the perpetuation of racism by White American 

cultural groups; and may begin to question 

previously held beliefs or refortify prior views. 

Resistance and Immersion: Increases awareness 

of one’s own racism and how racism is projected 

in society (e.g., media and language); likely feels 

angry about messages concerning other racial 

and cultural groups and guilty for being part of an 

oppressive system; may counteract feelings by 

assuming a paternalistic role (knowing what is 

best for clients without their involvement) or 

overidentifying with another racial/cultural group. 

Introspection: Begins to redefine what it means 

to be a White American and to be a racial and 

cultural being; recognizes the inability to fully 

understand the experience of others from diverse racial and cultural backgrounds; may feel 

disconnected from the White American group.

Integrative Awareness: Appreciates racial, 

ethnic, and cultural diversity; is aware of and 

understands self as a racial and cultural being; is 

aware of sociopolitical influences of racism; 

internalizes a nonracist identity.

Commitment to Antiracist Action: Commits to 

social action to eliminate oppression and disparity 

(e.g., voicing objection to racist jokes, taking 

steps to eradicate racism in institutions and public 

policies); likely to be pressured to suppress efforts 

and conform rather than build alliances with 

people of color.

Sources: Sue 2001; Sue and Sue 1999b.

40
Chapter 2—Core Competencies for Counselors and Other Clinical Staff

“How To Map Racial and Cultural Identity 

Development” box on the next page) as preparation for counseling, treatment planning, or 

clinical supervision, clinicians can gain awareness of the many forces that influence culturally responsive treatment. 

Worldview: The cultural lens of 

counseling 

The term “worldview” refers to a set of

assumptions that guide how one sees, thinks

about, experiences, and interprets the world 

(Koltko-Rivera 2004). Starting in early childhood, worldview development is facilitated by 

significant relationships (particularly with 

parents and family members) and is shaped by

the individual’s environment and life experiences, influencing values, attitudes, beliefs, and 

behaviors. In more simplistic terms, each 

person’s worldview is like a pair of glasses with 

colored lenses—the person takes in all of life’s 

experiences through his or her own uniquely 

Case Study for Counselors: Racial and Cultural Identity

The client is a 20-year-old Latino man. His father immigrated to the United States from Mexico as a 

child, and his mother (of Latino/Middle Eastern descent) grew up near Albuquerque, New Mexico. 

Throughout the initial phase of mental health treatment, the client presented feelings, attitudes, and 

behavior consistent with the resistance and immersion stage of the R/CID model. During group 

counseling in a partial hospitalization program, the client said that he did not think treatment was 

going to work. He believed that no one in treatment, except other Latino men, really understood 

him or his life experiences. He thought that his low mood was due, in part, to his recent job loss. 

The client’s current concerns, symptoms, and diagnosis (bipolar I) were presented and discussed

during the treatment team meeting. The client’s counselor (a White American man in the dissonance 

stage of the WRID model) was concerned that the client might leave treatment against medical 

advice and also stated that this would not be the first time a Latino client had done so. The team 

recognized that a Latino counselor would likely be useful in this situation (depending on the counselor’s cultural competence). However, no Latino counselor was available, so the team decided that 

the client’s current counselor should try to gain support from the client’s parents to encourage the 

client to stay in treatment. 

Because the client had signed an appropriate release of information, his counselor was able to 

contact the parents and arrange a family session. During the family session, the counselor brought 

up the client’s need for a Latino counselor. His parents disagreed, expressing their belief that it was 

important for their son to learn to relate to the counselor. They said that this was just an excuse their 

son was using to leave treatment, which had happened before. The parents’ reaction exemplified a 

conformity response, although other information would need to have been gathered to determine 

their current stage more accurately. 

The counselor, client, parents, and organization were operating from different stages of racial and 

cultural identity development. Considering the lack of a proactive plan to provide appropriate 

resources—including the hiring of Latino staff or the development of other culturally appropriate 

resources (e.g., a peer counselor program)—the organization was most likely in the conformity 

phase of the WRID model. The counselor had some awareness of the client’s racial and cultural 

needs and of the organization’s failure to meet them, but he alienated the client despite his good 

intentions and reinforced mistrust by engaging the client’s parents before working directly with the 

client. Had the counselor taken the time to understand the client’s concerns and needs, he would 

likely have created an opportunity to challenge his own beliefs, learn more about the client’s racial 

and cultural experiences and values, advocate for more appropriate resources for the client within 

the organization, be more flexible with treatment solutions, and enable the client to have an experience that exceeded his expectations of the treatment provider.

41
Improving Cultural Competence

tinted view. Not unlike clients, counselors 

enter the treatment process with their own 

cultural worldviews that shape their concept of 

time; definition of family; organization of 

priorities and responsibilities; orientation to 

self, family, and/or community; religious or 

How To Map Racial and Cultural Identity Development

Completing this diagram can give a clearer perspective on past and anticipated dialog among key 

stakeholders. The diagram can be used as a training tool to teach racial and cultural identity development, to help clinicians and organizations recognize their own development, to explore clinical 

issues and dialogs that occur when diverse parties are at similar or different developmental stages, 

and to develop tools and resources to address issues that arise from this developmental process. 

Using case studies, this diagram can serve as an interactive educational exercise to help counselors, 

clinical supervisors, and agencies gain awareness of the effects of race, ethnicity, and cultural groups.

Materials needed: Paper and pencils; handouts on the R/CID and WRID models. 

Instructions: 

• Identify all relevant parties, including client, counselor, family, supervisor, referral source, other 

staff members, and staff from other agencies (e.g., probation/parole, medical center/office, child 

and youth services). Include yourself. Place the names at each intersection of the hexagon. 

• List the common statements and behaviors (including lack of verbal responses) that you witness 

regarding the cultural needs of the client and/or the general statements made by each party regarding race, ethnicity, and culture. Write these as one-line abbreviated phrases that represent 

each person/agency’s stance under the appropriate entry on the diagram. 

• Using current information, choose the cultural identity development stage that best fits the 

statements or behaviors (knowing that you may be inaccurate); write it under each name. 

42
Chapter 2—Core Competencies for Counselors and Other Clinical Staff

spiritual beliefs; ideas about success; and so on

(Exhibit 2-2). 

However, counselors also contend with another worldview that is often invisible but still 

powerful—the clinical worldview (Bhugra and 

Gupta 2010; Tilburt and Geller 2007; Tseng 

and Streltzer 2004). Influenced by education, 

clinical training, and work experiences, counselors are introduced into a culture that reflects specific counseling theories, techniques, 

treatment modalities, and general office practices. This worldview, coupled with their 

personal cultural worldview, significantly 

shapes the counselor’s beliefs pertaining to the 

nature of wellness, illness, and healing; interviewing skills and behavior; diagnostic impressions; and prognosis. Moreover, it influences 

the definition of normal versus abnormal or 

disordered behavior, the determination of 

treatment priorities, the means of intervention, 

and the definitions of successful outcomes and 

treatment failures. 

Foremost, counselors need to remember that 

worldviews are often unspoken and inconspicuous; therefore, considerable reflection and 

self-exploration are needed to identify how 

their own cultural worldviews influence their 

interactions both inside and outside of counseling. Clinical staff members need to question 

how their perspectives are perpetuated in and 

shape client–counselor interactions, treatment 

decisions, planning, and selected counseling 

approaches. In sum, culturally responsive 

practice involves an understanding of multiple 

perspectives and how these worldviews interact throughout the treatment process—

including the views of the counselor, client, 

family, other clients and staff members, treatment program, organization, and other agencies, as well as the community. 

Stereotypes, prejudices, and history 

Cultural competence involves counselors’ 

willingness to explore their own histories of 

prejudice, cultural stereotyping, and discrimination. Counselors need to be aware of how 

their own perceptions of self and others have 

evolved through early childhood influences 

and other life experiences. For example, how 

were stereotypes of their own races and ethnic 

heritages perpetuated in their upbringing? 

What myths and stereotypes were projected 

onto other groups? What historical events 

shaped experiences, opportunities, and perceptions of self and others? 

Regardless of their race, cultural group, or 

ethnic heritage, counselors need to examine 

how they have directly or indirectly been 

affected by individual, organizational, and 

societal stereotypes, prejudice, and discrimination. How have certain attitudes, beliefs, and 

behaviors functioned as deterrents to obtaining equitable opportunities? In what ways 

have discrimination and societal biases provided benefits to them as individuals and as 

counselors? Even though these questions can 

be uncomfortable, difficult, or painful to explore, awareness is essential regarding how 

these issues affect one’s role as a counselor, 

status in the organization, and comfort level in 

exploring clients’ life experiences and perceptions during the treatment process. If counselors avoid or minimize the relevance of bias 

and discrimination in self-exploration, they 

will likely do the same in the assessment and 

counseling process. 

Clinical 

Worldview

Individual 

Cultural 

Worldview

Exhibit 2-2: Counselor Worldview

43
Improving Cultural Competence

Clients can have behavioral health issues and 

healthcare concerns associated with discrimination. If counselors are blind to these issues, 

they can miss vital information that influences 

client responses to treatment and willingness 

to follow through with continuing care and 

ancillary services. For example, a counselor

may refer a client to a treatment program 

without noting the client’s history or perceptions of the recommended program or type of 

program. The client may initially agree to 

attend the program but not follow through 

because of past negative experiences and/or 

the perception within his or her racial/ethnic 

community that the service does not provide 

adequate treatment for clients of color.

Trust and power 

Counselors need to understand the impact of 

their role and status within the client–

counselor relationship. Client perceptions of 

counselors’ influence, power, and control vary 

in diverse cultural contexts. In some contexts, 

counselors can be seen as all-knowing professionals, but in others, they can be viewed as 

representatives of an unjust system. Counselors need to explore how these dynamics affect 

the counseling process with clients from 

diverse backgrounds. Do client perceptions

inhibit or facilitate the process? How do they 

affect the level of trust in the client–counselor 

relationship? These issues should be identified 

and addressed early in the counseling process. 

Clients should have opportunities to talk 

about and process their perceptions, past 

experiences, and current needs. 

Practicing within limits 

A key element of ethical care is practicing 

within the limits of one’s competence. Counselors must engage in self-exploration, critical 

thinking, and clinical supervision to understand their clinical abilities and limitations 

Advice to Counselors and Clinical Supervisors: Using the RESPECT Mnemonic To 

Reinforce Culturally Responsive Attitudes and Behaviors

• Respect—Understand how respect is shown within given cultural groups. Counselors demonstrate this attitude through verbal and nonverbal communications. 

• Explanatory model—Devote time in treatment to understanding how clients perceive their presenting problems. What are their views about their own substance abuse or mental symptoms? 

How do they explain the origin of current problems? How similar or different is the counselor’s 

perspective? 

• Sociocultural context—Recognize how class, race, ethnicity, gender, education, socioeconomic 

status, sexual and gender orientation, immigrant status, community, family, gender roles, and so 

forth affect care.

• Power—Acknowledge the power differential between clients and counselors.

• Empathy—Express, verbally and nonverbally, the significance of each client’s concerns so that he 

or she feels understood by the counselor.

• Concerns and fears—Elicit clients’ concerns and apprehensions regarding help-seeking behavior 

and initiation of treatment.

• Therapeutic alliance/Trust—Commit to behaviors that enhance the therapeutic relationship; 

recognize that trust is not inherent but must be earned by counselors.

Sources: Bigby and American College of Physicians 2003; Campinha-Bacote et al. 2005.

All counselors should examine their 

stereotypes, prejudices, and emotional 

reactions toward others, including 

individuals from their own races or cultural 

backgrounds and individuals from other 

groups. They should examine how these 

attitudes and biases may be detrimental to 

clients in treatment for substance-related 

and mental disorders.

44
Chapter 2—Core Competencies for Counselors and Other Clinical Staff

regarding the services that they are able to 

provide, the populations that they can serve, 

and the treatment issues that they have sufficient training to address. Cultural competence 

requires an ability to assess accurately one’s 

clinical and cultural limitations, skills, and 

expertise. Counselors risk providing services 

beyond their expertise if they lack awareness 

and knowledge of the influence of cultural 

groups on client–counselor relationships, 

clinical presentation, and the treatment process or if they minimize, ignore, or avoid 

viewing treatment in a cultural context. 

Some counselors may assume that they have 

cultural competence based on having similar 

experiences as clients, being from the same 

race as clients, identifying as a member of the 

same ethnic heritage or cultural group as 

clients, or attending training on cultural competence. Other counselors may assume competence based on their current or prior 

relationships with others from the same race 

or cultural background as their clients. These 

experiences can be helpful and filled with 

many potential learning opportunities, but 

they do not make an individual eligible or 

competent to provide multicultural counseling. 

Likewise, the assumption that a person from 

the same cultural group, race, or ethnic heritage will intrinsically understand a client from 

a similar background is operating out of two 

common myths: the “myth of sameness” (i.e., 

that people from the same cultural group, race, 

or ethnicity are alike) and the myth that “familiarity equals competence” (Srivastava

2007). The Association for Multicultural 

Counseling and Development adopted a set 

of counselor competencies that was endorsed 

by the American Counseling Association 

(ACA) for counselors who work with a multicultural clientele (Exhibit 2-3). Competencies address the attitudes, beliefs, knowledge, 

and skills associated with the counselor’s need 

for self-knowledge. 

Knowledge of Other Cultural 

Groups 

In addition to an understanding of themselves 

and how their cultural groups and values can 

affect the therapeutic process, culturally competent counselors work to acquire cultural 

knowledge and understanding of clients and 

staff with whom they work. From the outset, 

counselors need general knowledge and 

awareness when working with other cultural 

groups in counseling. For example, they should 

acknowledge that culture influences communication patterns, values, gender roles and 

socialization, clinical presentations of distress, 

counseling expectations, and behavioral norms 

and expectations in and outside the counseling 

session (e.g. , touching, greetings, gift-giving, 

accompaniment in sessions, level of formality 

between counselor and client). Counselors 

should filter and interpret client presentation 

from a broad cultural perspective instead of 

using only their own cultural groups or previous client experiences as reference points. 

Counselors also need to invest the time to 

know clients and their cultures. Culturally 

responsive practice involves a commitment to 

obtaining specific cultural knowledge, not 

only through ongoing client interactions, but 

also through the use of outside resources, 

cultural training seminars and programs, 

cultural events, professional consultations, 

“Become familiar with the community in 

which the client lives and the general 

cultural norms of the individual client. This 

can be accomplished by visiting with 

people who know the community well, 

attending important community 

celebrations and other events, asking 

open-ended questions about community 

concerns and quality of life, and 

identifying community capacities that 

affect wellness in the community.” 

(Perez and Luquis 2008, p. 177)

45
Improving Cultural Competence

cultural guides, and clinical supervision. 

Counselors need to be mindful that they will 

not know everything about a specific population or initially comprehend how an individual 

client endorses or engages in specific cultural 

practices, beliefs, and values. For instance, 

some clients may not identify with the same 

cultural beliefs, practices, or experiences as 

other clients from the same cultural groups. 

Nevertheless, counselors need to be as knowledgeable as possible and attend to these cultural attributes—beginning with the intake 

and assessment process and continuing 

throughout the counseling and treatment 

relationship. For a review of content areas 

essential in knowing other cultural groups, 

refer to the ”What Are the Cross-Cutting

Factors in Race, Ethnicity, and Culture” section in Chapter 1. These cultural knowledge

content areas include: 

• Language and communication. 

• Geographic location. 

• Worldview, values, and traditions. 

• Family and kinship. 

• Gender roles. 

• Socioeconomic status and education. 

Exhibit 2-3: ACA Counselor Competencies: Counselors’ Awareness of Their Own 

Cultural Values and Biases 

Attitudes and beliefs: 

• Culturally skilled counselors have moved from being culturally unaware to being aware and 

sensitive to their own cultural heritages and to valuing and respecting differences. 

• Culturally skilled counselors are aware of how their own cultural backgrounds, experiences, 

attitudes, values, and biases influence psychological processes. 

• Culturally skilled counselors recognize the limits of their multicultural competence and expertise. 

• Culturally skilled counselors are comfortable with differences that exist between themselves and 

their clients in terms of race, ethnicity, culture, and beliefs.

Knowledge: 

• Culturally skilled counselors have specific knowledge about their own racial and cultural heritage 

and how it personally and professionally affects their definitions of normality, abnormality, and 

the process of counseling. 

• Culturally skilled counselors possess knowledge and understanding of how oppression, racism, 

discrimination, and stereotyping affect them personally and in their work. This allows them to 

acknowledge their own racist attitudes, beliefs, and feelings. Although this standard applies to 

all groups, for White American counselors, it can mean that they understand how they may have 

directly or indirectly benefited from individual, institutional, and cultural racism. 

• Culturally skilled counselors possess knowledge about their social impact on others. They are 

knowledgeable about communication style differences and how their style may clash with or foster the counseling process with minority clients. They anticipate the impact their style may have 

on others.

Skills: 

• Culturally skilled counselors seek out educational, consultative, and training experiences to 

improve their understanding and effectiveness in working with culturally diverse populations. Being able to recognize the limits of their competencies, they seek consultation, seek further training or education, refer out to more qualified individuals or resources, or engage in a 

combination of these. 

• Culturally skilled counselors are constantly seeking to understand themselves as racial and 

cultural beings and are actively seeking a nonracist identity.

Source: American Counseling Association Web site (http://www.counseling.org/docs/competencies/ 

cross-cultural_competencies_and_objectives.pdf). Adapted with permission.

46
Chapter 2—Core Competencies for Counselors and Other Clinical Staff

• Immigration, migration, and acculturation 

stress. 

• Acculturation and cultural identification. 

• Heritage and history. 

• Sexuality. 

• Religion and spirituality. 

• Health, illness, and healing. 

Counselors should not make assumptions 

about clients’ race, ethnic heritage, or culture 

based on appearance, accents, behavior, or 

language. Instead, counselors need to explore 

with clients their cultural identity, which can 

involve multiple identities (Lynch and Hanson

2011). Counselors should discuss what cultural

identity means to clients and how it influences 

treatment. For example, a young adult twospirited (gay) American Indian man may be 

more concerned with having access to traditional healing practices than to specialized 

services for gay men. Counselors and clients 

should collaboratively examine presenting 

treatment issues and obstacles to engaging in 

behavioral health treatment and maintaining 

recovery, and they should discuss how cultural 

groups and cultural identities can serve as

guideposts in treatment planning. 

Exhibit 2-4 lists ACA-endorsed counselor 

competencies for knowledge of the worldviews 

of clients from diverse cultural groups. 

Exhibit 2-4: ACA Counselor Competencies: Awareness of Clients’ Worldviews

Attitudes and beliefs: 

• Culturally skilled counselors are aware of their negative and positive emotional reactions toward 

other racial and ethnic groups and recognize that these reactions may prove detrimental to the 

counseling relationship. They are willing to contrast their own beliefs and attitudes with those of 

clients from diverse cultures in a nonjudgmental fashion. 

• Culturally skilled counselors are aware of the stereotypes and preconceived notions they may 

hold toward other racial and ethnic minority groups.

Knowledge:

• Culturally skilled counselors possess specific knowledge and information about the particular 

group(s) with whom they are working. They are aware of the life experiences, cultural heritages, 

and historical backgrounds of clients from cultures other than their own. This competence is 

strongly linked to the minority identity development models available in the literature. 

• Culturally skilled counselors understand how race, cultural group, ethnicity, and other factors can 

affect personality formation, vocational choices, manifestation of mental disorders, help-seeking 

behavior, and the appropriateness or inappropriateness of various counseling approaches. 

• Culturally skilled counselors understand and have knowledge of sociopolitical influences upon 

the lives of racial and ethnic minorities. They understand that factors such as immigration issues, 

poverty, racism, stereotyping, and powerlessness can affect self-esteem and self-concept in the 

counseling process.

Skills:

• Culturally skilled counselors familiarize themselves with relevant research and the latest findings 

regarding mental health and mental disorders that affect various ethnic and racial groups. They 

actively seek out educational experiences that enrich their knowledge, understanding, and crosscultural skills for more effective counseling behavior. 

• Culturally skilled counselors are actively involved with minority individuals outside of the counseling setting (community events, social and political functions, celebrations, friendships, neighborhood groups, etc.); their perspective of minorities is more than an academic/helping exercise.

Source: American Counseling Association Web site (http://www.counseling.org/docs/competencies/ 

cross-cultural_competencies_and_objectives.pdf). Adapted with permission.

47
Improving Cultural Competence

Cultural Knowledge of Behavioral 

Health

Counselors should learn how culture interacts 

with health beliefs, substance use, and other 

behavioral health issues. They can access literature and training that address cultural contexts 

and meanings of substance use, behavioral and 

emotional reactions, help-seeking behavior, and 

treatment. Chapter 5 gives information on 

culturally responsive behavioral health services 

for major ethnic and racial groups. The howto box below lists ways to improve one’s cultural knowledge of health issues by acquiring 

knowledge in key areas to work successfully 

with diverse clients: 

• Patterns of substance use and treatmentseeking behavior specific to people of 

diverse racial and cultural backgrounds. 

• Beliefs and traditions surrounding substance use, including cultural norms concerning the use of alcohol and drugs.

• Beliefs about treatment, including expectations and attitudes toward health care and 

counseling.

• Community perceptions of behavioral 

health treatment.

• Obstacles encountered by specific populations that make it difficult to access treatment, such as geographic distance from 

treatment services.

• Patterns of co-occurring disorders and 

conditions specific to people from diverse

racial and cultural backgrounds (e.g., culturally specific syndromes, earlier onset of

How To Improve Cultural Knowledge of Health, Illness, and Healing

To promote culturally responsive services, counselors need to acquire cultural knowledge regarding 

concepts of 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 wellbeing 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? 

• Are there specific biological and physiological variations among members of this population?

• What are the common symptoms that lead to misdiagnosis within this population? 

• Where do people from this cultural group typically seek help? 

• What traditional healing practices and treatments 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, including social determinants of health, for this population?

• 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?

48
Chapter 2—Core Competencies for Counselors and Other Clinical Staff

diabetes, higher prevalence of depression

and substance dependence).

• Assessment and diagnosis, including 

culturally appropriate screening and assessment and awareness of common diagnostic biases associated with symptom 

presentation.

• Individual, family, and group therapy 

approaches that hold promise in addressing mental and substance-related disorders 

specific to the racial and cultural backgrounds of diverse clients. 

• Culturally appropriate peer support, 

mutual-help, and other support groups

(e.g., the Wellbriety movement, a culturally appropriate 12-Step program for Native 

American people).

• Traditional healing and complementary 

methods (e.g., use of spiritual leaders, 

herbs, and rituals). 

• Continuing care and relapse prevention, 

including attention to clients’ cultural environments, treatment needs, and accessibility of care within their communities. 

• Treatment engagement/retention patterns.

Skill Development

Becoming culturally competent is an ongoing 

process—one that requires introspection, 

awareness, knowledge, and skill development. 

Counselors need to develop a positive attitude 

toward learning about multiple cultural 

groups; in essence, counselors should commit

to cultural competence and the process of 

growth. This commitment is evidenced via 

investment in ongoing learning and the pursuit of culturally congruent skills. Counselors 

can demonstrate commitment to cultural 

competence through the attitudes and corresponding behaviors indicated in Exhibit 2-5. 

Beyond the commitment to and development 

of these fundamental attitudes and behaviors, 

counselors need to work toward intervention 

strategies that integrate the skills discussed in 

the following sections. 

Frame issues in culturally relevant 

ways 

Counselors should frame clinical issues with 

culturally appropriate references. For example, 

in cultural groups that value the community or 

family as much as the individual, it is helpful 

to address substance abuse in light of its consequences to family or the community. The 

counselor might ask, “How are your family 

and community affected by your use? How do 

family and community members feel when 

they see you high?” For clients who place more 

value on their independence, it can be more 

effective to point out how substance dependence undermines their ability to manage their 

own lives through questions like “How might 

your use affect your ability to reach your goals?” 

Exhibit 2-5: 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

(Continued on the next page.)

49
Improving Cultural Competence

Exhibit 2-5: Attitudes and Behaviors of Culturally Competent Counselors 

(continued)

Attitude Behavior

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)

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 (Srivastava 

2007)

• 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 persons from diverse cultural groups can 

use different cognitive styles (e.g., placing more attention on reflecting and 

processing than on content; being task oriented)

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

• Integrating cultural practices as treatment strategies (e.g., Alaska Native 

traditional practices, such as tundra walking and sustenance activities)

50
Chapter 2—Core Competencies for Counselors and Other Clinical Staff

Allow for complexity of issues based 

on cultural context 

Counselors must take care with suggesting 

simple solutions to complex problems. It is 

often better to acknowledge the intricacies of 

the client’s cultural context and circumstances. 

For instance, a Native American single mother 

who upholds traditional values could balk at a 

suggestion to stop spending time with family 

members who drink heavily. Here, the counselor might encourage the woman to broaden 

support within her community by connecting 

with an elder who supports recovery or by 

engaging in a women’s talking circle. Likewise, 

a referral for a psychiatric evaluation for major 

depression may not be an appropriate initial 

recommendation for a Chinese client who 

relies on cultural remedies and healing traditions. An alternative approach would be to 

explore the client’s beliefs in healing, develop 

steps that respect and incorporate the client’s 

help-seeking practices, and coordinate services 

to secure a culturally responsive intervention 

(Cardemil et al. 2011; Gallardo et al. 2012; 

Lynch and Hanson 2011). 

Make allowances for variations in 

the use of personal space 

Cultural groups have different expectations 

and norms of propriety concerning how close 

people can be while they communicate and 

how personal communications can be depending on the type of relationship (e.g., peers 

versus elders).The concept of personal space 

involves more than the physical distance 

between people. It also involves cultural expectations regarding posture or stance and the use 

of space within a given environment. These 

cultural expectations, although they are subtle, 

can have an impact on treatment. For example, 

an Alaska Native may feel more comfortable 

sitting beside a counselor, whereas a European 

may prefer to be separated from a counselor by 

a desk (Sue and Sue 2013a). The use of space 

can also be a nonverbal expression of power. 

Standing too close to someone can, for example, suggest power over them. Standing too far 

away or sitting behind a desk can indicate 

aloofness. Acceptable or expected degrees of 

closeness between people are culturally specific; 

counselors should be educated on the general 

Advice to Counselors and Clinical Supervisors: Behaviors for Counselors To Avoid 

• Addressing clients informally; 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 clients 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).

• Providing an explanation of how current difficulties can be resolved without including the client 

in the process to obtain his or her 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 2008; Lynch and Hanson 2011; Pack-Brown and Williams 2003; Srivastava 2007. 

51
Improving Cultural Competence

parameters and expectations of the given 

population. However, counselors should not 

predetermine the clients’ expectations; instead, 

they should follow the clients’ lead and inquire 

about their preferences. 

Display sensitivity to culturally 

specific meanings of touch

Some treatment and many support groups 

have opening or closing traditions that include 

holding hands or giving hugs. This form of 

touching can be very uncomfortable to new 

clients regardless of cultural groups; cultural 

prescriptions, including religious beliefs, concerning appropriate touching can compound 

this effect (Comas-Diaz 2012). Many cultural 

groups use touch to acknowledge or greet 

someone, to show respect or convey status or 

power, or to display comfort. As counselors, it 

is essential to understand cultural norms about 

touch, which often are guided by gender and 

age, and the contexts surrounding “appropriate”touch for specific cultural groups (Srivastava 2007). Counselors need to devote time 

to understanding their clients’ norms for and 

interpretations of touch, to assisting clients in 

negotiating and upholding their cultural 

norms, and to helping clients understand the 

context and cultural norms that are likely to 

prevail in support and treatment groups. 

Explore culturally based experiences 

of power and powerlessness

Ideas about power and powerlessness are 

influenced by the client’s culture and social 

class. What constitutes power and powerlessness varies from culture to culture according to 

the individual’s gender, age, occupation, ancestry, religious affiliation, and a host of other 

factors. For example, power can be defined in 

terms of one’s place within the family, with the 

oldest member being the most powerful and 

the youngest being the least powerful. Even 

the words “power” and “powerlessness” carry 

cultural meaning. These words can carry 

negative connotations for clients with histories

of discrimination and multiple experiences 

with racism, for some women, for indigenous 

peoples with histories of colonization, and for 

refugees or immigrants who have left oppressive regimes. In this regard, counselors should 

use these words carefully. For example, a 

Hmong refugee who experienced trauma in 

her country of origin could already feel helpless and powerless over the events that occurred; thus, the concept of powerlessness, 

often used in drug and alcohol treatment 

programs, can be contraindicated in addressing her substance-related disorder. However, a 

White American business executive who has 

authority over others and a history of financial 

influence may need help acknowledging that 

he cannot control his substance abuse. 

Adjust communication styles to the 

client’s culture

Cultural groups all have different communication styles. Norms for communicating vary in 

and between cultural groups based on class, 

gender, geographic origins, religion, subcultures, and other individual variations. Counselors should educate themselves as much as 

possible regarding the patterns of communicating in the client’s cultural, racial, or ethnic 

population while also being aware of his/her 

own communication style. For a comprehensive guide in self-assessment and understanding of communication styles, refer to Culture 

Matters: The Peace Corps Cross-Cultural 

Workbook (Peace Corps Information 

Collection and Exchange 2012).

The following are general guidelines for ascertaining the client’s communication style:

• Understand the client’s verbal and nonverbal ways of communicating. Be aware of 

the possible need to move away from 

comprehending and interpreting client responses in conventional professional ways 

52
Chapter 2—Core Competencies for Counselors and Other Clinical Staff

How To Assess Differences in Communication Styles 

This exercise can be used by counselors and clinical supervisors as a self-assessment tool and a means 

of exploring differences in communication styles among counselors, clients, and supervisors. It can also 

serve as a group exercise to help clients discuss and understand cultural differences in communicating

with others. This self-administered tool promotes self-understanding and cultural knowledge. It is not 

an empirically based instrument, nor is it meant to assess client communication styles or skills formally. 

Materials needed: Colored pencils/pens and copies of the exercise.

Instructions: 

• First, place an X along the line for each item that best matches your style or pattern of communication overall. Communication patterns can change across situations and environments depending on expectations, stress level, and familiarity, (e.g., attending a staff meeting versus spending 

time with friends); try to assign the style that best reflects your patterns across situations. 

• After reviewing your own patterns, compare differences between you and your client, clinical 

supervisor, or fellow staff member. For example, select a recent client you treated and place a 

second X (using a different color pen) on each line to mark your perceived view of this client’s 

communication style. Then examine the differences between you and your client and generate a 

list of potential misunderstandings that could occur due to these differences. Use clinical supervision to discuss how your own patterns can hinder and/or promote the counseling process.

NONVERBAL PATTERNS

Eye Contact

When talking: 

 Direct, sustained Indirect or not sustained

When listening: 

 Direct, sustained Indirect or not sustained

Vocal Pitch/Tone

 High/loud Low/soft

More expressive Less expressive

Speech Rate

 Fast Slow

Pauses or Silence

 Little use of silence in dialog Pauses; uses silence in dialog

Facial Expressions

 Frequent expression Little expression

Use of Other Gestures

 Frequent expression Little expression

VERBAL PATTERNS

Emotional Expression

Does express and identify feelings in speech 

Does not express or identify 

feelings in speech

Self-Disclosure

Frequently Rarely or little

Formality

Informal

Formal in addressing

and showing respec

 others 

t 

(Continued on the next page.)

53
Improving Cultural Competence

• Styles of communication and nonverbal

methods of communication are important 

aspects of cultural groups. Issues such as 

the appropriate space to have between 

people; preferred ways of moving, sitting, 

and standing; the meaning of gestures; and 

the degree of eye contact expected are all 

culturally defined and situation specific 

(Hall 1976). As an example, high-context 

cultural groups place greater importance 

on nonverbal cues and message context, 

whereas low-context cultural groups rely 

largely on verbal message content. Most 

Asian Americans come from high-context 

cultural groups in which sensitive messages 

are encoded carefully to avoid offending 

others. A provider who listens only to the 

content could miss the message. What is 

not said can possibly be more important 

than what is said.

• Listen to storytelling carefully, as it can be

a way of communicating with the therapist. As in any good therapy, follow the associations and listen for possible 

metaphors to better understand relational 

meaning, cognition, and emotion within 

the context of the conversation. 

Interpret emotional expressions in 

light of the client’s culture 

Feelings are expressed differently across and 

within cultural groups and are influenced by 

the nature of a given event and the individuals 

involved in the situation. A certain level of 

emotional expression can be socially appropriate within one culture yet inappropriate in 

another. In some cultural groups, feelings may 

not be expressed directly, whereas in other 

cultural groups, some emotions are readily 

expressed and others suppressed. For example, 

expressions of sadness may at first be more 

readily shared by some clients in counseling 

settings, whereas others may find it more

How To Assess Differences in Communication Styles (continued)

Directness

Verbally explicit 

Indirect; subtle; doesn’t 

believe in saying everything

Context

Low context; relies more on 

words to convey meaning 

High context: verbal and 

nonverbal cues convey 

much of the meaning

Orientation

Orientation to self; use of “I” 

statements 

Orientation to others, use of 

plural and third-person 

pronouns (e.g., we, he)

Other Things To Consider in Exploring Communication Styles:

• Are there known differences in body language and expression within the given cultural group?

• What are the common, culturally appropriate parameters of touch across situations? For example, a handshake could be appropriate as a means of introduction for one cultural group but not

for another.

• How is personal space used in and outside of the office? Are there known cultural patterns in the

use of space and proximity of communication?

• What verbal and nonverbal counselor behaviors may affect trust in the counseling process?

Sources: Cormier et al. 2009; Fontes 2008; Srivastava 2007; Sue and Sue 2013a. 

54

(Bland and Kraft 1998). Always be curious 

about the client’s cultural context and be 

willing to seek clarification and better understanding from the client. It is as important for counselors to access and 

engage in cultural consultation to acquire 

more specific knowledge and experience.
Chapter 2—Core Competencies for Counselors and Other Clinical Staff

comfortable to express anger as their initial 

response. Counselors must recognize that not 

all cultures place the same value on verbalizing 

feelings. In fact, clients from some cultures 

may not perceive that emotional expression is 

a worthy course of treatment and healing at 

all. Thus, counselors should not impose a 

prescribed approach that measures progress 

and equates healing with the ability to display 

emotions. Likewise, counselors should be 

careful not to attribute meaning based on their 

own cultural backgrounds or to project their 

own feelings onto clients’ experiences. Instead, 

counselors need to assist their clients in identifying and labeling feelings within their own 

cultural contexts. 

Expand roles and practices 

Counselors need to acquire a mindset that 

allows for more flexible roles and practices—

while still maintaining appropriate professional boundaries—when working with clients. 

Some clients whose culture places considerable emphasis upon and orientation toward 

family could look to counselors for advice with 

unrelated issues pertaining to other family 

members. Other clients may expect a more 

prescribed and structured approach in which

counselors give specific recommendations and 

advice in the session. For example, Asian 

American clients appear to expect and benefit 

from a more directive and highly structured 

approach (Fowler et al. 2011; Lee and Mock 

2005a; Sue 2001; Uba 1994). Still others could 

expect that counselors be connected to their 

communities through participation in community events, in working with traditional 

healers, or in building collaborative relationships with other community agencies. As 

counselors, it is important to understand the 

cultural contexts of clients and how this translates to expectations in the client–counselor 

relationship. The appropriate role usually 

Results from the counselor’s understanding of 

and sensitivity to the values, cultures, and 

special needs of the individuals and groups 

being served (Sue and Sue 2013d). Counselors 

need to adopt an ongoing commitment to 

developing skills and endorsing practices that 

assist clients in receiving and experiencing the 

best possible care. Exhibit 2-6 lists counselor 

competencies endorsed by ACA for culturally 

appropriate intervention strategies. 

Self-Assessment for 

Individual Cultural 

Competence

Several instruments for evaluating an individual’s cultural competence have been developed 

and are available online. One assessment tool 

that has been widely circulated is Goode’s SelfAssessment Checklist for Personnel Providing 

Services and Supports to Children and Youth 

With Special Health Needs and Their Families. It 

can be adapted for counselors treating adult 

clients with behavioral health concerns. This 

tool and other additional resources are provided in Appendix C. For an interactive Webbased tool on cultural competence awareness, 

visit the American Speech-Language-Hearing 

Association Web site (http://www.asha.org). 

Providing good care goes beyond counselors’ general knowledge, clinical skills, and 

approaches; it involves understanding the 

multicultural context of clients and of 

themselves as counselors. Cultural competence is an ethical issue requiring counselors to be invested in developing the tools 

to provide culturally congruent care—care 

that matches the needs and context of the 

client. For a review of ethics and ethical 

dilemmas in a multicultural context, refer 

to Pack-Brown and Williams (2003).

55
Improving Cultural Competence

Exhibit 2-6: ACA Counselor Competencies: Culturally Appropriate Intervention 

Strategies 

Attitudes and beliefs:

• Culturally skilled counselors respect clients’ religious and/or spiritual beliefs and values, including attributions and taboos, because they affect worldview, psychosocial functioning, and expressions of distress.

• Culturally skilled counselors respect traditional helping practices and intrinsic help-giving networks in minority communities.

• Culturally skilled counselors value bilingualism and do not view another language as an impediment to counseling.

Knowledge:

• Culturally skilled counselors have a clear and explicit knowledge and understanding of the

generic characteristics of counseling and therapy (culture bound, class bound, and monolingual) 

and how they could clash with the cultural values of various minority groups.

• Culturally skilled counselors are aware of institutional barriers that prevent minorities from using 

behavioral health services.

• Culturally skilled counselors know of the potential biases in assessment instruments and use procedures and interpret findings in keeping with the cultural and linguistic characteristics of clients.

• Culturally skilled counselors have knowledge of minority family structures, hierarchies, values, 

and beliefs. They are knowledgeable about family and community characteristics and resources.

• Culturally skilled counselors are aware of relevant discriminatory practices at the social and community levels that could be affecting the psychological welfare of the populations being served.

Skills: 

• Culturally skilled counselors are able to engage in a variety of verbal and nonverbal helping 

responses. They are able to send and receive both verbal and nonverbal messages accurately 

and appropriately. They are not tied down to only one method or approach, recognizing that 

helping styles and approaches can be culture bound. When they sense that their helping style is 

limited and potentially inappropriate, they can anticipate and ameliorate its negative impact.

• Culturally skilled counselors are able to exercise institutional intervention skills on behalf of their 

clients. They can help clients determine whether a problem stems from racism or bias in others 

(the concept of health paranoia) so that clients do not inappropriately personalize problems.

• Culturally skilled counselors are not averse to seeking consultation with traditional healers, 

religious and spiritual leaders, and practitioners in the treatment of culturally diverse clients 

when appropriate.

• Culturally skilled counselors take responsibility for interacting in the languages requested by 

their clients; if not feasible, they make appropriate referrals. A serious problem arises when the 

linguistic skills of a counselor do not match the language of the client. When language matching 

is not possible, counselors should seek a translator with cultural knowledge and appropriate professional background and/or refer to a knowledgeable and competent bilingual counselor.

• Culturally skilled counselors have training and expertise in the use of traditional assessment and 

testing instruments, understand their technical aspects, and are aware of their cultural limitations. This allows counselors to use test instruments for the welfare of diverse clients.

• Culturally skilled counselors are aware of and work to eliminate biases, prejudices, and discriminatory practices. They are aware of sociopolitical contexts in conducting evaluation and providing interventions and are sensitive to issues of oppression, sexism, elitism, and racism.

• Culturally skilled counselors educate clients about the processes of psychological intervention, 

explaining such elements as goals, expectations, legal rights, and the counselor’s theoretical orientation.

Source: American Counseling Association Web site (http://www.counseling.org/docs/competencies/ 

cross-cultural_competencies_and_objectives.pdf). Adapted with permission.

56
Culturally Responsive 

Evaluation and 

Treatment Planning

Zhang Min, a 25-year-old first-generation Chinese woman, was 

referred to a counselor by her primary care physician because she 

reported having episodes of depression. The counselor who conducted the intake interview had received training in cultural competence and was mindful of cultural factors in evaluating Zhang 

Min. The referral noted that Zhang Min was born in Hong Kong, 

so the therapist expected her to be hesitant to discuss her problems, given the prejudices attached to mental illness and substance 

abuse in Chinese culture. During the evaluation, however, the 

therapist was surprised to find that Zhang Min was quite forthcoming. She mentioned missing important deadlines at work and 

calling in sick at least once a week, and she noted that her coworkers had expressed concern after finding a bottle of wine in her desk. 

She admitted that she had been drinking heavily, which she linked 

to work stress and recent discord with her Irish American spouse. 

Further inquiry revealed that Zhang Min’s parents, both Chinese, 

went to school in England and sent her to a British school in Hong 

Kong. She grew up close to the British expatriate community, and 

her mother was a nurse with the British Army. Zhang Min came to 

the United States at the age of 8 and grew up in an Irish American 

neighborhood. She stated that she knew more about Irish culture 

than about Chinese culture. She felt, with the exception of her 

physical features, that she was more Irish than Chinese—a view 

accepted by many of her Irish American friends. Most men she had 

dated were Irish Americans, and she socialized in groups in which 

alcohol consumption was not only accepted but expected. 

Zhang Min first started to drink in high school with her friends. 

The counselor realized that what she had learned about Asian 

3

 IN THIS CHAPTER

• Step 1: Engage Clients 

• Step 2: Familiarize Clients 

and Their Families With 

Treatment and Evaluation 

Processes

• Step 3: Endorse 

Collaboration in 

Interviews, Assessments, 

and Treatment Planning 

• Step 4: Integrate 

Culturally Relevant 

Information and Themes

• Step 5: Gather Culturally 

Relevant Collateral 

Information

• Step 6: Select Culturally 

Appropriate Screening 

and Assessment Tools

• Step 7: Determine 

Readiness and Motivation 

for Change

• Step 8: Provide Culturally 

Responsive Case 

Management 

• Step 9: Incorporate

Cultural Factors Into 

Treatment Planning

57
Improving Cultural Competence

Americans was not necessarily applicable to 

Zhang Min and that knowledge of Zhang 

Min’s entire history was necessary to appreciate the influence of culture in her life. The 

counselor thus developed treatment strategies 

more suitable to Zhang Min’s background. 

Zhang Min’s case demonstrates why thorough 

evaluation, including assessment of the client’s 

sociocultural background, is essential for treatment planning. To provide culturally responsive 

evaluation and treatment planning, counselors 

and programs must understand and incorporate 

relevant cultural factors into the process while 

avoiding a stereotypical or “one-size-fits-all” 

approach to treatment. Cultural responsiveness 

in planning and evaluation entails being open

minded, asking the right questions, selecting 

appropriate screening and assessment instruments, and choosing effective treatment providers and modalities for each client. Moreover, 

it involves identifying culturally relevant concerns and issues that should be addressed to 

improve the client’s recovery process. 

This chapter offers clinical staff guidance in 

providing and facilitating culturally responsive 

interviews, assessments, evaluations, and 

treatment planning. Using Sue’s (2001) multidimensional model for developing cultural 

competence, this chapter focuses on clinical 

and programmatic decisions and skills that are 

Multidimensional Model for Developing Cultural Competence: Clinical/Program 

Level 

58
Chapter 3—Culturally Responsive Evaluation and Treatment Planning

important in evaluation and treatment planning processes. The chapter is organized 

around nine steps to be incorporated by clinicians, supported in clinical supervision, and 

endorsed by administrators. 

Step 1: Engage Clients 

Once clients are in contact with a treatment 

program, they stand on the far side of a yet-tobe-established therapeutic relationship. It is up 

to counselors and other staff members to bridge 

the gap. Handshakes, facial expressions, greetings, and small talk are simple gestures that 

establish a first impression and begin building 

the therapeutic relationship. Involving one’s 

whole being in a greeting—thought, body, 

attitude, and spirit—is most engaging.

Fifty percent of racially and ethnically diverse 

clients end treatment or counseling after one 

visit with a mental health practitioner (Sue and 

Sue 2013e). At the outset of treatment, clients 

can feel scared, vulnerable, and uncertain about 

whether treatment will really help. The initial 

meeting is often the first encounter clients have

with the treatment system, so it is vital that 

they leave feeling hopeful and understood. 

Paniagua (1998) describes how, if a counselor 

lacks sensitivity and jumps to premature conclusions, the first visit can become the last:

Pretend that you are a Puerto Rican taxi driver in New York City, and at 3:00 p.m. on a 

hot summer day you realize that you have 

your first appointment with the therapist...later, you learned that the therapist 

made a note that you were probably depressed 

or psychotic because you dressed carelessly 

and had dirty nails and hands...would you 

return for a second appointment? (p. 120)

To engage the client, the counselor should try 

to establish rapport before launching into a 

series of questions. Paniagua (1998) suggests 

that counselors should draw attention to the 

presenting problem “without giving the impression that too much information is needed 

to understand the problem” (p. 18). It is also 

important that the client feel engaged with 

any interpreter used in the intake process. A 

common framework used in many healthcare 

training programs to highlight culturally 

responsive interview behaviors is the LEARN 

model (Berlin and Fowkes 1983). The how-to 

box on the next page presents this model. 

Step 2: Familiarize Clients 

and Their Families With

Treatment and Evaluation 

Processes

Behavioral health treatment facilities maintain 

their own culture (i.e., the treatment milieu). 

Counselors, clinical supervisors, and agency 

administrators can easily become accustomed 

to this culture and assume that clients are used 

to it as well. However, clients are typically new 

to treatment language or jargon, program 

expectations and schedules, and the intake and 

treatment process. Unfortunately, clients from 

diverse racial and ethnic groups can feel more 

estranged and disconnected from treatment 

services when staff members fail to educate 

them and their families about treatment expectations or when the clients are not walked 

Improving Cross-Cultural Communication

Health disparities have multiple causes. One 

specific influence is cross-cultural communication 

between the counselor and the client. Weiss 

(2007) recommends these six steps to improve 

communication with clients: 

1. Slow down.

2. Use plain, nonpsychiatric language.

3. Show or draw pictures.

4. Limit the amount of information provided at 

one time.

5. Use the “teach-back” method. Ask the client, 

in a nonthreatening way, to explain or show 

what he or she has been told.

6. Create a shame-free environment that encourages questions and participation.

 59
Improving Cultural Competence

through the treatment process, starting with 

the goals of the initial intake and interview. By 

taking the time to acclimate clients and their 

families to the treatment process, counselors 

and other behavioral health staff members

tackle one obstacle that could further impede 

treatment engagement and retention among 

racially and ethnically diverse clients. 

Step 3: Endorse 

Collaboration in 

Interviews, Assessments, 

and Treatment Planning

Most clients are unfamiliar with the evaluation and treatment planning process and how 

they can participate in it. Some clients may 

view the initial interview and evaluation as 

intrusive if too much information is requested 

or if the content is a source of family dishonor 

or shame. Other clients may resist or distrust 

the process based on a long history of racism 

and oppression. Still others feel inhibited from 

actively participating because they view the 

counselor as the authority or sole expert. 

The counselor can help decrease the influence 

of these issues in the interview process 

through a collaborative approach that allows 

time to discuss the expectations of both counselor and client; to explain interview, intake, 

and treatment planning processes; and to 

establish ways for the client to seek clarification of his or her assessment results (Mohatt 

et al. 2008a). The counselor can encourage 

collaboration by emphasizing the importance 

of clients’ input and interpretations. Client 

feedback is integral in interpreting results and 

How To Use the LEARN Mnemonic for Intake Interviews

Listen to each client from his or her cultural perspective. Avoid interrupting or posing questions 

before the client finishes talking; instead, find creative ways to redirect dialog (or explain session 

limitations if time is short). Take time to learn the client’s perception of his or her problems, concerns 

about presenting problems and treatment, and preferences for treatment and healing practices.

Explain the overall purpose of the interview and intake process. Walk through the general agenda 

for the initial session and discuss the reasons for asking about personal information. Remember that 

the client’s needs come before the set agenda for the interview; don’t cover every intake question at 

the expense of taking time (usually brief) to address questions and concerns expressed by the client.

Acknowledge client concerns and discuss the probable differences between you and your clients. 

Take time to understand each client’s explanatory model of illness and health. Recognize, when 

appropriate, the client’s healing beliefs and practices and explore ways to incorporate these into the 

treatment plan. 

Recommend a course of action through collaboration with the client. The client must know the 

importance of his or her participation in the treatment planning process. With client assistance, client 

beliefs and traditions can serve as a framework for healing in treatment. However, not all clients have 

the same expectations of treatment involvement; some see the counselor as the expert, desire a 

directive approach, and have little desire to participate in developing the treatment plan themselves. 

Negotiate a treatment plan that weaves the client’s cultural norms and lifeways into treatment goals, 

objectives, and steps. Once the treatment plan and modality are established and implemented, 

encourage regular dialog to gain feedback and assess treatment satisfaction. Respecting the client’s 

culture and encouraging communication throughout the process increases client willing to engage in 

treatment and to adhere to the treatment plan and continuing care recommendations. 

Sources: Berlin and Fowkes 1983; Dreachslin et al. 2013; Ring 2008. 

60
Chapter 3—Culturally Responsive Evaluation and Treatment Planning

can identify cultural issues that may affect 

intake and evaluation (Acevedo-Polakovich et 

al. 2007). Collaboration should extend to client 

preferences and desires regarding inclusion of

family and community members in evaluation 

and treatment planning.

Step 4: Integrate 

Culturally Relevant 

Information and Themes 

By exploring culturally relevant themes, 

counselors can more fully understand their 

clients and identify their cultural strengths 

and challenges. For example, a Korean woman’s family may serve as a source of support 

and provide a sense of identity. At the same 

time, however, her family could be ashamed 

of her co-occurring generalized anxiety and 

substance use disorders and respond to her 

treatment as a source of further shame because it encourages her to disclose personal 

matters to people outside the family. The 

following section provides a brief overview of 

suggested strength-based topics to incorporate into the intake and evaluation process. 

Immigration History

Immigration history can shed light on client 

support systems and identify possible isolation 

or alienation. Some immigrants who live in 

ethnic enclaves have many sources of social 

support and resources. By contrast, others may 

be isolated, living apart from family, friends, 

and the support systems extant in their countries of origin. Culturally competent evaluation should always include questions about the 

client’s country of origin, immigration status, 

length of time in the United States, and connections to his or her country of origin. Ask 

American-born clients about their parents’ 

country of origin, the language(s) spoken at 

home, and affiliation with their parents’ culture(s). Questions like these give the counselor 

important clues about the client’s degree of 

acculturation in early life and at present, cultural identity, ties to culture of origin, potential 

cultural conflicts, and resources. Specific questions should elicit information about: 

• Length of time in the United States, 

noting when immigration occurred or the 

number of generations who have resided in 

the United States.

• Frequency of returns and psychological 

and personal ties to the country of origin.

• Primary language and level of English 

proficiency in speaking and writing.

• Psychological reactions to immigration 

and adjustments made in the process.

• Changes in social status and other areas as 

a result of coming to this country.

• Major differences in attitudes toward 

alcohol and drug use from the time of 

immigration to now.

Advice to Counselors: Conducting 

Strength-Based Interviews 

By nature, initial interviews and evaluations can 

overemphasize presenting problems and concerns while underplaying client strengths and 

supports. This list, although not exhaustive, 

reminds clinicians to acknowledge client 

strengths and supports from the outset. 

Strengths and supports: 

• 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 2008. 

 61
Improving Cultural Competence

Cultural Identity and 

Acculturation

As shown in Zhang Min’s case at the beginning of this chapter, cultural identity is a 

unique feature of each client. Counselors 

should guard against making assumptions 

about client identity based on general ethnic 

and racial identification by evaluating the 

degree to which an individual identifies with 

his or her culture(s) of origin. As Castro and 

colleagues (1999b) explain, “for each group, 

the level of within-group variability can be 

assessed using a core dimension that ranges 

from high cultural involvement and acceptance of the traditional culture’s values to 

low or no cultural involvement” (p. 515). For 

African Americans, for example, this dimension is called “Afrocentricity.” Scales for Afrocentricity have been developed in an attempt 

to provide an indicator of an individual’s level 

of involvement within the traditional or core 

African-oriented culture (Baldwin and Bell 

1985; Cokley and Williams 2005; Klonoff and 

Landrine 2000). Many other instruments 

based on models of identity evaluate acculturation and identity. A detailed discussion of 

the theory behind such models is beyond the 

scope of this Treatment Improvement Protocol (TIP); however, counselors should have a 

general understanding of what is being measured when administering such instruments. 

The “Asking About Culture and Acculturation” advice box at right addresses exploration 

of culture and acculturation with clients. For 

more information on instruments that measure 

acculturation and/or identity, see Appendix B. 

Other areas to explore include the crosscutting factors outlined in Chapter 1, such as 

socioeconomic status (SES), occupation, 

education, gender, and other variables that can 

distinguish an individual from others who 

share his or her cultural identity. For example, 

a biracial client could identify with African 

American culture, White American culture, or 

both. When a client has two or more racial/ethnic identities, counselors should assess 

how the client self-identifies and how he or 

she negotiates the different worlds.

Membership in a Subculture

Clients often identify initially with broader 

racial, ethnic, and cultural groups. However, 

each person has a unique history that warrants 

an understanding of how culture is practiced

and has evolved for the person and his or her 

Advice to Counselors: Asking About 

Culture and Acculturation 

A thoughtful exploration of cultural and ethnic 

identity issues will provide clues for determining cultural, racial, and ethnic identity. There 

are numerous clues that you may derive from 

your clients’ answers, and they cannot all be 

covered in this TIP; this is only one set of 

sample questions (Fontes 2008). Ask these 

questions tactfully so they do not sound like an 

interrogation. Try to integrate them naturally 

into a conversation rather than asking one after 

another. Not all questions are relevant in all 

settings. Counselors can adapt wording to suit 

clients’ cultural contexts and styles of communication, because the questions listed here and 

throughout this chapter are only examples: 

• 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?

• What are your goals for this interview?

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Chapter 3—Culturally Responsive Evaluation and Treatment Planning

family; accordingly, counselors should avoid 

generalizations or assumptions. Clients are 

often part of a culture within a culture. There 

is not just one Latino, African American, or 

Native American culture; many variables 

influence culture and cultural identity (see the 

“What Are the Cross-Cutting Factors in Race, 

Ethnicity, and Culture” section in Chapter 1).

For example, an African American client from 

East Carroll Parish, LA, might describe his or 

her culture quite differently than an African 

American from downtown Hartford, CT. 

Beliefs About Health, Healing, 

Help-Seeking, and Substance Use 

Just as culture shapes an individual’s sense of 

identity, it also shapes attitudes surrounding 

health practices and substance use. Cultural 

acceptance of a behavior, for instance, can 

mask a problem or deter a person from seeking treatment. Counselors should be aware of 

how the client’s culture conceptualizes issues 

related to health, healing and treatment practices, and the use of substances. For example, 

in cases where alcohol use is discouraged or 

frowned upon in the community, the client 

can experience tremendous shame about

drinking. Chapter 5 reviews health-related 

beliefs and practices that can affect helpseeking behavior across diverse populations. 

Trauma and Loss 

Some immigrant subcultures have experienced 

violent upheavals and have a higher incidence 

of trauma than others. The theme of trauma 

and loss should therefore be incorporated into 

general intake questions. Specific issues under 

this general theme might include: 

• Migration, relocation, and emigration 

history—which considers separation from 

homeland, family, and friends—and the 

stressors and loss of social support that can 

accompany these transitions.

• Clients’ personal or familial experiences 

with American Indian boarding schools. 

• Experiences with genocide, persecution, 

torture, war, and starvation.

Advice to Counselors: Eliciting 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?

• How have you treated your drug and/or 

alcohol problem or emotional distress?

• What has been your experience with treatment programs?

Sources: Lynch and Hanson 2011; Tang and 

Bigby 1996; Taylor 2002.

 63
Improving Cultural Competence

Step 5: Gather Culturally 

Relevant Collateral 

Information 

A client who needs behavioral health treatment services may be unwilling or unable to 

provide a full personal history from his or her 

own perspective and may not recall certain 

events or be aware of how his or her behavior 

affects his or her well-being and that of others. Collateral information—supplemental 

information obtained with the client’s permission from sources other than the client—can 

be derived from family members, medical and 

court records, probation and parole officers, 

How To Use a Multicultural Intake Checklist

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 questions about the following topics using the client’s terminology, 

rather than using the word “problem.” Asking questions about the following topics can help you 

explore how a client may view 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

 Help-seeking patterns

 Beliefs about wellness 

 Beliefs about mental illness and mental health 

treatment

 Beliefs about substance use, abuse, and dependence

 Beliefs about substance abuse treatment

 Family views on substance use and substance 

abuse 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

 SES and financial concerns

 Cultural group affiliation 

 Current network of support

 Community concerns

 Review of confidentiality parameters and concerns

 Cultural concepts of distress (DSM-5*)

 DSM-5 culturally related V-codes

*Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American Psychiatric Association [APA] 2013). 

Sources: Comas-Diaz 2012; Constantine and Sue 2005; Sussman 2004.

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Chapter 3—Culturally Responsive Evaluation and Treatment Planning

community members, and others. Collateral 

information should include culturally relevant 

information obtained from the family, such as 

the organizational memberships, beliefs, and 

practices that shape the client’s cultural identity and understanding of the world.

As families can be a vital source of information, counselors are likely to attain more 

support by engaging families earlier in the 

treatment process. Although counselor interactions with family members are often limited 

to a few formal sessions, the families of racially

and ethnically diverse clients tend to play a 

more significant and influential role in clients’ 

participation in treatment. Consequently, 

special sensitivity to the cultural background 

of family members providing collateral information is essential. Families, like clients, 

cannot be easily defined in terms of a generic 

cultural identity (Congress 2004; Taylor et al. 

2012). Even families from the same racial 

background or ethnic heritage can be quite 

dissimilar, thus requiring a multidimensional 

approach in understanding the role of culture 

in the lives of clients and their families. Using 

the culturagram tool on the next page in 

preparation for counseling, treatment planning, or clinical supervision, clinicians can 

learn about the unique attributes and histories

that influence clients’ lives in a cultural context.

Step 6: Select Culturally 

Appropriate Screening 

and Assessment Tools 

Discussions of the complexities of psychological testing, the interpretation of assessment 

measures, and the appropriateness of screening procedures are outside the scope of this 

TIP. However, counselors and other clinical 

service providers should be able to use assessment and screening information in culturally 

competent ways. This section discusses several 

instruments and their appropriateness for 

specific cultural groups. Counselors should 

continue to explore the availability of mental 

health and substance abuse screening and 

assessment tools that have been translated into 

or adapted for other languages. 

Culturally Appropriate Screening 

Devices

The consensus panel does not recommend any 

specific instruments for screening or assessing 

mental or substance use disorders. Rather, 

when selecting instruments, practitioners 

should consider their cultural applicability to 

the client being served (AACE 2012; Jome 

and Moody 2002). For example, a screening 

instrument that asks the respondent about his 

or her guilt about drinking could be ineffective 

for members of cultural, ethnic, or religious 

groups that prohibit any consumption of 

alcohol. Al-Ansari and Negrete’s (1990) research supports this point. They found that 

the Short Michigan Alcoholism Screening 

Test was highly sensitive with people who use 

alcohol in a traditional Arab Muslim society; 

however, one question—“Do you ever feel 

guilty about your drinking?”—failed to distinguish between people with alcohol dependency

disorders in treatment and people who drank

in the community. Questions designed to 

measure conflict that results from the use of 

alcohol can skew test results for participants 

from cultures that expect complete abstinence 

from alcohol and/or drugs. Appendix D summarizes instruments tested on specific populations (e.g., availability of normative data for 

the population being served).

Culturally Valid Clinical Scales

As the literature consistently demonstrates, 

co-occurring mental disorders are common in 

people who have substance use disorders. 

Although an assessment of psychological 

problems helps match clients to appropriate 

 65
Improving Cultural Competence

How To Use a Culturagram for Mapping the Role of Culture 

The culturagram is an assessment tool that helps clinicians understand culturally diverse clients and 

their families (Congress 1994, 2004; Congress and Kung 2005). It examines 10 areas of inquiry, 

which should include not only questions specific to clients’ life experiences, but also questions 

specific to their family histories. This diagram can guide an interview, counseling, or clinical supervision session to elicit culturally relevant multigenerational information unique to the client and the 

client’s family. Give a copy of the diagram to the client or family for use as an interactive tool in the 

session. Throughout the interview, the client, family members, and/or the counselor can write brief 

responses in each box to highlight the unique attributes of the client’s history in the family context. 

This diagram has been adapted for clients with co-occurring mental and substance use disorders; 

sample questions follow.

Reasons for 

relocation or

migration

Legal and 

socioeconomic 

status

Time in 

community

Language 

spoken at home 

and in 

community

Family: List 

each member 

and circle the 

client’s name

Health beliefs 

and beliefs 

about drug 

and alcohol 

use

Values about 

structure, 

power, myths, 

and rules

Values about 

education and 

work Religious and 

cultural 

institutions, 

food, clothing, 

and holidays

Oppression 

and 

discrimination 

Impact of trauma, 

substance abuse, 

and other crisis 

events

Values about family structure, power, myths, and rules: 

• Are there specific gender roles and expectations in your family?

• Who holds the power within the family? 

• Are family needs more important than, or equally as important as, individual needs?

• Whom do you consider family?

Reasons for relocation or migration:

• Are you and your family able to return home?

• What were your reasons for coming to the United States?

• How do you now view the initial reasons for relocation? 

• What feelings do you have about relocation or migration? 

• Do you move back and forth from one location to another?

• How often do you and your family return to your homeland?

• Are you living apart from your family?

Legal status and SES:

• Has your SES improved or worsened since coming to this country? 

• Has there been a change in socioeconomic status across generations?

(Continued on the next page.)

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Chapter 3—Culturally Responsive Evaluation and Treatment Planning

How To Use a Culturagram for Mapping the Role of Culture (continued)

• What is the family history of documentation? (Note: Clients often need to develop trust before 

discussing legal status; they may come from a place where confidentiality is unfamiliar.)

Time in the community:

• How long have you and your family members been in the country? Community?

• Are you and your family actively involved in a culturally based community?

Languages spoken in and outside the home:

• What languages are spoken at home and in the community? 

• What is your and your family’s level of proficiency in each language? 

• How dependent are parents and grandparents on their children for negotiating activities surrounding the use of English? Have children become the family interpreters? 

Health beliefs and beliefs about help-seeking:

• What are the family beliefs about drug and alcohol use? Mental illness? Treatment?

• Do you and your family uphold traditional healing practices?

• How do help-seeking behaviors differ across generations and genders in your family? 

• How do you and your family define illness and wellness?

• Are there any objections to the use of Western medicine?

Impact of trauma and other crisis events:

• How has trauma affected your family across generations?

• How have traumas or other crises affected you and/or your family?

• Has there been a specific family crisis?

• Did the family experience traumatic events prior to migration—war, other forms of violence, 

displacement including refugee camps, or similar experiences?

Oppression and discrimination:

• Is there a history of oppression and discrimination in your homeland? 

• How have you and your family experienced discrimination since immigration?

Religious and cultural institutions, food, clothing, and holidays:

• Are there specific religious holidays that your family observes?

• What holidays do you celebrate?

• Are there specific foods that are important to you?

• Does clothing play a significant cultural or religious role for you?

• Do you belong to a cultural or social club or organization?

Values about education and work: 

• How much importance do you place on work, family, and education?

• What are the educational expectations for children within the family?

• Has your work status changed (e.g., level of responsibility, prestige, and power) since migration?

• Do you or does anyone in your family work several jobs?

Sources: Comas-Diaz 2012; Congress 1994, 2004; Singer 2007.

treatment, clinicians are cautioned to proceed 

carefully. People who are abusing substances or 

experiencing withdrawal from substances can 

exhibit behaviors and thinking patterns consistent with mental illness. After a period of 

abstinence, symptoms that mimic mental 

illness can disappear. Moreover, clinical instruments are imperfect measurements of 

equally imperfect psychological constructs that 

were created to organize and understand 

clinical patterns and thus better treat them; 

they do not provide absolute answers. As 

research and science evolve, so does our understanding of mental illness (Benuto 2012). 

Assessment tools are generally developed for 

particular populations and can be inapplicable 

 67
Improving Cultural Competence

to diverse populations (Blume et al. 2005; 

Suzuki and Ponterotto 2008). Appendix D 

summarizes research on the clinical utility of 

instruments for screening and assessing cooccurring disorders in various cultural groups. 

Diagnosis

Counselors should consider clients’ cultural 

backgrounds when evaluating and assessing 

mental and substance use disorders (Bhugra 

and Gupta 2010). Concerns surrounding 

diagnoses of mental and substance use disorders (and the cross-cultural applicability of 

those diagnoses) include the appropriateness 

of specific test items or questions, diagnostic 

criteria, and psychologically oriented concepts 

(Alarcon 2009; Room 2006). Research into 

specific techniques that address cultural differences in evaluative and diagnostic processes so 

far remains limited and underrepresentative of 

diverse populations (Guindon and Sobhany 

2001; Martinez 2009). 

Does the DSM-5 accurately diagnose mental 

and substance use disorders among immigrants and other ethnic groups? Caetano and 

Shafer (1996) found that diagnostic criteria 

seemed to identify alcohol dependency consistently across race and ethnicity, but their 

sample was limited to African Americans, 

Latinos, and Whites. Other research has 

shown mixed results. 

In 1972, the World Health Organization 

(WHO) and the National Institutes of Health 

(NIH) embarked on a joint study to test the 

cross-cultural applicability of classification 

systems for various diagnoses, including substance use disorders. WHO and NIH identified factors that appeared to be universal 

aspects of mental and substance use disorders 

and then developed instruments to measure 

them. These instruments, the Composite 

International Diagnostic Interview (CIDI) 

and the Schedules for Clinical Assessment in 

Neuropsychiatry (SCAN), include some DSM 

and International Statistical Classification of 

Diseases and Related Health Problems criteria. 

Studies report that both the CIDI and SCAN 

were generally accurate, but the investigators 

urge caution in translation and interview procedures (Room et al. 2003). 

Advice to Counselors and Clinical Supervisors: 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 in 

responses. Unfamiliarity with mainstream United States 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 (AACE) 2012; Saldaña 2001. 

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Chapter 3—Culturally Responsive Evaluation and Treatment Planning

Overall, psychological concepts that are appropriate for and easily translated by some 

groups are inappropriate for others. In some 

Asian cultures, for example, feeling refers more 

to a physical than an emotive state; questions 

designed to infer emotional states are not 

easily translated. In most cases, these issues 

can be remedied by using culture-specific 

resources, measurements, and references while 

also adopting a cultural formulation in the 

interviewing process (see Appendix E for the 

APA’s cultural formulation outline). The 

DSM-5 lists several cultural concepts of distress (see Appendix E), yet there is little empirical literature providing data or treatment 

guidance on using the APA’s cultural formulation or addressing cultural concepts of distress

(Martinez 2009; Mezzich et al. 2009). 

Step 7: Determine 

Readiness and Motivation 

for Change

Clients enter treatment programs at different 

levels of readiness for change. Even clients 

who present voluntarily could have been 

pushed into it by external pressures to accept 

treatment before reaching the action stage. 

These different readiness levels require different approaches. The strategies involved in 

motivational interviewing can help counselors 

prepare culturally diverse clients to change 

their behavior and keep them engaged in 

treatment. To understand motivational interviewing, it is first necessary to examine the 

process of change that is involved in recovery. 

See TIP 35, Enhancing Motivation for Change 

in Substance Abuse Treatment (Center for 

Substance Abuse Treatment [CSAT] 1999b), 

for more information on this technique. 

Stages of Change 

Prochaska and DiClemente’s (1984) classic 

transtheoretical model of change is applicable 

to culturally diverse populations. This model 

divides the change process into several stages: 

• Precontemplation. The individual does not 

see a need to change. For example, a person at this stage who abuses substances 

does not see any need to alter use, denies

that there is a problem, or blames the 

problem on other people or circumstances.

• Contemplation. The person becomes aware 

of a problem but is ambivalent about the 

course of action. For instance, a person 

struggling with depression recognizes that 

the depression has affected his or her life 

and thinks about getting help but remains 

ambivalent on how he/she may do this.

• Preparation. The individual has determined that the consequences of his or her 

behavior are too great and that change is 

necessary. Preparation includes small steps 

toward making specific changes, such as 

when a person who is overweight begins 

reading about wellness and weight management. The client still engages in poor 

health behaviors but may be altering some 

behaviors or planning to follow a diet. 

• Action. The individual has a specific plan 

for change and begins to pursue it. In relation to substance abuse, the client may 

make an appointment for a drug and alcohol assessment prior to becoming abstinent from alcohol and drugs. 

• Maintenance. The person continues to 

engage in behaviors that support his or her 

decision. For example, an individual with 

bipolar I disorder follows a daily relapse 

prevention plan that helps him or her assess warning signs of a manic episode and 

reminds him or her of the importance of

engaging in help-seeking behaviors to 

minimize the severity of an episode. 

Progress through the stages is nonlinear, with 

movement back and forth among the stages at 

different rates. It is important to recognize 

that change is not a one-time process, but 

 69
Improving Cultural Competence

rather, a series of trials and errors that eventually translates to successful change. For example, people who are dependent on substances 

often attempt to abstain several times before 

they are able to acquire long-term abstinence. 

Motivational Interviewing

Motivational interventions assess a person’s 

stage of change and use techniques likely to 

move the person forward in the sequence. 

Miller and Rollnick (2002) developed a therapeutic style called motivational interviewing, 

which is characterized by the strategic therapeutic activities of expressing empathy, developing discrepancy, avoiding argument, rolling 

with resistance, and supporting self-efficacy. 

The counselor’s major tool is reflective listening and soliciting change talk (CSAT 1999c). 

This nonconfrontational, client-centered 

approach to treatment differs significantly 

from traditional treatments in several ways, 

creating a more welcoming relationship. TIP 

35 (CSAT 1999c) assesses Project MATCH 

and other clinical trials, concluding that the 

evidence strongly supports the use of motivational interviewing with a wide variety of 

cultural and ethnic groups (Miller and 

Rollnick 2013; Miller et al. 2008). TIP 35 is a 

good motivational interviewing resource. For 

specific application of motivational interviewing with Native Americans, see Venner and 

colleagues (2006). For improvement of treatment compliance among Latinos with depression through motivational interviewing, see 

Interian and colleagues (2010). 

Step 8: Provide Culturally 

Responsive Case 

Management 

Clients from various racial, ethnic, and cultural populations seeking behavioral health services may face additional obstacles that can 

interfere with or prevent access to treatment 

and ancillary services, compromise appropriate 

referrals, impede compliance with treatment 

recommendations, and produce poorer treatment outcomes. Obstacles may include immigration status, lower SES, language barriers, 

cultural differences, and lack of or poor coverage with health insurance. 

Case management provides a single professional contact through which clients gain 

access to a range of services. The goal is to 

help assess the need for and coordinate social, 

health, and other essential services for each 

client. Case management can be an immense 

help during treatment and recovery for a 

person with limited English literacy and 

knowledge of the treatment system. Case 

management focuses on the needs of individual clients and their families and anticipates 

how those needs will be affected as treatment 

proceeds. The case manager advocates for the 

client (CSAT 1998a; Summers 2012), easing 

the way to effective treatment by assisting the 

client with critical aspects of life (e.g., food, 

childcare, employment, housing, legal problems). Like counselors, case managers should 

possess self-knowledge and basic knowledge 

of other cultures, traits conducive to working 

well with diverse groups, and the ability to 

apply cultural competence in practical ways. 

Cultural competence begins with selfknowledge; counselors and case managers 

should be aware of and responsive to how 

their culture shapes attitudes and beliefs. 

This understanding will broaden as they 

gain knowledge and direct experience with 

the cultural groups of their client population, enabling them to better frame client 

issues and interact with clients in culturally 

specific and appropriate ways. TIP 27, 

Comprehensive Case Management for 

Substance Abuse Treatment (CSAT 

1998a), offers more information on effective case management.

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Chapter 3—Culturally Responsive Evaluation and Treatment Planning

Exhibit 3-1 discusses the cultural matching of 

counselors with clients. When counselors 

cannot provide culturally or linguistically 

competent services, they must know when and 

how to bring in an interpreter or to seek other 

assistance (CSAT 1998a). Case management 

includes finding an interpreter who communicates well in the client’s language and dialect 

and who is familiar with the vocabulary required to communicate effectively about sensitive subject matter. The case manager works 

within the system to ensure that the interpreter, when needed, can be compensated. Case 

managers should also have a list of appropriate

referrals to meet assorted needs. For example, 

an immigrant who does not speak English 

may need legal services in his or her language; 

an undocumented worker may need to know 

where to go for medical assistance. Culturally 

competent case managers build and maintain 

rich referral resources for their clients. 

The Case Management Society of America’s 

Standards of Practice for Case Management

(2010) state that case management is central 

in meeting client needs throughout the course 

of treatment. The standards stress understanding relevant cultural information and communicating effectively by respecting and being 

responsive to clients and their cultural contexts. 

For standards that are also applicable to case 

management, refer to the National Association 

of Social Workers’ Standards on Cultural 

Competence in Social Work Practice (2001). 

Step 9: Incorporate 

Cultural Factors Into

Treatment Planning

The cultural adaptation of treatment practices 

is a burgeoning area of interest, yet research is 

limited regarding the process and outcome of 

culturally responsive treatment planning in 

behavioral health treatment services for 

Exhibit 3-1: Client–Counselor Matching

The literature is inconclusive about the value of 

client–counselor matching based on race, 

ethnicity, or culture (Imel et al. 2011; Larrison et 

al. 2011; Suarez-Morales et al. 2010). Sue et al. 

(1991) found that for people whose primary 

language was not English, counselor–client 

matching for ethnicity and language predicted 

longer time in treatment (more sessions) with 

better outcomes for all ethnic groups studied: 

Asian Americans, African Americans, Mexican 

Americans, and White Americans. 

Ethnic matches may work better for Latinos in 

treatment; gender congruence seems more 

important than race or ethnicity in client–

counselor matching, particularly for female 

clients (Sue and Sue 2013a). For Asian Americans

and Pacific Islanders, the many different ethnic 

subgroups make a cultural match more difficult. 

In multicultural communities, racial and ethnic 

matching may help develop a working alliance 

between the therapist and the consumer (Chao 

et al. 2012). Other relevant variables of both the 

client and therapist are age, marital status, 

training, language, and parental status. The 

extent to which a cultural match is necessary in 

therapy depends on client preferences, characteristics, presenting problems, and treatment 

needs. For example, gender matching could be 

more important than race/ethnicity matching to 

female sexual abuse survivors, who may have 

difficulty discussing their trauma with male 

counselors.

Most clients want to know that their counselors 

understands their worldviews, even if they do 

not share them. Counselors’ understanding of 

their clients’ cultures improves treatment outcomes (Suarez-Morales et al. 2010). Fiorentine 

and Hillhouse (1999) found that empathy, 

regardless of race or ethnicity of counselor and 

client, was the most important predictor of 

favorable treatment outcomes. Sue et al. (1991) 

found that clients using outpatient mental 

health services more readily attended treatment 

and stayed longer if services were culturally 

responsive. In the treatment planning process, 

matching clients with providers according to 

cultural (and subcultural, when warranted) 

backgrounds can help provide treatment that is 

responsive to the personal, cultural, and clinical 

needs of clients (Fontes 2008).

 71
Improving Cultural Competence

diverse populations. How do counselors and 

organizations respond culturally to the diverse 

needs of clients in the treatment planning 

process? How effective are culturally adaptive 

treatment goals? (For a review, see Bernal and 

Domenech Rodriguez 2012.) Typically, programs that provide culturally responsive services approach treatment goals holistically, 

including objectives to improve physical 

health and spiritual strength (Howard 2003). 

Newer approaches stress implementation of 

strength-based strategies that fortify cultural 

heritage, identity, and resiliency. 

Treatment planning is a dynamic process that 

evolves along with an understanding of the 

clients’ histories and treatment needs. Foremost, counselors should be mindful of each

client’s linguistic requirements and the availability of interpreters (for more detail on interpreters, see Chapter 4). Counselors should be 

flexible in designing treatment plans to meet 

client needs and, when appropriate, should 

draw upon the institutions and resources of 

clients’ cultural communities. Culturally responsive treatment planning is achieved 

through active listening and should consider 

client values, beliefs, and expectations. Client 

health beliefs and treatment preferences (e.g., 

purification ceremonies for Native American 

clients) should be incorporated in addressing 

specific presenting problems. Some people seek 

help for psychological concerns and substance 

abuse from alternative sources (e.g., clergy, 

elders, social supports). Others prefer treatment 

programs that use principles and approaches 

specific to their cultures. Counselors can suggest appropriate traditional treatment resources 

to supplement clinical treatment activities. 

In sum, clinicians need to incorporate culturebased goals and objectives into treatment plans 

and establish and support open client–

counselor dialog to get feedback on the proposed plan’s relevance. Doing so can improve 

client engagement in treatment services, compliance with treatment planning and recommendations, and treatment outcomes. 

Group Clinical Supervision Case Study

Beverly is a 34-year-old White American who 

feels responsible for the tension and dissension 

in her family. Beverly works in the lab of an 

obstetrics and gynecology practice. Since early 

childhood, her younger brother has had problems that have been diagnosed differently by 

various medical and mental health professionals. He takes several medications, including one 

for attention deficit disorder. Beverly’s father 

has been out of work for several months. He is 

seeing a psychiatrist for depression and is on an 

antidepressant medication. Beverly’s mother 

feels burdened by family problems and ineffective in dealing with them. Beverly has always 

helped her parents with their problems, but she 

now feels bad that she cannot improve their 

situation. She believes that if she were to work 

harder and be more astute, she could lessen her 

family’s distress. She has had trouble sleeping. 

In the past, she secretly drank in the evenings to 

relieve her tension and anxiety. 

Most counselors agree that Beverly is too submissive and think assertiveness training will help 

her put her needs first and move out of the 

family home. However, a female Asian American 

counselor sees Beverly’s priorities differently, 

saying that “a morally responsible daughter is 

duty-bound to care for her parents.” She thinks 

that the family needs Beverly’s help, so it would 

be selfish to leave them.

Discuss: 

• How does the counselor’s worldview affect 

prioritizing the client’s presenting problems?

• How does the counselor’s individualistic or 

collectivistic culture affect treatment planning?

• How might a counselor approach the initial 

interview and evaluation to minimize the influence of his or her worldview in the evaluation and treatment planning process?

Sources: The Office of Nursing Practice and 

Professional Services, Centre for Addiction and 

Mental Health & Faculty of Social Work, University of Toronto 2008; Zhang 1994. 

72
Pursuing Organizational 

Cultural Competence

Cavin, a 42-year-old African American man, arrived at a wellknown private substance abuse treatment center confused and 

unable to provide his medical history at intake. Referred to the 

center through his employee assistance program, he was accompanied by his spouse and 14-year-old son. Cavin’s wife provided 

his medical history and recounted her husband’s 2-year decline 

from a promising career as a journalist, researcher, and social 

commentator to a bitter, often paranoid man who abused cocaine 

and alcohol. Cavin, she explained, had become increasingly unpredictable. 

Upon admission, Cavin was initially cooperative and grateful to 

his spouse for her efforts, but as withdrawal continued, he became 

increasingly agitated, insisting that he could detoxify on his own. 

He resisted any intervention by staff members whom he perceived 

to be critical or patronizing. On his fourth day in treatment, 

Cavin began to note the treatment center’s “White” environment. 

There were almost no African American employees—none at the 

clinical level. He noted how decor reflected only White American 

culture. Driven in part by his substance use disorder, he was looking for reasons to leave. Later that evening, he checked out. 

Cavin was unable to relate to his treatment. He found no cultural 

cues with which to identify or connect. Therefore, he started 

searching for reasons to leave—behavior typical in persons who 

abuse substances. People often leave treatment with the conscious

hope of managing their substance abuse themselves and the unconscious drive to relive positive experiences associated with substance use; meanwhile, they all too easily forget the pain imposed 

by the use of alcohol and other substances. Cavin may have remained in treatment if services had been more culturally responsive. This is an example of how behavioral health programs benefit

 IN THIS CHAPTER

• Cultural Competence at 

the Organizational Level

• Organizational Values

• Governance

• Planning

• Evaluation and 

Monitoring

• Language Services 

• Workforce and Staff 

Development

• Organizational 

Infrastructure

4

73
Improving Cultural Competence

from commitment to culturally responsive 

services, staffing, and treatment—if they make 

no such commitment, their services may be 

underused, unwelcome, and ineffective.

Cultural Competence at 

the Organizational Level

At the organizational level, cultural competence or responsiveness refers to a set of congruent behaviors, attitudes, and policies that 

enable a system, agency, or group of professionals to work effectively in multicultural 

environments (Cross et al. 1989). Organizational cultural responsiveness is a dynamic, 

ongoing process; it is not something that is 

achieved once and is then complete. Organizational structures and components change. The 

demographics and needs of communities 

change. Employees and their job descriptions 

change. Consequently, the commitment to 

increase cultural competence must also involve 

a commitment to maintain it through periodic 

reassessments and adjustments. Based on the 

Cross et al. (1989) definition of the culturally 

competent organization, Goode (2001) identifies three principal components (Exhibit 4-1) 

that coincide with Sue’s (2001) multidimensional model for developing cultural competence in behavioral health services.

Multidimensional Model for Developing Cultural Competence: Organizational/

Administrative Level 

74
Chapter 4—Pursuing Organizational Cultural Competence

This chapter provides a broad overview of 

how behavioral health organizations can create 

an institutional framework for culturally 

responsive program delivery, staff development, policies and procedures, and administrative practices. Built on the U.S. Department of 

Health and Human Services’ (HHS’s) Office 

of Minority Health (OMH) Enhanced 

National Standards for Culturally and 

Linguistically Appropriate Services in Health 

and Health Care (OMH 2013; for review, see 

Appendix C), this chapter is organized around 

the Health Resources and Services 

Administration’s (HRSA’s) domains of organizational cultural competence: organizational 

values, governance, planning, evaluation and 

monitoring, communication (language services), workforce and staff development, and 

organizational infrastructure (Linkins et al. 

2002). (Another domain, services and interventions, is covered in Chapter 3.) 

Within each domain, specific organizational 

tasks are suggested to aid program and administrative staff in developing a culturally 

responsive clinical, work, and organizational

environment (Exhibit 4-2); these domains and 

Exhibit 4-1: Requirements for 

Organizational Cultural Competence

• The organization needs a defined set of 

values and principles, along with demonstrated behaviors, attitudes, policies, and 

structures that enable effective work across 

cultures.

• The organization must value diversity, 

conduct self-assessment, manage the dynamics of difference, acquire and institutionalize cultural knowledge, and adapt to 

diversity and the cultural contexts of the 

communities it serves.

• The organization must incorporate the 

above in all aspects of policymaking, administration, and service delivery and systematically involve consumers and families.

Source: Goode 2001. 

Exhibit 4-2: Creating Culturally 

Responsive Treatment Environments

Organizational values tasks: 

• Commit to cultural competence.

• Review and update vision, mission, and 

value statements.

• Address cultural competence in strategic 

planning processes.

Governance tasks: 

• Assign a senior manager to oversee the 

organizational development of culturally responsive practices and services.

• Develop culturally competent governing and 

advisory boards.

• Create a cultural competence committee.

Planning tasks: 

• Engage clients, staff, and community in the 

planning, development, and implementation 

of culturally responsive services.

• Develop a cultural competence plan.

• Review and develop policies and procedures 

to ensure culturally responsive organizational practices. 

Evaluation and monitoring tasks: 

• Create demographic profiles of the community, clientele, staff, and board.

• Conduct an organizational self-assessment 

of cultural competence.

Language services tasks: 

• Plan for language services proactively.

• Establish practice and training guidelines for 

the provision of language services.

Workforce and staff development tasks: 

• Develop staff recruitment, retention, and 

promotion strategies that reflect the population(s) served.

• Create training plans and curricula that 

address cultural competence.

• Give culturally congruent clinical supervision.

• Evaluate staff performance on culturally 

congruent and complementary attitudes, 

knowledge, and skills.

Organizational infrastructure: 

• Invest in long-range fiscal planning to promote cultural competence. 

• Create an environment that reflects the 

populations served.

• Develop outreach strategies to improve 

access to care.

Source: Linkins et al. 2002. 

 75
Improving Cultural Competence

tasks are adapted to behavioral health services. 

Task overlap across domains may require work 

on several tasks at once. HRSA’s organizational 

cultural competence assessment profile is available online (http://www.hrsa.gov/cultural 

competence/healthdlvr.pdf; Linkins et al. 

2002).

Organizational Values

Journey Mental Health Center ( JMHC), a 

large outpatient mental health and substance 

abuse treatment clinic in Wisconsin, is an 

organization that is committed to providing 

accessible, community-focused, culturally 

responsive behavioral health services. JMHC 

offers the following commentary on the importance of clear, culturally responsive organizational values ( JMHC 2013, paragraphs 1-3): 

...cultural competence is fundamental to 

providing quality services that promote individual and family strengths, dignity, and selfreliance. Cultural competence broadens and 

enriches the delivery of mental health and 

alcohol and other drug abuse (AODA) services by providing a more holistic, relevant 

view of the world and the helping process. 

Cultural competence does not stand apart 

from, but is intrinsic to good clinical practice. 

Its threads are woven into the tapestry of effective assessment, treatment planning, intervention, advocacy, and support. In addition, 

cultural competence is intrinsic to effective 

staff relationships and business practices.

Cultural competence promotes relationships 

based upon understanding and knowledge of 

how one’s own cultural beliefs and values influence the organization of information, perceptions, feelings, experiences, and coping 

strategies. It involves being able to identify, 

learn from, and incorporate these into the 

helping process. When cultural competence is 

an integral part of personal competence, there 

is the maximum opportunity to increase the 

amount and quality of information and the 

speed with which that information can be 

shared and processed and to form healthy alliances.

Cultural competence demands an ongoing 

commitment to openness and learning, taking 

time and taking risks, sitting with uncertainty 

and discomfort, and not having quick solutions or easy answers. It involves building 

trust, mentoring, and developing and nurturing a frame of reference that considers alliances across culture as enriching rather than 

threatening shared goals. 

Task: Commit to Cultural 

Competence

Counselors are typically a part of a larger 

organization or system, but the focus on and 

responsibility for developing culturally responsive services has historically fallen on individual practitioners rather than on organizations. 

Most literature on cultural competence addresses the cultural awareness, knowledge, and 

skills of the practitioner, but until recently, it 

has failed to apply these same concepts to 

agencies. Cultural competence among counselors is only as effective as their agencies’

commitment to and support of cultural competence and ability to value diversity through 

culturally congruent administrative practices, 

including—but not limited to—policies and 

procedures, programming, staffing, and community involvement. 

Counselors are unlikely to affect organizational change to the same degree as the agency’s 

overall administration can. Hence, culturally 

responsive treatment cannot be sustained 

without an agency’s commitment and support. 

In fact, the organization itself can prevent 

clients from receiving culturally responsive 

services or treatment opportunities. Organizations that are unaware of cultural issues can 

fail to recognize that diverse groups may have 

difficulty accessing and engaging in treatment. 

Also, counselors who attempt to use culturally 

responsive practices—such as the involvement 

of family members (as defined by the client) 

and traditional healers—can encounter insurmountable hurdles if their agencies’ policies 

76
Chapter 4—Pursuing Organizational Cultural Competence

and resources do not support these practices. 

The system can actually impede efforts made 

by counselors invested and trained in cultural 

competence. Thus, the development of cultural 

competence begins at the top level of the 

organization, with an initial focus on systemic 

changes. 

Cultural competence does not occur by accident. To maximize its effectiveness in working 

with diverse groups, the organization must 

first view diversity as an asset. As importantly, 

the organization must ensure that its process 

of developing cultural competence has the 

genuine, full, and lasting support of the organization’s leadership. The chief executive officer 

(CEO), senior management, and board of 

directors play critical roles. A strong mandate 

from the board or CEO, coupled with a commitment to provide resources, can be a good 

motivator for staff and committees to undertake major organizational change. Support of 

cultural competence must be made clear 

throughout the organization and community 

in meaningful ways, in words and actions.

Leadership can make a difference in the implementation of culturally responsive practices 

by creating an organizational climate that 

encourages and supports such practices. This 

includes a willingness to discuss the importance of cultural competence, try new 

practices or approaches, tolerate the uncertainty that accompanies transitional periods during which practices and procedures are 

evolving, respond to unforeseen barriers, and 

revise innovations that are not working as 

intended. It is important that leadership be 

genuinely committed to the effort and that 

their support be tangibly apparent in the

allocation of relevant resources. A strong 

commitment to improving organizational 

cultural competence should include the obligation to monitor procedures after they have 

been implemented, maintain and reevaluate

new practices, and provide resources and 

opportunities for ongoing training and culturally competent supervision.

Task: Review and Update Vision, 

Mission, and Value Statements

The organization’s mission, vision, and value 

statements are vitally important in creating a 

conceptual framework that promotes culturally responsive behavioral health services. 

Agencies should examine how these statements are developed. Are stakeholders involved in the development process? In what 

ways does the organization ensure that its 

values and mission reflect the community and 

populations that it serves? Does the organization see this task as a singular event, or has it 

planned for periodic review of its values and 

mission to ensure continued organizational 

responsiveness as needs, populations, or environments change? 

Initially, the planning committee should determine how the culture of the organization as 

well as the surrounding community can support achievement of the mission and vision 

statements. Culturally responsive organizational statements cannot provide a tangible 

framework unless supported by community, 

referral, and client demographics; a needs 

assessment; and an implementation plan. 

Mission and vision statements need to be 

operationalized through identified goals as 

well as measurable indicators to track progress. 

The Hands Across Cultures Corporation of 

Organizations that fail to endorse and 

make a commitment to cultural competence will more than likely displace the 

responsibility of cultural competence onto 

counselors or clients. If the responsibility is 

on the clients, it is likely that the clients will 

have to “fit” or change to match the 

treatment or program rather than treatment services being adapted to fit the 

needs of clients.

 77
Improving Cultural Competence

northern New Mexico, which serves Native 

peoples within pueblos (American Indians), 

the City of Española, Pojoaque Valley, and 

surrounding communities (predominantly 

Latino), addresses the importance of the 

cultural context of its work in its mission and 

philosophy statements (Exhibit 4-3). 

Task: Address Cultural 

Competence in Strategic Planning 

Processes

The strategic planning process provides an 

opportunity to reevaluate an agency’s values, 

mission, and vision regarding cultural competence. A comprehensive process involves evaluating the organization’s internal and external 

environments prior to holding planning meetings; this evaluation involves conducting staff, 

client, and community assessments. From 

assessing current needs to evaluating global 

factors that influence the direction and delivery of services (e.g., funding sources, treatment mandates, changes in health insurance), 

organizations can begin to gain insight into 

the demands and challenges of providing 

culturally responsive services. Moreover, strategic planning is an opportunity to explore 

and develop short- and long-term goals that 

focus on incorporating culturally responsive 

delivery systems while addressing issues of 

sustainability (i.e., how to provide resources 

and support the implementation of culturally 

responsive policies and procedures over time). 

A formal strategic planning meeting should be 

held to determine specific goals, objectives, 

and tasks that will ensure quality improvement 

in culturally responsive services. The development of timelines and methods to evaluate 

progress, obstacles, and directions for each 

goal are equally important. For organizations 

that do not have a specific cultural competence 

plan prior to the strategic planning meeting, 

this process can provide the forum for developing the steps needed to create a formal plan. 

Governance

Task: Assign a Senior Manager To 

Oversee the Development of 

Culturally Responsive Practices 

and Services

From the outset, a senior staff member with 

the authority to implement change should be 

assigned to oversee the developmental process 

of planning, evaluating, and implementing 

culturally responsive administrative and clinical services. Key responsibilities include the 

ongoing development and facilitation of cultural competence committees and advisory 

boards, management of evaluative processes, 

facilitation of the development of a cultural 

competence plan and its implementation, and 

oversight of policies and procedures to ensure 

cultural competence within the organization 

and among staff. Cultural competence cannot 

come to fruition with only one voice being 

heard, but assigning a key person to oversee 

Exhibit 4-3: Hands Across Cultures 

Mission Statement 

Mission

To improve the health, education and well 

being of the people of Northern New Mexico 

through family-centered approaches deeply 

rooted in the multicultural traditions of their 

communities.

Philosophy

To believe in culture as the foundation of 

human growth; spirituality as the strength of 

the people; each person’s need to love and be 

loved; family preservation; individual responsibility; and the pursuit of human potential.

With a firm commitment to these beliefs, 

Hands Across Cultures’ Board of Directors, 

staff, and collaborators hold that:

Culture Is the Cure

La Cultura Cura

Source: Hands Across Cultures 2014. 

78
Chapter 4—Pursuing Organizational Cultural Competence

the process will more likely keep top-priority

goals and objectives in view.

Task: Develop Culturally 

Competent Governing and 

Advisory Boards

Beyond having the foresight to plan for and 

develop culturally responsive services, it is vital 

that executive staff members on governing and 

advisory boards and committees are educated 

about and invested in the organization’s mission and plan. For example, the board’s human resources committee may be more 

invested in developing and reinforcing culturally responsive recruitment and hiring policies 

and practices if they are involved in the strategic planning process and educated about the 

organization’s mission, values, and vision. At 

the same time, the organization should seek 

outside direction. Given that sharing information about the agency’s activities with 

others outside the organization can create 

some hesitancy or be a potential barrier, the 

executive staff can frame the planning process 

as an opportunity for positive development 

and community involvement as a powerful 

resource. The organization should establish a 

community advisory board that includes 

stakeholders, specialists, and/or experts in 

multicultural behavioral health services along 

with key administrators and staff. This advisory board should consist of local community 

members from whom the organization can 

solicit valuable advice, input, and potential 

support for the development of culturally 

responsive treatment (Minnesota Department 

of Human Services 2004). 

Representation should include clients, alumni, 

family members, and community-based 

organizations and institutions (e.g., community centers, faith communities, social service 

organizations). Developing an inclusive advisory board of community members can enhance and extend use of and referral from 

other community agencies. Moreover, this 

board can help identify community leaders 

and culturally appropriate resources for the 

client population to supplement treatment 

activities, such as traditional healing practices

(Castro et al. 1999a). The advice box on the 

next page reviews strategies for engaging

communities in the development of culturally 

responsive services.

Task: Establish a Cultural 

Competence Committee 

By creating a committee within the organization to guide the process of becoming culturally competent and responsive, the 

organization ensures that a core group will 

provide oversight and direction. This committee should be inclusive not only in terms of 

the racial and ethnic composition of the population served, but also in terms of drawing 

from all levels of the organization (Whaley 

and Longoria 2008). Representatives of the 

advisory board should also be included. Program administrators should provide direction 

to the cultural competence committee. The 

person assigned to take the lead on cultural 

competence should chair the committee, and 

the CEO should be noticeably involved.

The cultural competence committee will 

oversee the organization’s self-assessment

process while also creating the demographic 

profile of the organization’s community, developing a cultural competence plan, and formulating and monitoring procedures that evaluate 

the implementation and effectiveness of the 

organization’s plan in developing culturally 

responsive services and practices. The committee should ensure that the organization’s plans 

are continually updated. To succeed, this team 

must be empowered to influence, formulate, 

implement, and enforce initiatives on all levels 

and throughout every department of the 

organization (Constantine and Sue 2005; 

Fung et al. 2012), including, for example, 

 79
Improving Cultural Competence

presenting data and subsequent recommendations to the administration and boards based 

on employee feedback about their experiences 

with newly adopted, culturally responsive 

procedures in the organization. Exhibit 4-4 

highlights key issues in behavioral health 

treatment that must be addressed in providing 

culturally responsive services. 

Planning 

Task: Engage Clients, Staff, and 

the Community in the Planning, 

Development, and 

Implementation of Culturally 

Responsive Services 

Organizations can sometimes have the best 

intentions of creating culturally responsive 

services but miss the mark by operating in a 

vacuum. Initially, the vacuum approach can 

appear less time consuming, complex, and 

expensive, but it can also represent paternalism 

whereby organizations or administrators 

assume that they inherently know what is best 

for the program, clients, staff, and community. 

Instead, organizations and the services that 

Exhibit 4-4: Critical Treatment Issues 

To Consider in Providing Culturally 

Responsive Services

• Access: Degree to which services for clients 

are quickly and readily available.

• Engagement: Having appropriate skills and 

an environment that have a positive personal impact on the quality of clients’ 

commitment to treatment.

• Retention: The result of quality services 

that help maintain clients in treatment with 

continued commitment.

Source: The Connecticut Department of Children and Families, Office of Multicultural 

Affairs 2002. 

Advice to Administrators: Strategies To Engage Communities in Developing 

Culturally Responsive Treatment Services 

• Ask board members to help recruit key members of the local community.

• Create a community advisory group to complement the governing boards in assessing and

recommending culturally responsive policies, procedures, and practices.

• Develop local community focus groups to discuss key treatment needs, health beliefs, and attitudes and behaviors related to substance use, mental illness, and help-seeking that could be unknown to others outside of the community and in the organization.

• Develop a policy that supports the use of culturally congruent communication modalities and 

technologies for sharing information with communities. 

• Provide inservice training, continuing education, and other professional development activities 

(e.g., networking events) that focus on strengthening skills for collaboration with culturally and 

linguistically diverse communities.

• Develop policies and procedures to support community involvement in the treatment setting 

(e.g., incorporating peer support programs, having a presence at community housing events, 

developing partnerships with traditional healers).

• Develop local outreach and educational programs in multiple languages (e.g., provide family 

education on substance use patterns and community issues in Spanish at a community center). 

• Participate in community events to raise awareness of services, to develop trust and build relationships, and to gain further knowledge of local cultural groups and community practices. 

• Periodically analyze community demographic trends and populations served by the treatment 

organization; ensure representation of these diverse populations on the advisory board. 

• Become knowledgeable about and use available local goods and services.

Sources: Goode 2001; National Center for Cultural Competence 2013; Washington State Department of Social and Health Services 2011. 

80
Chapter 4—Pursuing Organizational Cultural Competence

they provide need to be congruent with the 

specific populations being served; clients and 

the community should have an opportunity to 

provide input on how services are delivered

and the types of services that are needed. 

Otherwise, services may be poorly matched to 

clients, underused by the community, and 

detrimental to agency financial resources. For 

example, an agency could decide that family 

therapy is a culturally appropriate service and 

proceed to create a multifamily program 

(treating several families together in a group 

format) without considering that, for some 

cultural groups, family shame associated with 

seeking help can deter the use of such services. 

Staff members are likely to have specific 

knowledge of client needs and to be able to 

identify potential obstacles or challenges in 

how an organization attempts to implement 

culturally responsive policies and procedures. 

A parallel process that can influence the potential success of staff involvement and commitment to the development of cultural 

competence is the organizational culture. 

Suppose, for example, that the staff perceives 

the organization’s new commitment to cultural 

competence as another expectation of more 

work without training, adequate clinical 

supervision, or ongoing support. Maybe staff 

members have historically experienced frequent announcements, mandates, or excitement generated by the administration that 

fade quickly. Perhaps the organization arranges committees and meetings, purporting 

that they want staff input despite the fact 

that decisions have already been made.

The organizational climate sets the stage for 

staff responsiveness and motivation in developing cultural competence and in implementing culturally responsive services. Without an 

organizational history and culture of supporting change across time, staff members will 

likely resent an increase in expectations without some means of compensating for additional work, perceive themselves as powerless 

over the proposed changes, or minimize the 

need to make any immediate changes. For 

example, staff members may view changes as 

temporary or a phase and believe that the 

organization will focus on other issues or new 

directions once the pressure or attention on 

this specific issue subsides. 

Task: Develop a Cultural 

Competence Plan

To ensure the delivery of culturally responsive 

services, it is important to develop a cultural 

competence plan (see the “Criteria for Developing an Organizational Cultural Competence Plan” advice box on the next page). 

Using demographic data and an organizational 

self-assessment (including community and 

advisory board input), the organization’s cultural competence committee can begin writing 

an organizational plan for improving cultural 

competence. The committee will need to 

assign staff members to research and write 

each component of the plan, which should 

outline specific objectives, means of achieving 

these objectives, and recommend timelines 

and processes for evaluating progress. The 

plan should contain at least the following 

components: 

• A narrative introduction that covers community demographics and history, organizational self-assessment and other 

evaluation tools, the rationale for providing culturally responsive services, and the 

organization’s strengths and needs for improvement in providing services that are

responsive to client cultural groups; a brief 

overview of current priorities, goals, and 

tasks to help the organization develop and 

improve culturally responsive clinical services and administrative practices is also 

advisable. 

 81
Improving Cultural Competence

• Strategies for recruiting, hiring, retaining, 

and promoting qualified diverse staff. 

• Resources and policies to support language 

services and culturally responsive services.

• Methods to enhance professional development (e.g.,staff education and training, 

peer consultation, clinical supervision) in 

culturally responsive treatment services.

• Mechanisms for community involvement, 

beginning with the development of a 

community advisory board and cultural 

competence committee and including 

community participation in relevant 

treatment activities or in support of treatment services (e.g., spiritual direction). 

• Approaches to amending facility design 

and operations to present a culturally congruent atmosphere.

• Identification of and recommendations for 

culturally and linguistically appropriate 

program materials.

• Programmatic strategies to incorporate 

culturally congruent clinical and ancillary 

treatment services. 

• Fiscal planning for funding and human 

resources needed for priority activities

(e.g., training, language services, program 

development, organizational infrastructure). 

• Guidelines for implementation that describe roles, responsibilities, timeframes, 

and specific activities for each step. 

The committee must determine how to oversee the plan (e.g., by tracking accomplishments, obstacles, and remediation strategies). 

Who will develop and revise guidelines for 

treatment planning, introduce new guidelines 

to the staff and provide counselor training, and 

coordinate revisions with the information 

technology specialist or department?

Task: Develop and Review Policies 

and Procedures To Ensure 

Culturally Responsive

Organizational Practices 

In essence, policies and procedures are the 

backbone of an organization’s implementation 

of culturally responsive services. By creating, 

reviewing, and adapting clinical and administrative policies and procedures in response to 

the ever-changing needs of client populations, 

the agency is able to provide counselors and 

Advice to Administrators: Criteria for Developing an Organizational Cultural 

Competence Plan

Using the core elements of access, engagement, and retention as criteria in developing a cultural 

competence plan, the following recommendations are offered: 

• Develop a thorough knowledge and understanding of the social, cultural, and historical experiences of the community of people your agency is serving.

• Identify and clearly articulate an understanding of the ethnic, cultural, linguistic, and social 

groups in the area your agency serves.

• Document, track, and evaluate/assess the reasons why clients are not accepted for services.

• Know the demographics of clients within the program and their rates of program completion.

• Keep profiles of clients who do not complete services.

• Design steps for your agency to take to remove identified barriers that keep clients from using 

your agency’s services.

• Establish steps your agency will implement or sustain to create a consumer-friendly environment 

that reflects and respects the diversity of the clients that use your services.

• Establish internal criteria the agency will use to measure the impact of the services and programs 

that it offers.

Source: The Connecticut Department of Children and Families, Office of Multicultural Affairs 2002. 

82
Chapter 4—Pursuing Organizational Cultural Competence

other workers with support and the means to 

respond in a consistent, yet flexible, manner. 

Programs are likely to have the foresight to 

develop relevant policies and procedures 

through the planning and evaluative processes 

outlined in this chapter, but it is unlikely that 

they will anticipate every situation. Thus,

ongoing flexibility is paramount.

When putting together an organizational 

cultural competence plan, providers should be 

careful to follow the requirements set by state 

licensing boards, accreditation agencies, and 

professional organizations that oversee certification and licensing of treatment professionals. Much of the push for cultural competence 

throughout the healthcare field is in response 

to the mandates of accrediting agencies, funders, and managed care organizations. These 

entities have standards and guidelines that 

state minimum expectations for client rights, 

program structure, and staffing, along with 

treatment content and conditions. Behavioral 

health organizations, including substance 

abuse treatment programs, must meet these 

standards to be accredited by national organizations and compensated by funders. 

Although many accrediting bodies require a 

cultural competence plan that is assessed as part 

of the accreditation process, their requirements 

can be minimal. Consequently, organizations 

should go beyond such requirements in their 

own thinking and planning to ensure that they 

are responding adequately to the needs of the 

communities they serve. Above all, are the 

policies, procedures, and systems of care suited 

to the served populations? Do policies reflect

the organization’s commitment to cultural 

competence in administrative practices? For 

example, are strategies for professional development, personnel recruitment, and retention 

of culturally competent staff members reflective of the populations and cultures that they 

serve?

If an organization fails to develop culturally 

responsive policies or procedures yet claims to 

endorse or support culturally responsive services, counselors and staff members will likely 

carry the entire burden of implementing these 

services and will face numerous obstacles that 

could prevent the delivery of responsive services. Take, for example, a counselor from a 

county-funded program who was directed by 

her supervisor to complement her counseling 

approach with the client’s traditional healing 

beliefs and practices. The agency did not 

provide staff support, have policies or procedures consistent with this request, or exhibit a 

willingness to adapt current procedures to 

meet the client’s needs. The counselor had 

difficulty following this direction because of 

barriers in finding an appropriate traditional 

practitioner in the local area, coordinating 

services, establishing and securing confidentiality for the client and with the practitioner 

(including educating the practitioner about 

confidentiality), arranging transportation for 

the client, obtaining a stipend for services, and 

discerning how and when to incorporate the 

traditional practice into the treatment milieu. 

Counselors who feel that they have been left 

to go it alone can view implementation of 

culturally responsive practices as an insurmountable challenge when the agency provides limited support or fails to endorse 

adaptive policies that are congruent with the 

needs of the client population. Counselors 

may have high motivation to incorporate 

culturally responsive care but find themselves 

without appropriate agency resources, permission, or infrastructure to implement it. By 

developing and endorsing culturally responsive 

policies and procedures, an organization can 

provide carefully thought-out strategies and 

processes to help staff members provide realtime responsive services. Well-defined policies 

and procedures reinforce commitment to and 

expectations of cultural competence. 

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Improving Cultural Competence

Evaluation and Monitoring

To develop a viable cultural competence plan, 

information must be gathered from all levels 

of the organization, from clients and community, and from other stakeholders. Beginning 

with acquiring initial demographic data from 

the populations that are or could be served by 

the agency and extending to soliciting feedback from various stakeholders, gathering 

information prior to plan development helps 

the organization provide direction and determine priorities. Gathering information also 

allows ongoing monitoring and feedback 

regarding the plan’s effectiveness and areas in 

need of improvement. Areas of evaluation and 

monitoring can include a demographic profile 

of the client, community, staff, and board 

constellations; community needs assessment; 

client, family, and referral feedback; administrative, clinical, medical, and nonclinical staff 

assessments; and more (American Evaluation 

Association 2011; LaVeist et al. 2008). 

Task: Create a Demographic 

Profile of the Community, 

Clientele, Staff, and Board 

Intake, admission, and discharge data provide 

a good starting point for determining the 

demographics of current populations being 

served. Programs would likely benefit from 

developing a demographic summary for each 

population served, consisting of age, gender, 

race, ethnic and cultural heritage, religion, 

socioeconomic status, spoken and written 

language preferences and capabilities, employment rates, treatment level, and health 

status (HHS 2003b). With adequate resources, 

the organization can generate reports dating 

back 5 years to determine program trends. 

Agencies should also gather demographic

information on groups in the agency’s local 

community (Hernandez et al. 2009). This 

information can be easily obtained through 

census data and national centers (e.g., Bureau 

of Labor Statistics) or through local sources, 

including the library, city hall, or the county 

commissioner’s office (Whealin and Ruzek 

2008). Community demographics can provide 

a quick benchmark on how well an agency 

serves the local community and how the 

community is represented at all levels of the 

organization. A demographic profile should 

also summarize information about clinical, 

medical, and nonclinical staff members as well 

as board members. Other information can also 

be helpful for specific agencies, as can hiring a 

consultant to gather demographic information 

and conduct the organization’s self-assessment 

of cultural competence to limit bias; however, 

lack of funding can prohibit this possibility. 

Task: Conduct Organizational SelfAssessment of Cultural 

Competence

An organization must have an awareness of 

how it functions within the context of a multicultural environment, evaluating operational 

aspects of the agency as well as staff ability 

and competence in providing culturally congruent services to racially and ethnically diverse populations. Therefore, an agency should 

assess how well it currently provides culturally 

responsive treatment. An honest and thorough 

organizational self-assessment can serve as a 

blueprint for the cultural competence plan 

and as a benchmark to evaluate progress 

across time (National Center for Cultural 

Competence 2013). To review a sample assessment guide, refer to Appendix C. 

The importance of organizational selfassessment cannot be overstated. Thorough, 

reliable, valid evaluations can gauge the effectiveness of an agency’s services, structure, and 

practices (e.g., clinical services, governing 

practices, policy development, staff composition, and professional development) with 

culturally and racially diverse clients, staff, and 

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Chapter 4—Pursuing Organizational Cultural Competence

communities. More and more, public and 

private funding sources—as well as accrediting 

bodies—use an organization’s self-assessment 

as a means of measuring compliance, effectiveness, or quality improvement practices. 

A self-assessment can seem intensive in terms 

of both labor and capital, but in the long run, 

it can guide an organization’s quality improvement process more efficiently by helping 

it provide the most relevant services at the 

right time. Gathering feedback from many 

internal and external sources gives agencies 

considerable information needed to effectively 

evolve as a culturally responsive organization, 

including data on current performance, areas 

needing improvement, and development 

needs. In the initial self-assessment, an organization should obtain demographic information and seek feedback from key 

stakeholders—including community members, clients, families, and referral sources 

(e.g., probation and parole offices, family and 

child services, private practitioners)—and 

from all levels of the organization, including 

administrative, managerial, clinical, medical, 

and support staff. The following steps are 

recommended to help an agency gain the 

information necessary to guide and support 

the development of its cultural competence 

plan. 

Step 1: With the advisory board and cultural 

competence committee, identify key stakeholders who can provide valuable feedback 

about current strengths and areas in need of

improvement regarding the function of the

organization and the needs of its community. 

Step 2: Adopt a self-assessment guideline for 

organizational cultural competence (see 

Appendix C). 

Step 3: Determine the feasibility of using 

consultants and/or external evaluators to 

select, analyze, and manage assessment. 

For many organizations, hiring outside consultants is financially prohibitive. Nonetheless, 

the cultural competence committee could 

recommend hiring outside evaluators and 

consultants to help them plan, conduct, and 

assess the results of the organizational selfevaluation. The committee should ensure that 

consultants understand the population being 

served by the treatment facility. This means 

understanding the population’s cultural groups 

across dimensions: language and communication, cultural beliefs and values, history, socioeconomic status, education, gender roles, 

substance use patterns, spirituality, and other 

distinctive aspects. Candidates should be able 

to articulate a clear understanding of cultural 

competence (American Evaluation Association

2011). If consultants will train staff, they 

should have specific knowledge and proficiency in training development and delivery. 

If financially feasible, it can be useful for the 

agency to consider using more than one consultant and to invite each prospective consultant to present their qualifications to the board 

of directors and/or to a cultural competence 

The Consumer Assessment of Healthcare Providers and Systems Cultural 

Competence Item Set 

This assessment tool evaluates provider cultural competence through client surveys. It helps identify 

strengths and weaknesses of individual behavioral health service providers and organizations, aids in 

provider comparisons, and assesses the extent to which client responses differ based on race, 

ethnicity, or primary language. The surveys are available online through the Agency for Healthcare 

Research and Quality (https://cahps.ahrq.gov/clinician_group/), as is an overview and instructions 

(https://cahps.ahrq.gov/surveys-guidance/hp/instructions/index.html).

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Improving Cultural Competence

committee so that the best match can be 

achieved between the agency’s needs and the 

consultant based on his or her expertise, cost, 

and consulting style. If a consultant is hired, 

the organization should establish guidelines 

for working closely with that person, including 

reporting requirements to the cultural competence committee. The organization must

retain ownership of the process and provide 

clear oversight and guidance. 

Step 4: Select assessment tools suitable for 

each stakeholder group (e.g., clinical staff, 

agency referrals, clients). Several selfassessment tools are available, including 

checklists and surveys, for use in evaluation or 

as development guides. To date, most instruments available have limited empirical support 

(Delphin-Rittmon et al. 2012b; Shorkey et al. 

2009). 

More often than not, surveys and feedback 

questionnaires will need to be individually 

developed and tailored to the organization and 

stakeholder group depending upon setting; 

available resources; racial, ethnic, and cultural 

backgrounds; language preferences; and community accessibility (e.g., rural versus urban). 

Appendix C provides standards and lists the 

items that should be included in evaluating an 

agency and its services. Additional resources 

for provider and organizational assessment of 

cultural competence are available through the 

National Center for Cultural Competence 

(http://nccc.georgetown.edu/) and the Hogg 

Foundation for Mental Health

(http://www.hogg.utexas.edu/index.php). 

Step 5: Determine distribution, administration, and data collection procedures (e.g., 

confidentiality, participant selection methods, 

distribution time frames). Whatever methods 

are used to gather data for the self-assessment 

process, it is critical to explain the context of 

the assessment to all participants. They need 

to know why the assessment is being conducted and how the information they give will be 

used. Confidentiality can be a major concern 

for some respondents, especially staff members 

and clients, and every effort should be made to 

address this concern. Ideally, the evaluation 

Advice to Administrators: Gathering Feedback From Clients, Community 

Members, and Referrals

Agencies should incorporate a client satisfaction survey into the assessment process. This survey 

should include questions to help determine whether clients believe that the organization relates well 

to persons of their ethnicity or race and gives them an opportunity to pinpoint problem areas. To 

review a sample assessment tool for clients, refer to the Iowa Cultural Understanding Assessment–

Client Form (White et al. 2009), available in Appendix C. The tool is also available in Spanish. 

If desired, external consultants can conduct interviews with a representative sample of clients, family 

members, and local community members. The key question should be “What can the treatment 

provider do to be more responsive to community needs?” The survey process can be as simple as a 

questionnaire, or it can involve interviews or focus groups with key people in touch with community 

issues. It can also be helpful to obtain a small but representative sample of community members at 

large to determine their level of awareness of the services available and their perceptions of the 

treatment agency based on what they have heard. Information from people not in treatment can be 

revealing and could suggest areas in which publicity is needed to counter misinformation. Likewise, 

facilitators can develop, from the information gathered, a map that highlights where people go to 

receive various services (Center for Substance Abuse Prevention 1995). The agency could also ask 

their sources of referrals, such as faith-based organizations, community agencies, or primary care 

physicians, whether they are referring clients to the agency, and if not, why. It is important to know 

who is not walking through the door.

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Chapter 4—Pursuing Organizational Cultural Competence

instrument(s) should be administered by an 

objective third party, such as a consultant or a 

member of the cultural competence committee. Staff members should be asked about their 

attitudes toward cultural issues with the understanding that their attitudes are not necessarily indicative of the degree to which the 

staff mirrors the cultural groups served. In 

soliciting community feedback, the more 

credibility the organization has in the community, the higher the return rate will likely 

be. The lower the credibility, the more the 

organization needs to reassure respondents

that it intends to listen to, and act on, what it 

hears. If many survey forms are to be distributed, the organization could consider hiring 

students or community members on a temporary basis to make follow-up or reminder calls. 

Step 6: Compile and analyze the data. The 

process of reviewing and assessing data should 

be overseen by the cultural competence committee. Basic data analysis procedures should 

be used to ensure the accuracy of results and 

credibility of reported information. For most 

well-designed instruments, there are relatively 

simple and appropriate ways to present data. 

All available data should be assembled in a 

report, along with interpretive comments and 

recommended action steps. The report should 

note areas of strength and needed improvement and should offer possible explanations 

for any shortcomings. For example, if the 

community is 20 percent African American, 

but only 2 percent of the agency’s clientele are 

African American, what are some possible 

explanations for this group’s apparent underuse of services? It is also particularly important to share results with those who 

participated in the assessment process. Findings should be made available to staff, clients, 

community members, boards, and managers. 

This increases overall sense of ownership in 

the assessment and cultural competence development process and in implementing the 

changes that will be made based on the findings of and the priorities established through 

this assessment.

Step 7: Establish priorities for the organization and incorporate these priorities into the 

cultural competence plan. After obtaining the 

results of the self-assessment process, the 

organization—including boards, cultural 

competence committee, community stakeholders, and staff members—needs to establish realistic priorities based on the current 

needs of clients and the community. Significant consideration should be given to the level 

of influence any given priority could have in 

effecting organizational change that will 

improve culturally responsive services. Some 

priorities will require more planning to implement and can involve more financial and 

staff resources, whereas other priorities will be 

easier to implement from the outset (e.g., 

hiring culturally competent counselors who 

are bilingual versus translating intake and 

program forms). Therefore, long- and shortrange priorities should be established at the 

same time to maintain the momentum of 

change in the organization. 

Step 8: Develop a system to provide ongoing 

monitoring and performance improvement

strategies. Similar to the clinical assessment 

process with clients, the organizational selfassessment is only valuable if it provides guidance, determines direction and priorities, and

facilitates action. Assessment is not a one-time 

activity. It is important to continue monitoring 

to identify barriers that may impede the full 

implementation of the cultural competence 

plan, to evaluate progress and performance, 

and to identify new service needs. Establishing 

a system to monitor an organization’s cultural 

responsiveness equips it with the information 

necessary to formulate strategies to meet new 

demands and to continuously improve quality 

of services. 

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Improving Cultural Competence

Language Services

Task: Plan for Language Services 

Proactively

An organization must anticipate the need for 

language services and the resources required to 

support these services, including funding, staff 

composition, program materials, and translation services. Assessing the language needs of 

the population to be served is essential. Upon 

determination, the foremost task is letting 

clients with limited English proficiency know 

that language services are available as a basic 

right for a client. Treatment providers need to 

plan for the provision of linguistically appropriate services, beginning with actively recruiting bicultural and bilingual clinical staff, 

establishing translation services and contracts, 

and developing treatment materials prior to 

client contact. Although it is not realistic to 

anticipate the language needs of all potential 

clients, it is important to develop a list of 

available resources and program procedures 

that staff members can follow when a client’s 

language needs fall outside the organization’s 

usual client demographics (The Joint 

Commission 2009). 

Planning for language services is crucial, and 

the need for these services must be assessed by 

staff members who have initial contact with 

clients, their family members, and/or other 

individuals in their support systems (American 

Psychological Association [APA] 1990, 2002). 

If frontline administrative and clinical staff 

members are bilingual, the initial screening 

and assessment process can begin uninterrupted. If this is not the case, receptionists or 

frontline clinical staff members should at least 

be familiar with some rudimentary phrases in 

the preferred languages of their client base. 

The conversation can be scripted so that they 

can convey their limited ability to speak the 

client’s language, obtain contact information 

and inquire about language service needs, and 

inform the client that someone who can speak 

the language more fluently will be made available to facilitate the initial screening process. 

Most importantly, procedures should be in 

place to provide pretreatment contact and 

follow-up in the client’s language to bridge the 

gap between initial contact and subsequent 

arrangement of language services. 

Written and illustrated materials or a video 

about the program in the languages spoken by 

the client population should be available to 

answer frequently asked questions. All materials given to clients, family members, and 

community members should be available in 

their primary languages. It is preferable to 

develop the materials initially in those 

languages rather than simply translating materials from one language to another. Along 

with language, one should also consider the 

level of literacy of the group in question. Some 

clients may be functionally illiterate even in 

their native languages. Materials should 

graphically reflect the population served 

through pictures or photographs, using ethnic 

themes and traditional elements familiar to 

the target audience. Also, materials should be 

tested with the populations with whom they 

How To Inform Clients About 

Language Assistance Services 

• Use language identification or “I speak...” 

cards.

• Post signs in regularly encountered languages at all points of entry.

• Establish uniform procedures for timely, 

effective telephone communication between staff members and persons with limited English proficiency.

• Include statements about the services 

available and the right to free language assistance services in appropriate non-English 

languages in brochures, booklets, outreach 

materials, and other materials that are routinely distributed to the public.

Source: OMH 2000.

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Chapter 4—Pursuing Organizational Cultural Competence

will be used, perhaps through focus groups, to 

ensure that they communicate effectively. 

Task: Establish Practice and 

Training Guidelines for the 

Provision of Language Services

Key issues to consider in implementing and 

overseeing language services within an organization include staff monitoring of language 

proficiencies, selection of translators and 

interpreters, confidentiality issues, and training needs. First, agencies need to assess language proficiencies among staff members and 

encourage them to learn a language relevant to 

the population served. At a minimum, staff 

members should acquire in the given language

some basic terminology and phrases that are 

commonly used in the treatment setting. 

In recruiting and hiring translators and interpreters, administrative staff members should 

consider experience, motivation, skill level, 

mastery of English, and fluency in the language in need of interpretation (OMH 2000; 

American Translators Association 2011). Be 

aware, however, that there can be considerable 

variation in dialects and levels of proficiency 

within the language, and these must be determined in the selection process. To supplement hiring practices, administrative policies 

should provide a means for determining the 

credentials of any language services organizations (Appendix F lists American Translators 

Association credentialing information). 

Other important hiring issues revolve around 

potential ethical dilemmas. In particular, care 

should be taken in using interpreters from the 

local community, which can create potential 

challenges with confidentiality and dual relationships (e.g., the interpreter may also be 

client’s cousin or neighbor). Policies should 

place the burden on language service providers

to identify and disclose dual relationships to 

supervisors immediately and on supervisors to 

assess and determine the appropriateness of 

using certain translator. Once a selection has 

been made, a confidentiality agreement should 

be signed. Organizations need to provide 

information routinely to clients about their 

confidentiality rights in using language services. Implementing a procedure for handling 

client grievances is also recommended.

In planning for the use of language services, 

organizations should initially provide training 

for staff on how to incorporate these services 

and should familiarize translators and interpreters with the clinical setting, terminology, 

behavioral expectations, and content related to 

behavioral health (see the “Training Content 

for Language Service Personnel” advice box

on the next page). The language of mental 

health and substance abuse services requires an 

additional degree of specialization. Experienced translators and interpreters who are 

unfamiliar with concepts of addiction, illness,

and recovery could convey information adequately from a linguistic perspective but not 

accurately convey the intent or meaning of 

clinically oriented information or dialog. 

Various training approaches can be used, 

including role-plays mirroring intakes, evaluations, and counseling sessions; indirect exposure to client sessions through audio or video

recordings of sessions or viewing from an 

observation room; direct observation by sitting 

in on a session, if appropriate; and consultation with other experienced language service 

providers and clinical staff. Using other experienced translators and interpreters for training and/or for consultations, as well as sharing 

experiences in a peer support format, can be 

very beneficial for new language service 

providers. 

 89
Improving Cultural Competence

Organizations must also create opportunities

for translators and interpreters to inquire 

about and clarify clinical content and meaning. Language service providers often attempt 

to convey terminology or concepts that do not

exactly match the words or meaning of the 

client’s language or culture by becoming more 

descriptive, taking longer to deliver the message in an effort to match the intent of a 

specific word or concept in English.

Workforce and Staff 

Development 

Task: Develop Staff Recruitment, 

Retention, and Promotion 

Strategies That Reflect the 

Populations Served 

To determine whether it adequately reflects 

the population it serves, an organization has to 

assess its personnel, including counselors, 

administrators, and board of directors. According to a 10-year study that collected data 

on treatment admissions, racial and ethnic 

composition of treatment populations has not 

significantly changed. Racially diverse groups 

(excluding non-Latino Whites) represent 

approximately 40 percent of treatment admissions (Substance Abuse and Mental Health 

Services Administration [SAMHSA] 2011c), 

yet 80 percent of counselors are non-Latino 

Whites (Duffy et al. 2004). In striving to 

improve cultural responsiveness, staff composition should be a major strategic planning 

consideration. As much as possible, the staff 

should mirror the client population. 

Nevertheless, providers should avoid hiring 

“ethnic representatives,” which means hiring a 

single person from an ethnic or cultural group 

and expecting him or her to serve as the cultural resource on that group for the entire 

staff. This can be burdensome, if not offensive, 

to that person. Belonging to a group does not 

ensure cultural responsiveness toward, 

knowledge of, or skill in working with members of that group, nor does it guarantee that 

the person culturally identifies with that cultural group or its heritage. Hiring ethnic 

Advice to Clinical Supervisors and 

Administrators: Training Content for 

Language Service Personnel 

Translators and interpreters need additional 

training to work in a clinical setting. Initial 

training should include:

• General mental health and substance 

abuse information. 

• Introduction to behavioral health services. 

• Familiarity with interviewing and assessment 

questions, instruments, and formats. 

• Legal and ethical issues, including confidentiality and professional boundaries. 

• Relevant programmatic policies and procedures.

• Review of program materials, forms, questionnaires, and other written clinical materials that clients receive during the course 

of treatment.

• Knowledge of technical vocabulary relevant 

to the behavioral health field. 

• Emphasis on the importance of accurate 

interpretation and translation without additions or omissions. 

• Behavioral and professional guidelines on 

how to manage potential client reactions in 

and outside the session (e.g., outward displays of anger or hostility; grief reactions; 

disclosing information to the translator with 

a request to keep it a secret from clinical 

staff; discomfort with translator’s biological, social, and/or demographic characteristics, such as gender orientation, age, or 

socioeconomic status ).

• Importance of cultural sensitivity in dialog 

between translator and client, including 

how questions are asked. 

• General guidelines on how to handle 

personal issues that can be elicited by participation in the intake, assessment, and 

treatment processes, including identification with similar clinical issues (e.g., substance use patterns, family dynamics, 

traumatic events, emotional distress).

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Chapter 4—Pursuing Organizational Cultural Competence

representatives undermines the expansion of 

diversity at all organizational levels and the 

importance of developing opportunities for all 

staff members to gain awareness and improve 

their ability to effectively work with clients.

Some organizations struggle to find multicultural staff members that represent the diversity 

of their communities and clienteles. If recruitment is perceived as an immediate shortterm goal, ongoing difficulties are likely in 

hiring, promoting, and retaining a diverse staff. 

Instead, recruitment strategies need to embrace a more comprehensive and long-term 

approach that includes internships, marketing 

to those interested in the field at an early age, 

mentoring programs for clinical and administrative roles, support networks, educational 

assistance, and training opportunities. 

Task: Create Training Plans and 

Curricula That Address Cultural 

Competence 

The primary purpose of training is to increase 

cultural competence in the delivery of services, 

beginning with outreach and extending to 

continuing care services that support behavioral health. Training should increase staff 

self-awareness and cultural knowledge, review

culturally responsive policies and procedures, 

and improve culturally responsive clinical skills 

(Anderson et al. 2003; Brach and Fraser 2000; 

Lie et al. 2011). The organization should be 

prepared to offer relevant professional development experiences consistent with counselors’ 

personal goals and assigned responsibilities as 

well as the organization’s goals for culturally 

responsive services. Board members, volunteers, and interpreters should all receive appropriate training. 

A professional development training plan 

details the frequency, content, and schedule for 

staff training and continuing education. Because becoming culturally competent is a 

process, training and support for engaging in 

culturally responsive services can be more 

appropriate when delivered across a period of 

time involving follow-up sessions rather than 

through a single session. Outcome research 

that evaluates the effectiveness of cultural 

competence training materials, format, and 

content in mental health services, including 

treatment for substance use disorders (Bhui et 

al. 2007; Lie et al. 2010), is limited. Nonetheless, numerous resources have suggested that 

effective cultural training does feature certain 

qualities (Exhibit 4-5). 

Sometimes, staff members will express resistance to participation in training activities 

aimed at promoting cultural competence—

they may feel forced to learn about cultural 

competence, or they may feel unable to take 

the time away from their clients to attend the 

“Improving the workforce to provide 

competent services to diverse populations 

goes far beyond merely increasing the 

number of individuals from each of the 

respective groups. While this is clearly an 

important strategy, there is a need not 

only to increase the numbers but also to 

improve the quality of training for all 

clinicians, regardless of their racial, ethnic, 

cultural, or linguistic background. This also 

includes the necessity to recruit, train, and 

support interpreters.” 

(Hoge et al. 2007, p. 192).

“The learning objectives of a professional 

development program should include 

awareness- and knowledge-based objectives and skills-based objectives that 

motivate students to explore personal 

perspectives and multiple worldviews, 

understand and embrace culturally competent health promotion strategies, and 

engage in self-directed competency 

development.” 

(Perez and Luquis 2008, p. 178).

 91
Improving Cultural Competence

trainings. Others might object on the grounds 

that they treat everyone equally, thus ignoring 

their own cultural blindness. 

The organization’s leadership needs to address 

staff reluctance and concerns regarding training through initial education on the rationale 

for cultural competence. Assume that staff 

members are invested in creating the best 

opportunities for their clients to achieve success, and use this premise to introduce the 

need for training centered on culturally responsive care. Some staff members may respond to incentives or predetermined

objectives and criteria reflected in employee 

performance evaluations. Others may be more 

motivated by opportunities that arise from the 

organization’s commitment to culturally responsive services or by other factors, such as 

specialized training and supervision, the 

Exhibit 4-5: Qualities of Effective Cultural Competence Training 

The qualifications of the trainer, the selection of training strategies, and the use of reputable training 

curricula are extremely important in developing culturally competent staff and responsive services. The 

following concepts should be considered in the development and implementation of cultural training: 

• Cultural training should begin with educating new staff members about the organization’s vision, 

values, and mission as related to culturally responsive services. Orientation should address the 

demographic composition of clientele, policies and procedures for cultural and linguistic services, counseling and performance expectations for assessment, treatment planning, and delivery of culturally responsive services. 

• Before developing and initiating a training plan for culturally responsive services, ask staff members about their training needs specific to the cultural groups that they serve. Receptivity will 

likely increase if managers and administrators involve clinical staff in the planning process rather 

than assuming that they know exactly what staff members need regarding cultural training. 

• Training should occur across time, and a training plan should detail how to provide training for 

new employees. Too often, trainings occur at one time, ignoring the complexity of cultural 

groups and suggesting that one training session is sufficient to achieve cultural competence. 

Cultural competence evolves from ongoing professional development.

• Training should incorporate diverse learning strategies, including experiential learning and 

cultural immersion when appropriate (e.g., participation in community activities, role-plays, case 

presentations). Training should be experientially based and process oriented, allowing selfreflection as part of the training and assigning self-reflection activities between training sessions 

(see the how-to box on self-reflection on the next page). 

• Training should provide information that is practice- or research-based to ensure that participants see it as reputable and clinically sound.

• Training should create a welcoming, nonjudgmental, and professional atmosphere in which staff 

members, regardless of race, ethnicity, or cultural group, have the freedom and safety to explore their own beliefs and to learn about other cultural groups. Training efforts should not 

scapegoat mainstream cultural groups or make general statements about specific racial or ethnic 

groups without noting that there are many cultural subgroups within a given racial or ethnic 

group—often characterized by, but not limited to, geographic location, socioeconomic status, or 

educational levels. Participation guidelines should be clarified for each training. 

• Training should be conducted by an interdisciplinary, multicultural training team that is experienced in training and well versed in cultural competence.

• Trainers should allow time for staff members to ask questions and process the presented materials and experiential exercises, and they should use staff questions and exercises to explore and 

correct misperceptions in a nonjudgmental manner.

Sources: Brach and Fraser 2000; Dixon and Iron 2006; Gilbert 2003; Pack-Brown and Williams 2003; 

Roysircar 2006; Russell 2009. 

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Chapter 4—Pursuing Organizational Cultural Competence

desire to be perceived by other staff members 

as team players, or their roles as agents of 

change with other staff members.

Opportunities for cultural competence training abound. National organizations, agencies 

dedicated to multicultural learning, academic 

institutions, government agencies, and information clearinghouses offer training or have 

information about training opportunities and 

curricula on cultural competence on their Web 

sites. In addition to OMH guidelines on staff 

education and training (Exhibit 4-6), guidelines are available from psychological and 

counseling associations (APA 2002). To review sample training modules, see Cultural 

Competence for Health Administration and 

Public Health (Rose 2011).

Task: Provide Culturally 

Congruent Clinical Supervision

Little research is available that measures cultural competence among clinical supervisors or 

evaluates the effects of supervision on cultural 

competence among counselors (Colistra and 

Brown-Rice 2011; Constantine and Sue 2005). 

Not much is known about the effectiveness of 

clinical supervision in enhancing culturally 

competent behavior among counselors, 

How To Engage in Self-Reflection: A Tool for Counselor Training and Supervision

Ask participants to preselect three clients whom they are currently counseling and will likely continue 

to counsel prior to the next training or supervision session. Selection should be based on clients’ 

diversity in age, race, gender, ethnicity, socioeconomic status, education, and/or geographic location. After each participant has selected three clients (remind participants not to disclose actual 

client identity if this is an external training outside of the agency), ask them to keep a self-reflection 

journal wherein the number of entries coincide with each client session until the next training. Participants should write about their internal process, including reactions such as feelings, thoughts, or 

behaviors during the session that relate to the influence of culture. For example:

• Identify racial, ethnic, and cultural similarities and differences between you and your client.

• Explain how your cultural and clinical worldviews influence your dialog, treatment planning, and 

expectations of yourself and your client in the session.

• Describe assumptions that you have learned to make about your client’s specific race, ethnicity, 

or culture(s).

• Even if you think these assumptions, beliefs, or biases do not play a role in your current counseling relationship and approach, discuss how they could influence your counseling. Provide a specific example.

• Describe the feelings that you have about your client. How do these feelings relate to your 

client’s racial, ethnic, or cultural identity?

• Explain the differences and similarities in worldviews between you and your client.

• Discuss how your and your client’s beliefs about health, healing, disease, and addiction differ.

• Describe how your client’s experience with discrimination, oppression, and prejudice could 

influence his/her current level of distress, psychological functioning, and response to treatment. 

• Explore how you attend to your client’s worldview in each session.

• Describe a misunderstanding or erroneous counseling response during a counseling session that 

appears related to differences in cultural identification, values, or behavior.

• Identify cultural knowledge that you must obtain to gain a better understanding of your client.

• Discuss the most important lessons that you have learned from your client.

“It takes time and energy to work through 

significant changes, whether in the workplace or in our personal lives. Many times, 

resistance to change is a natural reaction 

of people trying to understand what is 

expected of them and how the change will 

impact their lives.” 

(Addiction Technology Transfer Center 

2004, p. 28)

 93
Improving Cultural Competence

although some research with a multicultural 

focus has measured counselor self-efficacy 

after receiving supervision and has examined 

the dynamics of supervisee–supervisor relationships. Even though educational institutions have developed curricula and standards 

to reinforce the need for a multicultural perspective in training, many clinical supervisors 

lack sufficient training in this area (e.g., avoid 

cultural topics in supervision, have difficulty 

giving culturally appropriate consultations or 

direction, fail to guide/reinforce timely implementation of policies or procedures that 

support culturally responsive services with 

their supervisees). This can significantly impede organizations attempting to introduce or 

improve culturally responsive clinical services. 

It is essential for organizations to provide 

counselors with clinical supervisors who are 

culturally aware, have engaged in multicultural 

training, and model culturally competent 

behaviors in clinical supervision sessions (e.g., 

allowing or engaging in discussions centered 

on race, ethnicity, and cultural groups in the 

session). Clinical supervision is the glue that 

Advice to Clinical Supervisors: Culturally Competent Clinical Supervision 

Supported by a review of research on multicultural clinical supervision, Miville et al. (2005) suggest 

that clinical supervisors gain awareness of and assess:

• Their own racial, ethnic, and cultural identities and attitudes and those of their supervisees.

• Their own knowledge base, strengths, and weaknesses and those of their supervisees.

• Racial, ethnic, and cultural issues that generate reactions in supervisors and in supervisees.

• Current engagement in professional development activities that support culturally responsive 

practices (see the professional development advice box on the next page).

Exhibit 4-6: OMH Staff Education and Training Guidelines 

Only general agreement exists as to what constitutes an acceptable cultural competence curriculum. 

OMH (2000) recommends tailoring curriculum topics to the roles and responsibilities of trainees and 

the specific needs of populations served over time but suggests that training should at least address: 

• The effects of cultural differences between counselors and clients/consumers on clinical and 

other workforce encounters, such as the therapeutic alliance.

• The elements of effective communication among staff members and clients/consumers from 

diverse cultural groups who use different languages, including how to work with interpreters and 

telephone language services.

• Strategies for resolving racial, ethnic, or cultural conflicts between staff members and clients.

• The organization’s policies and procedures for written language access, including how to gain 

access to interpreters and translated written materials.

• Parts of the Civil Rights Act of 1964 that address services for clients with limited English proficiency. 

• The organization’s complaint or grievance procedures.

• The effects of cultural differences on health promotion and disease prevention, diagnosis and 

treatment, and supportive care.

• The impact of poverty and socioeconomic status, race and racism, ethnicity, and sociocultural 

factors on access to care, service use, quality of care, and health outcomes.

• Differences in the clinical management of diseases and conditions indicated by differences in the 

race or ethnicity of clients. 

• The effects of cultural differences among clients/consumers and staff members on health outcomes, client satisfaction, and treatment planning.

Source: OMH 2000. Adapted from material in the public domain.

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Chapter 4—Pursuing Organizational Cultural Competence

reinforces culturally competent behavior, and 

it is often the only avenue of ongoing clinical 

training and follow-up after specific workshops 

or trainings are offered by the organization.

Clinical supervisors should adopt a multicultural framework to guide the supervision 

process (e.g., Sue’s [2001] multidimensional 

model for developing cultural competence). 

Endorsement of a model for developing and 

enhancing cultural competence helps both 

supervisors and supervisees understand how to 

address cultural issues in supervision and 

pursue personal and professional development 

that supports culturally responsive clinical 

services. (For a specific example, see Field and 

colleagues’ [2010] Latina–Latino multicultural 

developmental supervisory model.) The model 

guides supervision and reinforces the premise

that cultural variables influence each aspect of 

supervision: the relationship between supervisors and supervisees, the supervisors’ and 

supervisees’ perceptions and assessments of 

clients’ presenting issues, the interactions 

between supervisees and their clients, and the 

treatment recommendations and directions 

that evolve from supervision. 

Task: Evaluate Staff Performance

on Culturally Congruent and 

Complementary Attitudes,

Knowledge, and Skills

Organizations committed to endorsing and 

implementing culturally responsive services 

need policies and procedures that reflect this 

commitment in job descriptions and staff 

evaluations across all levels of the organization. By incorporating specific goals,

How To Discuss Professional Development in Multicultural Counseling

This tool facilitates supervisee–supervisor discussions surrounding professional development activities that promote cultural competence. Supervisors can ask supervisees to review the list and check 

off activities that they have engaged in recently or in the past several months. Supervisors can then 

use the completed exercise as a starting point for gaining more specific information on activities

endorsed by supervisees. Even if supervisees check off no items, reviewing the list reinforces activities that build cultural competence. 

Materials needed: A printed copy of the checklist and a pen or pencil. 

Instructions: Mark off the activities you have engaged in during the past month and/or 6 months. 

Past Past 6

month months

____ ____ I recognized a prejudice I have about certain people.

____ ____ I talked to a colleague about a cultural issue.

____ ____ I sought guidance about a cultural issue that arose in therapy.

____ ____ I attended a multicultural training seminar.

____ ____ I attended a cultural event.

____ ____ I attended an event in which most other people weren’t of my race. 

____ ____ I reflected on my racial identity and how it affects my work with clients.

____ ____ I read a chapter or an article about multicultural issues.

____ ____ I read a novel about a racial group other than my own.

____ ____ I sought consultation or supervision about multicultural issues.

____ ____ I talked to a friend/associate about how our racial differences affect our 

relationship.

____ ____ I challenged a racist remark—my own or someone else’s.

Source: Pack-Brown and Williams 2003, p. 136. Used with permission.

 95
Improving Cultural Competence

expectations, and tasks into performance 

evaluations, staff members will receive an 

important and consistent message from the 

organization that culturally competent behavior and responsive services are valued and 

rewarded. 

Organizational 

Infrastructure

Task: Plan Long-Range Fiscal 

Support of Cultural Competence 

An organization’s commitment to providing 

culturally responsive treatment services will 

only succeed if resources are consistently 

dedicated to supporting the plan. Realistically, treatment program funds may be insufficient to initially meet the goals outlined in 

the organization’s self-assessment. More 

often than not, the committee, executive staff, 

and board will have to prioritize the specific 

changes that are financially feasible. However, 

this necessity does not preclude the organization from soliciting help from the community, finding creative and inexpensive ways to 

make organizational changes, and using 

strategic and financial planning to build 

resources designated for culturally responsive 

services. 

Task: Create an Environment That 

Reflects the Populations Served

The self-assessment process should include 

an environmental review of the organization’s 

physical facilities in which barriers to access 

are examined. The plan should address identified deficits. For example, signage should be 

written in all primary languages spoken by 

the clients served; it should be written at an 

appropriate level of literacy in those languages. When possible, signs should use 

pictures and graphics to replace written instructions. The design of the facility, including use of space and décor, should be inviting,

comfortable, and culturally sensitive. The 

plan should establish how to make facilities 

more accessible and culturally appropriate. In 

addition, the organization should create an 

environment that reflects the culture(s) of its 

clients not only within the facility, but 

through business practices, such as using local 

and community vendors. 

Task: Develop Outreach 

Strategies To Improve Access to 

Care

The best-laid plans for providing culturally 

competent treatment are futile if clients 

cannot access treatment. Providers should 

develop outreach plans for diverse ethnic and 

Advice to Administrators and Clinical Supervisors: Culturally Responsive 

Performance Evaluation Criteria 

Cultural competence is measured by the degree to which counselors, administrators, and other staff 

members engage in observable actions and attitudes that reflect cultural responsiveness. Following 

are examples of descriptive evaluation criteria that address a few aspects of culturally responsive 

behavior: 

• Engages in ongoing self-analysis to identify and address personal and cultural biases.

• Actively seeks to view life through the eyes of others and, through doing so, develops a greater 

level of sensitivity for the values and life challenges of other groups.

• Participates in hands-on training opportunities and seeks practice and feedback that build toward 

mastery of responsive needs assessment techniques.

• Seeks opportunities to engage in cross-cultural activities and interactions.

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Chapter 4—Pursuing Organizational Cultural Competence

Advice to Administrators: Improving Outreach and Access to Care

Whenever it is not feasible to provide behavioral health services in the neighborhoods or communities where they are needed, treatment providers should consider the following: 

• Referring clients to community resources: Ensure that all counselors and referral sources know 

where to refer individuals for culturally appropriate community services. Individuals should not 

have to “bounce around” through the system seeking care that is already difficult to access. 

Have culturally and linguistically appropriate brochures available that describe community services, eligibility, and the referral process. 

• Collaborating with other community services: Collaboration with other community-based 

organizations is essential to compensate for the limitations faced by any single agency. Behavioral health service providers can reach larger numbers of underserved populations by teaming with others who have complementary missions and, at times, greater funding, such as other 

behavioral health agencies and programs dealing with welfare-to-work services, homelessness, 

or HIV/AIDS. Additional collaboration to increase use includes sending culturally competent 

counselors to work at another agency or community group on at least a part-time basis, training 

community members or other agency personnel to provide brief interventions or referral services, and supporting the establishment of mutual-help groups with translated/adapted literature in neighborhood locations. 

• Co-locating community services (creating a one-stop facility): Co-locating with other agencies 

is often highly desirable, as it can facilitate connections among various community services that 

clients need and provide an easy central location to access these services (e.g., a substance 

abuse intensive outpatient treatment program, a community health service agency, and a community outpatient mental health program offered at one location). For culturally diverse people, 

the process of accessing services across agencies can be complex because of the need to obtain 

linguistically and culturally appropriate services and to overcome other barriers, such as economic challenges, issues surrounding eligibility, or the cumbersome repetition of completing 

forms for each agency. An effective one-stop facility ensures close coordination between each 

agency that participates while also ensuring client confidentiality. Co-location with a communitybased organization that already has solid, positive visibility in the community and a culturally 

competent workforce can help improve the outreach and treatment efforts of behavioral health 

organizations that have had difficulty connecting with the communities that they serve. 

• Eliciting support from the community and employing outreach workers: It is often easier and 

more persuasive for people who abuse substances or need mental health services to receive information and be encouraged to seek treatment by persons who are ethnically similar to them 

and speak the same language as they do. This is especially important for new immigrants, who 

do not yet know their way around the new country and could be unsure of whom they can trust. 

When possible, outreach workers should be of similar cultural origin as the population being 

served and should be familiar with the community where they are working. This allows them to 

explain the advantages of treatment in culturally appropriate ways, speak the appropriate language or dialect, address the concerns of community members, and respect clients’ priorities 

and issues. Outreach efforts can forge connections with important members of the community 

who encourage people with mental and substance use disorders and their families to seek 

treatment. These efforts are particularly important with new immigrants who may face legal and 

language barriers or may have a limited understanding of contemporary medicine and treatment 

possibilities. For example, lay people trained as promotores de salud (promoters of health) have 

been successful in reaching Latino migrant workers (Azevedo and Bogue 2001).

• Supplying support services: Providers can use a variety of means to make treatment accessible 

to culturally diverse clients. One strategy is to provide transportation from clients’ neighborhoods to the provider site. In many areas, people must travel long distances to receive culturally 

appropriate services. This limits the number of people able to receive treatment, especially

(Continued on the next page.)

 97
Improving Cultural Competence

racial communities, particularly those whose 

members may find it difficult to seek services 

on their own. For example, see CommunityDefined Solutions for Latino Mental Health 

Care Disparities (Aguilar-Gaxiola et al. 2012). 

From the outset, effective outreach and improved access to care should include formal 

and informal contacts with community organizations, spiritual leaders, and media. Providers 

can learn from these contacts about the behavioral health concerns in the community, special considerations for working with members 

of the community, cultural impediments to 

treatment, and cultural resources to aid treatment and recovery. 

Unfortunately, many providers lack sufficient 

funding to offer the level of outreach services 

needed by the communities they serve. Because they are overwhelmed already, the issue 

of outreach to underserved populations is 

often seen as a low priority, which can cause 

these providers to send people in need of 

treatment away, disappointed and disheartened. However, thoughtful and strategic use of 

community resources can result in more members of underserved populations receiving the 

treatment they need and deserve. At minimum, outreach enables providers to offer 

accurate information and referral to appropriate mutual-help or community groups. 

Regarding fiscal planning and funding opportunities, some HHS initiatives support 

outreach through integrated care. For example, the Health Resources and Services 

Administration (HRSA) Center for Integrated 

Health Solutions (CIHS) promotes the development of integrated primary and behavioral 

health services to better address the needs of 

individuals with mental health and substance 

use concerns. Resources are available to help 

physicians screen for behavioral health problems and refer individuals to appropriate 

treatment. SAMHSA’s Center for Substance 

Abuse Treatment has a Targeted Capacity 

Expansion Program that offers grants in 

support of outreach to specific populations. 

The challenges outlined in this chapter are 

burdensome but can be overcome. Many 

organizations have been able to develop cultural competence over time (for a historical 

perspective of one organization’s journey, see 

Exhibit 4-7). A well-defined and organized 

plan, coupled with a consistent organizational 

commitment, will enable organizations to 

initiate and accomplish the tasks necessary to 

promote culturally responsive services. 

Advice to Administrators: Improving Outreach and Access to Care (continued)

individuals with incomes too low to support travel. In addition, lengthy travel requirements reduce the chances of a person in the early stages of change with low motivation reaching a counselor who can help increase motivation and move the person toward recovery. Other strategies 

are the inclusion of child care and language services within the program. In addition, home-based 

outpatient treatment and telemedicine strategies can work, particularly for rural populations.

• Selecting culturally appropriate strategies to provide community education: Certain forms of 

outreach are more likely to be successful in some populations than in others. For example, in 

Chinese and Korean communities, community fairs are often an excellent way to publicize treatment services. Notices in community newspapers, on radio and television channels, on billboards, 

and in stores in the languages spoken locally can reach other potential clients. The person chosen 

to deliver or represent the messages in such situations should be someone familiar with the 

community and likely to inspire trust. Some agencies serving American Indian people have experienced success in publishing a monthly newsletter that is sent to individual American Indians and 

agencies serving the Native American community.

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Chapter 4—Pursuing Organizational Cultural Competence

Exhibit 4-7: Cultural Competence Initiative Across Time in One Organization

Late 1980s

• The executive director and board endorse the need to pursue cultural competence and outline 

agency goals.

• An agency cultural competence committee forms to help develop policies, procedures, and a 

cultural competence plan. Community and client representation is established.

• A senior staff member is hired to oversee the organization’s efforts to diversify staff.

Early 1990s

• The executive director, board of directors, and advisory board endorse the need to pursue 

culturally competent practices throughout the organization. 

• General goals are established and senior management and staff members begin educating the 

staff on cultural competence.

Mid 1990s

• Culturally competent clinical standards are developed and implemented.

• Initial vision, mission, and value statements are modified to include cultural competence.

• Training for management and clinical supervisors incorporates cultural competence in practice.

• The agency begins a community cultural assessment and introduces a client satisfaction survey 

to gain feedback on current implementation of culturally responsive practices and to guide future direction and focus. 

• Ongoing clinical supervisor training on cultural competence is initiated.

• The cultural competence committee develops recommendations for job descriptions and performance appraisals to reflect cultural competence skills and responsibilities.

Late 1990s

• Individuals and families who receive services are now involved in focus groups, orientations, and 

trainings.

• Partnerships with other agencies to promote cultural competence throughout the community 

are more strongly encouraged.

• A curriculum to train all staff members in the foundations of cultural competence is developed 

and implemented.

2000s

• Across the organization, clinical and administrative programs engage in cultural competence 

review and goal-setting.

• The mission statement is redefined to formally acknowledge the organization’s values of respect 

for cultural differences, recovery, and advocacy.

 

 99
Behavioral Health 

Treatment for Major 

Racial and Ethnic Groups 

John, 27, is an American Indian from a Northern Plains Tribe. He 

recently entered an outpatient treatment program in a midsized 

Midwestern city to get help with his drinking and subsequent low 

mood. John moved to the city 2 years ago and has mixed feelings

about living there, but he does not want to return to the reservation because of its lack of job opportunities. Both John and his 

counselor are concerned that (with the exception of his girlfriend, 

Sandy, and a few neighbors) most of his current friends and 

coworkers are “drinking buddies.” John says his friends and family 

on the reservation would support his recovery—including an uncle 

and a best friend from school who are both in recovery—but his 

contact with them is infrequent.

John says he entered treatment mostly because his drinking was 

interfering with his job as a bus mechanic and with his relationship 

with his girlfriend. When the counselor asks new group members 

to tell a story about what has brought them to treatment, John 

explains the specific event that had motivated him. He describes 

having been at a party with some friends from work and watching

one of his coworkers give a bowl of beer to his dog. The dog kept 

drinking until he had a seizure, and John was disgusted when people laughed. He says this event was “like a vision;” it showed him 

that he was being treated in a similar fashion and that alcohol was 

a poison. When he first began drinking, it was to deal with boredom and to rebel against strict parents whose Pentecostal Christian 

beliefs forbade alcohol. However, he says this vision showed him 

that drinking was controlling him for the benefit of others. 

Later, in a one-on-one session, John tells his counselor that he is 

afraid treatment won’t help him. He knows plenty of people back

5

 IN THIS CHAPTER

• Introduction

• Counseling for African 

and Black Americans

• Counseling for Asian 

Americans, Native

Hawaiians, and Other 

Pacific Islanders

• Counseling for Hispanics 

and Latinos

• Counseling for Native 

Americans

• Counseling for White 

Americans

101
Improving Cultural Competence

home who have been through treatment and 

still drink or use drugs. Even though he 

doesn’t consider himself particularly traditional, he is especially concerned that there is 

nothing “Indian” about the program; he dislikes that his treatment plan focuses more on 

changing his thinking than addressing his 

spiritual needs or the fact that drinking has 

been a poison for his whole community. 

John’s counselor recognizes the importance of 

connecting John to his community and, if 

possible, to a source of traditional healing. 

After much research, his counselor is able to 

locate and contact an Indian service organization in a larger city nearby. The agency puts 

him in touch with an older woman from 

John’s Tribe who resides in that city. She, in 

turn, puts the counselor in touch with another 

member of the Tribe who is in recovery and 

had been staying at her house. This man 

agrees to be John’s sponsor at local 12-Step 

meetings. With John’s permission, the counselor arranges an initial family therapy session 

that includes his new sponsor, the woman who 

serves as a local “clan mother,”John’s girlfriend, and, via telephone, John’s uncle in 

recovery, mother, and brother. With John’s 

permission and the assistance of his new 

sponsor, the counselor arranges for John and 

some other members of his treatment group to 

attend a sweat lodge, which proves valuable in 

helping John find some inner peace as well as 

giving his fellow group members some insight 

into John and his culture. 

To provide culturally responsive treatment, 

counselors and organizations must be committed to gaining cultural knowledge and clinical 

skills that are appropriate for the specific racial 

and ethnic groups they serve. Treatment providers need to learn how a client’s identification with one or more cultural groups 

influences the client’s identity, patterns of 

substance use, beliefs surrounding health and 

healing, help-seeking behavior, and treatment 

expectations and preferences. Adopting Sue’s 

(2001) multidimensional model in developing 

cultural competence, this chapter identifies 

cultural knowledge and its relationship to 

treatment as a domain that requires proficiency in clinical skills, programmatic development, and administrative practices. This 

chapter focuses on patterns of substance use 

and co-occurring disorders (CODs), beliefs 

about and traditions involving substance use, 

beliefs and attitudes about behavioral health 

treatment, assessment and treatment considerations, and theoretical approaches and treatment interventions across the major racial and 

ethnic groups in the United States.

Introduction

Culture is a primary force in the creation of a 

person’s identity. Counselors who are culturally 

competent are better able to understand and 

respect their clients’ identities and related 

cultural ways of life. This chapter proposes 

strategies to engage clients of diverse racial 

and ethnic groups (who can have very different life experiences, values, and traditions) in 

treatment. The major racial and ethnic groups 

in the United States covered in this chapter 

are African Americans, Asian Americans 

(including Native Hawaiians and other Pacific 

Islanders), Latinos, Native Americans (i.e., 

Alaska Natives and American Indians), and 

White Americans. In addition to providing 

epidemiological data on each group, the chapter discusses salient aspects of treatment for 

these racial/ethnic groups, drawing on clinical 

and research literature. This information is 

only a starting point in gaining cultural 

knowledge as it relates to behavioral health. 

Understanding the diversity within a specific 

culture, race, or ethnicity is essential; not all 

information presented in this chapter will 

apply to all individuals. The material in this 

chapter has a scientific basis, yet cultural beliefs,

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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Multidimensional Model for Developing Cultural Competence: Cultural 

Knowledge of Behavioral Health 

traditions, and practices change with time and 

are not static factors to consider in providing 

services for clients, families, or communities. 

Although these broad racial/ethnic categories 

are often used to describe diverse cultural 

groups, the differences between two members 

of the same racial/ethnic group can be greater 

than the differences between two people from

different racial/ethnic groups (Lamont and 

Small 2008; Zuckerman 1998). It is not possible to capture every aspect of diversity within 

each cultural group. Behavioral health workers

should acknowledge that there will be many 

individual variations in how people interact 

with their environments, as well as in how 

environmental context affects behavioral 

health. However, to provide a framework for

understanding many diverse cultural groups, 

some generalizations are necessary; thus, broad 

categories are used to organize information in 

this chapter. Counselors are encouraged to 

learn as much as possible about the specific 

populations they serve. Sources listed in

Appendix F provide additional information. 

Counseling for African and 

Black Americans

According to the 2010 U.S. Census definition, 

African Americans or Blacks are people whose 

103
Improving Cultural Competence

origins are “in any of the black racial groups of 

Africa”(Humes et al. 2011, p. 3). The term 

includes descendants of African slaves brought 

to this country against their will and more 

recent immigrants from Africa, the Caribbean, 

and South or Central America (many individuals from these latter regions, if they come 

from Spanish-speaking cultural groups, identify or are identified primarily as Latino). The 

term “Black”is often used interchangeably 

with African American, although sometimes 

the term “African American” is used specifically to describe people whose families have 

been in this country since at least the 19th

century and thus have developed distinct

African American cultural groups. “Black” can 

be a more inclusive term describing African 

Americans as well as more recent immigrants 

with distinct cultural backgrounds.

Beliefs About and Traditions 

Involving Substance Use 

In most African American communities, 

significant alcohol or drug use may be socially 

unacceptable or seen as a sign of weakness 

(Wright 2001), even in communities with 

limited resources, where the sale of such substances may be more acceptable. Overall, 

African Americans are more likely to believe 

that drinking and drug use are activities for 

which one is personally responsible; thus, they 

may have difficulty accepting alcohol 

abuse/dependence as a disease (Durant 2005).

Substance Use and Substance Use 

Disorders 

To date, there has not been much research 

analyzing differences in patterns of substance 

use and abuse among different groups of 

Blacks, but there are indications that some 

gender differences exist. For example, alcohol 

consumption among African American women increases as they grow older, but Caribbean 

Black women report consistently low alcohol 

consumption as they grow older (Center for 

Substance Abuse Treatment [CSAT] 1999a;

Galvan and Caetano 2003). Rates of overall 

substance use among African Americans vary 

significantly by age. Several researchers have 

observed that despite Black youth being less 

likely than White American youth to use 

substances, as African Americans get older, 

they tend to use at rates comparable with 

those of White Americans (Watt 2008). This 

increase in substance use with age among 

Blacks is often referred to as a crossover effect.

However, Watt (2008), in her analysis of 4 

years of National Survey on Drug Use and

Health (NSDUH) data (1999–2002), found 

that when controlling for factors such as drug 

exposure, marriage, employment, education, 

income, and family/social support, the crossover effect disappeared for Blacks ages 35 and 

older; patterns for drug and heavy alcohol use 

among Black and White American adults 

remained the same as for Black and White 

American adolescents (i.e., White Americans 

were significantly more likely to use substances). Watt concludes that systemic issues, such 

as lower incomes and education levels, and 

other factors, such as lower marriage rates, 

contribute to substance use among Black 

adults. Additional research also suggests that 

exposure to discrimination increases willingness to use substances in African American 

youth and their parents (Gibbons et al. 2010). 

When comparing African Americans with 

other racial and ethnic groups, NSDUH data 

from 2012 suggest that they are somewhat 

more likely than White Americans to use illicit 

drugs and less likely than White Americans to 

use alcohol. They also appear to have an incidence of alcohol and drug use disorders similar to that seen in White Americans 

(Substance Abuse and Mental Health Services 

Administration [SAMHSA] 2013d). Crack 

cocaine use is more prevalent among Blacks 

104
Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

than White Americans or Latinos, whereas

rates of abuse of methamphetamine, inhalants, 

most hallucinogens, and prescription drugs are 

lower (SAMHSA 2011a). Phencyclidine use 

also appears to be a more serious problem, 

albeit affecting a relatively small group, among 

African Americans than among members of 

other racial/ethnic groups. 

There appear to be some other differences in 

how African Americans use substances compared with members of other racial/ethnic 

groups. For example, Bourgois and Schonberg 

(2007) observed that among people who injected heroin in San Francisco, White Americans

tended to administer the drug quickly whether 

or not they could find a vein, which led them 

to inject into fat or muscle tissue and resulted 

in a higher rate of abscesses. However, African 

Americans who injected heroin were more 

methodical and took the time to find a vein,

even if it took multiple attempts. This, in turn, 

often resulted in using syringes that were 

already bloodied and increased their chances 

of contracting HIV/AIDS and other bloodborne diseases. African Americans who injected heroin were significantly more likely to also 

use crack cocaine than were White Americans 

who injected heroin (Bourgois et al. 2006).

African American patterns of substance use 

have changed over time and will likely continue to do so. Based on treatment admission 

data, admissions of African Americans who 

injected heroin declined by 44 percent during 

a 12-year period, whereas admissions declined 

by only 14 percent among White Americans 

(Broz and Ouellet 2008). Additionally, during 

this period, the peak age for African Americans

who injected heroin increased by 10 years, yet 

it decreased by 10 years for White Americans. 

This suggests that the decrease in injectable 

heroin use among African Americans was 

largely due to decreased use among younger 

individuals.

Some preliminary evidence suggests that 

African Americans are less likely to develop 

drug use disorders following initiation of use 

(Falck et al. 2008), yet more research is needed 

to identify variables that influence the development of drug use disorders. Even though 

African Americans seem less likely than 

White Americans to develop alcohol use 

disorders, a number of older studies have 

found that they more frequently experience 

liver cirrhosis and other alcohol-related health 

problems (Caetano 2003; Polednak 2008). In 

tracking 25 years of data, Polednak (2008) 

found that the magnitude of difference has 

decreased over time; nonetheless, health disparities continue to exist for African Americans in 

terms of access to and quality of care, which 

can affect a number of health problems

(Agency for Healthcare Research and Quality 

2009; Smedley et al. 2003).

Mental and Co-Occurring 

Disorders

A number of studies have found biases that 

result in African Americans being overdiagnosed for some disorders and underdiagnosed 

for others. African Americans are less likely 

than White Americans to receive treatment 

for anxiety and mood disorders, but they are 

more likely to receive treatment for drug use 

disorders (Hatzenbuehler et al. 2008). In one 

study evaluating posttraumatic stress disorder 

(PTSD) among African Americans in an 

outpatient mental health clinic, only 11 percent of clients had documentation referring to 

PTSD, even though 43 percent of the clients 

showed symptoms of PTSD (Schwartz et al.

2005). Black immigrants are less likely to be 

diagnosed with mental disorders than are 

Blacks born in the United States (Burgess et 

al. 2008; Miranda et al. 2005b).

African Americans are more likely to be 

diagnosed with schizophrenia and less likely 

to be diagnosed with affective disorders than 

105
Improving Cultural Competence

White Americans, even though multiple 

studies have found that rates of both disorders

among these populations are comparable

(Baker and Bell 1999; Bresnahan et al. 2000;

Griffith and Baker 1993; Stockdale et al. 2008; 

Strakowski et al. 2003). African Americans are 

about twice as likely to be diagnosed with a 

psychotic disorder as White Americans and 

more than three times as likely to be hospitalized for such disorders. These differences in 

diagnosis are likely the result of clinician bias 

in evaluating symptoms (Bao et al. 2008; 

Trierweiler et al. 2000; Trierweiler et al.

2006). Clinicians should be aware of bias in 

assessment with African Americans and with 

other racial/ethnic groups and should consider ways to increase diagnostic accuracy by 

reducing biases. For an overview of mental 

health across populations, refer to Mental 

Health United States, 2010 (SAMHSA 

2012a).

In some African American communities, 

incidence and prevalence of trauma exposure 

and PTSD are high, and substance use appears to increase trauma exposure even further 

(Alim et al. 2006; Breslau et al. 1995; CurtisBoles and Jenkins-Monroe 2000; Rich and 

Grey 2005). Black women who abuse substances report high rates of sexual abuse 

(Ross-Durow and Boyd 2000). Trauma histories can also have a greater effect on relapse for 

African American clients than for clients from 

other ethnic/racial groups (Farley et al. 2004). 

There are few integrated approaches to trauma and substance abuse that have been evaluated with African American clients, and 

although some have been found effective at 

reducing trauma symptoms and substance 

use, the extent of that effectiveness is not 

necessarily as great as it is for White 

Americans (Amaro et al. 2007; Hien et al. 

2004; SAMHSA 2006).

African Americans are less likely than White 

Americans to report lifetime CODs (Mericle

et al. 2012). However, limited research indicates that, as with other racial groups, there are 

differences across African American groups in 

the screening and symptomatology of CODs. 

Seventy-four percent of African Americans 

who had a past-year major depressive episode 

were identified as also having both alcohol and 

marijuana use disorders (Pacek et al. 2012). 

Miranda et al. (2005b) found that Americanborn Black women were more than twice as 

likely to be screened as possibly having depression than African- or Caribbean-born Black 

women, but this could reflect, in part, differences in acculturation (see Chapter 1). However, research findings strongly suggest that 

cultural responses to some disorders, and 

possibly the rates of those disorders, do vary 

among different groups of Blacks. Differences 

do not appear to be simply reflections of 

differences in acculturation ( Joe et al. 2006). 

For a review of African American health, see

Hampton et al. (2010).

Treatment Patterns

African Americans may be less likely to receive mental health services than White 

Americans. In the Baltimore Epidemiologic 

Catchment Services Area study conducted 

during the 1980s, African Americans were less 

likely than White Americans to receive mental 

health services. However, at follow-up in the 

early 1990s, African American respondents 

were as likely as White Americans to receive 

such services, but they were much more likely 

to receive those services from general practitioners than from mental health specialists 

(Cooper-Patrick et al. 1999). Stockdale et al. 

(2008) analyzed 10 years of data from the 

National Ambulatory Medical Care Survey; 

they found significant improvements in diagnosis and care for mental disorders among 

African Americans in psychiatric settings 

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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

between 1995 and 2005, but they also found 

that disparities persisted in the diagnosis and 

treatment of mental disorders in primary care 

settings. Fortuna et al. (2010) suggest that 

persistent problems exist in the delivery of 

behavioral health services, as evidenced by 

lower retention rates for treating depression.

Even among people who enter substance 

abuse treatment, African Americans are less

likely to receive services for CODs. A study of 

administrative records from substance abuse 

and mental health treatment providers in New 

Jersey found that African Americans were 

significantly more likely than White Americans

to have an undetected co-occurring mental 

disorder, and, if detected, they were significantly less likely than White Americans or 

Latinos to receive treatment for that disorder 

(Hu et al. 2006). Among persons with substance use disorders and co-occurring mood or 

anxiety disorders, African Americans are 

significantly less likely than White Americans 

to receive services (Hatzenbuehler et al. 2008). 

African Americans who do receive services for 

CODs are more likely to obtain them through 

substance abuse treatment programs than 

mental health programs (Alvidrez and 

Havassy 2005). 

According to the Treatment Episode Data 

Sets (TEDS) from 2001 to 2011, African 

American clients entering substance abuse 

treatment most often reported alcohol as their 

primary substance of abuse, followed by marijuana. However, gender differences are evident, 

indicating that women report a broader range 

of substances as their primary substance of 

abuse than men do (SAMHSA, Center for 

Behavioral Health Statistics and Quality 

[CBHSQ], 2013). Most recent research suggests that African Americans are about as 

likely to seek and eventually receive substance 

abuse treatment as are White Americans 

(Hatzenbuehler et al. 2008; Perron et al. 2009; 

SAMHSA, CBHSQ 2011; Schmidt et al. 

2006). Data analyzed by Perron et al. (2009)

indicate that among African Americans with 

lifetime diagnoses of drug use disorders, 20.8 

percent had received some type of treatment, 

as defined broadly to include resources such as 

pastoral counseling and mutual-help group 

attendance. This made them more likely to 

have received treatment than White Americans (15.5 percent of whom received treatment) or Latinos (17.3 percent of whom 

received treatment). Although data indicate 

that African Americans were less likely to 

receive services from private providers, they 

also indicate that African Americans were 

more likely to use more informal services (e.g.,

pastoral counseling, mutual help). 

Although most major studies have found that 

race is not a significant factor in receiving 

treatment, African Americans report lengthier 

waiting periods, less initiation of treatment, 

more barriers to treatment participation (e.g., 

lack of childcare, lack of insurance, lack of 

knowledge about available services), and 

shorter lengths of stay in treatment than do 

White Americans (Acevedo et al. 2012; 

Brower and Carey 2003; Feidler et al. 2001; 

Grant 1997; Hatzenbuehler et al. 2008; Marsh 

et al. 2009; SAMHSA 2011c; Schmidt et al. 

2006). In SAMHSA’s 2010 NSDUH, 33.5 

percent of African Americans who had a need 

for substance abuse treatment but did not 

receive it in the prior year reported that they 

lacked money or the insurance coverage to pay 

for it (SAMHSA, CBHSQ 2011). Economic 

disadvantage does leave many Africans Americans uninsured; approximately 16.1 percent of 

non-Latino Blacks had no coverage in 2004 

(Schiller et al. 2005). 

Likewise, some researchers have found that 

African Americans are less likely than White 

Americans to receive needed services or an 

appropriate level of service (Alegria et al. 

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Improving Cultural Competence

2011; Bluthenthal et al. 2007; Marsh et al. 

2009). For example, African Americans and 

Latinos are less likely than White Americans 

to receive residential treatment and are more 

likely to receive outpatient treatment, even 

when they present with more serious substance 

use problems (Bluthenthal et al. 2007). Other 

studies have found that African Americans

with severe substance use or CODs were less 

likely to enter or receive treatment than White 

Americans with equally severe disorders

(Schmidt et al. 2006, 2007). 

African Americans are overrepresented among 

people who are incarcerated in prisons and 

jails (for review, see Fellner 2009), and a substantial number of those who are incarcerated 

(64.1 percent of jail inmates in 2002) have 

substance use disorders (Karberg and James

2005) and mental health problems (SAMHSA

2012a). However, according to Karberg and 

( James 2005), African Americans with substance dependence disorders who were in jail 

in 2002 were less likely than White Americans 

or Latinos to participate in substance abuse 

treatment while under correctional supervision 

(32 percent of African Americans participated

compared with 37 percent of Latinos and 45 

percent of White Americans). In the 2010 

TEDS survey, African Americans entering 

treatment were also less likely than Asian 

Americans, White Americans, Latinos, Native 

Hawaiians/Pacific Islanders, or American 

Indians in the same situation to be referred to 

treatment through the criminal justice system 

(SAMHSA, CBHSQ 2012). Notwithstanding, African Americans are more likely to be 

referred to treatment from criminal justice 

settings rather than self-referred or referred by 

other sources (Delphin-Rittmon et al. 2012)

Beyond issues related to diagnosis and care 

that can prevent African Americans from 

accessing mental health services, research 

suggests that a lack of familiarity with the 

value and use of specialized behavioral health 

services among some African Americans may 

limit service use. Hines-Martin et al. (2004) 

found a positive relationship between familiarity and use of mental health services among 

African Americans. Additionally, factors such 

as social and familial prejudices (Ayalon and 

Alvidrez 2007; Mishra et al. 2009; Nadeem et 

al. 2007) and fears relating to past abuses of 

African Americans within the mental health 

system ( Jackson 2003) can contribute to the 

lack of acceptance and subsequent use of these 

services. An essential step in decreasing disparity in behavioral health services among 

African Americans involves conducting culturally appropriate mental health screenings

and using culturally sensitive instruments and 

evaluation tools (Baker and Bell 1999). 

Beliefs and Attitudes About 

Treatment

According to 2011 NSDUH data, African 

Americans were, next to Asian Americans, 

the least likely of all major ethnic and racial 

groups to state a need for specialized substance abuse treatment (SAMHSA, CBHSQ 

2013a). Still, logistical barriers may pose a 

greater challenge for African Americans than 

for members of other major racial and ethnic 

groups. For example, 2010 NSDUH data 

regarding individuals who expressed a need 

for substance abuse treatment but did not 

receive it in the prior year indicate that

African Americans were more likely than 

members of other major ethnic/racial groups 

to state that they lacked transportation to the 

program or that their insurance did not cover 

the cost of such treatment (SAMHSA 

2011a). African Americans experience several 

challenges in accessing behavioral health 

treatment, including fears about the therapist 

or therapeutic process and concerns about 

discrimination and costs (Holden et al. 2012; 

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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Holden and Xanthos 2009; Williams et al.

2012). 

Longstanding suspicions regarding established 

healthcare institutions can also affect African 

Americans’ participation in, attitudes toward, 

and outcomes after treatment (for review, see 

Pieterse et al. 2012). Historically, the mental 

health system has shown bias against African 

Americans, having been used in times past to 

control and punish them (Boyd-Franklin and 

Karger 2012; Jackson 2003). After controlling 

for socioeconomic factors, African Americans 

are significantly more likely to perceive the 

healthcare system as poor or fair and significantly more likely to believe that they have 

been discriminated against in healthcare 

settings (Blendon et al. 2007). Attitudes toward psychological services appear to become 

more negative as psychological distress increases (Obasi and Leong 2009). In many 

African American communities, there is a 

persistent belief that social and treatment 

services try to impose White American values, 

adding to their distrust of the treatment system (Larkin 2003; Solomon 1990). 

African Americans, even when receiving the 

same amount of services as White Americans, 

are less likely to be satisfied with those services 

(Tonigan 2003). However, recent evidence 

suggests that, once engaged, African American

clients are at least as likely to continue participation as members of other ethnic/racial 

groups (Harris et al. 2006). Because distrust of 

the healthcare system can make it more difficult to engage African American clients initially in treatment, Longshore and Grills 

(2000) recommend culturally congruent motivational enhancement strategies to address 

African American clients’ ambivalence about 

treatment services. Providers also need to craft 

culturally responsive health-related messages 

for African Americans to improve treatment 

engagement and effectiveness (Larkin 2003). 

Most importantly, providers need to demonstrate multicultural experience. In a study 

comparing outcomes among Black and White 

clients at community mental health centers, 

the only clinician factor that predicted more 

favorable outcomes was clinicians’ general 

experiences and relationships with people 

from racial/ethnic and cultural groups other 

than their own (Larrison et al. 2011).

Treatment Issues and 

Considerations 

African American clients generally respond 

better to an egalitarian and authentic relationship with counselors (Sue 2001). Paniagua 

(1998) suggests that in the initial sessions with 

African American clients, counselors should 

develop a collaborative client–counselor relationship. Counselors should request personal 

information gradually rather than attempting 

to gain information as quickly as possible, 

avoid information-gathering methods that 

clients could perceive as an interrogation, pace 

the session, and not force a data-gathering 

agenda (Paniagua 1998; Wright 2001). Counselors must also establish credibility with 

clients (Boyd-Franklin 2003).

Next, counselors should establish trust. Selfdisclosure can be very difficult for some clients 

because of their histories of experiencing 

racism and discrimination. These issues can be 

exacerbated in African American men whose

experience of racism has been more severe or 

who have had fewer positive relationships with 

White Americans (Reid 2000; Sue 2001).

Counselors, therefore, need to be willing to 

address the issue of race and to validate African 

American clients’ experiences of racism and its 

reality in their lives, even if it differs from 

their own experiences (Boyd-Franklin 2003; 

Kelly and Parsons 2008). Moreover, racism 

and discrimination can lead to feelings of 

anger, anxiety, or depression. Often, these 

feelings are not specific to any given event; 

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Improving Cultural Competence

Exhibit 5-1: Core Culturally 

Responsive Principles in Counseling 

African Americans

According to Schiele (2000), culturally responsive counseling for African American clients

involves adherence to six core principles: 

1. Discussion of clients’ substance use should 

be framed in a context that recognizes the 

totality of life experiences faced by clients 

as African Americans. 

2. Equality is sought in the therapeutic counselor–client relationship, and counselors 

are less distant and more disclosing.

3. Emphasis is placed on the importance of 

changing one’s environment—not only for 

the good of clients themselves, but also for 

the greater good of their communities. 

4. Focus is placed on alternatives to substance use that underscore personal rituals, 

cultural traditions, and spiritual well-being.

5. Recovery is a process that involves gaining 

power in the forms of knowledge, spiritual 

insight, and community health.

6. Recovery is framed within a broader context of how recovery contributes to the 

overall healing and advancement of the 

African American community.

rather, they are pervasive (Boyd-Franklin et al. 

2008). Counselors should explore with clients 

the psychological effects of racism and develop 

approaches to challenge internal negative 

messages that have been received or generated 

through discrimination and prejudice (Gooding 2002).

Additional methods that may enhance engagement and promote participation include 

peer-supported interventions and strategies 

that promote empowerment by emphasizing 

strengths rather than deficits (Paniagua 1998; 

Tondora et al. 2010; Wright 2001). It is 

important to explore with clients the 

strengths that have brought them this far. 

What personal, community, or family 

strengths have helped them through difficult 

times? What strengths will support their 

recovery efforts? Exhibit 5-1 gives an 

overview of core guiding principles in working with African American clients.

Theoretical Approaches and 

Treatment Interventions

Research suggests that culturally congruent 

interventions are effective in treating African 

Americans (Longshore and Grills 2000; 

Longshore et al. 1998a; Longshore et al.

1998b; 1999). Although there are conflicting 

results on the effectiveness of motivational 

interviewing among African American clients 

(Montgomery et al. 2011), some motivational 

interventions have been found to reduce substance use among African Americans 

(Bernstein et al. 2005; Longshore and Grills 

2000). Longshore and Grills (2000) describe a 

culturally specific motivational intervention 

for African Americans involving both peer 

and professional counseling that makes use of 

the core African American value of communalism by addressing the ways in which the 

individual’s substance abuse affects his or her 

whole community. The motivational program 

affirms “the heritage, rights, and responsibilities of African Americans...using interaction 

styles, symbols and values shared by members 

of the group” (Longshore et al. 1998b, p. 319). 

So too, African American music, artwork, and 

food can help programs create a welcoming 

and familiar atmosphere, as is the case for 

other racial and ethnic groups when familiar 

cultural symbols appear in the clinical setting.

Many of the interventions developed for 

substance abuse treatment services in general 

have been evaluated with populations that 

were at least partly composed of African 

Americans; many of these interventions are as 

effective for African Americans as they are for 

White Americans (Milligan et al. 2004; Tonigan 2003). One intervention that appears to 

work better for African American (and Latino)

clients than for White American clients—

perhaps because it focuses on improving 

110
Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

client–counselor communication—is nodelink mapping (visual representation using 

information diagrams, fill-in-the-blank graphic tools, and client-generated diagrams or 

visual maps). This approach was associated 

with lower rates of substance use, better treatment attendance, and better counselor ratings 

of motivation and confidence among African 

Americans than among White Americans 

(Dansereau et al. 1996; Dansereau and 

Simpson 2009).

In addition, cognitive–behavioral therapy 

(CBT) has certain distinct advantages for 

African American clients; it fosters a collaborative relationship and recognizes that clients 

are experts on their own problems (Kelly and 

Parsons 2008). Maude-Griffin et al. (1998) 

compared CBT and 12-Step facilitation for a 

group of mostly African American (80 percent) men who were homeless and found that 

CBT achieved significantly better abstinence 

outcomes, except among those who considered 

themselves very religious (these individuals 

had better outcomes with 12-Step facilitation). 

Other interventions that use CBT principles 

have also been effective with African American

populations. For example, a number of studies 

have evaluated contingency management 

approaches with predominantly African 

American client populations, finding that this 

model was effective at reducing cocaine and 

illicit opioid use, improving employment 

outcomes for clients in methadone maintenance (Silverman et al. 2002; Silverman et al.

2007), reducing substance use during and after 

treatment, and improving self-reported quality 

of life (Petry et al. 2004; Petry et al. 2005; Petry 

et al. 2007). The Living in the Balance intervention, which uses psychoeducation and CBT 

techniques, has also been evaluated with a 

mostly African American sample and has been 

shown to improve treatment retention and 

reduce substance use (Hoffman et al. 1996). 

Another therapy that has been evaluated with 

African American clients and found effective 

is supportive–expressive psychotherapy, which 

reduces substance use and improves psychological functioning for individuals in methadone maintenance (Woody et al. 1987; Woody 

et al. 1995). Medications for substance abuse 

can also work well with African American 

clients. In one large study, African Americans 

were more likely than Latinos or White 

Americans to indicate that they found methadone helpful (Gerstein et al. 1997), and in 

another study, they reported greater perceived 

quality of life as a result of participation in a 

methadone program (Geisz 2007). Schroeder et 

al. (2005) also reported that African Americans

in a methadone program had significantly 

fewer adverse medical events (e.g., infections, 

gastrointestinal complaints) than did White 

American participants. African Americans 

who were being treated for cocaine dependence remained in treatment significantly 

longer than did other African Americans if 

they received disulfiram (Milligan et al. 2004). 

A review of cultural adaptations of evidencebased practices is given by Bernal and 

Domenech Rodriguez (2012). For an overview of gender-specific treatment considerations for mental and substance use disorders 

among African American men and women, 

see Shorter-Gooden (2009).

Family therapy

African American clients appear more likely 

to stay connected with their families throughout the course of their addiction. For instance, 

Bourgois et al. (2006) reported that in comparing African American and White American

individuals who injected heroin, African 

Americans appeared to be more likely to 

maintain contact with their extended families. 

Some research also suggests that African 

Americans with substance use disorders are 

more likely to have family members with 

111
Improving Cultural Competence

Advice to Counselors: Strengths of 

African American Families 

African American kinship bonds have historically

been sources of strength. Although substance 

abuse lessens the strength of the family and 

can erode relationships, counselors can use the 

inherent strengths of the family to benefit 

clients and their families (Boyd-Franklin and 

Karger 2012; Larkin 2003; Reid 2000). BellTolliver et al. (2009) and Hill (1972) suggest that 

strengths of African American family life include:

• Strong bonds and extensive kinship.

• Adaptability of family roles.

• A strong family hierarchy.

• A strong work orientation.

• A high achievement orientation.

• A strong religious orientation.

histories of substance abuse, suggesting an 

even greater need to address substance abuse 

within the family (Brower and Carey 2003). 

Strong family bonds are important in African 

American cultural groups. African American 

families are embedded in a complex kinship 

network of biologically related and unrelated 

persons. Hence, counselors should be willing 

to expand the definition of family to a more 

extended kinship system (Boyd-Franklin 

2003; Hines and Boyd-Franklin 2005). Clients 

need to be asked how they define family, 

whom they would identify as family or “like 

family,” who resides with them in their homes, 

and whom they rely on for help. Hines and 

Boyd-Franklin (2005) discuss the importance 

of both blood and nonblood kinship networks 

for African American families. To build a 

support network for African American clients, 

counselors should start by asking clients to 

identify people (whether biological kin or not) 

who would be willing and able to support 

their recovery and then ask clients for permission to contact those people and include them 

in the treatment process.

Family therapy is often a productive approach 

to treatment with African Americans (BoydFranklin 2003; Hines and Boyd-Franklin 

2005; Larkin 2003). However, the extended 

family can be large and have many ties with 

other families in a community; therefore, the 

family therapist sometimes needs to take on 

other roles to assist with case management or 

other activities, including involvement in 

community-wide interventions (Sue 2001). In 

reviewing specific family therapy approaches 

for African Americans, Boyd-Franklin (2003) 

discusses the use of a multisystem family 

therapy approach, which incorporates an 

extended network of relationships that play a 

part in clients’ lives. Using this model, social 

service and other community agencies can be 

considered a significant part of the family 

system. Network therapy, which involves 

clients’ extended social networks, has also been 

found to improve substance use outcomes for 

African American clients when added to 

standard treatment (Keller and Galanter 

1999). Likewise, the family team conference 

model can be a useful approach, given that it 

also engages both families and communities in 

the helping process by attempting to stimulate 

extensive mobilization of activity in the formal 

and informal relationships in and around clients’ families (State of New Jersey Department 

of Human Services 2004).

Brief structural family therapy and strategic 

family therapy reduce substance use as well, 

but research has primarily focused on African 

American youth (Santisteban et al. 1997; 

Santisteban et al. 2003; Szapocznik and 

Williams 2000). Multidimensional family 

therapy has increased abstinence from substance use among African American adolescents and produced more lasting effects than 

CBT, but it also has not been evaluated with 

adult clients (Liddle et al. 2008). In reviewing 

specific family programs, Larkin (2003) reports 

promising preliminary data on a family therapy 

intervention among African Americans in 

public housing that addresses substance abuse. 

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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

The program initially engages families via

psychoeducation on substance abuse and its 

effects on the family, followed by a strengthbased family therapy intervention. Despite the 

small sample size, all 10 families admitted to 

the program completed treatment, and 7 of 10 

family members with substance abuse problems entered recovery and continuing care. 

Participant surveys indicated that 60 percent 

of families preferred multiple-family therapy 

over single-family therapy, and 80 percent 

preferred services delivered in the housing 

project community center to other venues.

Engaging Moms is another family-oriented 

program and intervention developed specifically for African American mothers that has 

been shown to significantly improve treatment 

engagement (Dakof et al. 2003). The intervention is designed for women who have children 

and have been identified as cocaine users. The 

program focuses on mobilizing family members 

who would be likely to motivate the mothers to 

enroll and remain in substance abuse treatment. 

Research has shown no long-term impact, yet 

women who received the intervention were 

significantly more likely to enter treatment (88 

percent of women involved in the program 

versus 46 percent of the control group) and 

remain for at least 2 weeks.

Group therapy

Because of the communal, cooperative values 

held by many African Americans, group therapy can be a particularly valuable component 

of the treatment process (Sue and Sue 2013b). 

A strong oral tradition is one of many forms 

of continuity with African tradition maintained in the African American experience;

therefore, speaking in groups is generally 

acceptable to African American clients. However, Bibb and Casimer (2000) note that Black 

Caribbean Americans can be less comfortable 

with the group process, particularly the requirement that they self-disclose personal 

problems to people who are relative strangers. 

African Americans seem less likely to selfdisclose about the past in group settings that 

include non-Hispanic Whites ( Johnson et al.

2011; Richardson and Williams 1990). Consequently, groups composed only of African 

Americans can be more beneficial. Homogenous African American groups can also be 

good venues for clients to deal with systemic 

problems, such as racism and lack of economic 

opportunities in the African American community ( Jones et al. 2000).

Mutual-help groups

A variety of mutual-help groups are available 

for African Americans entering recovery from 

substance use and mental disorders. However, 

most of the literature focuses on 12-Step 

groups, including Alcoholics Anonymous 

(AA) and Narcotics Anonymous. Some find 

that the 12-Step approach warrants careful 

consideration with African Americans, who 

can find the concept of powerlessness over 

substances of abuse to be too similar to experiences of powerlessness via discrimination. 

Additionally, the disease concept of addiction 

presented in 12-Step meetings can be difficult 

for many African Americans (Durant 2005). 

In some instances, the Black community has 

changed the mutual-help model for substance 

use and mental health to make it more empowering and relevant to African American 

participants. For additional information on the 

12 Steps for African Americans, visit Alcoholics Anonymous World Services (AAWS), AA 

for the Black and African American Alcoholic, 

available online (http://www.aa.org/ 

pdf/products/p-51_CanAAHelpMeToo.pdf).

Despite their emphasis on the concept of 

powerlessness, 12-Step programs are significant 

support systems for many African Americans. 

In AA’s 2011 membership survey, 4 percent of 

members identified their race as Black 

(AAWS 2012). Analysis of 2006–2007 

113
Improving Cultural Competence

NSDUH data showed that African Americans

were less likely to use mutual-help groups in 

the past year for substance use (about 11

percent did) than White Americans (about 67

percent did) or Latinos (about 16 percent did; 

SAMHSA 2013d). However, the National 

Epidemiologic Survey on Alcohol and Related 

Conditions (NESARC) survey did find that 

African Americans who had a lifetime drug 

use disorder diagnosis and had sought help 

were more than three times as likely to have 

attended mutual-help meetings as were White 

Americans or Latinos (Perron et al. 2009). 

Several other surveys suggest that African 

Americans with alcohol-related problems are 

at least as likely to participate in AA as White 

Americans and that greater problem severity is 

associated with increased likelihood of participation (Kingree and Sullivan 2002). Of the 

participants who attended mutual-help group 

sessions for mental health in the past year, 

approximately 10 percent were Black or African American, 75 percent were White American, and 11.4 percent were Latino (SAMHSA 

2010). 

Durant (2005) observes that African American

12-Step participants tend to participate differently in meetings where participants are mostly White Americans than in meetings where 

most participants are African American. In 

some areas, there are 12-Step meetings that 

are largely or entirely composed of African 

American members, and some African 

American clients feel more comfortable participating in these meetings. Mutual-help 

groups can be particularly helpful for African 

Americans who consider themselves religious. 

Maude-Griffin et al. (1998) found that individuals who identified as highly religious did 

significantly better when receiving 12-Step 

facilitation than when receiving CBT, but that 

pattern was reversed for those who did not 

consider themselves highly religious. Other 

studies have found that African Americans 

express a greater degree of comfort with sharing in meetings, and they are more likely to 

engage in AA services and state that they had 

a spiritual awakening as a result of AA participation (Bibb and Casimer 2000; Kaskutas et 

al. 1999; Kingree 1997).

Research suggests that African Americans 

who attend 12-Step programs have higher 

levels of affiliation than White Americans in 

the same programs (Kingree and Sullivan 

2002). However, they are less likely to have a 

sponsor or to read program materials (Kaskutas

et al. 1999), and their abstinence appears to be 

less affected by meeting attendance (Timko et 

al. 2006). Other research has found that 

African Americans who participate in 12-Step 

groups report an increase in the number of 

people within their social networks who support their recovery efforts (Flynn et al. 2006). 

Other mutual-help groups for African 

Americans are available, particularly faithbased programs to support recovery from 

mental illness and substance use disorders and

to aid individuals in the process of transitioning from correctional institutions. For example, the Nation of Islam has been involved in 

successful substance abuse recovery efforts, 

especially for incarcerated persons (Sanders 

2002; White and Sanders 2004).

Traditional healing and 

complementary methods

In general, African Americans are less likely to 

make use of popular alternative or complementary healing methods than White Americans or Latinos (Graham et al. 2005). 

However, the African American culture and 

history is steeped in healing traditions passed 

down through generations, including herbal 

remedies, root medicines, and so forth (Lynch 

and Hanson 2011). The acceptance of traditional practices by African American clients 

and their families does not necessarily indicate 

that they oppose or reject the use of modern 

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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Advice to Counselors: The Role of African American Religious Institutions in 

Treatment and Recovery

Within African American communities, religious institutions and clergy often function as service 

providers as well as counselors (Boyd-Franklin 2003; Reid 2000; Taylor et al. 2000). It is not uncommon for African Americans to approach clergy first when faced with their own or family members’ 

mental health or substance abuse problems, but many African American clergy members believe 

they are not well-prepared to address those problems (Neighbors et al. 1998; Sexton et al. 2006). 

According to NESARC data, African Americans are twice as likely as Latinos and nearly three times as 

likely as White Americans to receive pastoral counseling for their drug use (Perron et al. 2009). 

For many African Americans in recovery, churches play a significant role in helping them maintain 

abstinence (Perron et al. 2009). Beyond pastoral counseling, research suggests that other means of 

engagement within the church can lead to recovery. For example, participation in religious services 

has been associated with significantly better outcomes for African American men in continuing care 

following court-mandated treatment (Brown et al. 2004). Stahler et al. (2007) also report successful 

use of peer mentors drawn from churches for African American women in treatment, marked by 

significantly fewer drug-positive urine samples in the 6 months following treatment.

Counselors working with African American clients should prepare to include churches, mosques, or 

other faith communities in the therapeutic process, and they should develop a list of appropriate 

spiritual resources in the community. Treatment providers may consider involving African American 

clergy in treatment programs to improve clergy members’ understanding of behavioral health problems and treatments and to better engage clients and their families. Programs can conduct outreach 

with local faith-based institutions and clergy to facilitate treatment referrals (Taylor et al. 2000).

therapeutic approaches or other alternative 

approaches. They can accept and use all forms 

of treatment selectively, depending on the 

perceived nature of their health problems. 

That said, psychological and substance abuse 

problems can be seen as having spiritual causes 

that need to be addressed by traditional healers or religious practices (Boyd-Franklin 

2003). Moreover, African Americans are much 

more likely to use religion or spirituality as a 

response to physical or psychological problems 

(Cooper et al. 2003; Dessio et al. 2004; 

Graham et al. 2005; Nadeem et al. 2008).

African American cultural and religious institutions (see advice box below) play an important role in treatment and recovery, and 

African Americans who use spirituality or 

religion to cope with health problems are nearly 

twice as likely as other African Americans to 

also make use of complementary or alternative medicine (Dessio et al. 2004). Likewise, 

African American churches and mosques play 

a central role in education, politics, recreation, 

and social welfare in African American communities. To date, African Americans report 

the highest percentage (87 percent) of religious affiliation of any major racial/ethnic 

group (Kosmin and Keysar 2009; Pew Forum 

on Religion and Public Life 2008). Even 

though most are committed to various 

Christian denominations (with the Baptist and 

African Methodist Episcopal churches accounting for the largest percentages), a growing 

number of African Americans are converts to 

Islam, and many recent immigrants from 

Africa to the United States are also Muslims 

(Boyd-Franklin 2003; Pew Forum on Religion

and Public Life 2008). 

Relapse prevention and recovery

African Americans appear to be responsive to 

continuing care participation and recovery 

activities associated with substance use and 

mental disorders, yet research is very limited. 

According to NESARC data (Dawson et al. 

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Improving Cultural Competence

2005), African Americans in recovery from 

alcohol dependence were more than twice as 

likely as White Americans to maintain abstinence rather than just limiting alcohol consumption or changing drinking patterns. In 

another study analyzing the use of continuing 

care following residential treatment in the U.S. 

Department of Veterans Affairs care system, 

African American men were significantly 

more likely than White Americans to participate in continuing care (Harris et al. 2006). 

Other research evaluating continuing care for 

African American men who had been mandated to outpatient treatment by a parole or 

probation office found that participants assigned to a continuing care intervention were 

almost three times as likely to be abstinent and 

five times less likely to be using any drugs on a 

weekly basis during the 6-month follow-up 

period compared with those who did not 

receive continuing care (Brown et al. 2004). 

In evaluating appropriate relapse prevention 

strategies for African American clients, 

Walton et al. (2001) found that African 

American clients leaving substance abuse 

treatment reported fewer cravings, greater use 

of coping strategies, and a greater belief in 

their self-efficacy. However, they also expected 

to be involved in fewer sober leisure activities, 

to be exposed to greater amounts of substance 

use, and to have a greater need for continuing 

care services (e.g., housing, medical care, 

assistance with employment). Walton notes 

that these findings could reflect a tendency of 

African American clients to underestimate the 

difficulties they will face after treatment; they 

report a greater need for resources and greater 

exposure to substance use, but they still have a 

greater belief in their ability to remain free of 

substances. Although an individual’s belief in 

coping can have a positive effect on initially 

managing high-risk situations, it also can lead 

to a failure to recognize the level of risk in a 

given situation, anticipate the consequences, 

secure resources and appropriate support when 

needed, or engage in coping behaviors conducive to maintaining recovery. Counselors can

help clients practice coping skills by roleplaying, even if clients are confident that they 

can manage difficult or high-risk situations. 

Counseling for Asian 

Americans, Native 

Hawaiians, and Other 

Pacific Islanders

Asian Americans, per the U.S. Census Bureau 

definition, are people whose origins are in the 

Far East, Southeast Asia, or the Indian subcontinent (Humes et al. 2011). The term includes East Asians (e.g., Chinese, Japanese, and 

Korean Americans), Southeast Asians (e.g., 

Cambodian, Laotian, and Vietnamese 

Americans), Filipinos, Asian Indians, and 

Central Asians (e.g., Mongolian and Uzbek

Americans). In the 2010 Census, people who 

identified solely as Asian American made up 

4.8 percent of the population, and those who 

identified as Asian American along with one 

or more other races made up an additional 0.9 

percent. Census data includes specific information on people who identify as Asian Indian, 

Chinese, Filipino, Japanese, Korean, 

Vietnamese, and “other Asians.”The largest 

Asian populations in the United States are 

Chinese Americans, Filipino Americans, 

Asian Indian Americans, Korean Americans, 

and Vietnamese Americans. Asian Americans 

overwhelmingly live in urban areas, and more 

than half (51 percent) live in just three states 

(NY, CA, and HI; Hoeffel et al. 2012).

Not all people with origins in Asia belong to 

what is commonly conceived of as the Asian 

race. Some Asian Indians, for example, selfidentify as White American. For this reason, 

among others, counselors should be careful to 

learn from their Asian American clients how 

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they identify themselves and which national 

heritages they claim. Counselors should recognize that clients who appear to be Asian 

may not necessarily think of themselves primarily as persons of Asian ancestry or have a 

deep awareness of the traditions and values of 

their countries of origin. For example, Asian 

orphans who have been adopted in the United 

States and raised as Americans in White 

American families may have very little connection with the cultural groups of their biological parents (St. Martin 2005). Counselors 

should not make generalizations across Asian 

cultures; each culture is quite distinct.

Little literature on substance use and mental

disorders, rates of co-occurrence, and treatment

among Asian Americans focuses on behavioral 

health treatment for Native Hawaiians and 

Pacific Islanders; thus, a text box at the end 

of this section summarizes available

information.

Beliefs About and Traditions 

Involving Substance Use 

Within many Asian societies, the use of intoxicants is tolerated within specific contexts. For 

example, in some Asian cultural groups, alcohol is believed to have curative, ceremonial, or 

beneficial value. Among pregnant Cambodian 

women, small amounts of herbal medicines 

with an alcohol base are sometimes used to 

ensure an easier delivery. Following childbirth, 

similar medicines are generally used to increase blood circulation (Amodeo et al. 1997). 

Some Chinese people believe that alcohol 

restores the flow of qi (i.e., the life force). The 

written Chinese character for “doctor” contains the character for alcohol, which implies 

the use of alcohol for medicinal purposes. 

Some Asian American cultural groups make 

allowances for the use of other substances.

Marijuana, for instance, has been used medicinally in parts of Southeast Asia for many years 

(Iversen 2000; Martin 1975). However, some 

Asian Americans tend to view illicit substance 

use and abuse as a serious breach of acceptable 

behavior that cannot readily be discussed. 

Nonetheless, there are broad differences in 

Asian cultures’ perspectives on substance use, 

thus requiring counselors to obtain more 

specific information during intake and subsequent encounters.

Acknowledging a substance abuse problem 

often leads to shame for Asian American 

clients and their families. Families may deny 

the problem and inadvertently, or even intentionally, isolate members who abuse substances 

(Chang 2000). For example, some Cambodian 

and Korean Americans perceive alcohol abuse 

and dependence as the result of moral weakness, which brings shame to the family 

(Amodeo et al. 2004; Kwon-Ahn 2001). 

Substance Use and Substance Use 

Disorders

According to the 2012 NSDUH, Asian 

Americans use alcohol, cigarettes, and illicit 

substances less frequently and less heavily than 

members of any other major racial/ethnic 

group (SAMHSA 2013d). However, large 

surveys may undercount Asian American 

substance use and abuse, as they are typically 

conducted in English and Spanish only 

(Wong et al. 2007b). Despite the limitations of 

research, data suggest that although Asian 

Americans use illicit substances and alcohol 

less frequently than other Americans, substance abuse problems have been increasing 

among Asian Americans. The longer Asian 

Americans reside in the United States, the 

more their substance use resembles that of 

other Americans. Excessive alcohol use, intoxication, and substance use disorders are more 

prevalent among Asians born in the United 

States than among foreign-born Asians living 

in the United States (Szaflarski et al. 2011). 

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Improving Cultural Competence

Among Asian Americans who entered substance abuse treatment between 2000 and 

2010, methamphetamine and marijuana were 

the most commonly reported illicit drugs 

(SAMHSA, CBHSQ 2012). Methamphetamine abuse among Asian Americans is particularly high in Hawaii and on the West Coast 

(OAS 2005a). As with other racial and ethnic 

groups, numerous factors—such as age, birth 

country, immigration history, acculturation, 

employment, geographic location, and income—add complexity to any conclusions 

about prevalence among specific Asian cultural groups. Asian Americans who are recent 

immigrants, highly acculturated, unemployed, 

or living in Western states are generally more 

likely than other Asian Americans to abuse 

drugs or alcohol (Makimoto 1998). For example, according to the National Latino and 

Asian American Study (NLAAS), Asians who 

are more acculturated are at greater risk for 

prescription drug abuse (Watkins and Ford 

2011).

There are variations among particular groups 

of Asians; some Asian cultural groups have 

different attitudes toward substance use than 

others, and these differences tend to be obscured in large-scale surveys. Researchers have 

found that Korean American college students 

drank more frequently and drank greater 

quantities than did Chinese American students at the same schools and were more likely 

to consider drinking socially acceptable 

(Chang et al. 2008). Another study in the 

District of Columbia and surrounding metropolitan area compared substance use among 

different groups of Southeast Asians (i.e., 

Cambodian, Laotian, and Vietnamese 

Americans); Vietnamese Americans had the 

highest rates of alcohol use, but Cambodian 

Americans had the highest rates of illicit drug 

use (Wong et al. 2007b). Research in San 

Francisco found Chinese Americans to be less 

likely than Vietnamese or Filipino Americans 

to use illicit drugs, whereas Filipino Americans

had the highest rate of illicit drug use 

(Nemoto et al. 1999). In that same study, 

Filipino American immigrants were also 

significantly more likely to have begun using 

substances prior to immigrating than were 

Chinese or Vietnamese immigrants. Other 

studies have found that Filipino Americans are 

more likely to use illicit drugs and to inject 

drugs than other Asian American populations 

(see review in Nemoto et al. 2002).

To date, the largest national study to assess 

substance use and mental disorders across 

Asian American groups is the NLAAS 

(Takeuchi et al. 2007). This study found that 

Filipino American men were 2.38 times more 

likely to have a lifetime substance use disorder 

than were Chinese American men, whereas 

the differences among women of diverse Asian 

ethnicities were much smaller. Other research 

suggests that Korean Americans are more 

likely to have family histories of alcohol dependence than are Chinese Americans 

(Ebberhart et al. 2003).

Besides the variations across different cultures, 

substance use and abuse among Asian Americans is also influenced by age. Substance abuse 

appears higher for young Asian Americans 

than for those who are older (possibly reflecting differences in acculturation). A study

conducted in New York City showed that 

Asian American junior and senior high school 

students had the lowest percentage of heavy 

drinkers of any ethnic group, but those who 

were heavy drinkers drank twice as much daily 

as those who did not drink heavily (Makimoto 

1998). Asian American youth, especially immigrants, tend to start using substances at a 

later age than members of other ethnic groups, 

which could be a factor in the lower levels of 

abuse seen among Asian Americans. 

Despite rates of substance use disorders 

among Asian Americans having increased over 

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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

time, research has regularly found that, of all 

major racial/ethnic groups in United States, 

Asian Americans have the lowest rates of 

alcohol use disorders (Grant et al. 2004; 

SAMHSA 2012b). This phenomenon has 

typically been explained in part by the fact 

that some Asians lack the enzyme aldehyde 

dehydrogenase, which chemically breaks down 

alcohol (McKim 2003). Thus, high levels of 

acetaldehyde, a byproduct of alcohol metabolism, accumulate and cause an unpleasant 

flushing response (Yang 2002). The alcohol 

flushing response primarily manifests as flushing of the neck and face but can also include 

nausea, headaches, dizziness, and other 

symptoms.

Additional factors that could play a part in 

increasing the likelihood of substance use 

disorders among Asian Americans include 

experiences of racism and the absence of 

ethnic identification. Compared with Asian 

Americans who do not have alcohol use disorders, Asian Americans who have alcohol use 

disorders are more than five times as likely to 

report unfair treatment because of their race 

and are more than twice as likely to deny 

strong ethnic identification (Chae et al. 2008). 

Compared with other racial and ethnic 

groups, Asian Americans who drink heavily 

are more likely to have friends or peers who 

also drink heavily (Chi et al. 1989).

Mental and Co-Occurring 

Disorders 

Overall, health and mental health are not 

seen as two distinct entities by Asian American cultural groups. Most Asian American 

views focus on the importance of virtue, 

maturity, and self-control and find full emotional expression indicative of a lack of maturity and self-discipline (Cheung 2009).

Given the potential shame they often associate

with mental disorders and their typically

holistic worldview of health and illness, Asian 

Americans are more likely to present with 

somatic complaints and less likely to present 

with symptoms of psychological distress and 

impairment (Hsu and Folstein 1997; Kim et 

al. 2004; Room et al. 2001; U.S. Department 

of Health and Human Services [HHS] 2001; 

Zhang et al. 1998), even though mental illness 

appears to be nearly as common among Asian 

Americans as it is in other ethnic/racial 

groups. In 2009, approximately 15.5 percent of 

Asians reported a mental illness in the past 

year, but only 2 percent reported past-year 

occurrence of serious mental illness (SAMHSA 

2012a). Asian Americans have a lower incidence of CODs than other racial/ethnic groups 

because the prevalence of substance use disorders in this population is lower. In the 2012

NSDUH, 0.3 percent of Asian Americans 

indicated co-occurring serious psychological 

distress and substance use disorders, and 1.1

percent had some symptoms of mental distress 

along with a substance use disorder—the lowest rates of any major racial/ethnic group in the 

survey (SAMHSA 2013c).

Considerable variation in the types of mental 

disorders diagnosed among diverse Asian 

American communities is evident, although it 

is unclear to what extent this reflects diagnostic 

and/or self-selection biases. For example, 

Barreto and Segal (2005) found that Southeast

Asians were more likely to be treated for 

major depression than other Asians or members of other ethnic/racial groups; East Asians 

were the most likely of all Asian American 

groups to be treated for schizophrenia (nearly 

twice as likely as White Americans). Traumatic experiences and PTSD can be particularly 

difficult to uncover in some Asian American 

clients. Although Asian Americans are as 

likely to experience traumatic events (e.g., 

wars experienced by first-generation immigrants from countries such as Vietnam and 

Cambodia) in their lives, their cultural responses to trauma can conceal its psychological

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Improving Cultural Competence

effects. For instance, some Asian cultural 

groups believe that stoic acceptance is the 

most appropriate response to adversity (Lee 

and Mock 2005a,b). 

Treatment Patterns

Treatment-seeking rates for mental illness are 

low among most Asian populations, with rates 

varying by specific ethnic/cultural heritage 

and, possibly, level of acculturation (Abe-Kim 

et al. 2007; Barreto and Segal 2005; Lee and 

Mock 2005a,b). Asian Americans who seek 

help for psychological problems will most 

likely consult family members, clergy, or traditional healers before mental health professionals, in part because of a lack of culturally and 

linguistically appropriate mental health services available to them (HHS 2001; Spencer 

and Chen 2004). However, among those Asian 

Americans who seek behavioral health treatment, the amount of services used is relatively 

high (Barreto and Segal 2005).

Asian Americans tend to enter treatment with 

less severe substance abuse problems than 

members of other ethnic/racial groups and 

have more stable living situations and fewer 

criminal justice problems upon leaving treatment (Niv et al. 2007). However, for Asian 

Americans involved in the criminal justice 

system, there is a more pronounced relationship between crime and drug abuse than for 

other ethnic and racial groups. In the early 

1990s, an estimated 95 percent of Asian 

Americans in California prisons were there 

because of drug-related crimes (Kuramoto

1994). According to SAMHSA’s 2010 TEDS

data, 48.5 percent of Asian Americans in 

treatment were referred by the criminal justice 

system in that year, compared with 36.4 percent of African Americans and 36.6 percent of 

White Americans (SAMHSA, CBHSQ 

2012). According to 2010 NSDUH data 

regarding individuals who reported a need for 

treatment but did not receive it in the prior 

year, Asian Americans were also the most 

likely of all major racial/ethnic groups to 

report that they could not afford or had no 

insurance coverage for substance abuse treatment (SAMHSA, CBHSQ 2011). 

Beliefs and Attitudes About 

Treatment

Compared with the general population, Asian 

Americans are less likely to have confidence in 

their medical practitioners, feel respected by 

their doctors, or believe that they are involved 

in healthcare decisions. Many also believe that 

their doctors do not have a sufficient understanding of their backgrounds and values; this 

is particularly true for Korean Americans 

(Hughes 2002). Even so, Asian Americans,

especially more recent immigrants, seem more 

likely to seek help for mental and substance 

use disorders from general medical providers 

than from specialized treatment providers 

(Abe-Kim et al. 2007). Many Asian American 

immigrants underuse healthcare services due to 

confusion about eligibility and fears of jeopardizing their residency status (HHS 2001).

As with other groups, discrimination, acculturation stress, and immigration and generational status, along with language needs, have 

a large influence on behavioral health and 

treatment-seeking for Asian Americans (Meyer

et al. 2012; Miller et al. 2011). The NLAAS 

found that although rates of behavioral health 

service use were lower for Asian Americans

who immigrated recently than for the general 

population, those rates increased significantly 

for U.S.-born Asian Americans; thirdgeneration U.S.-born individuals’rates of service use also were relatively high (Abe-Kim et 

al. 2007). Of those Asian Americans who had

any mental disorder diagnosis in the prior year, 

62.6 percent of third-generation Americans 

sought help for it in the prior year compared

with 30.4 percent of first-generation

Americans.

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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Overall, Asian Americans place less value on 

substance abuse treatment than other population groups and are less likely to use such 

services (Yu and Warner 2012). Niv et al. 

(2007) found that Asian and Pacific Islanders 

entering substance abuse treatment programs 

in California expressed significantly more 

negative attitudes toward treatment and rated 

it as significantly less important than did 

others entering treatment. Seeking help for 

substance abuse can be seen, in some Asian 

American cultural groups, as an admission of 

weakness that is shameful in itself or as an 

interference with family obligations (Masson 

et al. 2013). Among 2010 NSDUH respondents who stated a need for substance abuse 

treatment in the prior year but did not receive 

it, Asian Americans were more likely than 

members of all other major racial/ethnic 

groups to say that they could handle the problem without treatment or that they did not 

believe treatment would help (SAMHSA 

2011c). Combining NSDUH data from 2003 

to 2011 NSDUH, Asian Americans who 

needed but did not receive treatment in the 

past year were the least likely of all major 

ethnic/racial groups to express a need for such 

treatment (SAMHSA, CBHSQ 2013c).

Treatment Issues and 

Considerations

It is important for counselors to approach 

presenting problems through clients’ culturally

based explanations of their own issues rather 

than imposing views that could alter their

acceptance of treatment. In Asian cultural 

groups, the physical and emotional aspects of 

an individual’s life are undifferentiated (e.g., 

the physical rather than emotional or psychological aspect of a problem can be the focus 

for many Asian Americans); thus, problems as 

well as remedies are typically handled holistically. Some Asian Americans with traditional 

backgrounds do not readily accept Western 

biopsychosocial explanations for substance use 

and mental disorders. Counselors should 

promote discussions focused on clients’ understanding of their presenting problems as well 

as any approaches the clients have used to 

address them. Subsequently, presenting problems need to be reconceptualized in language 

that embraces the clients’ perspectives (e.g., an 

imbalance in yin and yang, a disruption in chi; 

Lee and Mock 2005a,b). It is advisable to 

educate Asian American clients on the role of 

the counselor/therapist, the purpose of therapeutic interventions, and how particular aspects 

of the treatment process (e.g., assessment) can 

help clients with their presenting problems

(Lee and Mock 2005a,b; Sue 2001). Asian 

American clients who receive such education

participate in treatment longer and express 

greater satisfaction with it (Wong et al. 2007a).

As with other racial/ethnic groups, Asian 

American clients are responsive to a warm and 

empathic approach. Counselors should realize, 

though, that building a strong, trusting relationship takes time. Among Asian American 

clients, humiliation and shame can permeate 

the treatment process and derail engagement 

with services. Thus, it is essential to assess and 

discuss client beliefs about shame (see the 

“Assessing Shame in Asian American Clients”

advice box on the next page). In some cases, 

self-disclosure can be helpful, but the counselor should be careful not to self-disclose in a 

way that will threaten his or her position of 

respect with Asian American clients.

Asian American clients may look to counselors for expertise and authority. Counselors 

should attempt to build client confidence in 

the first session by introducing themselves by 

title, displaying diplomas, and mentioning his 

or her experience with other clients who have 

similar problems (Kim 1985; Lee and Mock 

2005a,b). Asian American clients may expect 

and be most comfortable with formalism on 

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Improving Cultural Competence

the part of counselors, especially at the beginning of treatment and prior to assessment of 

clients’ needs (Paniagua 1998). Many Asian 

American clients expect counselors to be 

directive (Leong and Lee 2008). Passivity on 

the part of the counselor can be misinterpreted as a lack of concern or confidence. 

Counselors who are unaccustomed to working 

with Asian populations will likely encounter 

conflict between their theoretical worldview of 

counseling and the deference to authority and 

avoidance of confrontation that is common 

among more traditional Asian American 

clients. Some clients can be hesitant to contradict the counselor or even to voice their 

own opinions. Confrontation can be seen as 

something to avoid whenever possible. Furthermore, many Asian cultural groups have 

high-context styles of communication, meaning that members often place greater importance on nonverbal cues and the context of 

verbal messages than on the explicit content of 

messages (Hall 1976). Asian Americans often 

use indirect communication, relying on subtle 

gestures, expressions, or word choices to convey meaning without being openly confrontational. Counselors must not only be observant 

of nuances in meaning, but also learn about 

verbal and nonverbal communication styles 

specific to Asian cultural groups (for a review 

of guidelines to use when working with Asian 

Americans, see Gallardo et al. 2012). 

Asian American clients appear to respond 

more favorably to treatment in programs that 

provide services to other Asian clients. 

Takeuchi et al. (1995) found that Asian 

Americans were much more likely to return to 

mental health clinics where most clients were 

Asian American than to programs where that 

was not the case (98 percent and 64 percent 

returned, respectively). When demographic 

differences were controlled for, those who 

attended programs that had predominantly 

Asian clients were 15 times more likely to 

return after the initial visit. Asian Americans 

were also more likely to stay in treatment 

when matched with an Asian American counselor regardless of the type of program they 

attended. Sue et al. (1991) also found that 

Asian American clients attended significantly 

more treatment sessions if matched with an 

Asian American counselor.

Among Asian American women, crucial 

strategies include reducing the shame of substance abuse and focusing on the promotion of 

overall health rather than just addressing 

substance abuse. Such strategies reduce the 

chance of a woman and her family seeing

substance abuse as an individual flaw. Home 

visits, when agreed in advance with the client, 

can be appropriate in some cases as a way to 

gain the trust of, and show respect for, Asian 

American women. Asian American women 

may not be as successful in mixed-gender 

Advice to Counselors: Assessing 

Shame in Asian American Clients

Shame and humiliation can be significant barriers to treatment engagement for Asian Americans. Gaw (1993) suggests that the presence of 

the following factors may indicate that a client 

has shame about seeking treatment:

• The client or a family member is extremely 

concerned about the qualifications of the 

counselor.

• The client is hesitant to involve others in 

the treatment process.

• The client is excessively worried about 

confidentiality.

• The client refuses to cover expenses with 

private insurance.

• The client frequently misses or arrives late 

for treatment.

• Family members refuse to support treatment.

• The client insists on having a White American counselor to avoid opening up to another Asian.

• The client refuses treatment even when 

severe problems are evident.

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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

groups if strict gender roles exist whereby

communication is constricted within and outside the family; women will likely remain silent 

or defer to the men in the group (Chang 2000). 

For more information on treating women, see 

Treatment Improvement Protocol (TIP) 51,

Substance Abuse Treatment: Addressing the 

Specific Needs of Women (CSAT 2009c). 

Theoretical Approaches and 

Treatment Interventions

Some Asian cultural groups emphasize cognitions. For instance, Asian cultural groups that 

have a Buddhist tradition, such as the Chinese, 

view behavior as controlled by thought. Thus, 

they accept that addressing cognitive patterns 

will affect behaviors (Chen 1995). Some Asian 

cultural groups encourage a stoic attitude 

toward problems, teaching emotional suppression as a coping response to strong feelings 

(Amodeo et al. 2004; Castro et al. 1999b; Lee 

and Mock 2005a,b; Sue 2001). Treatment can 

be more effective if providers avoid approaches 

that target emotional responses and instead 

use strategies that are more indirect in discussing feelings (e.g., saying “that might make 

some people feel angry” rather than asking 

directly what the client is feeling; Sue 2001). 

Asian Americans often prefer a solutionfocused approach to treatment that provides 

them with concrete strategies for addressing 

specific problems (Sue 2001). Even though 

little research is available in evaluating specific 

interventions with Asian Americans, clinicians 

tend to recommend cognitive–behavioral, 

solution-focused, family, and acceptance 

commitment therapies (Chang 2000; Hall et 

al. 2011; Iwamasa et al. 2006; Rastogi and 

Wadhwa 2006; Sue 2001). Asian American 

clients are likely to expect that their counselors 

take an active role in structuring the therapy 

session and provide clear guidelines about 

what they expect from clients. CBT has the 

Advice to Administrators: Culturally Responsive Program Development 

Behavioral health service program administrators can improve engagement and retention of Asian 

clients by making culturally appropriate accommodations in their programs. The accommodations 

required will vary according to the specific cultural groups, language preferences, and levels of 

acculturation in question. The following culturally responsive program suggestions were initially 

identified for Cambodian clients but can be adapted to match the unique needs of other Asian 

clients from different ethnic and cultural backgrounds:

• Create an advisory committee using representatives from the community.

• Incorporate cultural knowledge and maintain flexible attitudes as a counselor.

• Use cotherapist teams in which one member is Asian and bilingual. 

• Provide services in the clients’ primary language.

• Develop culturally specific questionnaires for intake to capture information that may be missed 

by standard questionnaires.

• Conduct culturally appropriate assessments of trauma that ask about the traumatic experiences 

common to the population in question.

• Visit client homes to improve family involvement in treatment.

• Provide support to families during transitions from and to professional care.

• Emphasize traditional values.

• Explore client coping mechanisms that draw upon cultural strengths.

• Use acupuncture or other traditional practices for detoxification.

• Integrate Buddhist ideas, values, and practices into treatment when appropriate.

• Emphasize relationship-building; help clients with life problems beyond behavioral health concerns.

• Provide concrete services, such as housing assistance and legal help.

Sources: Amodeo et al. 2004; Park et al. 2011. 

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Improving Cultural Competence

advantages of being problem focused and time 

limited, which will likely increase its appeal for 

many Asian Americans who might see other 

types of therapy as failing to achieve real goals 

(Iwamasa et al. 2006). Although specific data 

on the effectiveness of CBT among Asian 

Americans is not available, there is some 

research indicating that CBT is effective for 

treating depressive symptoms in Asians (Dai 

et al. 1999; Fujisawa et al. 2010). In China, a 

Chinese Taoist version of CBT has been 

developed to treat anxiety disorders and was 

found to be effective, especially in conjunction 

with medication (Zhang et al. 2002). 

Family therapy 

Some Asian Americans, particularly those 

who are less acculturated, prefer individual 

therapy to group or family interventions because it better enables them to save face and 

keep their privacy (Kuramoto 1994). Some 

clients may wish to enter treatment secretly so 

that they can keep their families and friends 

from knowing about their problems. Once 

treatment is initiated, counselors should

strongly reinforce the wisdom of seeking help 

through statements such as “you show concern 

for your husband by seeking help” or “you are 

obviously a caring father to seek this help.” 

The norm in Asian families is that “all problems (including physical and mental problems) 

must be shared only among family members”; 

sharing with others can cause shame and guilt, 

exacerbating problems (Paniagua 1998, pp. 

59–60). Counselors should expect to take 

more time than usual to learn about clients’ 

situations, anticipate client needs for reassurance in divulging sensitive information, and 

frame discussions in a culturally competent 

way. For example, counselors can assure clients that discussing problems is a step toward 

resuming their full share of responsibility in 

their families and removing some of the stress 

their families have been feeling.

For most Asian Americans, particularly those 

who are less acculturated, successful treatment 

involves the client’s family (Chang 2000; Kim 

et al. 2004; Rastogi and Wadhwa 2006). Even 

in individual treatment, it is important to 

understand the client’s family and his or her 

relationship with its members, the dynamics 

and style of the family, and the family’s role in 

the client’s substance abuse (Meyer et al. 

2012). Particularly among Asian American 

women, family involvement can be essential 

due to the client’s concern about being responsive to her family’s needs. Nonetheless, 

involving the family can be quite difficult, as 

both male and female clients may wish to 

conceal their substance abuse from their families because of the shame that it brings. 

Advice to Counselors: Culturally 

Responsive Family Therapy 

Guidelines for Asian Families 

Kim et al. (2004) reviewed references that 

provide guidelines for family therapy with 

Korean Americans. They established 11 essential ingredients applicable to Korean and other 

Asian American groups and families. To provide culturally responsive therapy to Asian 

Americans, counselors should: 

• Assess support from community and extended family systems.

• Assess immigration history, if appropriate.

• Establish credibility as a professional in the 

initial meeting with the family.

• Explain the key principles and expectations 

of family therapy and the family roles (especially elders/decisionmakers) in the process.

• Enable clients, particularly male elders or 

decisionmakers, to save face. 

• Validate and address somatic complaints.

• Be both problem focused and present 

focused.

• Be directive in guiding therapy.

• Respect the family’s hierarchy.

• Avoid being confrontational and facilitate 

interactions that are nonconfrontational.

• Reframe problems in positive terms.

Source: Kim et al. 2004.

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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

To engage family members in the client’s 

treatment, the counselor first needs to be

familiar with the way the family functions. 

Different acculturation levels among individual family members and across generations can 

affect how the family functions, producing 

significant stress and internal conflict. Also, 

the counselor must be aware of how gender 

roles and generational status influence the 

communication patterns and rules within each 

family (e.g., expectations of how a child addresses a parent, the potential relegation of 

authority among female family members). 

Even more than for other clients, it is critical 

for Asian Americans to “avoid embarrassing 

the family members in front of each other. 

The counselor should always protect the 

dignity and self-respect of the client and his or 

her family”(Paniagua 1998, p. 71). 

Group therapy

Group therapy may not be a good choice for 

Asian Americans, as many prefer individual 

therapy (Lai 2001; Sandhu and Malik 2001). 

Paniagua (1998, p. 73) suggests that “group 

therapy...would be appropriate in those cases 

in which the client’s support system (relatives 

and close friends) is not available and an 

alternative support system is quickly needed.”

Some Asian Americans participating in group 

therapy will find it difficult to be assertive in a 

group setting, preferring to let others talk. 

They can also abide by more traditional roles 

in this context; men might not want to divulge 

their problems in front of women, women can 

feel uncomfortable speaking in front of men, 

and both men and women might avoid contradicting another person in group (especially 

an older person). It may not make sense to 

Asian American clients to hear about the 

problems of strangers who are not part of their 

community. 

Asian Americans are likely to be motivated to 

work for the good of the group; presenting

group goals in this framework can garner 

active participation. Still, in group settings and 

in other instances, Asian American clients 

may expect a fair amount of direction from the 

group leader. Chen (1995) described leadership of a culturally specific therapy group for 

Chinese Americans, noting that clients expect 

a group leader to act with authority and give 

more credence to his or her expertise than to 

other group members. If members of the 

group belong to the same Asian American 

community, the issue of confidentiality will 

loom large, because the community is often 

small. Asian cultural groups generally appreciate education in more formal settings, so 

psychoeducation groups can work well for 

Asian Americans. It is possible for a psychoeducational group with Asian American 

participants to evolve comfortably into group 

therapy.

Mutual-help groups

According to 2012 NSDUH data, Asian 

Americans were less likely than other racial 

and ethnic groups to report the use of mutualhelp groups in the past year (SAMHSA 

2013d). Mutual-help groups can be challenging for Asian Americans who find it difficult 

and shaming to self-disclose publicly. The 

degree of emotion and candor within these 

groups can further alienate traditional Asian 

American clients. Furthermore, linguistically 

appropriate mutual-help groups are not always 

available for people who do not speak English. 

Highly acculturated Asian Americans may

perceive participation in mutual-help groups 

as less of a problem, but nevertheless, Asian 

Americans can benefit from culture-specific 

mutual-help groups where norms of interpersonal interaction are shared. Asian American 

12-Step groups are available in some locales. 

It is important for counselors to assess client

attitudes toward mutual-help participation 

and find alternative strategies and resources, 

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Improving Cultural Competence

including encouragement to attend without 

sharing (Sandhu and Malik 2001).

Although they are not mutual-help groups in 

the traditional sense, mutual aid societies and 

associations are important in some Asian 

American communities. Some mutual aid 

societies have long histories and have provided 

assistance ranging from financial loans to help 

with childcare and funerals. The Chinese have 

family associations for people with the same 

last name who share celebrations and offer 

each other help. Japanese, Chinese, and South 

Asians have specific associations for people 

from the same province or village. For some 

Asian American groups, such as Koreans, 

churches are the primary organizational vehicles for assistance. These social support groups 

can be important resources for Asian American

clients, their families, and the behavioral 

health agencies that provide services to them.

Traditional healing and 

complementary methods

Asian Americans are twice as likely as other 

Americans to report making use of acupuncture and traditional healers. Even though there 

is considerable variation in their use of complementary and traditional medicine (Hughes 

2002), many Asian Americans highly regard 

traditional healers, herbal preparations, and 

other culturally specific interventions as a 

means of restoring harmony and balance. 

However, Asian American clients do not 

always readily disclose the use of traditional 

medicine to Western treatment providers. Ahn 

et al. (2006) found that about two-thirds of 

Chinese and Vietnamese Americans who 

spoke no or limited English had used traditional medicine, but only 7.6 percent had 

discussed the use of these therapies with their 

Western medical providers. 

Traditional treatment to restore physical and 

emotional balance for Asian Americans occurs 

through a variety of culture-specific interventions. For example, some Southeast Asian 

cultural groups practice cao gio—massaging 

the skin with ointment and hot coins (Chan 

and Chen 2011). The Chinese have developed 

enormously complex systems of medical 

treatment over centuries of pragmatic experimentation. Traditional herbal medicine combines plant substances according to precise 

formulas to have the desired influence on the 

affected organs of the body. Acupuncture 

techniques involve regulating the flow of 

energy (qi) through the body by inserting 

needles at precise locations called acupuncture 

points. In traditional Chinese medicine, which 

has influenced traditional medical practices in 

other Asian cultural groups, illness is seen as 

an imbalance of yin and yang; a return to 

physical wellness can require introducing 

elements such as herbs to increase yin or yang

as needed (Torsch and Ma 2000).

Among less acculturated Asian Americans, 

Western medicine, including Western behavioral health services, can be insufficient to deal 

with a problem such as substance abuse and its 

effects on clients and their families. For example, all health problems for the Hmong 

(whether physical or psychological) are considered spiritual in nature; if providers ignore 

the clients’ understanding of their problems as 

spiritual maladies, they are unlikely to effect 

positive change (Fadiman 1997). Even for 

more acculturated Asian Americans, the use of 

traditional healing methods and spirituality 

can be a very important aspect of treatment 

(see Chan and Chen 2011 for an overview of 

health beliefs and practices). Such use can 

provide a spiritual connection that helps manage feelings that are especially difficult to 

express to others. Many practices associated 

with meditation, yoga, and Eastern religious 

traditions can help disperse the stress and 

anxiety experienced during treatment and 

recovery. In the United States, there are few 

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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Behavioral Health Counseling for Native Hawaiians and Other Pacific Islanders

The ancestors of Native Hawaiians and other Pacific Islanders were the original inhabitants of Hawaii, 

Guam, Samoa, and other Pacific islands. The population of Native Hawaiians and other Pacific 

Islanders grew more than three times faster than the total U.S. population from 2000 to 2010. More 

than half of Native Hawaiian and other Pacific Islanders live in Hawaii and California. The largest 

Pacific Islander populations in the United States comprise Hawaiians, Samoans, and Chamorros—the 

indigenous people of the Mariana Islands, of which Guam is the largest (Hixson et al. 2012).

Native Hawaiians and other Pacific Islanders make up a relatively small proportion of the total United 

States population. In the 2010 Census, 540,000 people, or 0.2 percent of the population, reported 

their race as Native Hawaiian or other Pacific Islander, and another 685,000 people (0.2 percent of 

the population) stated that they were Native Hawaiian or other Pacific Islander in addition to one or 

more other races (Hixson et al. 2012). The largest concentration of Native Hawaiians and other 

Pacific Islanders is in Hawaii, where individuals with at least some of this ancestry made up 23.3 

percent of the population.

In 2012, according to NSDUH data, 5.4 percent of Native Hawaiians and other Pacific Islanders 

interviewed had a substance use disorder in the prior year, and 7.8 percent engaged in current illicit 

drug use (SAMHSA 2013d). Binge and heavy drinking appear to be relatively high, especially among 

Native Hawaiian/Pacific Islander women. Data from the 2001–2011 TEDS surveys indicate that the

most common primary substances of abuse among Native Hawaiians and other Pacific Islanders 

entering substance abuse treatment are alcohol, cannabis, and methamphetamine (SAMHSA 2013c). 

Because of its relatively small size, many studies have either ignored or been unable to make conclusions about substance use and abuse in this population; other research has grouped Native 

Hawaiians and other Pacific Islanders together with Asians (more for the sake of convenience than 

for underlying cultural similarities).

According to NSDUH data, 1.8 percent of adult Native Hawaiians and other Pacific Islanders reported serious mental illness. Insufficient data were available to analyze past-year mental illness rates 

(SAMHSA 2013c). Similar to substance use data, specific mental health data are limited across 

national studies, primarily because the population has been grouped with Asians. However, the 

evidence that is available suggests that Native Hawaiians are less likely than other racial/ethnic 

groups in Hawaii to access treatment services even though they experience higher rates of mental 

health problems (for a review of health beliefs and practices, see Mokuau and Tauili’ili 2011).

A few examples of culturally specific interventions for Native Hawaiians have been presented in the 

literature. For example, the Rural Hawai’i Behavioral Health Program, which provides substance 

abuse and mental health services to Native Hawaiians living in rural areas, incorporates Native 

Hawaiian beliefs and practices into all areas of the program, emphasizing the value of ‘ohana (family) 

relations, including the importance of respecting and honoring ancestors and elders and passing on 

cultural ways to the next generation. Program staff members are trained in Native Hawaiian culture 

and beliefs, including spirituality and the essential value of graciousness, the honoring of mana (life 

energy), healing rituals such as pule (prayer), the use of healing herbs, and Native Hawaiian beliefs 

about the causes of illness, such as wrongdoing and physical disruption (Oliveira et al. 2006). 

Ho’oponopono is a form of group therapy used by Native Hawaiians; it involves family members and 

is facilitated by a Küpuna (elder). A qualitative study by Morelli and Fong (2000) of Ho’oponopono 

with pregnant or postpartum women with substance use disorders (primarily methamphetamine 

abuse) reported high client satisfaction and positive outcomes (80 percent were abstinent 2 years 

after treatment). The Na Wahine Makalapua Project, sponsored by the Hawaii Department of 

Health’s Alcohol and Drug Abuse Division and SAMHSA’s Center for Substance Abuse Prevention, 

uses elements of Hawaiian culture to treat women with substance use disorders, such as by having 

Küpuna counsel younger generations.

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Improving Cultural Competence

examples of culturally specific treatment programs that focus on Asian religious or spiritual 

treatment; however, there are programs overseas, such as the Thai Buddhist treatment 

center described by Barrett (1997). 

Asian Americans are much more likely than 

members of other racial/ethnic groups to label 

themselves as secular, agnostic, or atheist 

(Kosmin and Keysar 2009; Pew Forum on 

Religion and Public Life 2008). That said, a 

substantial number of Asian Americans still 

have religious affiliations. About 45 percent 

are Protestant; 17 percent, Catholic; 14 percent, Hindu; 9 percent, Buddhist; and 4 percent, Muslim (Pew Forum on Religion and

Public Life 2008). More acculturated Asian 

Americans are likely to enter treatment 

through medical settings and to be comfortable with a medical model for treatment, but 

those who are less acculturated or are foreignborn can prefer the use of traditional healing 

and/or religious traditions and beliefs as part 

of their treatment ( Ja and Yuen 1997). Religious institutions can play an important part 

in the treatment of some groups of Asian 

Americans. For example, Kwon-Ahn (2001) 

notes that many Korean Americans, particularly more recent immigrants, turn to Christian clergy or church groups for assistance 

with family and personal problems, such as 

substance abuse, before seeking professional 

help. Amodeo et al. (2004) suggest that, in 

working with Cambodian immigrants, providers integrate Buddhist philosophy and practices into treatment, and, if possible, partner with 

Buddhist temples to facilitate treatment entry 

or to provide services for clients who choose 

to reside in Buddhist temples.

Relapse prevention and recovery 

Little research has evaluated relapse prevention and recovery promotion strategies specifically for Asian Americans. However, issues 

involving shame can make the adjustment to 

abstinence difficult for Asian clients. Counselors should take this into account and address 

difficulties that can arise for clients with families who have shame about mental illness or 

substance use disorders. To date, there are no 

indications that standard approaches are unsuitable for Asian American clients. For more 

information on these approaches, see the 

planned TIP, Relapse Prevention and Recovery 

Promotion in Behavioral Health Services 

(SAMHSA planned e).

Counseling for Hispanics 

and Latinos

The terms “Hispanic” and “Latino”refer to 

people whose cultural origins are in Spain and 

Portugal or the countries of the Western 

Hemisphere whose culture is significantly 

influenced by Spanish or Portuguese colonization. Technically, a distinction can be drawn 

between Hispanic (literally meaning people 

from Spain or its former colonies) and Latino 

(which refers to persons from countries ranging 

from Mexico to Central and South America

and the Caribbean that were colonized by 

Spain, and also including Portugal and its 

former colonies); this TIP uses the more 

inclusive term (Latino), except when research 

specifically indicates the other. The term 

“Latina”refers to a woman of Latino descent.

Latinos are an ethnic rather than a racial 

group; Latinos can be of any race. According 

to 2010 Census data, Latinos made up 16 

percent of the total United States population; 

they are its fastest growing ethnic group (Ennis

et al. 2011). Latinos include more than 30 

national and cultural subgroups that vary by 

national origin, race, generational status in the 

United States, and socioeconomic status 

(Padilla and Salgado de Snyder 1992; 

Rodriguez-Andrew 1998). According to Ennis 

et al. (2011), of Latinos currently living in the 

United States (excluding Puerto Rico and 

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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

other territories), Mexican Americans are the 

largest group (63 percent), followed by Central 

and South Americans (13.4 percent), Puerto 

Ricans (9.2 percent), and Cubans (3.5 percent).

Beliefs About and Traditions 

Involving Substance Use

Attitudes toward substance use vary among 

Latino cultural groups, but Latinos are more 

likely to see substance use in negative terms 

than are White Americans. Marin (1998) 

found that Mexican Americans were significantly more likely to expect negative consequences and less likely to expect positive 

outcomes as a result of drinking than were 

White Americans. Similarly, Hadjicostandi 

and Cheurprakobkit (2002) note that most 

Latinos believe that prescription drug abuse 

could have dangerous effects (85.7 percent), 

that individuals who abuse substances cause 

their whole families to suffer (81.4 percent), 

and that people who use illicit drugs will 

participate in violent crime (74.9 percent) and 

act violently toward family members (78.9 

percent). Driving under the influence of alcohol is one of the most serious substance use 

problems in the Latino community. 

Other research suggests that some Latinos 

hold different alcohol expectancies. When 

comparing drinking patterns and alcohol 

expectancies among college students, VelezBlasini (1997) found that Puerto Rican participants were more likely than other students to 

see increased sociability as a positive expectancy related to drinking and sexual impairment 

as a negative expectancy. Puerto Rican participants were also significantly more likely to 

report abstinence from alcohol. In another 

study comparing Puerto Ricans and Irish 

Americans, Puerto Rican participants who 

expected a loss of control when drinking had 

fewer alcohol-related problems, whereas Irish 

Americans who expected a loss of control had 

a greater number of such problems ( Johnson 

and Glassman 1999). The authors concluded 

that “losing control” has a different cultural 

meaning for these two groups, which in turn 

affects how they use alcohol.

For many Latino men, drinking alcohol is a 

part of social occasions and celebrations. By 

contrast, solitary drinking is discouraged and 

seen as deviant. Social norms for Latinas are 

often quite different, and those who have 

substance abuse problems are judged much 

more harshly than men. Women can be perceived as promiscuous or delinquent in meeting their family duties because of their 

substance use (Hernandez 2000). Amaro and 

Aguiar (1995) note that the heavy emphasis 

on the idealization of motherhood contributes 

to the level of denial about the prevalence of 

substance use among Latinas. Women who 

use injection drugs feel the need to maintain 

their roles as daughters, mothers, partners, and 

community members by separating their drug 

use from the rest of their lives (Andrade and 

Estrada 2003), yet research suggests that 

substance abuse among women does not go 

unrecognized within the Latino community 

(Hadjicostandi and Cheurprakobkit 2002).

Among families, Latino adults generally show 

strong disapproval of alcohol use in adolescents of either gender (Flores-Ortiz 1994). 

Adults of both genders generally disapprove of 

the initiation of alcohol use for youth 16 years 

of age and under (Rodriguez-Andrew 1998). 

Long (1990) also found that even among 

Latino families in which there has been multigenerational drug abuse, young people were 

rarely initiated into drug abuse by family 

members. However, evidence regarding parental substance use and its influence on youth 

has been mixed; most studies show some 

correlation between parental attitudes toward 

alcohol use and youth drinking (RodriguezAndrew 1998). For instance, research with 

college students found that family influences 

129
Improving Cultural Competence

had a significant effect on drinking in Latinos 

but not White Americans; the magnitude of 

this effect was greater for Latinas than for 

Latino men (Corbin et al. 2008). 

Substance Use and Substance Use 

Disorders

According to 2012 NSDUH data, rates of 

past-month illicit substance use, heavy drinking, and binge drinking among Latinos were 

lower than for White Americans, Blacks, and 

Native Americans, but not significantly so 

(SAMHSA 2013d). The same data showed 

that 8.3 percent of Latinos reported pastmonth illicit drug use compared with 9.2 

percent of White Americans and 11.3 percent 

of African Americans. 

Although data are available from a number of 

studies regarding Latino drinking and drug 

use patterns, more targeted research efforts are 

needed to unravel the complexities of substance use and the many factors that affect use, 

abuse, and dependence among subgroups of 

Latino origin (Rodriguez-Andrew 1998). For 

example, some studies show that Latino men 

are more likely to have an alcohol use disorder 

than are White American men (Caetano 

2003), whereas others have found the reverse 

to be true (Schmidt et al. 2007). Disparities 

in survey results may reflect varying efforts to 

develop culturally responsive criteria (Carle 

2009; Hasin et al. 2007). The table in Exhibit 

5-2 shows lifetime prevalence of substance 

use disorders among Latinos based on

Exhibit 5-2: Lifetime Prevalence of Substance Use Disorders According to Ethnic 

Subgroup and Immigration Status 

Ethnic 

Subgroup

Any 

Substance Use

Disorder, %

Alcohol 

Abuse, %

Alcohol 

Dependence, 

% 

Drug 

Abuse, %

Drug 

Dependence, 

% 

Puerto Ricans 

(born in the U.S. 

mainland) 

15.9 7.7 5.6 4.6 4.3

Puerto Ricans 

(born in 

Puerto Rico)

11.1 4.6 5.3 4.3 3.6

Cuban 

Americans (born in 

the U.S.)

20.9 6.5 8.2 3.6 5.7

Cuban 

Americans 

(foreign-born)

6.4 3.4 2.2 2.2 1.9

Mexican Americans (born in the 

U.S.) 

21.4 9.4 7.7 5.8 5.3

Mexican Americans (foreign-born) 7 3.5 2.8 2.0 1.7

Other Latino (born

in the U.S.) 20.4 10.4 5.3 8.4 5.2

Other Latino 

(foreign-born) 5.7 3.2 2.2 2.1 1.0

Source: Alegria et al. 2008a. 

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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

immigration status and ethnic subgroup 

(Alegria et al. 2008a). 

Among diverse Latino cultural groups, different patterns of alcohol use exist. For example, 

some older research suggests that Mexican 

American men are more likely to engage in 

binge drinking (having five or more drinks at 

one time; drinking less frequently, but in 

higher quantities) than other Latinos but use 

alcohol less frequently (Caetano and Clark 

1998). There are also differences regarding the 

abuse of other substances. Among Latinos 

entering substance abuse treatment in 2006, 

heroin and methamphetamine use were especially high among Puerto Ricans and Mexican 

Americans, respectively. Other research has 

found that Puerto Ricans are more likely to 

inject drugs and tend to inject more often 

during the course of a day than do other 

Latinos (Singer 1999). 

Patterns of substance use are also linked to 

gender, age, socioeconomic status, and acculturation in complex ways (Castro et al. 1999a; 

Wahl and Eitle 2010). For instance, increased 

frequency of drinking is associated with greater acculturation for Latino men and women,

yet the drinking patterns of Latinas are affected significantly more than those of Latino 

men (Markides et al. 2012; Zemore 2005).

Age appears to influence Latino drinking 

patterns somewhat differently than it does for 

other racial/ethnic groups. Research indicates 

that White Americans often “age out” of 

heavy drinking after frequent and heavy alcohol use in their 20s, but for many Latinos, 

drinking peaks between the ages 30 and 39.

Latinos in this age range have the lowest 

abstention rates and the highest proportions 

of frequent and heavy drinkers of any age 

group (Caetano and Clark 1998). In the same 

study, Latino men between 40 and 60 years of 

age had higher rates of substance use disorders 

than men in the same age group across other 

racial/ethnic populations. 

Latino youth appear to start using illicit drugs 

at an earlier age than do members of other 

major ethnic/racial groups. Cumulative data 

from 28 years of the Monitoring the Future 

Study show Latino eighth graders as having 

higher rates of heavy drinking, marijuana use, 

cocaine use, and heroin use than African or 

White Americans in the same grade. Among 

youth in grade 12, the rates of use among 

Latino and White American students are 

more similar, but Latinos still had the highest 

rates of crack cocaine and injected heroin use 

( Johnston et al. 2003). 

Patterns of substance use and abuse vary based 

on Latinos’ specific cultural backgrounds. 

Among Latinos, rates of past-year alcohol 

dependence were higher among Puerto Rican 

and Mexican American men (15.3 percent and 

15.1 percent, respectively) than among 

South/Central American or Cuban American 

men (9 percent and 5.3 percent, respectively). 

Among Latinas, past-year alcohol dependence 

rates were significantly higher for Puerto 

Rican women (6.4 percent) than for Mexican 

American (2.1 percent), Cuban American (1.6 

percent), or South/Central American (0.8 

percent) women (Caetano et al. 2008).

Mental and Co-Occurring 

Disorders

As with other populations, it is important to 

address CODs in Latino clients, as CODs 

have been associated with higher rates of 

treatment dropout (Amodeo et al. 2008). 

There are also reports of diagnostic bias, suggesting that some disorders are underreported 

and others are overreported. Minsky et al. 

(2003) found that, at one large mental health 

treatment site in New Jersey, major depression 

was overdiagnosed among Latinos, especially 

Latinas, whereas psychotic symptoms were 

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Improving Cultural Competence

sometimes ignored. Among Latinos with 

CODs, other mental disorders preceded the 

development of a substance use disorder 70 

percent of the time (Vega et al. 2009). 

Overall, research indicates fewer mental disorders and CODs among Latinos than among 

White Americans (Alegria et al. 2008a; Vega 

et al. 2009). However, data from the 2012

NSDUH indicate that the magnitude of the 

difference may be decreasing; 1.2 percent of 

Latinos had both serious mental illness and 

substance use disorders in the prior year, as did

White Americans, similar to the rate seen

among African Americans (0.9 percent; 

SAMHSA 2013c). When any mental disorder 

symptoms co-occurring with a substance use 

disorder diagnosis were evaluated, Latinos had 

a slightly higher rate of co-occurrence (3.4

percent) than did African Americans (3.3

percent; SAMHSA 2013c). Rates of mental 

disorders and CODs also vary by Latino 

subgroup (Alegria et al. 2008a), and acculturation can play a confounding, but inconsistent, 

role in the identification and development of 

CODs in Latino populations (Alegria et al. 

2008a; Vega et al. 2009). 

Treatment Patterns

Barriers to treatment entry for Latinos include, but are not limited to, lack of Spanishspeaking service providers, limited English 

proficiency, financial constraints, lack of culturally responsive services, fears about immigration status and losing custody of children 

while in treatment, negative attitudes toward 

providers, and discrimination (Alegria et al.

2012; Mora 2002). Among all ethnic/racial 

groups included in the 2010 NSDUH, Latinos were the most likely to report that they 

had a need for treatment but did not receive it 

because they could not find a program with 

the appropriate type of treatment or because 

there were no openings in programs that they 

wished to attend, which may reflect a lack of 

linguistically and/or culturally appropriate 

services (SAMHSA 2011c). They were about 

twice as likely to state the former and four 

times as likely to state the latter as members of 

the group that was the next most likely to 

make such statements.

A significant problem prohibiting participation in substance abuse treatment among 

Latinos is the lack of insurance coverage to 

pay for treatment. In SAMHSA’s 2010 

NSDUH, 32 percent of Latinos who needed 

but did not receive substance abuse treatment 

in the past year reported that they lacked money or insurance coverage to pay for it compared 

with 29.5 percent of White Americans and 

33.5 percent of African Americans 

(SAMHSA 2011c). Other national surveys 

also found that Latinos with self-identified 

drinking problems were significantly more 

likely than either White Americans or African 

Americans to indicate that they did not seek 

treatment because of logistical barriers, such as 

a lack of funds or being unable to obtain 

childcare (Schmidt et al. 2007). 

Latinos with substance use disorders are about 

as likely to enter substance abuse treatment 

programs as White Americans (Hser et al. 

1998; Perron et al. 2009; Schmidt et al. 2006). 

Latinos tend to enter treatment at a younger 

age than either African Americans or White 

Americans (Marsh et al. 2009). There are also 

significant differences in treatment-seeking 

patterns among Latino cultural groups. For 

example, Puerto Ricans who inject heroin are 

much more likely to participate in methadone 

main-tenance and less likely to enter other 

less-effective detoxification programs than 

are Dominicans, Central Americans, and 

other Latinos (Reynoso-Vallejo et al. 2008). 

The researchers note, however, that this could 

be due partially to the fact that Puerto Ricans, 

compared with other Latinos, have a greater 

awareness of treatment options.

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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Beliefs and Attitudes About 

Treatment 

In general, Latino attitudes toward health care 

are shaped by a lack of access to regular quality 

care, including inability to afford it (see review 

of health beliefs and help-seeking behaviors 

among Mexican Americans and Mexicans 

dwelling in the United States in Rogers 2010). 

DeNavas-Walt et al. (2006) found that Latinos are less likely to have health insurance 

(32.7 percent were uninsured in 2005) than 

either non-Latino White Americans (11.3 

percent were uninsured) or African Americans 

(19.6 percent were uninsured). They are also 

less likely to have had a regular place to go for 

conventional medical care (Schiller et al. 

2005). Lack of knowledge about available 

services can be a major obstacle to seeking 

services (Vega et al. 2001). In their review, 

Murguia et al. (2000) identified several factors 

that influence the use of medical services, 

including cultural health beliefs, demographic 

barriers, level of acculturation, English proficiency, accessibility of service providers, and 

flexibility of intake procedures; they found 

that many Latinos only seek medical care for 

serious illnesses.

Research on substance abuse indicates that 

Latinos who use illicit drugs appear to have 

relatively unfavorable attitudes toward treatment and perceive less need for treatment than 

do illicit drug users among every other major 

ethnic and racial group but Native Americans

(Brower and Carey 2003). However, in the 

2011 NSDUH, Latinos were more likely than 

White Americans, African Americans, or 

Asian Americans to indicate that they had a 

need for substance abuse treatment in the 

prior year but did not receive it (SAMHSA 

2012b). Other studies have found that Latinos 

with substance use disorders are about as likely 

to enter substance abuse treatment programs 

as other racial and ethnic groups (Hser et al. 

1998; Perron et al. 2009; Schmidt et al. 2006). 

Latinos who receive substance abuse treatment 

also report less satisfaction with the services 

they receive than White or African Americans 

(Wells et al. 2001). Even when receiving a 

level of substance abuse treatment services 

comparable to those received by White and 

African Americans, Latinos are more likely to 

be dissatisfied with treatment (Tonigan 2003). 

Treatment Issues and 

Considerations

Latino clients’responsiveness to therapy is 

influenced not only by counselor and program 

characteristics, but also by individual characteristics, including worldview, degree of acculturation, gender orientation, religious beliefs, 

and personality traits. As with other cultural 

groups, efforts to establish clear communication and a strong therapeutic alliance are 

essential to positive treatment outcomes 

among Latino clients. Foremost, counselors 

should recognize the importance of—and 

integrate into their counseling style and approach—expressions of concern, interest in 

clients’families, and personal warmth (personalismo; Ishikawa et al. 2010). 

Counselors and clinical supervisors need to be 

educated about culturally specific attributes 

that can influence participation and clinical 

interpretation of client behavior in treatment. 

For instance, some Latino cultural groups view 

time as more flexible and less structured; thus, 

rather than negatively interpreting the client’s 

behavior regarding the keeping of strict 

schedules or appointment times, counselors 

should adopt scheduling strategies that provide more flexibility (Alvarez and Ruiz 2001; 

Sue 2001). However, counselors should also 

advise Latino clients of the need to take relevant actions with the aim of arriving on time 

for each appointment or group session. Counselors should try to avoid framing noncompliance in Latino clients as resistance or anger. It 

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Improving Cultural Competence

is often, instead, a pelea nonga (relaxed fight) 

showing both a sense of being misunderstood 

and respeto (respect that also encompasses a 

sense of duty) for the counselor’s authority 

(Barón 2000; Medina 2001).

Unfortunately, many providers who work with 

Latino cultural groups continue to have misperceptions and can even see culture as a 

hindrance to effective treatment rather than as 

a source of potential strength (Quintero et al. 

2007). For instance, in treating the alcohol 

problems of Latinas, many counselors believe 

that they should not incorporate endorsement 

of traditional and possibly harmful cultural 

patterns into the services they provide (Mora 

2002). However, other counselors note that 

the transformative value of the most positive 

aspects of Latino cultural groups can be emphasized: strength, perseverance, flexibility, 

and an ability to survive (Gloria and Peregoy

1996). Respecting women’s choices can mean 

supporting empowerment to pursue new roles 

and make new choices free of alcohol, guilt, 

and discrimination (Mora 2002). For others, it 

can mean reinvigorating the positivity of 

Latina culture to promote abstinence while 

respecting and maintaining traditional family 

roles for women (Gloria and Peregoy 1996). 

Because some research has found that Latinos 

have higher rates of treatment dropout than 

other populations (Amaro et al. 2006), programs working with this population should 

consider ways to improve retention and outcomes. Treatment retention issues for Latinos 

can be similar to those found for other populations (Amodeo et al. 2008), but culturally 

specific treatment has been associated with 

better retention for Latinos (Hohman and 

Galt 2001). Research evaluating ethnic matching with brief motivational interventions also 

found more favorable substance abuse treatment outcomes at 12-month follow-up when 

clients and providers were ethnically matched 

(Field and Caetano 2010). Available literature 

and research highlight four main themes surrounding general counseling issues and programmatic strategies for Latinos, as follows.

Socializing the client to treatment: Latino 

clients are likely to benefit from orientation 

sessions that review treatment and counseling 

processes, treatment goals and expectations, 

and other components of services (Organista 

2006).

Reassurance of confidentiality: Regardless of 

the particular mode of therapy, counselors 

should explain confidentiality. Many Latinos, 

especially undocumented workers or recent 

immigrants, are fearful of being discovered by 

authorities like the United States Citizenship 

and Immigration Services and subsequently 

deported back to their countries of origin 

(Ramos-Sanchez 2009). 

Client–counselor matching based on gender: To date, research does not provide consistent findings on client–counselor matching 

based on similarity of Latino ethnicity. However, client–counselor matching based on 

gender alone appears to have a greater effect 

on improving engagement and abstinence 

among Latinos than it does for clients of other 

ethnicities (Fiorentine and Hillhouse 1999). 

Client–program matching: Matching clients 

to ethnicity-specific programs appears to 

improve outcomes for Latinos. Takeuchi et al. 

(1995) found that only 68 percent of Mexican 

American clients in programs that had a 

majority of White American clients returned 

after the first session compared with 97 percent in those programs where the majority of 

clients were Mexican American. 

Theoretical Approaches and 

Treatment Interventions

Overall, research evaluating cultural adoption 

of promising or evidence-based practices in 

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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

treatment specifically for Latinos is scarce 

(Carvajal and Young 2009). For instance, 

empirical literature evaluating CBT specifically for substance abuse and substance use disorders in Latinos is quite limited. Still, a 

number of authors recommend CBT for 

Latinos in mental health and substance abuse 

treatment settings because it is action oriented, 

problem focused, and didactic (Alvarez and 

Ruiz 2001; Organista 2006; Organista and 

Muñoz 1998). CBT’s didactic component can 

educate Latinos about disorders and frame

therapy as an educational (and hence less 

shameful) experience. However, Organista’s 

(2006) review of available research on CBT 

for mental disorders among Latinos suggests 

that this approach is not always as effective 

with Latinos as it is with other populations.

Other effective interventions include contingency management and motivational interviewing; see the review by Amaro et al. (2006)

for more on these interventions. Methadone 

maintenance, too, has been associated with

long-term reductions in the use of alcohol as 

well as heroin and other illicit drugs among 

Mexican Americans with opioid use disorders, 

although 33 percent of the original cohort 

died before the 22-year longitudinal study 

concluded (Goldstein and Herrera 1995). 

Another therapeutic intervention that can 

improve outcomes for Latino clients is nodelink mapping (visual representation using 

information diagrams, fill-in-the blank graphic tools, and client-generated diagrams or 

visual maps), which has been associated with 

lower levels of opioid and cocaine use, better 

treatment attendance, and higher counselor 

ratings of motivation and confidence for 

Latinos in methadone maintenance treatment 

(Dansereau et al. 1996; Dansereau and Simpson 2009). For a review of Latino outcome 

studies in health, substance abuse, and mental 

health in social work, refer to Jani and colleagues (2009).

Family therapy

Family therapy is often recommended for 

treating Latinos with substance use disorders 

(Amaro et al. 2006; Barón 2000; Hernandez 

2000). Although there is little research evaluating the effectiveness of family therapy for 

adults, both multidimensional family therapy 

(Liddle 2010) and brief strategic family therapy (Santisteban et al. 1997; Santisteban et al.

2003; Szapocznik and Williams 2000) have 

been found to reduce substance use and improve psychological functioning among Latino 

youth. The term familismo refers to the centrality of the family in Latino culture and can 

include valuing and protecting children, respecting the elderly, preserving the family 

name, and consulting with one another before 

making important decisions. As highlighted in 

the case study of a Puerto Rican client on the 

next page, counselors must consider the potentially pivotal roles families can play in supporting treatment and recovery. Latino families are

likely to have a strong sense of obligation and 

commitment to helping their members, including those who have substance use disorders. Even so, the level of family support for 

people who have substance use or mental 

disorders varies among Latinos depending on 

country of origin, level of acculturation, degree 

of family cohesion, socioeconomic status, and 

factors related to substance use (Alegria et al.

2012). For example, Reynoso-Vallejo et al. 

(2008) concluded that significantly higher 

rates of homelessness found among people 

from Central American countries who injected heroin compared with other Latinos could 

stem from lower levels of tolerance for injection drug use among their families. 

For counselors who lack cultural understanding, it can be easy to simply label and judge 

families’ behavior as enabling or codependent. 

Instead, counselors should move away from 

labeling the behavior and focus more on helping families recognize how their behavior can 

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Improving Cultural Competence

affect one member’s substance abuse and how 

best to handle it. The advice box on the next 

page provides general therapeutic guidelines 

for working with Latino families. 

Group therapy 

Little information is available concerning 

Latinos’ preferences in behavioral health 

services, but a study evaluating mental health 

treatment preferences for women in the United States found that Latinas were significantly 

more likely to prefer group treatment 

(Nadeem et al. 2008). According to Paniagua 

(1998), the use of group therapy with Latino 

clients should emphasize a problem-focused 

approach. Group leaders should allow members to learn from each other and resist functioning as a content expert or a representative 

of the rules of the system. Otherwise, members could see group therapy as oppressive. 

Facilitators in groups consisting mostly of 

Latino clients must establish trust, responsibility, and loyalty among members. In addition, 

acculturation levels and language preferences 

should be assessed when forming groups so 

that culturally specific or Spanish-speaking 

groups can be made available if needed. 

Mutual-help groups 

Findings on the usefulness of 12-Step groups 

for Latino clients are inconsistent. Membership surveys of AA indicate that Latinos 

comprise about 5 percent of AA membership 

(AAWS 2012). Latinos who received inpatient 

treatment were less likely to attend AA than 

White Americans (Arroyo et al. 1998). Rates 

Case Study: A Puerto Rican Client

Anna is a 27-year-old woman who was born in New York and self-identifies as Puerto Rican. She has 

a 12th-grade education, is unemployed, and lives with her parents, her 4-year-old daughter, and a 

nephew. Anna is separated from her partner, who is also her daughter’s father. She entered treatment as a result of feeling depressed ever since her partner physically assaulted her because she 

refused to use heroin (the event that sparked their separation). She states, “I want to be clean and 

take care of my family.” At intake, she had just undergone detoxification and had stopped using 

alcohol, crack cocaine, and heroin. 

Anna states that she feels guilty about her drug use and the way it caused her to neglect her family. 

She has been having serious problems with her mother, who is critical of her substance use, but 

believes that her mother is important in her recovery because of the structure she provides at home.

She describes her father as a very important figure with whom she enjoys spending time. Her father 

had stopped drinking 9 years before and is very supportive of her abstinence. He is willing to help in 

any way he can but has been very sick lately and was diagnosed with prostate cancer. Her father had 

never received treatment for his drinking problem, and her mother believes that Anna should be 

able to stop just like her father did. As she describes her situation in treatment, Anna’s vergüenza

(shame) and sense of hopelessness is very evident. She fears her father’s death and her mother’s 

subsequent rejection of her for not helping out. 

Anna’s treatment includes family therapy to restructure communication patterns, rules, expectations, and roles. For family sessions, either her mother or both parents participate, depending on her 

father’s physical condition. Initially, her parents displayed a tendency to focus on the problems of the 

past, but the counselor directed them to focus on changes needed to help Anna’s recovery. The 

counselor has also worked with other family members to rally support and use their strengths while 

also clarifying perceptions, feelings, and behaviors that will help them function as a family unit. 

Anna’s counselor recognizes that, within the context of her culture, her reliance on her family can be 

used to aid her recovery and that her family, as defined by Anna, can be used as a support system.

Source: Medina 2001. Adapted with permission.

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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Advice to Counselors: Family Therapy 

Guidelines for Latino Families 

• Provide bilingual services.

• Use family therapy as a primary method of 

treatment. 

• Assess cultural identity and acculturation 

level for each family member.

• Determine the family’s level of belief in 

traditional and complementary healing 

practices; integrate these as appropriate.

• Discuss the family’s beliefs, history, and 

experiences with standard American behavioral health services. 

• Explore migration and immigration experiences, if appropriate.

• Provide additional respect to the father or 

father figure in the family.

• Interview family members or groups of 

family members (e.g., children) separately 

to allow them to voice concerns.

• Generate solutions with the family. Do not 

force changes in family relationships.

• Provide specific, concrete suggestions for 

change that can be quickly implemented. 

• Focus on engaging the family in the first 

session using warmth and personalismo. 

Sources: Bean et al. 2001; Hernandez 2005; 

Lynch and Hanson 2011.

of mutual-help participation among people 

with drug use disorders are also lower for 

Latinos (Perron et al. 2009). Language can 

present a barrier to mutual-help group participation for Spanish-speaking Latinos; however, 

Spanish-language meetings are held in some 

locations. Counselors should consider the 

appropriateness of 12-Step participation on a 

case-by-case basis (Alvarez and Ruiz 2001). 

For example, Mexican American men who 

identify with attitudes of machismo can feel 

uncomfortable with the 12-Step approach. 

Concern about divulging family issues in public 

can cause hesitation to address substancerelated problems in public meetings. 

For Latinos who do participate in 12-Step 

programs, findings suggest higher rates of 

abstinence, degree of commitment, and level 

of engagement than for White American 

participants (Hoffman 1994; Tonigan et al. 

1998). For some Latinos, 12-Step groups can 

appeal to religious and spiritual beliefs. Hernandez (2000) suggests that mutual-help 

groups composed solely of Latinos make it 

easier for participants to address the cultural 

context of substance abuse. Some Latino 12-

Step groups do not hold that substance abuse 

is a biopsychosocial problem, instead conceptualizing the disorder as a weakness of character that must be corrected. Hoffman (1994) 

studied Latino 12-Step groups in Los Angeles 

and observed that, in addition to a more 

traditional form of AA, there were groups that 

practiced terapia dura (i.e., rough therapy), 

which often uses a confrontational approach 

and endorses family values related to machismo

(e.g., by reinforcing that overcoming substance 

abuse rather than drinking is manly). However, these groups were not overly welcoming of

female members and gay men. In such cases, 

gay Latino men and Latinas can benefit from 

attending 12-Step groups that are not culturally specific or that do not use terapia dura. 

Traditional healing and 

complementary methods 

In a study of the use of alternative and complementary medical therapies, Latinos were 

less likely to use medical alternatives than 

were White Americans (Graham et al. 2005). 

However, those who did use such approaches 

were more likely to do so because they could 

not afford standard medical care (Alegria et al. 

2012). As in other areas, the use of complementary and traditional medicine likely varies 

according to acculturation level and country of 

origin. For instance, the use of faith and religious practices to cope with mental and emotional problems is significantly more common 

among foreign-born Latinos than among 

those born in the United States (Nadeem et al. 

2008; Vega et al. 2001).

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Improving Cultural Competence

Many Latinos place great importance on the 

practice of Roman Catholicism. Yamamoto 

and Acosta (1982) describe the central tenets 

of Latino Catholicism as sacrifice, charity, and 

forgiveness. These beliefs can hinder assertiveness in some Latinos, but they can also be a 

source of strength and recovery. Traditionally, 

Latinos have been Catholic, although several 

Protestant and evangelical groups have converted millions of Latinos to their religions 

since the 1970s. Some Latinos also believe in 

syncretistic religions (e.g., Santería or 

Curanderismo) or practices derived from them

and make use of a variety of traditional healing practices and rituals to heal mental and 

spiritual ailments (Lefley et al. 1998; Sandoval 

1979). Among Puerto Ricans, espiritismo

(spiritualism) is a popular traditional healing 

system successfully used to address mental 

health issues (Lynch and Hanson 2011; Molina 2001). Some Mexican Americans rely on 

curanderos, folk healers who address problems 

that might be framed as psychological (Falicov 

2005, 2012). For a review of culturally responsive interventions with Latinos, refer to 

Gallardo and Curry (2009).

Relapse prevention and recovery

There are no substantial studies evaluating the 

use of relapse prevention and recovery promotion with Latinos, yet literature suggests that 

they would be appropriate and effective for 

this population (Blume et al. 2005; Castro et 

al. 2007). Overall, Latinos can face somewhat 

different triggers for relapse relating to acculturative stress or the need to uphold particular 

cultural values (e.g., personalismo, machismo; 

Castro et al. 2007), which can lead to higher 

rates of relapse among some Latino clients. 

For example, in a study of relapse patterns 

among White American and Latino individuals who used methamphetamine, Brecht et al. 

(2000) found that Latino participants relapsed 

more quickly than White American 

participants.

Data are lacking on long-term recovery for 

Latinos. Given the many obstacles that block 

accessibility to treatment for Latinos, continuing care planning can benefit from greater use 

of informal or peer supports. For example, 

White and Sanders (2004) recommend the 

use of a recovery management approach with 

Latinos. They point to an early example of the 

East Harlem Protestant Parish’s work, which 

helped Puerto Rican individuals recovering 

from heroin dependence connect to social 

clubs and religious communities that supported recovery. Latinos use community and 

family support in addition to spirituality to 

address mental disorders (Lynch and Hanson 

2011; Molina 2001). Castro et al. (2007) also 

note that family support systems can be especially important for Latinos in recovery.

Counseling for Native 

Americans 

There are 566 federally recognized American 

Indian Tribes, and their members speak more 

than 150 languages (U.S. Department of the 

Interior, Indian Affairs 2013a); there are 

numerous other Tribes recognized only by 

states and others that still go unrecognized by 

government agencies of any sort. According to 

the 2010 U.S. Census (Norris et al. 2012), the 

majority (78 percent) of people who identified 

as American Indian or Alaska Native, either 

alone or in combination with one or more 

other races, lived outside of American Indian 

and Alaska Native areas. Approximately 60 

percent of the 5.2 million people who identified as American Indian or Alaska Native, 

alone or in combination with one or more 

other races, reside in urban areas (Norris et al.

2012). The category of Alaska Natives includes four recognized Tribal groups—

Alaskan Athabascan, Aleut, Eskimo, and 

Tingit-Haida—along with many other independent communities (Ogunwole 2006). 

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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Native Americans who belong to federally 

recognized Tribes and communities are members of sovereign Indian nations that exist 

within the United States. On lands belonging 

to these Tribes and communities, Native 

Americans are able to govern themselves to a 

large extent and are not subject to most state 

laws—only to federal legislation that is specifically designated as applying to them (Henson 

2008). Although health care (including substance abuse treatment) is provided to many 

Native Americans by Indian Health Services 

(IHS), Tribal governments do have the option 

of taking over those services. Counselors 

working with these populations should remember that Native Americans, by virtue of 

their membership in sovereign Tribal entities, 

have rights that are different from those of 

other Americans; this distinguishes them from 

members of other ethnic/racial groups. 

American Indians live in all 50 states; the 

states with the largest populations of American Indians are Oklahoma, California, and 

Arizona. The 2000 Census allowed people to 

identify, for the first time, as a member of 

more than one race. Of persons who checked 

two or more races, nearly one in five indicated 

that they were part American Indian or Alaska 

Native (U.S. Census Bureau 2001a,b). 

Behavioral health service providers should 

recognize that Native American Tribes represent a wide variety of cultural groups that 

differ from one another in many ways (Duran 

et al. 2007). Alaska Natives who live in coastal 

areas have very different customs from those 

inhabiting interior areas (Attneave 1982). The 

diversity of Native American Tribes notwithstanding, they also share a common bond of 

respect for their cultural heritages, histories, 

and spiritual beliefs, which are different from 

those of mainstream American culture. For 

more information on the treatment and prevention of substance abuse and mental illness 

among Native Americans, see the planned TIP, 

Behavioral Health Services for American Indians 

and Alaska Natives (SAMHSA planned a).

Beliefs About and Traditions 

Involving Substance Use 

Few American Indian Tribes and no Alaska 

Natives consumed alcoholic beverages prior to 

contact with non-Native people, and those 

who did used alcohol primarily for special 

occasions and ceremonies. Most Tribes first 

encountered the use of alcohol when they 

encountered European settlers and traders. 

Because of this lack of experience with alcohol, few Native Americans had a context for 

drinking besides what they learned from these 

non-Natives, who at the time drank in large 

quantities and often engaged in binge drinking. Although patterns of alcohol consumption in the mainstream population of the 

United States changed over time, they remained relatively the same in the more isolated Native American communities. According 

to an NSDUH report on American Indian 

and Alaska Native adults, binge drinking 

continues to be a significant problem for these 

populations. Both binge drinking and illicit 

drug use is higher among Native Americans 

than the national average (30.2 percent versus

23 percent and 12.7 percent versus 9.2 percent, 

respectively; SAMHSA 2013d). 

American Indian drinking patterns vary a 

great deal by Tribe. Tribal attitudes toward 

alcohol influence consumption in complicated 

ways. For example, in Navajo communities, 

excessive drinking was acceptable if done in a 

group or during a social activity. However, 

solitary drinking (even in lesser amounts) was 

considered to be deviant (Kunitz et al. 1994). 

Kunitz et al. (1994) observed that during the 

1960s, binge drinking was acceptable among 

the Navajo during public celebrations, whereas 

any drinking was considered unacceptable 

among the neighboring Hopi population, 

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Improving Cultural Competence

wherein regular drinkers were shunned or, in 

some cases, expelled from the community. 

Hopi individuals who did drink tended to do 

so alone or moved off the reservation to border towns where heavy alcohol use was common. The ostracism of Hopi drinkers seemed 

to lead to even greater levels of abuse, given 

that there were much higher death rates from 

alcoholic cirrhosis among the Hopi than 

among the Navajo. 

Native American recovery movements have 

often viewed substance abuse as a result of 

cultural conflict between Native and Western 

cultures, seeing substances of abuse as weapons 

that have caused further loss of traditions 

(Coyhis and White 2006). To best treat this 

population, substance abuse treatment providers need to expand their perspectives regarding 

substance abuse and dependence and must 

embrace a broader view that explores the 

spiritual, cultural, and social ramifications of 

substance abuse (Brady 1995; Duran 2006; 

Jilek 1994).

Substance Use and Substance Use 

Disorders

According to 2012 NSDUH data, American 

Indian and Alaska Native peoples have the 

highest rates of substance use disorders and 

binge drinking (SAMHSA 2013d). Although 

rates of substance abuse are high among 

Native Americans, so too are rates of abstinence. American Indians and Alaska Natives 

are more likely to report no alcohol use in the 

past year than are members of all other major 

racial and ethnic groups (OAS 2007). The 

American Indian Services Utilization and 

Psychiatric Epidemiology Risk and Protective 

Factors Project (AI-SUPER PFP) also found 

that rates of lifetime abstinence from alcohol 

for American Indians in the study were significantly higher than lifetime abstinence rates 

among the general population (Beals et al. 

2003). Data on alcohol consumption also 

show that Alaska Natives are significantly 

more likely to abstain than are other Alaskans 

(Wells 2004).

The most common pattern of abusive drinking among American Indians appears to be 

binge drinking followed by long periods of 

abstinence (French 2000; May and Gossage 

2001). A similar pattern is seen among Alaska 

Natives (Seale et al. 2006; Wells 2004). As an 

example, the Urban Indian Health Institute 

(2008) found that binge drinking was significantly more common among the Native 

American population (with 21.3 percent 

engaging in binge drinking in the prior 30 

days compared with 15.8 percent of nonNative Americans) and that, among those who 

drank, 40.7 percent of Native American participants engaged in binge drinking compared 

with 26.9 percent of non-Natives.

There are a number of historical reasons for 

the development of binge drinking among 

Native Americans. The existence of dry reservations (which can limit the times when individuals are able to get alcohol), high levels of 

poverty, lack of availability (e.g., in remote 

Alaska Native villages), a history of trauma, 

and the loss of cultural traditions can all contribute to the development and continuation 

of this pattern of drinking. Native Americans 

are also more likely than members of other 

major racial/ethnic groups to have had their 

first drink before the age of 21 or before the 

age of 16, which also may shape drinking 

patterns (SAMHSA 2011c).

However, data on heavy and binge drinking do 

not reflect the same pattern of alcohol consumption for all Native American Tribes. One 

analysis of alcohol dependence among members of seven different Tribes found rates of 

dependence varying from 56 percent of men 

and 30 percent of women in one Tribe to 1 

percent of men and 2 percent of women in 

another (Koss et al. 2003). Other research 

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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

confirms significant differences in alcohol use 

among diverse Native American communities 

(O’Connell et al. 2005; Whitesell et al. 2006).

In addition to alcohol, methamphetamine and 

inhalant abuse are major concerns for a number of Native American communities. Nonetheless, there are considerable regional 

differences in patterns and prevalence of drug 

use (Miller et al. 2012). According to the 

National Congress of American Indians 

(2006), 74 percent of Tribal police forces 

ranked methamphetamine as the drug causing 

the most problems in their communities. 

Methamphetamine abuse can be even more 

serious for Native Americans living in rural 

areas than for those in urban areas, but it is 

also a serious problem for growing numbers of 

American Indians, especially women, entering 

treatment in urban areas (Spear et al. 2007). 

American Indians and Alaska Natives are 

more likely to report having used inhalants at 

some time during their lives, but use tends to 

peak in 8th grade and then decrease (Miller et 

al. 2012). In some Native American communities (e.g., on the Kickapoo reservation in Texas), inhalants have been a major drug of abuse 

for adults as well as youth. During the early 

1990s, about 46 percent of the adult population on that reservation were thought to abuse 

inhalants (Fredlund 1994). Although more 

recent data are not available, reports from the 

area suggest that inhalant abuse remains a 

significant problem (Morning Star 2005).

Rates of substance use disorders appear to be 

higher in individuals who consider themselves 

exclusively Native American than for those 

who identify as more than one race/ethnicity, 

but even when surveys ask whether people are 

of mixed race, those who report themselves to 

be partially Native American still have high 

rates of substance use disorders (OAS 2007). 

Native Americans are about 1.4 times more 

likely than White Americans to have a lifetime

diagnosis of an alcohol use disorder (Gilman 

et al. 2008). Illicit drug use is also more common for Native Americans than for members 

of other major racial/ethnic groups.

Among Native Americans entering treatment 

in 2010, alcohol use disorders alone or in 

conjunction with drug use disorders were the 

most pressing substance-related problem, with 

cannabis and opioids other than heroin being 

the next most common primary substances of 

abuse. One of the largest studies on American 

Indian substance use and abuse to date, the 

AI-SUPER PFP, found that 31.2 percent of 

American Indians met criteria for a lifetime 

diagnosis of a substance use disorder, and 13.4 

percent met criteria for a past-year diagnosis 

(Beals et al. 2003). The study found that rates 

of alcohol use disorders were high among men 

from the three Tribes represented but varied 

to a greater degree among women across 

Tribes (Mitchell et al. 2003).

American Indians have high rates of certain 

diseases and conditions. In particular, the 

incidence of diabetes is increasing among 

Native Americans, and approximately 38

percent of elder Native Americans have diabetes (Moulton et al 2005). Diabetes is also 

associated with both substance use disorders 

and depression in this population (Tann et al. 

2007). Other health problems associated with 

alcohol use include fetal alcohol syndrome, 

cirrhosis, and depression. 

Mental and Co-Occurring 

Disorders

According to the 2012 NSDUH, 28.3 percent 

of American Indians and Alaska Natives 

report having a mental illness, with approximately 8.5 percent indicating serious mental 

illness in the past year (SAMHSA 2013c). 

Native Americans were nearly twice as likely 

to have serious thoughts of suicide as members 

of other racial/ethnic populations, and more 

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Improving Cultural Competence

than 10 percent reported a major depressive 

episode in the past year. Common disorders 

include depression, anxiety, and substance use.

As with other groups, substance use disorders 

among Native Americans have been associated 

with increased rates of a variety of different 

mental disorders (Beals et al. 2002; Tann et al. 

2007; Westermeyer 2001). The 2012 NSDUH 

revealed that 14 percent of Native Americans 

reported both past-year substance use disorders and mental illness. Among those who 

reported mental illness, nearly 5 percent reported several mental illnesses co-occurring 

with substance use disorders (SAMHSA 

2013c).

Native American communities have experienced severe historical trauma and discrimination (Brave Heart and DeBruyn 1998; Burgess 

et al. 2008). Studies suggest that many Native 

Americans suffer from elevated exposure to 

specific traumas (Beals et al. 2005; Ehlers et al. 

2006; Manson 1996; Manson et al. 2005), and 

they may be more likely to develop PTSD as a 

result of this exposure than members of other 

ethnic/racial groups. PTSD comparison rates 

taken from the AI-SUPER PFP study and 

the National Comorbidity Study show that 

12.8 percent of the Southwest Tribe sample 

and 11.5 percent of the Northern Plains Tribe 

sample met criteria for a lifetime diagnosis of 

PTSD compared with 4.3 percent of the 

general population (Beals et al. 2005). Trauma 

histories and PTSD are so prevalent among 

Native Americans in substance abuse treatment that Edwards (2003) recommends that 

assessment and treatment of trauma should be 

a standard procedure for behavioral health 

programs serving this population. For example, Native American veterans with substance 

use disorders are significantly more likely to 

have co-occurring PTSD than the general 

population of veterans with substance use 

disorders (Friedman et al. 1997). 

Treatment Patterns

Despite a number of potential barriers to 

treatment (Venner et al. 2012), Native Americans are about as likely as members of other 

racial/ethnic groups to enter behavioral health 

programs. According to data from the 2003 

and 2011 NSDUH (SAMHSA, CBHSQ

2012), Native Americans were more likely to 

have received substance use treatment in the 

past year than persons from other racial/ethnic 

groups (15.0 percent versus 10.2 percent). 

Other studies indicate that about one-third of 

Native Americans with a current substance use 

disorder had received treatment in the prior 

year (Beals et al. 2006; Herman-Stahl and 

Chong 2002). The 2012 NSDUH reported 

that approximately 15 percent of Native 

Americans received mental health treatment 

(SAMHSA 2013c).

Native Americans were least likely of all major 

ethnic/racial groups to state that they could not 

find the type of program they needed and were 

the next least likely after Native Hawaiians and 

other Pacific Islanders to state that they did not 

know where to go or that their insurance did 

not cover needed treatment. Among Native 

Americans who identified a need for treatment in the prior year but did not enter treatment, the most commonly cited reasons for 

not attending were lack of transportation, lack 

of time, and concerns about what one’s neighbors might think (SAMHSA 2011c). 

Many Native Americans, especially those 

residing on reservations or other Tribal lands, 

seek mental health and substance abuse treatment through Tribal service providers or IHS 

(Jones-Saumty 2002; McFarland et al. 2006). 

However, an analysis using multiple sources 

found that 67 percent of Native Americans 

entering substance abuse treatment over the 

course of a year did so in urban areas, and the 

majority of those urban-based programs were 

not operated by IHS (McFarland et al. 2006). 

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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

The same research also found that Native 

Americans were somewhat more likely than 

the general treatment-seeking population to 

enter residential programs.

Native Americans were more likely to enter 

treatment as a result of criminal justice referrals than were White Americans or African 

Americans: 47.9 percent of American Indians 

and Alaska Natives entering public treatment 

programs in 2010 were court-ordered to 

treatment compared with 36.6 percent of 

White Americans and 36.4 percent of African 

Americans (SAMHSA, CBHSQ 2012). The 

lack of recognition of special needs and 

knowledge of Native American cultures within 

behavioral health programs may be the main 

reasons for low treatment retention and underuse of help-seeking behaviors among 

Native Americans (LaFromboise 1993; Sue 

and Sue 2013e). 

Beliefs and Attitudes About 

Treatment

Duran et al. (2005) evaluated obstacles to 

treatment entry among American Indians on 

three different reservations; most frequently 

mentioned were the perception that goodquality or suitable services were unavailable 

and the perceived need for individuals to be 

self-reliant. They also found social relationships to be extremely important in overcoming 

these barriers. Jumper-Thurman and Plested 

(1998) reported that focus groups of American 

Indian women listed mistrust as one of the 

primary barriers for seeking treatment. This is 

due, in part, to the women’s belief that they 

would encounter people they knew among 

treatment agency staff; they also doubted the 

confidentiality of the treatment program.

Treatment Issues and 

Considerations

Each Tribe and community will likely have 

different customs, healing traditions, and 

beliefs about treatment providers that can 

influence not only willingness to participate in 

treatment services, but also the level of trust 

clients have for providers. Counselors and 

other behavioral health workers must develop 

ongoing relationships within local Native 

American communities to gain knowledge of 

the unique attributes of each community, to 

show investment in the community, and to 

learn about community resources (Exhibit 5-

3). Identifying and developing resources within Native communities can help promote

culturally congruent relationships. 

Exhibit 5-3: Native Americans and 

Community 

Many Native Americans believe that recovery 

cannot happen for individuals alone and that 

their entire community has become sick. 

Coyhis calls this the “healing forest” model: 

one cannot take a sick tree from a sick forest, 

heal it, and put it back in the same environment expecting that it will thrive. Instead, the 

community must embrace recovery. 

Today, community development models are 

being implemented in American Indian and 

Alaska Native communities to address prevention and treatment issues for mental and substance use disorders as well as related issues, 

such as suicide prevention (Edwards and 

Egbert-Edwards 1998; HHS 2010; May et al. 

2005). Using these models, communities move 

toward greater commitment to social problemsolving and the development of effective, 

culturally congruent strategies relevant to their 

Tribes or villages. According to Edwards et al. 

(1995), community approaches often lead to: 

• A reduction of substance use.

• Breaking intergenerational cycles of alcohol abuse.

• Increased community support.

• The strengthening of individual and group 

cultural identity.

• Leadership development.

• Increased interpersonal and inter-Tribal 

problem-solving skills and solidarity.

For an example, see Jumper-Thurman et al. 

(2001).

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Improving Cultural Competence

To provide culturally responsive treatment, 

providers need to understand the Native 

American client’s Tribe; its history, traditions, 

worldview, and beliefs; the dimensions of its 

substance abuse problem and other community problems; the incidence of trauma and 

abuse among its members; its traditional 

healing practices; and its intrinsic strengths. 

Providers who work with Native Americans 

but do not have an understanding of their 

cultural identity and acculturation patterns are 

at a distinct disadvantage (Ponterotto et al. 

2000). Before beginning any treatment, providers should routinely seek consultation with 

knowledgeable professionals who are experienced in working with the specific Tribal 

group in question (Duran 2006; Edwards and

Egbert-Edwards 1998; Straits et al. 2012) and 

should conduct thorough client assessments 

that evaluate cultural identity (see Appendix F 

and Chapter 2 for resources). Some Native 

American persons have a strong connection to 

their cultures and others do not; some identify 

with a blend of American Indian cultural 

groups called pan-Indianism or inter-Tribal 

identity. Still others are comfortable with a 

dual identity that embraces both Native and 

non-Native cultural groups.

Native Americans often approach the beginning of a relationship in a calm, unhurried 

manner, and they may need more time to 

develop trust with providers. Concerns about 

confidentiality can be an important issue to 

address with Native American clients, especially for those in small, tightly-knit communities. For providers, it is very important to 

make clear to clients that what they say to the 

counselor will be held in confidence, except 

when there is an ethical duty to report. 

Native American cultural groups generally 

believe that health is nurtured through balance 

and living in harmony with nature and the 

community (Duran 2006; Garrett et al. 2012). 

They also, for the most part, have a holistic 

view of health that incorporates physical, 

emotional, and spiritual elements (Calabrese 

2008), individual and community healing 

(Duran 2006; McDonald and Gonzalez 2006),

and prevention and treatment activities 

(Johnston 2002). For many, culture is the path 

to prevention and treatment.

However, not all Native Americans have a 

need to develop stronger connections to their 

communities and cultural groups. As Brady 

(1995) cautions, culture is complex and changing, and a return to the values of a traditional 

culture is not always desired. An initial inquiry 

into each client’s connection with his or her 

culture, cultural identity, and desire to incorporate cultural beliefs and practices into 

treatment is an essential step in culturally 

competent practice. When appropriate, providers can help facilitate the client’s reconnection with his or her community and cultural 

values as an integral part of the treatment 

plan. In addition, treatment providers need to 

adapt services to be culturally responsive. In 

doing so, outcomes are likely to improve not 

only for Native American clients, but for all 

clients within the program. Fisher et al. (1996) 

modified a therapeutic community in Alaska 

to incorporate Alaska Native spiritual and 

cultural practices and found that retention 

rates improved for White and African American clients as well as Alaska Native clients 

participating in the program. 

In working with Native American clients, 

providers should be prepared to address spirituality and to help clients access traditional 

healing practices. Culturally responsive treatment should involve community events, group 

activities, and the ability to participate in 

ceremonies to help clients achieve balance and 

find new insight (Calabrese 2008). Stronger 

attachment to Native American cultural 

groups protects against substance use and 

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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

abuse; therefore, strengthening this connection 

is important in substance abuse treatment 

(Duran 2006; Moss et al. 2003; Spicer 2001; 

Stone et al. 2006). 

Theoretical Approaches and 

Treatment Interventions

Some clinicians caution that a model of counseling that requires self-disclosure to relative 

strangers can be counterproductive with Native

American clients. Other authors recommend 

CBT and social learning approaches for 

Native American clients, as such approaches 

typically have less cultural bias, focus on problem-solving and skill development, emphasize 

client strengths and empowerment, recognize 

the need to accept personal responsibility for 

change, and make use of learning styles that 

many Native Americans find culturally appropriate (Heilbron and Guttman 2000;

McDonald and Gonzalez 2006). Motivational 

interviewing is also recommended for Native 

American clients. In a small study, Villanueva 

et al. (2007) found that all treatment modalities resulted in improvements at 15-month 

follow-up, but clients who received motivational enhancement therapy reported significantly fewer drinks per drinking day during 

the 10- to 15-month posttreatment follow-up 

period. Venner et al. (2006) wrote a manual for 

motivational interviewing with Native 

American clients.

Family therapy 

Family involvement in treatment leads to 

better outcomes for Native Americans at the 

time of discharge from treatment (Chong and 

Lopez 2005). Research also suggests that 

family and community support can have a 

significant effect on recovery from substance 

use disorders for this population ( JonesSaumty 2002; Paniagua 1998). Family therapy

can be quite helpful and perhaps even essential 

for American Indian clients (Coyhis 2000), 

especially when other social supports are 

lacking ( Jones-Saumty 2002). 

American Indians place high value on family 

and extended family networks; restoring or 

healing family bonds can be therapeutic for 

clients with substance use disorders. Moreover, Native American clients are sometimes 

less motivated to engage in “talk therapy” and 

more willing to participate in therapeutic 

activities that involve social and family relationships ( Joe and Malach 2011). Treatment 

approaches should remain flexible and include clients’ families when appropriate. 

Counselors should be able to recognize what 

constitutes family, family constellations, and 

Advice to Counselors: Counseling 

Native Americans

When working with Native American clients, 

providers should:

• Use active listening and reflective responses.

• Avoid interrupting the client.

• Refrain from asking about family or personal matters unrelated to substance abuse 

without first asking the client’s permission 

to inquire about these areas.

• Avoid extensive note-taking or excessive 

questioning. 

• Pay attention to the client’s stories, experiences, dreams, and rituals and their relevance to the client. 

• Recognize the importance of listening and 

focus on this skill during sessions. 

• Accept extended periods of silence during

sessions. 

• Allow time during sessions for the client to 

process information.

• Greet the client with a gentle (rather than 

firm) handshake and show hospitality (e.g., 

by offering food and/or beverages).

• Give the client ample time to adjust to the 

setting at the beginning of each session. 

• Keep promises.

• Offer suggestions instead of directions 

(preferably more than one to allow for client choice).

Sources: Aragon 2006; Trimble et al. 2012. 

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Improving Cultural Competence

family characteristics. The Native American 

concept of family can include elders, others 

from the same clan, or individuals who are not 

biologically related. In many Tribes, all members are considered relatives. Families can be 

matrilineal (i.e., kinship is traced through the 

female line) and/or matrilocal (i.e., married 

couples live with wife’s parents). 

When families do enter treatment, they may 

initially prefer to focus on a concrete problem, 

but not necessarily on the most significant 

family issue. Discussion of a clearly defined 

presenting problem enables families to assess 

the therapeutic process and better understand 

what is expected of them in treatment. Providers should be aware that the entire clan and/or 

Tribe could know about a given client’s treatment and progress. Family therapy models 

such as network therapy, which makes use of 

support structures outside the immediate 

family and which were originally developed 

for Native American families living in urban 

communities, can be particularly effective with 

Native clients, especially when they have been 

cut off from their home communities because 

of substance abuse or other issues. For more 

information on network therapy and similar 

approaches, see TIP 39, Substance Abuse 

Treatment and Family Therapy (CSAT 2004b).

Group therapy

Although researchers and providers once 

viewed group therapy as ineffective for American Indian clients (Paniagua 1998), opinion 

has shifted to recognize that, when appropriately structured, group therapy can be a powerful treatment component (Garrett 2004; 

Garrett et al. 2001; Trimble and JumperThurman 2002). Garrett (2004) notes that 

many Native American Tribes have traditional 

healing practices that involve groups; for many 

of these cultural groups, healing needs to occur 

within the context of the group or community 

(e.g., in talking circles). Thus, if properly 

adapted, group therapy can be very beneficial 

and culturally congruent. It is important, 

however, to determine Native American clients’

level of acculturation before recommending 

Western models of group therapy, as less 

acculturated Native clients are likely to be less 

comfortable with group talk therapy (Mail and 

Shelton 2002). Group therapy for Alaska 

Natives should also be nonconfrontational and 

focus on clients’strengths.

Group therapy can incorporate Native

American traditions and rituals to make it 

more culturally suitable. For example, the 

talking circle is a Native tradition easily 

adapted for behavioral health treatment. In 

this tradition, the members of the group sit in 

a circle. An eagle feather, stone, or other symbolic item is passed around, and each person 

speaks when he or she is handed the item. 

Based on a review of the literature, Paniagua 

(1998) recommends that providers using 

group therapy with Native American clients: 

• Earn support or permission from Tribal 

authorities before organizing group therapy.

• Consult with Native professionals.

• If group members consent, invite respected 

Tribal members (e.g., traditional healers or 

elders) to participate in sessions. 

Mutual-help groups

Native American peoples have a long history 

of involvement in mutual-help activities that 

predates the 12-Step movement (Coyhis and 

White 2006). Depending on acculturation, 

availability of a community support network, 

and the nature of their presenting problems, 

Native American clients may be more likely to 

solicit help from significant others, extended 

family members, and community members. 

Contemporary manifestations of Native 

American mutual-help efforts include adaptations of the 12 Steps (Exhibit 5-4) and of 12-

Step meeting rituals and practices (Coyhis and 

White 2006). Another modified element of 

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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

the 12 Steps is use of a circular, rather than a 

linear, path to healing. The circle is important 

to American Indian philosophy, which sees the 

great forces of life and nature as circular 

(Coyhis 2000). In addition, staff members of 

the White Bison program have also rewritten 

the AA “Big Book” from a Native American 

perspective (Coyhis and Simonelli 2005). The 

principles of the 12 Steps, which involve using 

the group or community to provide support 

and motivation while emphasizing spiritual 

reconnection, appeal to many Native Americans who see treatment as social in nature and 

who view addiction as a spiritual problem.

The Native American Wellbriety movement is 

a modern, indigenous mutual-help program 

that has its roots in 12-Step groups but incorporates Native American spiritual beliefs and 

cultural practices (Coyhis and Simonelli 2005; 

Coyhis and White 2006; White Bison, Inc. 

2002; also see http://www.whitebison.org). 

Although the Wellbriety movement is popular 

with many Native Americans in recovery, a 

considerable number also continue to participate in traditional 12-Step groups. In the AISUPER-PFP, 47 percent of Northern Plains 

Tribe respondents and 28.8 percent of Southwest Tribe respondents with a past-year substance use disorder reported 12-Step group 

attendance in the prior year (Beals et al. 2006). 

Mohatt et al. (2008b) found that more Alaska 

Natives in recovery reported participation in 

12-Step groups than in substance abuse treatment. In Venner and Feldstein’s (2006) research with American Indians in recovery, 84 

percent of respondents had attended some 

mutual-help meetings. 

Traditional healing and 

complementary methods 

Native American peoples have a range of beliefs about health care—from traditional beliefs 

to strong support for modern science—and 

may use a number of strategies when addressing health problems.Traditional healing practices are often used in conjunction with modern 

medicine. For example, American Indians 

Exhibit 5-4: The Lakota Version of the 12 Steps

The Lakota Tribe has adapted the 12 Steps to suit its particular belief system as follows: 

1. I admit that because of my dependence on alcohol, I have been unable to care for myself and my 

family.

2. I believe that the Great Spirit can help me to regain my responsibilities and model the life of my 

forefathers (ancestors).

3. I rely totally on the ability of the Great Spirit to watch over me.

4. I strive every day to get to know myself and my position within the nature of things.

5. I admit to the Great Spirit and to my Indian brothers and sisters the weaknesses of my life.

6. I am willing to let the Great Spirit help me correct my weaknesses.

7. I pray daily to the Great Spirit to help me correct my weaknesses.

8. I make an effort to remember all those that I have caused harm to and, with the help of the Great 

Spirit, achieve the strength to try to make amends.

9. I do make amends to all those Indian brothers and sisters that I have caused harm to whenever 

possible through the guidance of the Great Spirit.

10. I do admit when I have done wrong to myself, those around me, and the Great Spirit.

11. I seek through purification, prayer, and meditation to communicate with the Great Spirit as a 

child to a father in the Indian way.

12. Having addressed those steps, I carry this brotherhood and steps to sobriety to all my Indian 

brothers and sisters with alcohol problems and together we share all these principles in all our 

daily lives.

Source: CSAT 1999b, p. 56. Reprinted from material in the public domain.

147
Improving Cultural Competence

There are a number of potential pitfalls 

that can occur when trying to integrate 

Native spiritual and cultural practices into 

treatment. Cultural groups are complex 

systems; removing pieces of them for 

implementation as part of a treatment 

program can be a disservice to the culture 

as well as the clients (Kunitz et al. 1994; 

Moss et al. 2003); a breach of customs 

and traditions; and a sign of disrespect for 

the community and Tribe, Tribal leadership, and Native American practices. It 

is important to take the time to build 

relationships and seek consultation with 

Tribal elders, and other Tribal leaders to 

ensure that the best and most appropriate 

steps are taken in creating a culturally 

relevant and responsive treatment 

model and program. 

traditionally view all things as deeply interconnected. Disruption of the physical, mental, 

spiritual, or emotional sides of a person can 

result in illness. A Native American client may

consult a medical doctor to address part of the 

problem and a traditional healer to help regain

balance and harmony.

The use of traditional healing for substance 

abuse and mental health problems is fairly 

common among Native Americans (HermanStahl and Chong 2002; Herman-Stahl et al. 

2003). For example, among Native American 

individuals who reported a substance use 

disorder in the past year, 57.4 percent of those 

from a Southwest Tribe and 31.7 percent from 

a Northern Plains Tribe used traditional healers or healing practices (Beals et al. 2006). In a 

survey of American Indians from three different Arizona Tribes, 27.4 percent stated that 

they had used traditional healers and/or healing practices to help with mental health problems (Herman-Stahl and Chong 2002). 

Overall, many Native Americans believe that 

culture is the primary avenue of healing and 

that connecting with one’s culture is not only a 

means of prevention, but also a healing treatment (Bassett et al. 2012) 

Each Native American culture has its own 

specific healing practices, and not all of those 

practices are necessarily appropriate to adapt 

to behavioral health treatment settings. However, many traditional healing activities and 

ceremonies have been made accessible during 

treatment or effectively integrated into treatment settings (Castro et al. 1999b; Coyhis 

2000; Coyhis and White 2006; Mail and 

Shelton 2002; Sue 2001; White 2000). These 

practices include sacred dances (such as the 

Plains Indians’ sun dance and the Kiowa’s 

gourd dance), the four circles (a model for 

conceptualizing a harmonious life), the talking 

circle, sweat lodges, and other purification 

practices (Cohen 2003; Mail and Shelton 

2002; White 2000). The sweat lodge, in particular, is frequently used in substance abuse 

treatment settings (Bezdek and Spicer 2006; 

Schiff and Moore 2006). 

Alaskan behavioral health programs have 

developed recovery camps to provide a treatment setting that incorporates Native beliefs 

and seasonal practices (e.g., Old Minto Family 

Recovery Camp:

http://www.tananachiefs.org/ healthservices/old-minto-family-recovery-campnew/). Recovery camps are based on the model of traditional Native Alaskan fishing camps

and provide a context in which clients can 

learn about traditional practices, such as sustenance activities. Another program, the Village 

Sobriety Project, incorporates traditional 

Yup’ik and Cup’ik Eskimo traditions of hunting, chopping wood, berry picking, and taking 

tundra walks (Mills 2003). See Niven (2010) 

for a review of client-centered, culturally 

responsive behavioral health techniques for 

use with Alaska Natives. 

It is difficult to measure the effectiveness of

Native American healing practices using 

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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Western standards and practices. Limited or 

inconsistent funding, migration patterns, 

culturally incompetent or incongruent evaluation practices, and abuses incurred during or 

after data collection are major confounding 

variables that have limited knowledge on the 

effectiveness of incorporating traditional 

practices into Western approaches to the 

treatment of substance abuse and mental 

illness. Nonetheless, Mail and Shelton (2002) 

reviewed earlier literature on the use of “indigenous therapeutic interventions”for alcohol 

abuse and dependence and suggest that a 

number of these interventions have been of 

value to Native Americans with substance use 

disorders. Other authors have concurred 

(Coyhis and White 2006; Sabin et al. 2004).

Regardless of whether a program adapts specific Native American healing practices, providers working with this population should 

recognize that spirituality is central to its 

values and is perceived as an integral part of 

life itself. It is through spiritual experiences 

that Native Americans believe they will find 

meaning in life. Some Native languages have 

words that refer to spirituality as “walking 

around” or “living the path.”In many cases, the 

spiritual traditions of Native Americans are 

not (and have never been) conceived of as a 

religion, but rather as a set of beliefs and 

practices that pervades every aspect of daily 

life (Deloria 1973). 

Despite religion and spirituality often playing 

important roles in recovery from mental and 

substance use disorders for Native Americans, 

providers should not assume that only indigenous spirituality is relevant. The majority of 

Native Americans do not practice their traditional spirituality exclusively, and Christian 

religious institutions like the Native American 

Church and Pentecostal churches have been 

instrumental in helping many Native Americans overcome substance use disorders 

(Garrity 2000). In 2001, roughly 20 percent of 

American Indians identified as Baptist, 17 

percent as Catholic, 17 percent as having no 

religious preference, and 3 percent as following 

a Tribal religion (Kosmin et al. 2001). 

The relative importance of religion can also 

vary among diverse Native American communities. Before pursuing traditional methods, 

assessment of clients’spiritual orientation is 

important. Spirituality is a personal issue that 

treatment providers must respect; clients 

should choose which spiritual and cultural 

methods to incorporate into treatment. Providers should also be wary of an obsession 

with their clients’ cultural activities, which may

be considered intrusive (LaFromboise et al. 

1993). Checking with community resources 

on the subject and asking the client “What 

feels right for you?” are appropriate steps to 

take in identifying whether traditional healing 

practices will have therapeutic value. Providers 

should consult with Native healers or Tribal 

leaders about the appropriateness of using a 

particular practice as part of behavioral health 

services. Rather than using traditional healing 

methods themselves, counselors may wish to 

refer clients to a Native American healer in 

the community or in the treatment program. 

Relapse prevention and recovery 

Despite limited data on long-term recovery 

for Native Americans who have substance use 

disorders, a few studies have found high rates 

of relapse following substance abuse treatment 

(see review in Chong and Herman-Stahl 

2003). White and Sanders (2004) recommend 

that long-term recovery plans for Native 

Americans make use of a recovery management rather than a traditional continuing care 

approach. Such an approach emphasizes the 

use of informal recovery communities and 

traditional healing approaches to provide 

extended monitoring and support for Native 

Americans leaving treatment.

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Improving Cultural Competence

Researchers have conducted interviews with 

both American Indians (Bezdek and Spicer 

2006) and Alaska Natives (Hazel and Mohatt 

2001; Mohatt et al. 2008; People Awakening 

Project 2004) who have achieved extended 

periods of recovery. Bezdek and Spicer (2006) 

identified two key tasks for American Indians 

entering recovery. First, they need to learn how 

to respond to family and friends who drank 

with them and to those who supported their 

recovery. Next, they have to find new ways to 

deal with boredom and negative feelings. By 

accomplishing these tasks, Native clients can

build new social support systems, develop 

effective coping strategies for negative feelings, 

and achieve long-term recovery. The People 

Awakening Project found that, among Alaska 

Natives who had a substantial period of recovery, the development of active, culturally appropriate coping strategies was essential (e.g., 

distancing themselves from friends or family 

who drank heavily, getting involved in church, 

doing community service, praying; Hazel and 

Mohatt 2001; Mohatt et al. 2008; People 

Awakening Project 2004).

Counseling for White 

Americans

According to the 2010 U.S. Census definition, 

White Americans are people whose ancestors

are among those ethnic groups believed to be 

the original peoples of Europe, the Middle 

East, or North Africa (Humes et al. 2011). 

The racial category of White Americans 

includes people of various ethnicities, such as 

Arab Americans, Italian Americans, Polish 

Americans, and Anglo Americans (i.e., people 

with origins in England), among others. Many 

Latinos will also identify racially (if not ethnically) as White American. Non-Latino White 

Americans constitute the largest racial group 

in the United States (making up 63.7 percent 

of the population in the 2010 Census; Mather

et al. 2011). 

White Americans, like other large ethnic and 

cultural groups, are extremely heterogeneous 

in historical, social, economic, and personal 

features, with many (often subtle) distinctions 

among subgroups. Perhaps because White 

Americans have been the majority in the 

United States, it is sometimes forgotten how 

historically important certain distinctions 

between diverse White American ethnic 

heritages have been (and continue to be, for 

some). Conversely, many White American 

people prefer not to see themselves as such

and instead identify according to their specific 

ethnic background (e.g., as Irish American). 

For similar reasons, certain cross-cutting 

cultural issues (see Chapter 1) like geographic 

location, sexual orientation, and religious 

affiliation are important in defining the cultural orientations of many White Americans.

Beliefs About and Traditions 

Involving Substance Use 

Historically, use of alcohol was accepted 

among White/European cultural groups 

because it provided an easy way to preserve 

fruit and grains and did not contain bacteria 

that might be found in water. Over time, the 

production and consumption of alcohol became an often-integral part of cultural activities, which can be seen in the way some White 

cultural groups take particular pride in national brands of alcoholic beverages (e.g., Scotch 

whisky, French wine; Abbott 2001; Hudak 

2000). A number of European cultural groups 

(e.g., French, Italian) traditionally believed 

that daily alcohol use was healthy for both 

mind and body (Abbott 2001; Marinangeli 

2001), and for others (e.g., English, Irish), the 

bar or pub was the traditional center of community life (O’Dwyer 2001). Despite some 

variations in cultural attitudes toward appropriate drinking practices, alcohol has been and 

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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

remains the primary recreational substance for 

Whites in the United States. Predominant

attitudes toward drinking in the United States

more closely reflect those of Northern Europe; 

alcohol use is generally accepted during celebrations and recreational events, and, at such 

times, excessive consumption is more likely to 

be acceptable. 

Typically, White European cultural groups 

accept alcohol use as long as it does not interfere with responsibilities, such as work or 

family, or result in public drunkenness (Hamid 

1998). However, among certain groups of 

White Americans (usually defined by religious 

beliefs), the use of alcohol or any other intoxicant is considered immoral (van Wormer 

2001). These religious beliefs, combined with 

concerns about the effects of problematic

drinking patterns (especially among men in 

the frontier; White 1998), became the impetus 

for the early 19th-century creation of the 

Temperance Movement and culminated in the 

passing of the 18th Amendment to the United 

States Constitution, which enacted Prohibition. 

Although the Temperance Movement is no 

longer a major political force, belief in the 

moral and social value of abstinence continues 

to be strong among some segments of the 

White American population.

Illicit drug use, on the other hand, has historically been demonized by White American 

cultural groups and seen as an activity engaged 

in by people of color or undesirable subcultures (Bonnie and Whitebread 1970; Hamid 

1998; Whitebread 1995). For example, White 

Americans typically link drug use to perceived threat of crime—particularly crimes 

perpetrated by people of color (Hamid 1998; 

Whitebread 1995). Attitudes have changed 

over time, but White American cultural 

groups continue to enforce strong cultural 

prohibitions against most types of illicit drug 

use. At the same time, White Americans are 

often more accepting of prescription medication abuse and less likely to perceive prescription medications as potentially harmful 

(Hadjicostandi and Cheurprakobkit 2002).

Despite illicit drug use now being as common 

among White Americans as people of color, 

White Americans still tend to perceive drug 

use as an activity that occurs outside their 

families and communities. In a 2001 survey, 

only 54 percent of White Americans expressed concern that someone in their family 

might develop a drug abuse problem compared 

with 81 percent of African Americans (Pew 

Research Center for the People and the Press 

2001). In the same survey, White Americans

expressed less concern about drug abuse in 

their neighborhoods than did other racial and 

ethnic groups. However, in terms of seeing 

drugs as a national problem, White Americans 

and other racial and ethnic groups are in closer 

agreement. Perhaps as a result of this misperception about the prevalence of drug use in 

their homes and communities, White 

American parents are less likely to convey 

disapproval of drug use to their children than 

African American parents (National Center 

on Addiction and Substance Abuse 2005) and 

much more likely than Latino or African 

American parents to think that their children 

have enough information about drugs (Pew 

Research Center for the People and the Press 

2001).

There are also differences in how White Americans, Latinos, and African Americans perceive 

drug and alcohol addictions. White Americans 

are less likely than African Americans, but 

more likely than Latinos, to state that they 

believe a person can recover fully from addiction (Office of Communications 2008). However, White Americans are more likely than 

African Americans to indicate that substance 

use disorders should be treated as diseases

(Durant 2005).

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Improving Cultural Competence

Substance Use and Substance Use 

Disorders

According to 2012 NSDUH data, rates of 

past-year substance use disorders were higher 

for White Americans than for Native 

Hawaiians, other Pacific Islanders, and Asian 

Americans; rates of current alcohol use were 

higher than for every other major ethnic/racial 

group (SAMHSA 2013d). Alcohol has traditionally been the drug of choice among White 

Americans of European descent; however, not 

all European cultural groups have the same 

drinking patterns. Researchers typically contrast a Northern/Eastern European pattern, in 

which alcohol is consumed mostly on weekends or during celebrations, with that of 

Southern Europe, in which alcohol is consumed daily or almost daily but in smaller 

quantities and almost always with food. The 

Southern European pattern involves more 

regular use of alcohol, but it is also associated 

with less alcohol-related harm overall (after 

controlling for total consumption; Room et al. 

2003). The pattern of White Americans typically follows that of Northern and Eastern 

Europe, but individuals from some ethnic 

groups maintain the Southern European 

pattern.

White Americans, on average, begin drinking 

and develop alcohol use disorders at a younger 

age than African Americans and Latinos 

(Reardon and Buka 2002). White Americans 

are more likely to have their first drink before 

the age of 21 and to have their first drink 

before the age of 16 than members of any 

other major racial/ethnic group except Native 

Americans (SAMHSA 2011c). Some data 

suggest that White Americans begin using 

illicit drugs at an earlier age than African 

Americans (Watt 2008) and that the mean age 

for White Americans who inject heroin has 

decreased (Broz and Ouellet 2008).

White Americans who use heroin are less likely 

than people who use heroin from all other

major racial/ethnic groups except African

Americans to have injected the drug 

(SAMHSA 2011c). White Americans are also 

more likely than members of other major 

racial/ethnic groups, except Native Hawaiians 

and other Pacific Islanders (for whom estimates may not be accurate), to have tried 

ecstasy. Except for Native Americans (some of 

whom may use the hallucinogen peyote for 

religious purposes), they are also more likely 

than other racial/ethnic groups to have tried

hallucinogens (SAMHSA 2011c). Research 

confirms that prescription drug misuse is 

more common among White Americans than 

African Americans or Latinos (Ford and 

Arrastia 2008; SAMHSA 2011c), and they are 

more likely to have used prescription opioids 

in the past year and to use them on a regular 

basis. 

Comparative studies indicate that White 

Americans are more likely than all other major 

racial/ethnic groups except Native Americans 

to have an alcohol use disorder (Hasin et al. 

2007; Perron et al. 2009; Schmidt et al. 2007). 

White Americans are at a greater risk of having 

severe alcohol withdrawal symptoms (such as 

delirium tremens) than are African Americans 

or Latinos with alcohol use disorders (Chan et 

al. 2009). So too, White Americans are more 

likely than African Americans or Latinos to 

meet diagnostic criteria for a drug use disorder 

at some point during their lives (Perron et al. 

2009). Overall, substance use disorders vary 

considerably across and within non-European 

White American cultural groups. For example, 

rates of substance abuse treatment admissions 

in Michigan from 2005 suggest that substance 

use disorders may be considerably lower for 

Arab Americans than other White Americans 

(Arfken et al. 2007).

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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Mental and Co-Occurring 

Disorders 

About 20 percent of White Americans reported some form of mental illness in the past year, 

and they were more likely to have past-year 

serious psychological distress than other population groups excluding Native Americans 

(SAMHSA 2012a). 

White Americans appear to be more likely 

than Latinos or Asian Americans to have 

CODs (Alegria et al. 2008a; Vega et al. 2009) 

and more likely to have concurrent serious 

psychological distress and substance use disorders (SAMHSA 2011c). White Americans 

with CODs are also more likely to receive 

treatment for both their substance use and 

mental disorders than are African Americans 

with CODs (Alvidrez and Havassy 2005; 

Hatzenbuehler et al. 2008), but they are perhaps less likely to receive treatment for their 

substance use disorder alone (Alvidrez and 

Havassy 2005). White Americans are more 

likely to receive family counseling and mental 

health services while in substance abuse treatment and less likely to have unmet treatment 

needs (Marsh et al. 2009; Wells et al. 2001). In 

addition, White Americans are significantly 

less likely than Latinos or African Americans 

to believe that antidepressants are addictive 

(Cooper et al. 2003).

The most common mental disorders among 

White Americans are mood disorders (particularly major depression and bipolar I disorder) and anxiety disorders (specifically 

phobias, including social phobia, and generalized anxiety disorder; Grant et al. 2004b). 

Among White Americans, these disorders are 

more prevalent than in any other ethnic/racial 

groups save Native Americans (Grant et al. 

2005; Hasin et al. 2005). For example, rates of a 

lifetime diagnosis of generalized anxiety disorder are about 40 percent lower for African 

Americans and Latinos than for White 

Americans and about 60 percent lower for 

Asian Americans (Grant et al. 2005). A similar pattern exists for major depressive disorder 

(Hasin et al. 2005). 

Treatment Patterns

White Americans are more likely to receive 

mental health treatment or counseling than

other racial/ethnic groups (SAMHSA 2012b). 

White Americans are more likely than African

Americans to receive substance abuse treatment services from a private physician or 

other behavioral health or primary care professional (Perron et al. 2009). Among White 

American clients entering substance abuse 

treatment programs in 2010, alcohol (alone or 

in conjunction with illicit drugs) was most 

often the primary substance of abuse, followed 

by heroin and cannabis. However, findings are 

inconsistent concerning the relative frequency 

with which White Americans enter substance 

abuse treatment. Some studies have found that 

White Americans are more likely to receive 

needed behavioral health services than both 

African Americans and Latinos (Marsh et al. 

2009; Wells et al. 2001). In contrast, other 

studies have found that African Americans 

with an identified need are somewhat more 

likely to enter treatment for drug use disorders 

and about as likely to receive treatment for 

alcohol use disorders when compared with 

White Americans (Hatzenbuehler et al. 2008; 

Perron et al. 2009; SAMHSA, CBHSQ 2012; 

Schmidt et al. 2006). 

Beliefs and Attitudes About 

Treatment

White Americans appear to be generally 

accepting of behavioral health services. They 

have better access to health care and are more 

likely to use services than people of color, but

this varies widely based on socioeconomic 

status and cultural affiliation. Most treatment 

services have historically been developed for 

153
Improving Cultural Competence

White American populations, so it is not 

surprising that White Americans are more 

likely than other racial/ethnic groups to be 

satisfied with treatment services (Tonigan 

2003). 

Still, attitudes differ among certain cultural 

subgroups of White Americans. For example, 

Russian immigrants from the former Soviet 

Union have a longstanding distrust of mental 

health systems and hence may avoid substance 

abuse treatment (Kagan and Shafer 2001). 

Other groups who have a strong family orientation, such as Italian Americans or ScotchIrish Americans, might avoid treatment that 

asks them to reveal family secrets (Giordano 

and McGoldrick 2005; Hudak 2000). 

According to 2010 NSDUH data regarding 

people who recognized a need for substance 

abuse treatment in the prior year but did not 

receive it, White Americans were more likely 

than members of other major racial/ethnic 

groups to state that it was because they had no 

time for treatment, that they were concerned 

what their neighbors might think, that they 

did not want others to know, and/or that they 

were concerned about how it might affect 

their jobs (SAMHSA 2011c). Other research 

confirms that White Americans are significantly more likely to avoid treatment due to fear of 

what others might think or because they are in 

denial (Grant 1997). White Americans may 

also have different attitudes toward recovery, at 

least regarding alcohol use disorders, than do 

members of other ethnic/racial groups. According to NESARC data on people who 

met criteria for a diagnosis of alcohol dependence at some point during their lives, 

White Americans were more likely than 

African Americans, Latinos, or other nonLatinos to have achieved remission from that 

disorder but were also less likely than African 

Americans or other non-Latinos (but not 

Latinos) to currently abstain from drinking, as 

opposed to being in partial remission or drinking without symptoms of alcohol dependence 

(Dawson et al. 2005).

Treatment Issues and 

Considerations

Most major treatment interventions have been 

evaluated with a population that is largely or 

entirely White American, although the role of 

White American cultural groups is rarely 

considered in evaluating those interventions. 

For example, as Straussner (2001) notes, “the 

paradox of writing about substance abusers of 

European background is that they are a group 

that is believed to be the group for whom the 

traditional alcohol and other drug treatment 

models have been developed, and yet they are 

a group whose unique treatment needs and 

treatment approaches have rarely been explored”(p. 165). Very few evaluations of 

treatment strategies and interventions (whether based on research or clinical observation) 

have taken into account ethnic and cultural 

differences among White American clients, 

and therefore it is generally not possible to 

make culturally responsive recommendations 

for specific subgroups of White Americans.

Culturally responsive treatment for many 

White Americans will involve helping them 

rediscover their cultural backgrounds, which 

sometimes have been lost through acculturation 

and can be an important part of their longterm recovery. Giordano and McGoldrick

(2005) note that ethnic identity and culture 

can be more important for some White 

Americans “in times of stress or personal 

crisis,”when they may want to “return to 

familiar sources of comfort and help, which 

may differ from the dominant society’s norms”

(p. 503). Appendix B provides information on 

instruments for assessing cultural identification. For an overview of challenges in maintaining mental health, access to health care, 

154
Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

and help-seeking among White Americans, 

see Downey and D’Andrea (2012).

Theoretical Approaches and 

Treatment Interventions

Overall, the optimum treatment approach 

with White Americans is a comprehensive 

one; the more tools in the toolkit, the greater 

the chance of success (McCaul et al. 2001). 

Within-group differences arise regarding

education level, socioeconomic status, gender, 

and other factors, which must be considered. 

Providers can, however, assume that most 

well-accepted treatment approaches and interventions (e.g., CBT, motivational interviewing, 

12-Step facilitation, contingency management, 

pharmacotherapies) have been tested and 

evaluated with White American clients.

Still, treatment is not uniformly appropriate 

even for White Americans. Approaches may 

need modification to suit class, ethnic, religious, and other client traits. Providers should 

establish not only the client’s ethnic background, but also how strongly the person 

identifies with that background. Few clinicians 

have made observations on best therapeutic 

approaches for members of particular White 

American cultural/ethnic subgroups. 

Family therapy

In White American families, individuals are 

generally expected to be independent and selfreliant; as a result, families in therapy can have 

trouble adjusting to work that focuses more on 

communication processes than specific problems or content (McGill and Pearce 2005). 

Van Wormer (2001) notes that many White 

Americans need help addressing communication issues. In family therapy, useful approaches include those that encourage open, direct, 

and nonthreatening communication. 

There is no singular description that fits

White American families within or across 

ethnic heritages, and there is no approach that 

is effective for all White Americans in family 

therapy (Hanson 2011). Hierarchical families, 

such as German American families, may 

expect the counselor to be authoritative, at 

least in the initial sessions (Winawer and 

Wetzel 2005), although a more egalitarian 

German American family might not respond 

well to such imperatives. In the same vein, one 

client of French background could readily 

accept direct and clear therapeutic assignments that contain measurable goals (Abbot 

2001), whereas another French American

client may value counseling that is more process oriented. Thus, it is imperative to assess 

the cultural identification of clients and their 

families, along with the treatment needs that 

best match their cultural worldviews. 

In some White American families, there is a 

longstanding culture of drinking. Attempts at 

abstinence can be perceived by family members as culturally inappropriate. In other families, there is deep denial about alcohol abuse or 

dependence, especially when talking about 

substance use to those outside the family. For 

example, some Polish American families can 

be resistant to the idea that drinking is the 

cause of family problems (Folwarski and 

Smolinski 2005) and sometimes believe that 

to admit an alcohol problem, especially to 

someone outside the family, signals weakness.

Group therapy

Standard group therapies developed for mental health and substance abuse treatment 

programs have generally been used and evaluated with White American populations. For 

details on group therapy in substance abuse 

treatment, see TIP 41, Substance Abuse Treatment: Group Therapy (CSAT 2005c).

Mutual-help groups

Mutual-help groups, of which AA is the most 

prevalent, have a largely White American 

155
Improving Cultural Competence

membership (AAWS 2008; Atkins and 

Hawdon 2007). In a 2011 survey, 87 percent 

of AA members indicated their race as White 

(AAWS 2012). In research with largely White 

populations, AA participation has been found 

to be an effective strategy for promoting 

recovery from alcohol use disorders (Dawson 

et al. 2006; McCrady et al. 2004; Moos and 

Moos 2006; Ritsher et al. 2002; Weisner et al. 

2003). Other mutual-help groups, such as 

Self-Management and Recovery Training, 

Secular Organizations for Sobriety/Save Our 

Selves, and Women for Sobriety, also have 

predominately White American membership 

and are based on Western ideas drawn from 

psychology (Atkins and Hawdon 2007; White 

1998).

The appeal of mutual-help groups among 

White Americans rests on the historical origins of this model. The 12-Step model was 

originally developed by White Americans 

based on European ideas of spirituality, faith, 

and group interaction. Although the model 

has been adopted worldwide by different 

cultural groups (White 1998), the 12-Step 

model works especially well for White ethnic 

groups, including Irish Americans, Polish 

Americans, French Americans, and ScotchIrish Americans, because it incorporates 

Western cultural traditions involving spiritual 

practice, public confession, and the use of 

anonymity to protect against humiliation 

(Abbott 2001; Gilbert and Langrod 2001; 

Hudak 2000; McGoldrick et al. 2005; Taggart 

2005). 

In addition to mutual-help groups for substance abuse, numerous recovery support 

groups, Internet resources, Web-based communities, and peer support programs are 

available to promote mental health recovery. 

Many resources are available through the 

National Alliance on Mental Illness

(http://www.nami.org).

Traditional healing and 

complementary methods

Only 12 percent of White Americans consider 

themselves atheist, agnostic, or secular without 

a religious affiliation, meaning that, as a group, 

White Americans are more religious than 

Asian Americans but less so than Latinos or 

African Americans (Pew Forum on Religion 

and Public Life 2008). As with other groups, 

White Americans belong to many different 

religions, although the vast majority belong to 

various Christian denominations, with approximately 57 percent identifying as Protestant 

and 25.9 percent as Catholic (National Center 

on Addiction and Substance Abuse, 2001). 

White Americans also make up 91 percent of 

practitioners of Judaism in the United States, 

14 percent of followers of Islam, and 32 percent of the American Buddhist population 

(Kosmin et al. 2001). For more religious 

White Americans, pastoral counseling or 

prayer can be useful aids in the treatment of 

substance use disorders. However, White 

Americans are significantly less likely to use 

prayer as a method of coping (Graham et al. 

2005). White Americans are more likely than 

members of other major racial/ethnic groups 

to use complementary or alternative medical 

therapies, such as herbal medicine, acupuncture, chiropractors, massage therapy, yoga, and 

special diets (Graham et al. 2005). 

Relapse prevention and recovery 

Factors that promote recovery for White 

Americans include the learning and use of 

coping skills (Litt et al. 2003; Litt et al. 2005; 

Maisto et al. 2006). Even though some research

suggests that White Americans are less likely 

to use coping skills than African Americans 

(Walton 2001) and have lower levels of selfefficacy upon leaving treatment (Warren et al. 

2007), the development of these skills and of 

self-efficacy is important in managing relapse 

risks and in maintaining recovery. Counselors 

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Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

may offer psychoeducation on the value of 

coping strategies, specific skills to manage 

stressful situations or environments, and opportunities to practice these skills during 

treatment. Some coping skills or strategies 

may be more important than others in managing high-risk situations, but research suggests 

that greater use of a variety of coping strategies is more important than the use of any one 

specific skill (Gossop et al. 2002).

Social and family supports are also important 

in maintaining recovery and preventing relapse among White Americans (Laudet et al.

2002; McIntosh and McKeganey 2000; 

Rumpf et al. 2002). Other important factors 

include continuing care, the development of 

substitute behaviors (i.e., reliance on healthy 

or positive activities in lieu of substance use), 

the creation of new caring relationships that 

do not involve substance use, and increased 

spirituality (Valliant 1983). Valliant (1983) 

and others (e.g., Laudet et al. 2002; McCrady 

et al. 2004; Moos and Moos 2006) conclude, 

based on research with mostly White participants, that mutual-help groups often play an 

important role in maintaining recovery. 

TIPs That Provide Supplemental Information on Topics in This Chapter

TIP 34: Brief Interventions and Brief Therapies for Substance Abuse (CSAT 1999a) 

TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment (CSAT 1999c) 

TIP 39: Substance Abuse Treatment and Family Therapy (CSAT 2004b) 

TIP 41: Substance Abuse Treatment: Group Therapy (CSAT 2005c) 

TIP 42: Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005d) 

TIP 44: Substance Abuse Treatment for Adults in the Criminal Justice System (CSAT 2005b) 

TIP 47: Substance Abuse: Clinical Issues in Intensive Outpatient Treatment (CSAT 2006c) 

TIP 51: Substance Abuse Treatment: Addressing the Specific Needs of Women (CSAT 2009c) 

TIP 57: Trauma-Informed Care in Behavioral Health Services (SAMHSA 2014) 

Planned TIP: Relapse Prevention and Recovery Promotion in Behavioral Health Services (SAMHSA 

planned e) 

157
Drug Cultures and the 

Culture of Recovery

Lisa is a 19-year-old White college student living in San Diego, 

CA, who was sent to treatment by her parents after failing her 

college classes and being placed on academic probation. While 

home on break earlier that year, her parents found pills in her room 

but let her return to school after she promised to stop using. The 

academic probation is only part of the reason her parents sent her 

to treatment. They were also concerned about her recent weight 

loss, as her older sister had previously struggled with bulimia. 

Lisa began using marijuana at age 15 with a cousin. In her first year 

of high school, she had difficulty fitting in. However, the next year, 

she became friendly with an electronic dance music clique that 

helped her define an identity for herself and introduced her to ecstasy (3,4-methylenedioxymethamphetamine, or MDMA), methamphetamine, and various hallucinogens, along with new ideas about 

politics, music, and art. She has since found similar friends at college 

and keeps in touch with several members of her high school clique. 

In treatment, Lisa tells her counselor that she has long felt neglected by her parents, who are too interested in material things. She 

sees her drug use and that of her friends as a rebellion against the 

materialistic attitudes of their parents. She also dismisses her family’s cultural heritage, insisting that her parents only identify as 

Americans even though they are first-generation Americans with 

European backgrounds. She talks at length about ways to acquire 

and prepare relatively unknown hallucinogens, the best music to 

listen to while using, and how to evaluate the quality of marijuana.

Lisa says that she doesn’t believe she has a problem. She thinks that 

her failing grades reflect her lack of interest in college, which she 

says she is attending only because people expect it of her. When 

asked what she would rather be doing, she says she does not have 

any clearly defined goals and just wants to do “something with art 

6

 IN THIS CHAPTER

• What Are Drug Cultures?

• The Role of Drug Cultures 

in Substance Abuse 

Treatment

159
Improving Cultural Competence

or music.” Lisa points out that, unlike most of 

her classmates, she doesn’t drink and has 

stopped doing addictive drugs like ecstasy and 

methamphetamine, which were responsible for 

her weight loss. She is convinced that she can 

continue to smoke pot and Salvia divinorum, 

which she notes “isn’t even illegal,” and take 

other botanical hallucinogens. She is adamant 

about keeping her friends, who she says have

been supportive of her and are not materialistic “sellouts” like her parents.

Her counselor places a priority on connecting 

Lisa with other people her age who are in 

recovery. She asks a client who graduated from 

the program and is only a year older than Lisa 

to accompany her to Narcotics Anonymous 

(NA) meetings attended mostly by younger 

people in recovery. The counselor also encourages Lisa’s friendships with other young people in the program. When Lisa complains 

about her parents’ materialism and the materialism of mainstream culture, her counselor 

brings up the spiritual elements of mutualhelp recovery groups and how they provide an 

Multidimensional Model for Developing Cultural Competence: Drug Cultures

This Treatment Improvement Protocol 

(TIP) emphasizes the concept that many 

subcultures exist within and across diverse 

ethnic and racial populations and cultures. 

Drug cultures are a formidable example—

these are cultures that can influence the 

presentation of mental, substance use, 

and co-occurring disorders as well as 

prevention and treatment strategies 

and outcomes.

160
Chapter 6—Drug Cultures and the Culture of Recovery

alternative model for interacting with others. 

The counselor begins to help Lisa explore how 

her drug use may be an attempt to fill her 

unmet emotional and social needs and may 

hinder the development of her own interests, 

identity, and goals. 

Treatment providers should consider how 

cultural aspects of substance use reinforce 

substance use, substance use disorders, and 

relapses. Factors to note include clients’ possible self-medication of psychological distress or 

mental disorders. Beyond specific biopsychosocial issues that contribute to the risk of 

substance-related disorders and the initiation 

and progression of use, counselors and treatment organizations must continually acquire 

knowledge about the ever-changing, diverse 

drug cultures in which client populations may 

participate and which reinforce the use of 

drugs and alcohol. Moreover, behavioral health 

service providers and program administrators 

need to translate this knowledge into clinical 

and administrative practices that address and 

counter the influence of these cultures within 

the treatment environment (e.g., by instituting 

policies that ban styles of dress that indicate 

affiliation with a particular drug culture). 

Adopting Sue’s multidimensional model (2001) 

for developing cultural competence, this chapter identifies drug cultures as a domain that 

requires proficiency in clinical skills, programmatic development, and administrative practices. It explores the concept of drug cultures, the 

relationship between drug cultures and mainstream culture, the values and rituals of drug 

cultures, and how and why people value their 

participation in drug cultures. This chapter 

describes how counselors can determine a 

client’s level of involvement in a drug culture, 

how they can help clients identify and develop 

alternatives to the drug cultures in which they 

participate, and the importance of assisting 

clients in developing a culture of recovery. 

What Are Drug Cultures?

Up to this point, this TIP has focused on 

cultures based on ethnicity, race, language, and 

national origin. The TIP looks primarily at 

those cultural groups because they are the 

major cultural forces that shape an individual’s 

life and worldview. However, there are other 

types of cultural groups (sometimes referred to 

as subcultures) that are also organized around 

shared values, beliefs, customs, and traditions; 

these cultural groups can have, as their core 

organizing theme, such factors as sexuality, 

musical styles, political ideologies, and so on. 

For most clients in treatment for substance use 

disorders (including those who have a cooccurring mental disorder), the drug subculture will likely have affected their substance 

use and can affect their recovery; that is the 

primary rationale for the development of this 

unique chapter. Research literature in this 

topic area is considerably limited. 

Some people question whether a given drug 

culture is in fact a subculture, but many seem 

to have all the elements ascribed to a culture 

(see Chapter 1). A drug culture has its own 

history (pertaining to drug use) that is usually 

orally transmitted. It has certain shared values, 

beliefs, customs, and traditions, and it has its 

own rituals and behaviors that evolve over 

time. Members of a drug culture often share 

similar ways of dressing, socialization patterns, 

language, and style of communication. Some 

even develop a social hierarchy that gives 

different status to different members of the 

culture based on their roles within that culture 

( Jenkot 2008). As with other cultures, drug 

cultures are localized to some extent. For example, people who use methamphetamines in 

Hawaii and Missouri could share certain attitudes, but they will also exhibit regional differences. The text boxes in this chapter offer 

examples of the distinct values, languages, 

161
Improving Cultural Competence

rituals, and types of artistic expression associated with particular drug cultures.

Many subcultures exist outside mainstream 

society and thus are prone to fragmentation. A 

single subculture can split into three or four 

related subcultures over time. This is especially 

true of drug cultures, in which people use 

different substances, are from different locales, 

or have different socioeconomic statuses; they

may also have very different cultural attitudes 

related to the use of substances. Bourgois and 

Schonberg (2007) described how ethnic and 

racial differences can affect the drug cultures 

of users of the same drugs to the point that 

even such things as injection practices can 

differ between Black and White heroin users 

in the same city. Exhibit 6-1 lists of some of 

the ways in which drug cultures can differ 

from one another.

Differences in the physiological and psychological effects of drugs account for some differences among drug cultures. For example, 

the drug culture of people who use heroin is 

typically less frenetic than the drug culture 

involving methamphetamine use. However, 

other differences seem to be more clearly 

related to the historical development of the 

culture itself or to the effects of larger social 

forces. Cultural and socioeconomic components contributed to the rise in methamphetamine use among gay men on the West Coast 

(Reback 1997) and among Whites of lower 

socioeconomic status in rural Missouri 

(Topolski and Anderson-Harper 2004). However, in these two cases, the details of those 

change factors are quite different. In Missouri, 

the low cost and easy production of the drug 

influenced development of a methamphetamine drug culture. Missouri leads the nation 

in the number of methamphetamine labs seized 

by police; a disproportionately large number of 

seizures occur in rural areas (Carbone-Lopez et 

al. 2012; Topolski and Anderson-Harper 

2004). The popularity of the drug among 

How To Identify Key Characteristics of a Drug Culture 

Counselors and clinical supervisors must acquire knowledge about drug cultures represented within 

the client population. Drug cultures can change rapidly and vary across racial and ethnic groups, 

geographic areas, socioeconomic levels, and generations, so staying informed is challenging. Besides 

needing an understanding of current drug cultures (to help prevent infiltration of related behaviors 

and attitudes within the treatment environment), counselors also need to help clients understand how 

such cultures support use and pose dynamic relapse risks. 

(Continued on the next page.)

Exhibit 6-1: How Drug Cultures Differ

• There is overlap among members, but drug 

cultures differ based on substance used—

even among people from similar ethnic and 

socioeconomic backgrounds. The drug culture of heroin use (McCoy et al. 2005; 

Pierce 1999; Spunt 2003) differs from the 

drug culture of ecstasy use (Reynolds 1998).

• Drug cultures differ according to geographic area; people who use heroin in the 

Northeast United States are more likely to 

inhale than inject the drug, whereas the 

opposite is true among people in the 

Western United States who use heroin 

(Office of Applied Studies [OAS] 2004).

• Drug cultures can differ according to other 

social factors, such as socioeconomic status. 

The drug culture of young, affluent people 

who use heroin can occasionally mirror the 

drug culture of the street user, but it will also have notable differences (McCoy et al. 

2005; Pierce 1999; Spunt 2003). 

• Drug cultures (even involving the same 

drugs and the same locales) change over 

time; older people from New York who use 

heroin and who entered the drug culture in 

the 1950s or 1960s feel marginalized within 

the current drug scene, which they see as 

promoting a different set of values 

(Anderson and Levy 2003).

162
Chapter 6—Drug Cultures and the Culture of Recovery

How To Identify and Discuss Key Characteristics of a Drug Culture (continued)

Counselors can use this exercise to begin to educate clients about the influence of drug cultures and 

help them identify the specific behaviors, values, and attitudes that constitute their experience of using 

alcohol and drugs. It can be a helpful tool in improving clients’ understanding of the reinforcing aspects of alcohol and drug use beyond physiological effects. In addition, this exercise can be used as a 

training tool in clinical supervision to help counselors understand the influence and potential reinforcing qualities of a drug culture among clients and within the treatment milieu. 

Materials needed: Diagram handout and pencils.

Instructions:

• Determine whether this exercise is more appropriate as an individual or group exercise. Assess 

the newness and variability of recovery within the group constellation. If several group members 

support recovery-related behavior, conducting this exercise may be a beneficial educational tool 

and means of intervention with clients who continue to identify mainly with their drug culture. 

Conversely, if most group members are new or have had difficulty accepting treatment or 

treatment guidelines, this exercise may be more aptly used as an individual tool. 

• Attention: In group settings, strict parameters need to be established at the beginning of the 

session to ensure that the discussion remains centered on attitudes, values, and behaviors surrounding drug and alcohol use—not on specific techniques or procedures for using drugs or rituals surrounding intake or injection.

• Start the discussion by first presenting the idea that drug cultures exist—describing the main 

elements that constitute culture (refer to Chapter 1 or the categories identified in the “Drug 

Culture” diagram below). Next, provide examples of how drug culture can support continued

use and relapse. Keep in mind that not all clients are engaged in a drug culture. 

• Following the general introduction, review each block in the diagram and ask clients to provide 

examples related to their own use and involvement with drugs and alcohol. After discussing 

their examples, ask them to identify the most significant behaviors, attitudes, and values that reinforce their use (e.g., a feeling of acceptance or camaraderie). 

• Counselors can redirect this general discussion to related topics—for example, by identifying 

behaviors, values, and attitudes likely to support recovery or by shifting from discussion to roleplays that will help clients address relapse risks associated with their drug culture and practice 

coping skills (e.g., assertiveness or refusal skills to counter the influence of others once they are 

discharged from the program or to address situations that arise during the course of treatment).

Drug Culture

Establishing Trust and 

Credibility

How do you go about 

establishing credibility?

Socialization

How were you introduced to the 

culture?

Values

What values are upheld or 

devalued in the group?

Status

In what ways can you obtain 

status or be seen as a success?

Rules

Are there spoken and unspoken 

rules or norms?

Gender Roles and 

Relationships

What gender expectations 

exist surrounding drug use?

Concepts of Sanction, 

Punishment, and Conflict 

Mediation

How does the group deal with 

in-group conflicts?

Symbols and Images

Are there symbols that represent 

a particular association with a 

group or substance?

Dress

Are there specific ways to 

dress that show allegiance 

to a specific substance or 

group?

View of Past, Present, 

and Future

Are there specific beliefs about 

the past, present, and/or future?

Language & Communication

Are there special verbal or 

nonverbal ways to communicate 

about substancerelated activities?

Attitudes

What are common attitudes 

toward others (nonusers, 

police, etc.)?

163
Improving Cultural Competence

Whites could be linked to the historical development of the methamphetamine trade by 

White motorcycle gangs (Morgan and Beck 

1997). On the other hand, most gay men who 

use the drug report having first used it at 

parties with the expectation of involvement in 

sexual activity (Hunt et al. 2006). In studies of 

gay men who used methamphetamine, the 

main reason for use was to heighten sexual 

experience (Halkitis et al. 2005; Kurtz 2005; 

Reback 1997). Morgan and Beck (1997) 

found that increased sexual activity was one 

reason why certain women and heterosexual 

men used methamphetamine, but it was not as 

important a reason as it was for gay men. 

This chapter aims to explain that people who 

use drugs participate in a drug culture, and 

further, that they value this participation. 

However, not all people who abuse substances 

are part of a drug culture. White (1996) draws 

attention to a set of individuals whom he calls 

“acultural addicts.” These people initiate and 

sustain their substance use in relative isolation 

from other people who use drugs. Examples of 

acultural addicts include the medical professional who does not have to use illegal drug 

networks to abuse prescription medication, or 

the older, middle-class individual who “pill 

shops” from multiple doctors and procures 

drugs for misuse from pharmacies. Although 

drug cultures typically play a greater role in 

the lives of people who use illicit drugs, people 

who use legal substances—such as alcohol—

are also likely to participate in such a culture 

(Gordon et al. 2012). Drinking cultures can 

develop among heavy drinkers at a bar or a 

college fraternity or sorority house that works 

to encourage new people to use, supports high 

levels of continued or binge use, reinforces 

denial, and develops rituals and customary 

behaviors surrounding drinking. In this chapter, drug culture refers to cultures that evolve 

from drug and alcohol use. 

The Relationship Between Drug 

Cultures and Mainstream Culture

To some extent, subcultures define themselves 

in opposition to the mainstream culture. Subcultures may reject some, if not all, of the values 

and beliefs of the mainstream culture in favor 

of their own, and they will often adapt some 

elements of that culture in ways quite different 

from those originally intended (Hebdige 1991; 

Issitt 2009; Exhibit 6-2). Individuals often 

identify with subcultures—such as drug cultures—because they feel excluded from or 

Exhibit 6-2: The Language of a Drug Culture 

One of the defining features of any culture is the language it uses; this need not be an entire language, and may simply comprise certain jargon or slang and a particular style of communication. The 

use of slang regarding drugs and drug activity is a well-recognized aspect of drug culture. Not as 

well-known is the diversity of that language and how it varies across time and place. Rather than 

coining new words, the language of drug culture often borrows words from mainstream culture and 

adapts them to new purposes. 

For example, Williams (1992) examined the use of Star Trek terminology among people who used 

crack cocaine in New York during the 1980s. They adopted the persona of members of the Star Trek 

Enterprise crew in their use of language—such as “going on a mission” when they went looking for 

cocaine; “beam me up, Scotty” when they wanted to get high; and referring to crack cocaine itself as 

“Scotty.” Crack cocaine users even created an imaginary book entitled The Book of Tech that they 

referred to as if it contained important information for people who use and sell crack cocaine (e.g., 

how to cook freebase cocaine from cocaine hydrochloride). This language (and other terms derived 

from other sources) helped members of this drug culture recognize other members. People who did 

not understand the terms used were typically taken advantage of during drug transactions.

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Chapter 6—Drug Cultures and the Culture of Recovery

unable to participate in mainstream society. 

The subculture provides an alternative source 

of social support and cultural activities, but 

those activities can run counter to the best 

interests of the individual. Many subcultures 

are neither harmful nor antisocial, but their 

focus is on the substance(s) of abuse, not on 

the people who participate in the culture or

their well-being.

Mainstream culture in the United States has 

historically frowned on most substance use 

and certainly substance abuse (Corrigan et al.

2009; White 1979, 1998). This can extend to 

legal substances such as alcohol or tobacco 

(including, in recent years, the increased prohibition against cigarette smoking in public 

spaces and its growing social unacceptability 

in private spaces). As a result, mainstream 

culture does not—for the most part—have an 

accepted role for most types of substance use, 

unlike many older cultures, which may accept 

use, for example, as part of specific religious 

rituals. Thus, people who experiment with 

drugs in the United States usually do so in 

highly marginalized social settings, which can 

contribute to the development of substance 

use disorders (Wilcox 1998). Individuals who 

are curious about substance use, particularly 

young people, are therefore more likely to 

become involved in a drug culture that encourages excessive use and experimentation 

with other, often stronger, substances (for a 

review of intervention strategies to reduce 

discrimination related to substance use disorders, see Livingston et al. 2012).

When people who abuse substances are marginalized, they tend not to seek access to 

mainstream institutions that typically provide 

sociocultural support (Myers et al. 2009). This 

can result in even stronger bonding with the 

drug culture. A marginalized person’s behavior 

is seen as abnormal even if he or she attempts 

to act differently, thus further reducing the 

chances of any attempt to change behavior 

(Cohen 1992). The drug culture enables its 

members to view substance use disorders as 

normal or even as status symbols. The disorder 

becomes a source of pride, and people may 

celebrate their drug-related identity with other 

members of the culture (Pearson and Bourgois 

1995; White 1996). Social stigma also aids in 

the formation of oppositional values and 

beliefs that can promote unity among members of the drug culture (Exhibit 6-3).

When people with substance use disorders 

experience discrimination, they are likely to 

delay entering treatment and can have less 

positive treatment outcomes (Fortney et al. 

2004; Link et al. 1997; Semple et al. 2005). 

Discrimination can also increase denial and 

step up the individual’s attempts to hide substance use (Mateu-Gelabert et al. 2005). The 

immorality that mainstream society attaches 

to substance use and abuse can unintentionally 

serve to strengthen individuals’ties with the 

drug culture and decrease the likelihood that 

they will seek treatment.

The relationship between the drug and mainstream cultures is not unidirectional. Since the 

beginning of a definable drug culture, that 

culture has had an effect on mainstream cultural institutions, particularly through music 

(Exhibit 6-4), art, and literature. These connections can add significantly to the attraction 

a drug culture holds for some individuals 

(especially the young and those who pride 

themselves on being nonconformists) and 

create a greater risk for substance use escalating to abuse and relapse.

Understanding Why People Are 

Attracted to Drug Cultures

To understand what an individual gains from 

participating in a drug culture, it is important 

first to examine some of the factors involved 

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Improving Cultural Competence

Exhibit 6-3: The Values and Beliefs of a Heroin Culture

Many core values of illicit drug cultures involve rejecting mainstream society and its cultural values. 

Stephens (1991) analyzed value statements from people addicted to heroin and extracted the core 

tenets of this drug culture’s value system. They are:

• Antisocial viewpoint—Members of this drug culture share a viewpoint that sees all people as 

basically dishonest and egocentric; they are especially distrustful of those who do not use heroin.

• Rejection of middle-class values—Members denigrate values such as the need for hard work, 

security, and honesty.

• Excitement/hedonism—Members value immediate gratification and the intense pursuit of pleasure over more stable and lasting values.

• Importance of outward appearances—As much as members of the drug culture may complain 

about the mainstream culture’s shallowness, they strongly believe in conspicuous consumption 

and the importance of owning things that give an image of prosperity.

• Valence of street addict subcultures—Members of this drug culture value the continued participation of others in the culture, even to the point of expecting individuals who have stopped using to continue to participate in the culture.

• Emotional detachment—People involved in this drug culture value emotional aloofness and see 

emotional involvement with others as a weakness.

These core values (initially examined by Stephens et al. 1976) were taken from a specific drug culture 

(heroin), but they can be found in many other drug cultures that center on the use of illicit drugs. 

However, these same values will not be upheld in every drug culture. For instance, the drug culture 

of people who use MDMA does not appear to value emotional aloofness, but rather to appreciate 

the drug’s ability to create a feeling of emotional intimacy among those who use it (Gourley 2004; 

Reynolds 1998). Drug cultures involving legal substances (notably alcohol) are less likely to reject the 

core values of mainstream society and are less likely to be rejected by that society. They will, however, still value excitement/hedonism and the participation of others in the subculture.

Exhibit 6-4: Music and Drug Cultures

Since the 1920s, when marijuana use became associated with jazz musicians, there has been a connection between certain music subcultures and particular types of substance use (Blake 2007; 

Gahlinger 2001). As Blackman (1996) notes, “Before the emergence of post-war youth culture, there 

was a direct connection between the development of the popular music—jazz—and the use of illicit 

drugs in terms of musicians who used drugs, including heroin, cocaine, and cannabis and their narratives about these drugs through songs” (p. 137). Early Federal legislation criminalizing marijuana was 

motivated, in part, by use of the drug by jazz musicians and fear that their example would influence 

youth (Whitebread 1995). 

In recent years, the link between drug culture and music has been exemplified by the importance of 

MDMA in the rave music scene (Kotarba 2007; Murguia et al. 2007). Reynolds (1998) credits the 

development of rave music to MDMA’s ability to create a feeling of intimacy among relative 

strangers and the way in which people who use it respond to repetitive, up-tempo music. Conversely, Adlaf and Smart (1997) found that adolescents in Canada typically became involved in the 

rave music scene after starting to use MDMA and other drugs. Regardless of how the relationship 

developed, MDMA and rave music are so closely linked that it is hard to tell where the music culture 

ends and the drug culture begins. 

Blackman (1996) states that drug use has become an essential element of youth culture mainly 

through its association with musical artists. Similarly, Knutagard (1996) observes how different youth 

cultures, each defined in part by its members’ choices in music and substance use, have made some 

types of substance use acceptable to many young people. Esan (2007) notes that urban music and 

drug 

 

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Chapter 6—Drug Cultures and the Culture of Recovery

in substance use and the development of 

substance use disorders. Despite having differing theories about the root causes of substance 

use disorders, most researchers would agree 

that substance abuse is, to some extent, a 

learned behavior. Beginning with Becker’s 

(1953) seminal work, research has shown that 

many commonly abused substances are not 

automatically experienced as pleasurable by 

people who use them for the first time 

(Fekjaer 1994). For instance, many people find

the taste of alcoholic beverages disagreeable 

during their first experience with them, and 

they only learn to experience these effects as 

pleasurable over time. Expectations can also be 

important among people who use drugs; those 

who have greater expectancies of pleasure 

typically have a more intense and pleasurable 

experience. These expectancies may play a part 

in the development of substance use disorders 

(Fekjaer 1994; Leventhal and Schmitz 2006). 

Additionally, drug-seeking and other behaviors associated with substance use have a 

reinforcing effect beyond that of the actual 

drugs. Activities such as rituals of use (Exhibit 

6-5), which make up part of the drug culture, 

provide a focus for those who use drugs when 

the drugs themselves are unavailable and help 

them shift attention away from problems they 

might otherwise need to face (Lende 2005).

Drug cultures serve as an initiating force as 

well as a sustaining force for substance use and 

abuse (White 1996). As an initiating force, the 

culture provides a way for people new to drug 

use to learn what to expect and how to appreciate the experience of getting high. As White 

(1996) notes, the drug culture teaches the new 

user “how to recognize and enjoy drug effects” 

(p. 46). There are also practical matters involved 

in using substances (e.g., how much to take, 

how to ingest the substance for strongest effect) 

that people new to drug use may not know 

when they first begin to experiment with drugs. 

The skills needed to use some drugs can be 

quite complicated, as shown in Exhibit 6-6. 

The drug culture has an appeal all its own that 

promotes initiation into drug use. Stephens 

(1991) uses examples from a number of ethnographic studies to show how people can be as

taken by the excitement of the drug culture as 

they are by the drug itself. Media portrayals, 

along with singer or music group autobiographies, that glamorize the drug lifestyle may 

increase its lure (Manning 2007; Oksanen 

2012). In buying (and perhaps selling) drugs, 

individuals can find excitement that is missing 

in their lives. They can likewise find a sense of 

purpose they otherwise lack in the daily need to 

seek out and acquire drugs. In successfully 

navigating the difficulties of living as a person

Exhibit 6-4: Music and Drug Cultures (continued)

culture have a shared appeal to young people based on their apparently antagonistic relationship to 

mainstream culture. Since the 1990s, rock group confessional memoirs have become increasingly 

popular, often depicting a lifestyle and culture of excess and providing explicit details of drug use 

and methods; consumption-driven, high-risk, or excessive behaviors; tragic consequences of use; 

and, sometimes, the author’s participation in rehabilitation (Oksanen 2012). 

Certain drugs and the drug-dealing lifestyle are featured prominently in different types of music, 

including hip hop (Esan 2007; Schensul et al. 2000) or narcocorridos (a popular form of Mexican and 

Mexican American border music that tells of the lives of drug traffickers [Edberg 2004]). However, 

even music that is not overtly concerned with drug use can become connected to a drug culture or to 

substance use in an individual’s mind. According to White (1996), links between particular songs and 

the recall of euphoric drug experiences are especially common and may need to be addressed explicitly in treatment. Hearing these songs can act as a trigger for drug use and can, therefore, be a 

potential cause of relapse.

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Improving Cultural Competence

Exhibit 6-5: The Rituals of Drug Cultures

Several authors have noted that illicit drug use and alcohol use typically involve ritualized behaviors 

(Alverson 2005; Carlson 2006; Carnes et al. 2004; Grund 1993; White 1996). The rituals of substance 

use affect where, when, and how substances are used. Substance-related rituals serve both instrumental and social functions. Instrumental functions include maximizing drug effects, minimizing 

negative effects of drug use, and preventing secondary problems. Socially, the rituals display one’s 

affiliation with the drug culture to other people and help create a sense of community within the 

culture. Obviously, the social function is more central to group activities than to solitary rituals.

Most drug-related social rituals involve sharing substances or sharing the experience of intoxication. 

Some drug cultures (e.g., marijuana) encourage the sharing of substances, but even when they are 

not shared, drugs are often used with other people who use, such as in crack houses and shooting 

galleries (Bourgois 1998; Grund 1993; Williams 1992). Rituals involving shared substance use and 

public substance use strengthen the bonds between members of a drug culture and sustain the drug 

culture. Some social rituals are so important to members of the drug culture that they participate in 

them even when they have no drugs, such as when marijuana smokers smoke an inert substance 

(e.g., horse manure, banana peels) together when they have no marijuana (White 1996). Drug use 

can also be incorporated into other ritualized behaviors, such as sexual activity (Carnes et al. 2004).

Individuals develop their own drug-related rituals through the influence of other members of the 

culture and also through trial and error. This allows them to determine what works best for them to 

maximize the drug’s effect and minimize related problems. For example, Grund (1993) found, 

through observing the rituals surrounding the injection of cocaine and heroin among people in the 

Netherlands, that specific rituals governed the timing and administration of the drugs so that heroin 

lessened the unpleasant side effects of the cocaine. Other recent examples are the combination of 

energy drinks with alcohol to delay the normal onset of sleepiness (Howland and Rohsenow 2013; 

Substance Abuse and Mental Health Services Administration [SAMHSA] 2013c) and the combination 

of methylphenidate with alcohol to intensify euphoric effects (for review of central nervous system 

stimulant use and emergency room information, see SAMHSA 2013b).

Exhibit 6-6: Questions Regarding Knowledge and Skill Demands of Heroin Use

• If first use is by snorting, how is it done (assuming the person has never taken a drug intranasally)? Is there a special technique for using heroin this way?

• If first use is by injection, is it best to inject the drug under the skin (skin-popping) or into a vein?

• What equipment is required? If one doesn’t have a hypodermic syringe, what other equipment 

can be substituted to make up a set of “works” or an “outfit”?

• How is heroin prepared (cooked) for injection?

• What techniques or procedures are used to inject the drug?

• What does one do if the needle clogs?

• Is there any way to test the purity of the drug?

• How much of the drug constitutes a desirable dose?

• If more than one person is using and an outfit is being shared, who uses it first?

• If sharing, how can the works be cleaned to prevent the transmission of disease?

• How does one know if he or she has injected too much?

• Are there any unpleasant side effects one should anticipate?

• How long will the effects of the drug last?

• Is there any way to maximize the drug’s effects?

• Is there anything one should not do while high on the drug?

• How much time must pass before the drug can be used again?

• If a bruise or an abscess develops at the injection site, how can it be hidden and treated (without 

seeing a physician)?

Source: White 1996. 

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Chapter 6—Drug Cultures and the Culture of Recovery

who uses drugs, they can gain approval from 

peers who use drugs and a feeling that they are 

successful at something. 

In some communities, participation in the 

drug trade—an aspect of a drug culture—is 

simply one of the few economic opportunities 

available and is a means of gaining the admiration and respect of peers (Bourgois 2003; 

Simon and Burns 1997). However, drug dealing as a source of status is not limited to economically deprived communities. In studying 

drug dealing among relatively affluent college 

students at a private college, Mohamed and 

Fritsvold (2006) found that the most important motives for dealing were ego gratification, status, and the desire to assume an outlaw 

image.

Marginalized adolescents and young adults 

find drug cultures particularly appealing. 

Many individual, family, and social risk factors 

associated with adolescent substance abuse are 

also risk factors for youth involvement with a 

drug culture. Individual factors—such as 

feelings of alienation from society and a strong 

rejection of authority—can cause youth to 

look outside the traditional cultural institutions available to them (family, church, school, 

etc.) and instead seek acceptance in a subculture, such as a drug culture (Hebdige 1991;

Moshier et al. 2012). Individual traits like 

sensation-seeking and poor impulse control, 

which can interfere with functioning in mainstream society, are often tolerated or can be 

freely expressed in a drug culture. Family 

involvement with drugs is a significant risk 

factor due to additional exposure to the drug 

lifestyle, as well as early learning of the values 

and behaviors (e.g., lying to cover for parents’

illicit activities) associated with it (Haight et 

al. 2005). Social risk factors (e.g., rejection by 

peers, poverty, failure in school) can also increase young people’s alienation from traditional cultural institutions. The need for social 

acceptance is a major reason many young 

people begin to use drugs, as social acceptance 

can be found with less effort within the drug 

culture.

In addition to helping initiate drug use, drug 

cultures serve as sustaining forces. They support continued use and reinforce denial that a 

problem with alcohol or drugs exists. The 

importance of the drug culture to the person 

using drugs often increases with time as the 

person’s association with it deepens (Moshier 

et al. 2012). White (1996) notes that as a 

person progresses from experimentation to 

abuse and/or dependence, he or she develops a 

more intense need to “seek for supports to 

sustain the drug relationship”(p. 9). In addition to gaining social sanction for their substance use, participants in the drug culture 

learn many skills that can help them avoid the 

pitfalls of the substance-abusing lifestyle and 

thus continue their use. They learn how to 

avoid arrest, how to get money to support 

their habit, and how to find a new supplier 

when necessary. 

The more an individual’s needs are met within 

a drug culture, the harder it will be to leave 

that culture behind. White (1996) gives an 

example of a person who was initially attracted 

in youth to a drug culture because of a desire 

for social acceptance and then grew up within 

that culture. Through involvement in the drug 

culture, he was able to gain a measure of selfesteem, change his family dynamic, explore his 

sexuality, develop lasting friendships, and find 

a career path (albeit a criminal one). For this 

individual, who had so much of his life invested in the drug culture, it was as difficult to 

conceive of leaving that culture as it was to 

conceive of stopping his substance use. 

Online Drug Cultures 

One major change that has occurred in drug 

cultures in recent years is the development of

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Improving Cultural Competence

How To Lead an Exercise Examining Benefits, Losses, and the Future 

Counselors and clinical supervisors can help clients identify reinforcing aspects (besides physiological effects) of their drug and alcohol use and the losses associated with use, including unmet goals 

and dreams. The physiological, social, and emotional gains and losses that have transpired during 

their use (whether or not they associate these losses with their use) can serve as risks for relapse. 

This exercise works well as an interactive psychoeducational lecture for clients, as a training tool for 

counselors, and as a group counseling exercise. It can also be adapted for individual sessions.

Materials needed: Group room with sufficient space to move around. 

Instructions:

• Select an amenable client aware of the losses and consequences associated with his/her use. 

Later in the exercise, select other clients to give other group members a more direct experience. 

• Divide the group in two. For large groups, select only 6 to 8 people for each side. Have each 

subgroup stand on opposite sides of the room facing each other. One group will represent the 

benefits of use; the other, losses associated with use (see diagram for room set-up).

• Rather than using the client’s personal benefits and losses (at least initially), ask group members 

to brainstorm about their experiences that represent each side. Begin with the side of the room 

that represents “benefits of use” and ask everyone in the room to name some benefits. Then, 

assign a specific benefit to each person in the “benefits of use” group and create a one-line 

message for each (a first-person statement describing the benefit), asking the representative client to remember the line. For example, if the group named a benefit of use as immediate acceptance from others who use, assign this benefit to one person and create a message to 

capture it: “I make you feel like you belong,” or “We are family now.” Continue brainstorming 

until you have assigned six or more benefits.

• Next, go to the opposite group that represents the losses associated with use and begin to 

solicit losses from everyone in the room. Assign a loss to each person in the “loss” group, create 

a one-line message that coincides with each loss, and then ask an individual to remember each 

loss message (e.g., “I am the loss of your children,” “I am the loss of your self-respect,” “I am 

the loss of your health”). In addition, ask the group to name future goals and plans that were 

curtailed because of use. Assign these losses as well, following the same format (e.g., “I am the 

loss of a college degree,” “I am the loss of intimate relationships,” “I am the loss of belief in the 

future”). Note: If you run out of people, you can assign two roles to one person.

• At this point, the exercise can already be a powerful experience for many clients. Now, have the 

person who was originally selected as the client stand facing the “benefits of use” group. Have 

the client process what it is like to see the benefits of use. You can also have each person in the 

“benefits of use” group state his or her one-line message to help facilitate this process. Stand 

with the client as he or she moves to the “loss” group. Again, have the client stand and face this 

group while asking him or her what it is like to see the losses, including the losses related to 

goals and the future. Note: It is not important as an exercise to have benefits or losses specific 

only to this client. It is far better to gain a sample from the entire group so that everyone is involved and to maximize the exercise’s effectiveness as a psychoeducational tool.

• After the client has stood in front of both groups, ask him or her to move back and forth between each group several times to see what emotional changes occur in experiencing each 

group. It is important to process this experience as a group. You can invite other members to 

switch out of their roles and stand in as clients to experience this exercise more directly. Clients 

are likely to see how seductive the “benefits of use” group can be and how this attraction can 

lead back to relapse. This exercise may also help clients connect with the losses associated with 

their use. At times, clients may gain awareness that the very losses associated with their use can 

also serve as a trigger for use as a means of self-medicating feelings. 

(Continued on the next page.)

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Chapter 6—Drug Cultures and the Culture of Recovery

Internet communities organized around drug 

use (Gatson 2007a; Murguia et al. 2007) and 

drug use facilitation, including information on 

use, production, and sales (Bowker 2011; U.S. 

Department of Justice 2002). Such communities develop around Web sites or discussion 

boards where individuals can describe their 

drug-related experiences, find information on 

acquiring and using drugs, and discuss related 

issues ranging from musical interests to legal 

problems. Many of the Web sites where these 

online communities develop are originally 

created to lessen the negative consequences of 

substance use by informing people about various related legal and medical issues (Gatson

2007b; Murguia et al. 2007). As in other drug 

cultures, users of these Web sites and discussion boards develop their own language and 

values relating to drug use. Club drugs and 

hallucinogenics are the most often-discussed 

types of drugs, but online communities involve 

the discussion of all types of licit and illicit 

substances, including stimulants and opioids 

(Gatson 2007a; Murguia et al. 2007; TackettGibson 2007).

Murguia et al. (2007) reported on a survey of 

adult (ages 18 and older) participants in one 

online community. The self-selected survey 

sample included 1,038 respondents, 80 percent 

of whom were from the United States. Respondents were likely to be young (90 percent 

were under 30), male (76 percent), White (92 

percent), relatively affluent (58 percent had 

household incomes of $45,000 or more), 

employed (41 percent were employed full 

time; another 28 percent, part time), and/or in 

school (57 percent were attending school full 

or part time). According to the 2011 National 

Survey on Drug Use and Health, approximately 0.3 percent of individuals 12 years of 

age or older purchase prescription drugs 

through the Internet (SAMHSA, 2012b). 

The Role of Drug Cultures 

in Substance Abuse 

Treatment

Most people seek some kind of social affiliation; it is one aspect of life that gives meaning 

to day-to-day existence. Behavioral health 

service providers can better understand and 

help their clients if they have an understanding of the culture(s) with which they identify. 

This understanding can be even more important when addressing the role of drug 

culture in a client’s life because, of all cultural 

affiliations, it is likely to be the one most 

intimately connected with his or her substance 

How To Lead an Exercise Examining Benefits, Losses, and the Future (continued)

• Allot sufficient time for this psychoeducational lecture—not only to demonstrate the benefits and 

losses associated with use, but also to enable the group to process their thoughts and feelings.

Group Room Setup

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Improving Cultural Competence

abuse. The drug culture is likely to have had a 

considerable influence on the client’s behaviors related to substance use. 

Drug Cultures in Assessment and 

Engagement

The first step in understanding the role a drug 

culture plays in a client’s life is to assess which 

drug culture(s) the client has been involved 

with and his or her level of involvement. There 

are no textbooks that can inform providers 

about the drug cultures in their areas, but 

counselors probably know quite a bit about 

them already, as they learn much about drug 

cultures through talking with their clients. 

Counselors who are themselves in recovery 

may be familiar with some clients’ substanceusing lifestyles and social environments or will 

have insight into how to explore the issue with 

clients. They can also educate their colleagues.

Providers who have never personally abused 

substances can learn from recovered counselors as well as from their clients. However, 

asking a client point-blank about his or her 

involvement in a drug culture is likely to be 

answered with a blank stare. Instead, talking to 

clients about their relationships, daily activities 

and habits relating to substance use, values, 

and views of other people and the world can 

allow providers to develop a good sense of the 

meanings drug cultures hold for clients. 

To engage a client in treatment, understanding 

his or her relationship with a drug culture may 

be as important as understanding elements of 

that client’s racial or ethnic identity. Clients 

are unlikely to self-identify as members of the 

drug culture in the same way that they would 

identify as an African American or Asian 

American, for example, but they can still be 

offended or distrustful if they think the provider or program does not understand how their 

lifestyle relates to their substance use. Affiliation with a drug culture is a source of client 

identity; the client’s place in the drug culture 

can be important to his or her self-esteem. 

After the assessment and engagement stage, 

the provider’s attitude toward the client’s 

participation in a drug culture will be significantly different from his or her attitude toward the client’s other cultural affiliations. As 

most providers already know (even if they do 

not use the term drug culture), if a client 

How To Learn About Clients’ Daily Routines and Rituals

One way to gain an understanding of a client’s involvement in a specific drug culture is to learn about 

his or her daily routines and rituals. Keep in mind that there can be different routines on weekends or 

specific days of the week; ask about exceptions to the typical daily schedule. 

Materials needed: Weekly calendar. 

Instructions: 

• To elicit information about the client’s daily activities, use a cue or anchor to initiate this exploration, such as a calendar highlighting each day of a week—Monday through Sunday.

• Placing the calendar in front of the client, ask him or her to describe a typical day, beginning with 

the time that he or she generally wakes up and building on the morning routines (e.g., “What 

does an average morning look like for you?”). 

• Encourage the client to provide a specific account of his or her routine rather than a general 

response. Important information can be obtained by asking the client about feelings or reactions 

to daily activities as they unfold in the session. 

• After completing an example of an entire day, ask the client if there are exceptions to this schedule 

that routinely occur on another day of the week or during the weekend. Once these are processed, 

it can be beneficial to ask what it was like for him or her to talk about these daily routines. 

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Chapter 6—Drug Cultures and the Culture of Recovery

continues to be closely affiliated with the 

drug-using life, then he or she is more likely to 

relapse. The people, places, things, thoughts, 

and attitudes related to drug and/or alcohol 

use act as triggers to resume use of substances. 

Behavioral health service providers need to 

help their clients weaken and eventually eliminate their connections to the drug culture. 

White (1996) identifies an important issue to 

address during transition from engagement to 

treatment—in the process of engaging clients, 

providers help them identify how their connections to the drug culture prevent them 

from reaching their goals and how the loss of 

these connections would affect them if they 

chose to cut ties with the drug culture. 

Finding Alternatives to Drug 

Cultures 

A client can meet the psychosocial needs previously satisfied by the drug culture in a number 

of ways. Strengthening cultural identity can be 

a positive action for the client; in some cases, 

the client’s family or cultural peers can serve as 

a replacement for involvement in the drug 

culture. This option is particularly helpful when 

the client’s connection to a drug culture is 

relatively weak and his or her traditional culture 

is relatively strong. However, when this option 

is unavailable or insufficient, clinicians must 

focus on replacing the client’s ties with the drug 

culture (or the culture of addiction) with new 

ties to a culture of recovery.

To help clients break ties with drug cultures, 

programs need to challenge clients’ continued 

involvement with elements of those cultures 

(e.g., style of dress, music, language, or communication patterns). This can occur through 

two basic processes: replacing the element 

with something new that is positively associated with a culture of recovery (e.g., replacing a 

marijuana leaf keychain with an NA keychain), and reframing something so that it is 

no longer associated with drug use or the drug 

culture (e.g., listening to music that was associated with the drug culture at a sober dance 

with others in recovery; White 1996). The 

process will depend on the nature of the cultural element.

Developing a Culture of Recovery 

Just as people who are actively using or abusing substances bond over that common experience to create a drug culture that supports 

their continued substance use, people in recovery can participate in activities with others 

who are having similar experiences to build a 

culture of recovery. There is no single drug 

culture; likewise, there is no single culture of 

recovery. However, large international mutualhelp organizations like Alcoholics Anonymous 

(AA) do represent the culture of recovery for 

many individuals (Exhibit 6-7). Even within

such organizations, though, there is some 

cultural diversity; regional differences exist, for 

example, in meeting-related rituals or attitudes 

toward certain issues (e.g., use of prescribed 

psychotropic medication, approaches to 

spirituality). 

The planned TIP, Relapse Prevention and 

Recovery Promotion in Behavioral Health 

Services (SAMHSA planned e), provides more 

information on using mutual-help groups in 

“The culture of recovery is an informal 

social network in which group norms (prescribed patterns of perceiving, thinking, 

feeling, and behaving) reinforce sobriety 

and long-term recovery from addiction.”

(White 1996, p. 222)

Recovery from mental and substance use 

disorders is a process of change through 

which people improve their health and 

wellness, live in a self-directed manner, and 

work toward achieving their full potential.

(SAMHSA 2011b) 

173
Improving Cultural Competence

treatment settings and in long-term recovery. 

It contains detailed information about potential recovery supports that behavioral health

programs can use to foster cultures of recovery 

among clients and program graduates.

Most treatment programs try to foster a culture 

of recovery for their clients. Some modalities, 

with therapeutic communities being the lead 

example, focus on this issue as a primary treatment strategy. Even one-on-one outpatient 

treatment programs typically encourage attendance at mutual-help groups, such as AA, to 

meet sociocultural recovery needs. Most providers also recognize that clients need to 

replace the activities, beliefs, people, places, and 

things associated with substance abuse with 

new recovery-related associations—the central 

purpose of creating a culture of recovery.

Even programs that already recognize the 

need to create a culture of recovery for their 

clients can make doing so more of a focus in 

treatment. White (1996) explores ways to do 

this, including:

• Teaching clients about the existence of 

drug cultures and their potential influence 

in clients’ lives.

• Teaching clients about cultures of recovery 

and discussing how elements of the drug 

Exhibit 6-7: 12-Step Group Values and the Culture of Recovery

For historical reasons, cultures of recovery (like the recovery process in general) in the United States 

have been greatly influenced by 12-Step groups such as AA and NA (White 1998). These groups 

provide a clearly defined culture of recovery for a great many people. They provide members with a 

set of rituals, daily activities, customs, traditions, values, and beliefs.

The 12 Steps and 12 Traditions represent the core principles, values, and beliefs of such groups. 

Wilcox (1998) defines these values as surrender; faith; acceptance, tolerance, and patience; honesty, 

openness, and willingness; humility; willingness to examine character defects; taking life one day at a 

time; and keeping things simple. As seen by comparing these values with those common to the 

heroin culture described in the “The Values and Beliefs of a Heroin Culture” box earlier in this chapter, one of the ways in which 12-Step groups work is by instilling a set of values contrary to those 

found in drug cultures. However, they also provide members with a new set of values that are in 

some ways distinct from the values of the mainstream culture that were rejected when the individual 

began his or her involvement in the drug culture (Wilcox 1998).

Many of the values of AA and other 12-Step groups are embodied in rituals that take place in meetings and in members’ daily lives. White (1998) lists four ritual categories:

• Centering rituals help members stay focused on recovery by reading recovery literature, handling recovery tokens or symbols, and taking regular self-assessments or personal inventories 

each day.

• Mirroring rituals keep members in contact with one another and help them practice sober living 

together. Attending meetings, telling one’s story, speaking regularly by phone, and using slogans (e.g., “keep it simple,” “pass it on”), among others, are mirroring activities.

• Acts of personal responsibility include being honest and becoming time-conscious and punctual. Activities include the creation of new rituals of daily living related to sleeping, hygiene, and 

other areas of self-care while also being reliable and courteous.

• Acts of service involve performing rituals to help others in recovery. These acts are related to 

the Twelfth Step, which directs members to carry the message of their spiritual awakening to 

others who abuse alcohol or are dependent on it, thereby encouraging them to practice the 12 

Steps. Acts of service recognize that people in recovery have something of value to offer those 

still abusing alcohol.

These rituals aid the processes of personal transformation and integration into a new cultural group.

174
Chapter 6—Drug Cultures and the Culture of Recovery

culture can be replaced by elements of a 

culture of recovery.

• Establishing clear boundaries for appropriate behavior (e.g., behavior that does 

not reflect drug cultures) in the program 

and consistently correcting behaviors that 

violate boundaries (e.g., wearing shirts depicting pot leaves; displaying gangaffiliated symbols, gestures, and tattoos). 

• Working to shape a peer culture within the 

program so that longer-term clients and 

staff members can socialize new clients to 

a culture of recovery.

• Having regular assessments of clients and 

the entire program in which staff members 

and clients determine areas where work is 

needed to minimize cultural attitudes that 

can undermine treatment.

• Involving clients’ families (when appropriate) in the treatment process so they can 

support clients’ recovery as well as participate in their own healing process.

White (1996) suggests that programs build 

linkages with mutual-help groups; include 

mutual-help meetings in their programs or 

provide access to community mutual-help 

meetings; and include mutual-help rituals, 

symbols, language, and values in treatment 

processes. 

Other activities that can improve integration 

into a recovery culture include SAMHSA’s 

Recovery Community Services Program 

(http://www.samhsa.gov/grants/2011/ti_11_0

04.aspx), which was developed to provide and 

evaluate peer-based recovery support services, 

and Recovery Community Centers, which 

provide space for recovering people to socialize, organize, and develop a recovery culture 

(White and Kurtz 2006). Developing a culture

of recovery involves connecting individuals 

back to the larger community and to their 

cultures of origin (Davidson et al. 2008). This 

can require efforts to educate the community 

about recovery as well (e.g., by promoting a 

recovery month in the community, hosting 

recovery walks or similar events, or offering 

outreach to community groups, such as 

churches or fraternal/benevolent societies).

Programs that do not have a plan for creating 

a culture of recovery among clients risk their 

clients returning to the drug culture or holding on to elements of that culture because it 

meets their basic and social needs. In the worst 

case scenario, clients will recreate a drug culture among themselves within the program. In 

the best case, staff members will have a plan 

for creating a culture of recovery within their 

treatment population.

SAMHSA’s Guiding Principles of 

Recovery 

• Recovery emerges from hope.

• Recovery is person driven.

• Recovery occurs via many pathways.

• Recovery is holistic.

• Recovery is supported by peers and allies.

• Recovery is supported through relationship 

and social networks.

• Recovery is culturally based and influenced.

• Recovery is supported by addressing 

trauma.

• Recovery involves individual, family, and 

community strengths and responsibility.

• Recovery is based on respect.

More information on the Guiding Principles of 

Recovery is available at the SAMHSA Store 

(http://store.samhsa.gov/shin/content//PEP12-

RECDEF/PEP12-RECDEF.pdf).

Source: SAMHSA 2012c. 

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252
Appendix B—Instruments To 

Measure Identity and Acculturation

Some researchers have tested the usefulness of 

acculturation and identity models with people 

who abuse substances. For example, Peña and 

colleagues’ racial identity attitude scale was 

found, in a study of African American men in 

treatment for cocaine dependence, to help 

counselors better understand the roles that 

ethnic and cultural identity play in clients’

substance abuse issues (Peña et al. 2000). In 

1980, Cuellar and colleagues published their 

acculturation rating scale for Mexican 

Americans, which conceptualized acculturation as progressing across a 5-point continuum ranging from Mexican or low acculturated 

(level 1) to American or high acculturated 

(level 5). The mid-level designation of bicultural (level 3) was set as the midpoint between 

the two extremes, although various investigators have questioned this assumption 

(Oetting and Beauvais 1990; Sayegh and 

Lasry 1993). Since then, scholars have developed new ways to conceptualize identity and 

acculturation, ranging from simple scales to 

complex multidimensional models (Skinner 

2001). The table that begins on the next page 

summarizes the instruments available to 

measure acculturation and ethnic identity. 

(See also the Center of Excellence for 

Cultural Competence for additional resources 

at http://nyculturalcompetence.org).

Other scales have been developed to examine 

specific culture-related variables, including 

machismo (Cuellar et al. 1995; Fragoso and 

Kashubeck 2000), simpatía (Griffith et al. 

1998), familismo (Sabogal et al. 1987), traditionalism–modernism (Ramirez 1999), and 

family traditionalism and rural preferences 

(Castro and Gutierres 1997). Counselors can 

use acculturation scales to help match patients 

to providers, to make treatment plans, and to 

identify the role of identity in substance abuse. 

Although these instruments can be helpful, 

the counselor must not rely solely on them to 

determine the client’s identity or level of 

acculturation.

253
Improving Cultural Competence

Acculturation and Ethnic Identity Measures

Instrument Description Cultural Group

African American Acculturation Scale-Revised 

(Klonoff and Landrine 

2000)

This scale measures eight dimensions of African 

American culture: (1) traditional beliefs and practices, (2) traditional family structure and practices, 

(3) traditional socialization, (4) preparation and 

consumption of traditional foods, (5) preference 

for African American things, (6) interracial attitudes, (7) superstitions, and (8) traditional health 

beliefs and practices.

African Americans

Black Racial Identity 

Attitude Scale—Form B 

(Helms 1990)

This scale measures beliefs or attitudes of Blacks 

toward both Blacks and Whites using 5-point 

scales. It is available in short and long forms.

African Americans

Cross Racial Identity 

Scale (Worrell et al. 

2001)

This scale measures six identity clusters associated 

with four stages of racial identity development.

African Americans

Multidimensional Inventory of Black Identity 

(MIBI; Sellers et al. 1997)

The MIBI measures centrality of Black identity, 

ideology, and regard for a Black identity. It is 

available online at 

http://sitemaker.umich.edu/aaril/files/mibiscaleand

scoring.pdf.

African Americans

Scale To Assess African 

American Acculturation 

(Snowden and Hines 

1999)

This is a 10-item scale that assesses media preferences, racial bias in relationships, race-related 

attitudes, and comfort in interacting with other 

races.

African Americans

African SelfConsciousness Scale 

(Baldwin and Bell 1985)

This scale measures within-group variability in the 

level of acculturation/cultural identity continuum 

(Baldwin and Bell 1985) based on degree of 

Afrocentricity or Nigrescence (White and Parham 

1996). It indicates a client’s level of involvement in 

traditional African American culture or the core 

African-oriented culture.

African 

Americans/African 

Immigrants

Native American Acculturation Scale (Garrett 

and Pichette 2000)

The Native American Acculturation scale asks 20 

questions to ascertain a client’s level of involvement with Native American culture.

Native Americans

Rosebud Personal 

Opinion Survey 

(Hoffmann et al. 1985)

This assessment evaluates components of acculturation, including language use, values, social 

behaviors, social networks, religious affiliation and 

practice, home community, education, ancestry, 

and cultural identification.

Native Americans

Asian American Multidimensional Acculturation Scale (AAMAS; Gim 

Chung et al. 2004)

The AAMAS was developed to be easy to use with 

a variety of Asian American ethnic groups. It 

includes questions relating to cultural identity, 

language use, cultural knowledge, and food 

preferences.

Asian Americans

(Continued on the next page.)

254
Appendix B—Instruments To Measure Identity and Acculturation

Acculturation and Ethnic Identity Measures (continued)

Instrument Description Cultural Group

Cultural Adjustment 

Difficulties Checklist 

(CADC; Sodowsky and 

Lai 1997)

The CADC helps avoid potential problems relating 

to acculturation by asking about language use, 

social customs, family interactions, perceptions of 

prejudice, friendship networks, and cultural adjustment.

Asian Americans 

(East Asians)

East Asian Acculturation 

Measure (Barry 2001)

This instrument includes 29 items that assess 

assimilation, level of separation from other Asians, 

integration, and marginalization.

Asian Americans 

(East Asians)

General Ethnicity Questionnaire (GEQ; Tsai et 

al. 2000)

The GEQ is an instrument designed to be used 

with minor modifications for assessing cultural 

orientation with different cultural groups. There 

are original and abridged versions. The original 

includes 75 items asking about language use, 

social affiliations, cultural practices, and cultural 

identification.

Asian Americans 

(although 

designed to be 

multicultural in 

orientation)

Suinn-Lew Asian SelfIdentity Acculturation 

Scale (Suinn et al. 1992)

This instrument was modeled after the Acculturation Rating Scale for Mexican Americans, and 

research indicates it has high reliability.

Asian Americans

Ethnocultural Identity 

Behavioral Index (Yamada et al. 1998)

This is a 19-item self-report assessment with high 

validity.

Asian Americans 

and Pacific 

Islanders

Internal-External Ethnic 

Identity Measure (Kwan 

1997)

The instrument evaluates ethnic friendships and 

affiliation, ethnocommunal expression, ethnic food 

orientation, and family collectivism, in order to 

differentiate three Chinese American identity 

groups: (1) internal, (2) external, and (3) internalexternal undifferentiated.

Chinese 

Americans

Marín and Marín Acculturation Scale (Marín et 

al. 1987)

This scale is a 12-item instrument that assesses 

three domains: (1) language use, (2) media preferences, and (3) ethnic diversity of social relations. It 

is available online at 

http://www.columbia.edu/cu/ssw/projects/pmap/

docs/gupta_acculturation.pdf 

Chinese 

Americans

Behavioral Acculturation 

Scale and Value Acculturation Scale (Szapocznik et al. 1978)

These two scales, used in conjunction with one 

another, ask individuals about behaviors and 

values in order to determine acculturation. If used 

singly, the behavioral scale is the superior measure 

for acculturation.

Cuban Americans

Na Mea Hawai’i 

(Hawaiian Ways), A 

Hawaiian Acculturation 

Scale (Rezentes 1993)

This is a 34-item scale. An adolescent version is 

available (Hishinuma et al. 2000).

Native Hawaiians

(Continued on the next page.)

255
Improving Cultural Competence

Acculturation and Ethnic Identity Measures (continued)

Instrument Description Cultural Group

Abbreviated Multidimensional Acculturation Scale 

(AMAS-ZABB; Zea et 

al. 2003)

The AMAS-ZABB is a multidimensional, bilinear, 42-

item scale that evaluates identity, language competence, and cultural competence.

Latinos

Acculturation Scale 

(Marin et al. 1987)

This 12-item acculturation scale, available in English 

and Spanish, evaluates language use, media preferences, and social activities. It is available online at 

http://casaa.unm.edu/inst/MARIN%20Short%20Scale.

pdf

Latinos

Bicultural Involvement Questionnaire 

(BIQ; Szapocznik et 

al. 1980)

The BIQ assesses language use and involvement in 

both Latino and mainstream American activities. It 

relates two sets of scores to derive a measure of 

bicultural involvement, with individuals who are highly 

involved in both cultures scoring highest on the scale.

Latinos

The Bidimensional 

Acculturation Scale 

for Hispanics (Marin 

and Gamba 1996)

This 24-item scale asks questions about language use, 

language proficiency, and media preferences.

Latinos

Brief Acculturation 

Scale for Hispanics 

(Norris et al. 1996)

This scale has only four items, but scores on the scale 

have been correlated highly with generation, nativity, 

length of time in the United States, language preferences, and subjective perceptions of acculturation.

Latinos

Multidimensional 

Measure of Cultural 

Identity for Latinos 

(Felix-Ortiz et al. 

1994)

This measure places adolescents in one of four categories based on language, behavior/familiarity, and 

values/attitudes: (1) bicultural, (2) Latino-identified, (3) 

American-identified, and (4) low-level bicultural.

Latinos

Acculturation Rating 

Scale for Mexican 

Americans-I 

(ARSMA-I; Cuellar et 

al. 1980)

The ARSMA-I differentiates between 5 levels of acculturation: (1) Very Mexican, (2) Mexican-Oriented 

Bicultural, (3) True Bicultural, (4) Anglo-Oriented 

Bicultural, and (5) Very Anglicized. Established validity.

Mexican 

Americans

Acculturation Rating 

Scale for Mexican 

Americans-II (Cuellar 

et al. 1995)

This scale is like the ARSMA-I, except that it includes 

separate subscales to measure multidimensional 

aspects of cultural orientation toward Mexican and 

Anglo cultures independently.

Mexican 

Americans

Cultural Life Style 

Inventory (Mendoza 

1989)

This self-report instrument, available in Spanish and 

English, evaluates five dimensions of acculturation: 

intrafamily language use, extrafamily language use, 

social activities and affiliations, cultural knowledge 

and activities, and cultural identification and pride.

Mexican 

Americans

(Continued on the next page.)

256
Appendix B—Instruments To Measure Identity and Acculturation

Acculturation and Ethnic Identity Measures (continued)

Instrument Description Cultural Group

Cultural Life Style 

Inventory (Mendoza 

1989)

This self-report instrument, available in Spanish and 

English, evaluates acculturation on five dimensions: 

intrafamily language use, extrafamily language use, 

social activities and affiliations, cultural knowledge and 

activities, and cultural identification and pride.

Mexican 

Americans

Mexican American 

Acculturation Scale 

(Montgomery 1992)

This 28-item scale evaluates cultural orientation and 

comfort with ethnic identity. Items ask about language 

use, media preferences, cultural activities/traditions, 

and self-perceived ethnic identity.

Mexican 

Americans

Padilla’s 

Acculturation Scale 

(Padilla 1980)

Padilla’s Acculturation Scale is a 155-item questionnaire that assesses cultural knowledge and ethnic 

loyalties.

Mexican 

Americans

Bidimensional 

Acculturation Scale 

for Hispanics (Marín 

and Gamba 1996)

This scale measures evaluates two major dimensions 

of acculturation (Hispanic and non-Hispanic) using 12 

items measuring 3 language-related areas. It has been 

found to have high consistency and validity.

Mexican 

Americans and 

Central 

Americans

Stephenson 

Multigroup 

Acculturation Scale 

(Stephenson 2000)

This is a 32-item instrument that evaluates immersion 

in both culture of origin and the dominant culture of 

the society.

Multicultural

Vancouver Index of 

Acculturation (Ryder 

et al. 2000)

This instrument includes 20 questions that assess 

interest/participation in one’s “heritage culture” and 

“typical American culture” (available online at 

http://www2.psych.ubc.ca/~dpaulhus/Paulhus_measur

es/VIA.American.doc).

Multicultural

Bicultural Acculturation Scale (Cortés 

and Rogler 1994)

Developed for use with first- and second-generation 

Puerto Rican adults, this scale measures involvement 

in American culture and Puerto Rican culture, but it 

has limited evidence of validity and reliability.

Puerto Rican 

Americans

Psychological 

Acculturation Scale 

(Tropp et al. 1999)

The items on this scale pertain to the client’s sense of 

psychological attachment to and belonging within 

Anglo American and Hispanic/Latino cultures.

Puerto Ricans on 

the U.S. mainland

Acculturation Scale 

for Southeast Asians 

(Anderson et al. 

1993)

This 13-item scale evaluates languages proficiency and 

preferences regarding social interactions, cultural 

activities, and food. It includes two subscales for 

proficiency in languages, as well as language, social, 

and food preferences.

Cambodian, 

Laotian, and 

Vietnamese 

Americans

White Racial Identity 

Attitude Scale (Helms 

and Carter 1990)

This 50-item instrument rates items on a 5-point scale 

to measure attitudes associated with Helms’s stages of 

racial identity development for Caucasians.

White Americans

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Appendix C—Tools for Assessing 

Cultural Competence

There are numerous assessment tools available for evaluating cultural competence in clinical, 

training, and organizational settings. These tools are not specific to behavioral health treatment. 

Though more work is needed in developing empirically supported instruments to measure cultural competence, there is a wealth of multicultural counseling and healthcare assessment tools 

that can provide guidance in identifying areas for improvement of cultural competence. This 

appendix examines three resource areas: counselor self-assessment tools, guidelines and assessment tools to implement and evaluate culturally responsive services within treatment programs 

and organizations, and forms addressing client satisfaction with and feedback about culturally 

responsive services. Though not an exhaustive review of available tools, this appendix does provide samples of tools that are within the public domain. For additional resources and cultural 

competence assessment tools, visit the National Center for Cultural Competence 

(http://nccc.georgetown.edu) or refer to the University of Michigan Health System’s Program for 

Multicultural Health (http://www.med.umich.edu/multicultural/). 

Counselor Self-Assessment Tools

Multicultural Counseling Self Efficacy Scale—Racial Diversity Form 

This 60-item self-report instrument assesses perceived ability to perform various counselor behaviors in individual counseling with a racially diverse client population. For additional information on psychometric properties and scoring, refer to Sheu and Lent (2007). 

Self-Assessment Checklist for Personnel Providing Services and Supports to 

Children and Youth With Special Health Needs and Their Families 

This instrument was developed by Tawara D. Goode of the Georgetown University Center for 

Child and Human Development. This version is adapted with permission from Promoting Cultural 

Competence and Cultural Diversity in Early Intervention and Early Childhood Settings (June 1989). 

It is available from the Web site of the National Center for Cultural Competence 

(http://nccc.georgetown.edu/documents/ChecklistEIEC.pdf). 

Select A, B, or C for each numbered item listed: 

A = Things I do frequently B = Things I do occasionally C = Things I do rarely or never 

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Improving Cultural Competence

Physical Environment, Materials and Resources

_____ 1. I display pictures, posters, and other materials that reflect the cultures and ethnic backgrounds of children and families served by my program or agency.

_____ 2. I [e]nsure that magazines, brochures, and other printed materials in reception areas are 

of interest to and reflect the different cultures of children and families served by my program or 

agency.

_____ 3. When using videos, films, or other media resources for health education, treatment, or 

other interventions, I ensure that they reflect the cultures of children and families served by my 

program or agency.

_____ 4. When using food during an assessment, I [e]nsure that meals provided include foods 

that are unique to the cultural and ethnic backgrounds of children and families served by my 

program or agency.

_____ 5. I [e]nsure that toys and other play accessories in reception areas and those used during 

assessment are representative of the various cultural and ethnic groups within the local community and the society in general.

Communication Styles

_____ 6. For children who speak languages or dialects other than English, I attempt to learn and 

use key words in their language so that I am better able to communicate with them during assessment, treatment, or other interventions.

_____ 7. I attempt to determine any familial colloquialisms used by children and families that 

may have an impact on assessment, treatment, or other interventions. 

_____ 8. I use visual aids, gestures, and physical prompts in my interactions with children who 

have limited English proficiency.

_____ 9. I use bilingual staff members or trained/certified interpreters for assessment, treatment, 

and other interventions with children who have limited English proficiency. 

_____ 10. I use bilingual staff members or trained/certified interpreters during assessments, 

treatment sessions, meetings, and for other events for families who would require this level of 

assistance.

11. When interacting with parents who have limited English proficiency I always keep in mind that:

_____ Limitation in English proficiency is in no way a reflection of their level of intellectual functioning.

_____ Their limited ability to speak the language of the dominant culture has no bearing 

on their ability to communicate effectively in their language of origin.

_____ They may or may not be literate in their language of origin or English.

_____ 12. When possible, I ensure that all notices and communiqués to parents are written in 

their language of origin.

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Appendix C—Tools for Assessing Cultural Competence

_____ 13. I understand that it may be necessary to use alternatives to written communications 

for some families, as word of mouth may be a preferred method of receiving information.

Values and Attitudes

_____ 14. I avoid imposing values that may conflict or be inconsistent with those of cultures or 

ethnic groups other than my own.

_____ 15. In group therapy or treatment situations, I discourage children from using racial and 

ethnic slurs by helping them understand that certain words can hurt others.

_____ 16. I screen books, movies, and other media resources for negative cultural, ethnic, or racial 

stereotypes before sharing them with the children and their parents served by my program or 

agency.

_____ 17. I intervene in an appropriate manner when I observe other staff members or parents 

within my program or agency engaging in behaviors that show cultural insensitivity, bias, or 

prejudice.

_____ 18. I understand and accept that family is defined differently by different cultures (e.g., 

extended family members, fictive kin, godparents).

_____ 19. I recognize and accept that individuals from culturally diverse backgrounds may desire 

varying degrees of acculturation into the dominant culture.

_____ 20. I accept and respect that male–female roles in families may vary significantly among 

different cultures (e.g., who makes major decisions for the family, play, and social interactions 

expected of male and female children).

_____ 21. I understand that age and lifecycle factors must be considered in interactions with 

individuals and families (e.g., high value placed on the decisions of elders or the role of the eldest 

male in families). 

_____ 22. Even though my professional or moral viewpoints may differ, I accept the family/parents as the ultimate decisionmakers for services and supports for their children.

_____ 23. I recognize that the meaning or value of medical treatment and health education may 

vary greatly among cultures. 

_____ 24. I recognize and understand that beliefs and concepts of emotional well-being vary 

significantly from culture to culture.

_____ 25. I understand that beliefs about mental illness and emotional disability are culturally 

based. I accept that responses to these conditions and related treatment/interventions are heavily 

influenced by culture. 

_____ 26. I accept that religion and other beliefs may influence how families respond to illnesses, 

disease, disability, and death. 

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Improving Cultural Competence

_____ 27. I recognize and accept that folk and religious beliefs may influence a family’s reaction 

and approach to a child born with a disability or later diagnosed with a physical/emotional disability or special health care needs.

_____ 28. I understand that traditional approaches to disciplining children are influenced by 

culture.

_____ 29. I understand that families from different cultures will have different expectations of 

their children for acquiring toileting, dressing, feeding, and other self-help skills.

_____ 30. I accept and respect that customs and beliefs about food, its value, preparation, and use 

are different from culture to culture.

_____ 31. Before visiting or providing services in the home setting, I seek information on acceptable behaviors, courtesies, customs, and expectations that are unique to families of specific 

cultures and ethnic groups served by my program or agency.

_____ 32. I seek information from family members or other key community informants that will 

assist in service adaptation to respond to the needs and preferences of culturally and ethnically 

diverse children and families served by my program or agency.

_____ 33. I advocate for the review of my program’s or agency’s mission statement, goals, policies, 

and procedures to ensure that they incorporate principles and practices that promote cultural 

diversity and cultural competence.

There is no answer key with correct responses. However, if you frequently responded “C,” you 

may not necessarily demonstrate values and engage in practices that promote a culturally diverse 

and culturally competent service delivery system for children with disabilities or special health 

care needs and their families.

Ethnic-Sensitive Inventory (ESI; Ho 1991, reproduced with permission)

Here are some statements made by some practitioners with ethnic minority clients. How often 

do you feel this way when you work with ethnic minority clients? Every statement should be 

answered by circling one number ranging from 5 (always) to 4 (frequently), 3 (occasionally), 2 

(seldom), and 1 (never).

In working with ethnic minority clients, I . . .

A. Realize that my own ethnic and class background may influence my effectiveness.

B. Make an effort to ensure privacy and/or anonymity.

C. Am aware of the systematic sources (racism, poverty, and prejudice) of their problems.

D. Am against speedy contracting unless initiated by them.

E. Assist them to understand whether the problem is of an individual or a collective nature.

F. Am able to engage them in identifying major progress that has taken place.

G. Consider it an obligation to familiarize myself with their culture, history, and other ethnically 

related responses to problems.

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Appendix C—Tools for Assessing Cultural Competence

H. Am able to understand and “tune in” the meaning of their ethnic dispositions, behaviors, and 

experiences.

I. Can identify the links between systematic problems and individual concerns.

J. Am against highly focused efforts to suggest behavioral change or introspection.

K. Am aware that some techniques are too threatening to them.

L. Am able at the termination phase to help them consider alternative sources of support.

M. Am sensitive to their fear of racist or prejudiced orientations.

N. Am able to move slowly in the effort to actively “reach for feelings.”

O. Consider the implications of what is being suggested in relation to each client’s ethnic reality 

(unique dispositions, behaviors, and experiences).

P. Clearly delineate agency functions and respectfully inform clients of my professional expectations of them.

Q. Am aware that lack of progress may be related to ethnicity.

R. Am able to understand that the worker–client relationship may last a long time.

S. Am able to explain clearly the nature of the interview.

T. Am respectful of their definition of the problem to be solved.

U. Am able to specify the problem in practical, concrete terms.

V. Am sensitive to treatment goals consonant to their culture.

W. Am able to mobilize social and extended family networks.

X. Am sensitive to the client’s premature termination of service.

Scoring: The 24 items include four items for each of six treatment phases of client–counselor 

interaction. The sum of the numbers circled for each item relating to a treatment phase is the 

score for that phase. The scoring grid is given below. 

Scoring Grid for ESI 

Process Phase

Precontact

Problem Identification

Problem Specification

Mutual Goal Formulation

Problem Solving

Termination

Items

A _______ G _______ M _______ S _______

B _______ H _______ N _______ T _______

C _______ I _______ O _______ U _______

D _______ J _______ P _______ V _______

E _______ K _______ Q _______ W _______

F _______ L _______ R _______ X _______

Source: Ho 1991. Reproduced with permission.

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Improving Cultural Competence

Evaluating Cultural Competence in Treatment 

Programs and Organizations

Agency Cultural Competence Checklist—Revised Form (Dana 1998, 

reproduced with permission)

Staff and policy attitudes

______ Bilingual/bicultural

______ Bilingual 

______ Bicultural 

______ Culture broker

______ Flexible hours/appointments/home visits

______ Treatment immediate/day/week

______ Indigenous intake 

______ Match client–staff

______ Agency environment reflects culture

Total possible = 9 Total obtained = ______

Services

______ Culture-relevant assessment

______ Cultural context for problems

______ Cultural-specific intervention model

______ Culture-specific services:

___ Prevention ___ Crisis ___ Brief ___ Individual

___ Couple ___ Family ___ Child ___ Outreach

___ Community ___ Education ___ Non-mental health

___ Resource linkage ___ Natural helpers/systems

Total possible = 4 Total obtained = ______

Total possible services = 13 Total obtained = ______

Relationship to community

______ Agency operated by minority community

______ Agency in minority community 

______ Easy access

______ Uses existing minority community facilities

______ Agency ties to minority community

______ Community advocate for services

______ Community as adviser 

______ Community as evaluator

Total possible = 8 Total obtained = ______

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Appendix C—Tools for Assessing Cultural Competence

Training

______ In-service training for minority staff

______ In-service training for nonminority staff

Total possible = 2 Total obtained = ______

Evaluation

______ Evaluation plan/tool

______ Clients as evaluators/planners

Total possible = 2 Total obtained = ______

Enhanced National Standards for Culturally and Linguistically 

Appropriate Services in Health and Health Care

The standards presented in this section were developed by the Office of Minority Health (OMH

2013) in the Centers for Disease Control and Prevention (CDC) and are available online 

(https://www.thinkculturalhealth.hhs.gov/pdfs/EnhancedNationalCLASStandards.pdf). This 

section is reproduced from material in the public domain. Note that the Centers for Medicare 

and Medicaid Services (CMS) have also developed tools to assess linguistic competence and 

interpreter services as well as guidelines for planning culturally responsive services (see the CMS

Web site at http://www.cms.gov). The National Standards for Culturally and Linguistically 

Appropriate Services (CLAS) are meant to advance health equity, improve quality, and help eliminate health disparities by establishing a blueprint for health and health care organizations to:

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. 

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Improving Cultural Competence

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. 

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.

The Organizational Cultural Competence Assessment Profile

The Health Resources and Services Administration (HRSA) developed the Organizational 

Cultural Competence Assessment Profile from the cultural competence literature, guided by a 

team of experts. The profile was used during site visits to a variety of healthcare settings. It is an 

organizing framework and set of specific indicators to assist in examining, demonstrating, and 

documenting cultural responsiveness in organizations involved in the direct delivery of health care 

and services. The profile is not intended to be prescriptive; rather, it is designed to be adapted, 

modified, or applied in ways that best fit within an organization’s context. The profile is presented 

as a matrix that classifies indicators by critical domains of organizational functioning and by 

whether the indicators relate to the structures, processes, outputs, or outcomes of the organization. 

The indicators suggest that assessment of cultural competence should encompass both qualitative 

and quantitative data and evaluate progress toward achieving results, not just the end results. Although the profile can be used in whole or in part, the full application enables an organization to 

assess its level of cultural competence comprehensively. Adapted here from material in the public 

domain are the matrices for process and capacity/structure measures. For more information, see

http://www.hrsa.gov/culturalcompetence/ healthdlvr.pdf. 

Sample of Process Measures by Domain 

Domain Topic Areas Measures/Indicators

Communication Interpreter Yearly updated directory of trained interpreters is available within 

24 hours for routine situations and within 1 hour or less for urgent 

situations.

Communication Interpreter Percentage of clients with limited English proficiency who have 

access to bilingual staff or interpretation services.

(Continued on the next page.)

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Appendix C—Tools for Assessing Cultural Competence

Sample of Process Measures by Domain (continued)

Domain Topic Areas Measures/Indicators

Communication Linguistically 

competent 

organization

Number of trained translators and interpreters available 

Number of staff proficient in languages of the community

Communication Language 

ability, 

written and 

oral, of the 

consumer

Consumer reading and writing levels of primary languages and 

dialects is recorded.

Policies and 

procedures

Choice of 

health plan 

network

Contract continuation and renewal with health plan is contingent 

upon successful achievement of performance targets that demonstrate effective service, equitable access, and comparability of 

benefits for populations of racial/ethnic groups.

Policies and 

procedures

Staff hiring, 

recruitment

Number of multilingual/multicultural staff 

Ratio by culture of staff to clients

Family and 

community 

participation

Community 

and 

consumer 

participation

Degree to which families participate in key decisionmaking activities: 

• Family participation on advisory committees or task forces 

• Hiring of family members to serve as consultants to providers/programs 

• Inclusion of family members in planning, implementation, and 

evaluation of activities

Communication Translated 

materials

Allocated resources for interpretation and translation services for 

medical encounters and health education/promotion material.

Communication Linguistic 

capacity of 

the provider

Ability to conduct audit of the provider network, which includes the 

following components:

• Languages and dialects of community available at point of first 

contact. 

• Number of trained translators and interpreters available. 

• Number of clinicians and staff proficient in languages of the 

community.

Communication Provide 

information, 

education

• Organization has the capacity to disseminate information on 

health care plan benefits in languages of community. 

• Organization has the capacity to disseminate information and 

explanation of rights to enrollees.

Policies and 

procedures

Grievance 

and conflict 

resolution

Organization has structures in place to address cross-cultural ethical and legal conflicts in health care delivery and complaints or 

grievances by patients and staff about unfair, culturally insensitive, 

or discriminatory treatment, or difficulty in accessing services or 

denial of services.

Policies and 

procedures

Grievance 

and conflict 

resolution

Organization has feedback mechanisms in place to track number of 

grievances and complaints and number of incidents.

Policies and 

procedures

Planning 

and governance

Composition of the governing board, advisory committee, other 

policymaking and influencing groups, and consumers served reflects service area demographics.

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Improving Cultural Competence

Multiculturally Competent Service System Assessment Guide 

Reproduced with permission from The Connecticut Department of Children and Families, 

Office of Multicultural Affairs (2002). 

Instructions: Rate your organization on each item in Sections I through VIII using the following 

scale: 

1 2 3 4 5 

Not at all To a moderate degree To a great degree 

Suggested Rating Interpretations: 

#1 and #2: “Priority Concerns”; #3: “Needs Improvement”; #4 and #5: “Adequate” 

When you have rated all items and assessed each section, please follow the instructions in Section IX to make an assessment of your program or agency and then formulate a culturally competent plan that addresses the need you feel is a priority. 

I. Agency demographic data (assessment) 

A culturally competent agency uses basic demographic information to assess and determine the 

cultural and linguistic needs of the service area. 

____ Have you identified the demographic composition of the program’s service area (from 

recent census data, local planning documents, statement of need, etc.) which should include ethnicity, race, and primary language spoken as reported by the individuals? 

____ Have you identified the demographic composition of the persons served? 

Sample of Capacity/Structure Measures by Domain

Domain Topic Areas Measures/Indicators

Facility characteristics, capacity, and 

infrastructure

Available and 

accessible 

services

• Transportation is available from residential areas to culturally 

competent providers.

• Organization has the flexibility to conduct home visits and 

community outreach.

• Culturally responsive services are available evenings and 

weekends.

Facility characteristics, capacity, and 

infrastructure

Information 

systems

Capacity for tracking of access and utilization rates for population of different racial/ethnic groups in comparison to the 

overall service population.

Monitoring, 

evaluation, and 

research

Organizational 

assessment

Ability to conduct ongoing organizational self-assessments of 

cultural and linguistic competence and integration of measures 

of access, satisfaction, quality, and outcomes into other organizational internal audits and performance improvement programs.

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Appendix C—Tools for Assessing Cultural Competence

____ Have you identified the staff composition (ethnicity, race, language capabilities) in relation to the demographic composition of your service area? 

____ Have you compared the demographic composition of the staff with the client demographics? 

II. Policies, procedures and governance

A culturally competent agency has a board of directors, advisory committee, or policy-making 

group that is proportionally representative of the staff, client/consumers, and community. 

____ Has your organization appointed executives, managers, and administrators who take 

responsibility for, and have authority over, the development, implementation, and monitoring of the cultural competence plan? 

____ Has your organization’s director appointed a standing committee to advise management 

on matters pertaining to multicultural services? 

____ Does your organization have a mission statement that commits to cultural competence and 

reflects compliance with all federal and state statutes, as well as any current Connecticut 

Commission on Human Rights and Opportunities nondiscriminatory policies and affirmative action policies? 

____ Does your organization have culturally appropriate policies and procedures communicated orally and/or written in the principal language of the client/consumer to address confidentiality, individual patient rights and grievance procedures, medication fact sheets,

legal assistance, etc. as needed and appropriately? 

III. Services/programs 

A culturally competent agency offers services that are culturally competent and in a language that 

ensures client/consumer comprehension. 

A. Linguistic and communication support

____ Has the program arranged to provide materials and services in the language(s) of limited 

English-speaking clients/consumer (e.g., bilingual staff, in-house interpreters, or a contract with outside interpreter agency and/or telephone interpreters)? 

____ Do medical records indicate the preferred languages of service recipients? 

____ Is there a protocol to handle client/consumer/family complaints in languages other than 

English? 

____ Are the forms that client/consumers sign written in their preferred language? 

____ Are the persons answering the telephones, during and after-hours, able to communicate 

in the languages of the speakers? 

____ Does the organization provide information about programs, policies, covered services, and 

procedures for accessing and utilizing services in the primary language(s) of client/consumers and families? 

____ Does the organization have signs regarding language assistance posted at key locations? 

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Improving Cultural Competence

____ Are there special protocols for addressing language issues at the emergency room, treatment rooms, intake, etc.? 

____ Are cultural and linguistic supports available for clients/consumers throughout different 

service offerings along the service continuum? 

B. Treatment/rehabilitation planning 

____ Does the program consider the client/consumer’s culture, ethnicity and language in treatment planning (assessment of needs, diagnosis, interventions, discharge planning, etc.)?

____ Does the program involve client/consumers and family members in all phases of treatment, assessment, and discharge planning? 

____ Has the organization identified community resources (community councils, ethnic cultural social entities, spiritual leaders, faith communities, voluntary associations, etc.) that can 

exchange information and services with staff, client/consumers, and family members? 

____ Have you identified natural community healers, spiritual healers, clergy, etc., when appropriate, in the development and/or implementation of the service plan? 

____ Have you identified natural supports (relatives, traditional healers, spiritual resources, etc.) 

for purposes of reintegrating the individual into the community? 

____ Have you used community resources and natural supports to reintegrate the individual 

into the community? 

C. Cultural assessments 

____ Is the client/consumer’s culture/ethnicity taken into account when formulating a diagnosis or assessment? 

____ Are culturally relevant assessment tools utilized to augment the assessment/diagnosis 

process?

___ Is the client/consumer’s level of acculturation identified, described, and incorporated as 

part of cultural assessment? 

____ Is the client/consumer’s ethnicity/culture identified, described, and incorporated as part of

cultural assessment? 

D. Cultural accommodations 

____ Are culturally appropriate, educative approaches, such as films, slide presentations, or 

video tapes, utilized for preparation and orientation of client/consumer family members 

to your program?

____ Does your program incorporate aspects of each client/consumer’s ethnic/cultural heritage 

into the design of specialized interventions or services? 

____ Does your program have ethnic/culture-specific group formats available for engagement, 

treatment, and/or rehabilitation? 

____ Is there provider collaboration with natural community healers, spiritual healers, clergy, 

etc., where appropriate, in the development and/or implementation of the service plan?

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Appendix C—Tools for Assessing Cultural Competence

E. Program accessibility 

____ Do persons from different cultural and linguistic backgrounds have timely and convenient 

access to your services? 

____ Are services located close to the neighborhoods where persons from different cultures 

and linguistic backgrounds reside? 

____ Are your services readily accessible by public transportation? 

____ Do your programs provide needed supports to families of clients/consumers (e.g., meeting

rooms for extended families, child support, drop-in services)? 

____ Do you have services available during evenings and weekends? 

IV. Care management 

____ Does the level and length of care meet the needs for clients/consumers from different 

cultural backgrounds? 

___ Is the type of care for clients/consumers from different backgrounds consistently and 

effectively managed according to their identified cultural needs? 

____ Is the management of the services for people from different groups compatible with their 

ethnic/cultural background? 

V. Continuity of care 

____ Do you have letters of agreement with culturally oriented community services and organizations? 

____ Do you have integrated, planned, transitional arrangements between one service modality 

and another? 

____ Do you have arrangements, financial or otherwise, for securing concrete services needed 

by clients/consumers (e.g., housing, income, employment, medical, dental, other emergency personal support needs)?

VI. Human resources development 

A culturally competent agency implements staff training and development in cultural competence at all levels and across all disciplines, for leadership and governing entities as well as for 

management, supervisory, treatment, and support staff. 

____ Are the principles of cultural competence (e.g., cultural awareness, language training, 

skills training in working with diverse populations) included in staff orientation and ongoing training programs? 

____ Is the program making use of other programs or organizations that specialize in serving 

persons with diverse cultural and linguistic backgrounds as a resource for staff education 

and training? 

____ Is the program maximizing recruitment and retention efforts for staff who reflect the 

cultural and linguistic diversity of populations needing services? 

____ Has the staff’s training needs in cultural competence been assessed? 

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Improving Cultural Competence

____ Has the staff attended training programs on cultural competence in the past two years? 

Describe:___________________________________________________________ 

___________________________________________________________________ 

VII. Quality monitoring and improvement 

A culturally competent agency has a quality monitoring and improvement program that ensures 

access to culturally competent care. 

____ Does the quality improvement (QI) plan address the cultural/ethnic and language needs? 

____ Are client/consumers and families asked whether ethnicity/culture and language are appropriately addressed in order to receive culturally competent services in the organization?

____ Does the organization maintain copies of minutes, recommendations, and accomplishments of its multicultural advisory committee? 

____ Is there a process for continually monitoring, evaluating, and rewarding the cultural competence of staff? 

VIII. Information/management system 

____ Does the organization monitor, survey, or otherwise access, the QI utilization patterns, 

Against Medical Advice (AMA) rates, etc., based on the culture/ethnicity and language? 

____ Are client/consumer satisfaction surveys available in different languages in proportion to 

the demographic data? 

____ Are there data collection systems developed and maintained to track clients/consumers by 

demographics, utilization and outcomes across levels of care, transfers, referrals, readmissions, etc.? 

IX. Formulating a culturally competent plan based on the assessment of your 

program or agency

Focus on the following critical areas of concern as you develop goals for a culturally competent 

plan for your agency’s service system. 

Access: Degree to which services to persons are quickly and readily available. 

Engagement: The skill and environment to promote a positive personal impact on the quality of 

the client’s commitment to be in treatment. 

Retention: The result of quality service that helps maintain a client in treatment with continued 

commitment. 

Based on an assessment of your agency, determine whether, in your initial plan, you need to direct 

efforts of developing cultural competency toward one, or a combination, of the above critical 

areas. Then, structure your agency’s cultural competence plan using the following instructions: 

1. Based on the results of this assessment, summarize and describe your organization’s perceived 

strengths in providing services to persons from different cultural groups. Please provide 

specific examples. Attach supporting documentation (e.g., Data, Policies, Procedures, etc.) 

272
Appendix C—Tools for Assessing Cultural Competence

2. Based on your assessment, summarize and describe your organization’s primary areas considered either “Priority Concerns” (#1 and/or #2), or “Needs Improvement” (#3) in providing services to persons from different cultural groups. 

3. Based on your organization’s strengths and needs, prioritize both the organizational goals 

and objectives addressed in your cultural competence plan. Describe clearly what you will 

do to provide services to persons who are culturally and linguistically different. 

4. Using the developed goals and objectives, please describe in detail the plans, activities, and/or 

strategies you will implement to assist your organization in meeting each of the goals and objectives indicated. 

Patient Satisfaction and Feedback on Clinical and Program 

Culturally Responsive Services

Iowa Cultural Understanding Assessment–Client Form

Please indicate your level of agreement with the statements below by circling the number to the 

right of the statement that best fits your opinion. All responses are confidential. When you have 

completed the survey, please either use the pre-addressed, stamped envelope to return the survey 

by mail or place it in the drop box at the facility. Thank you very much for your participation! 

Demographic Information 

What is your sex? ____Male ____Female 

What is your race? ____Alaskan Native ____American Indian ____Asian ____Black or African American 

 ____Native Hawaiian or other Pacific Islander ____White 

Are you Hispanic or Latino? ____Yes ____No

RESPONSE

STATEMENT

Strongly 

Disagree Disagree

Neither Agree 

Nor Disagree Agree

Strongly 

Agree

1. The staff here understands some of 

the ideas that I, my family, and others 

from my cultural, racial, or ethnic 

group may have.

1 2 3 4 5 

2. Staff here understands the importance of my cultural beliefs in my 

treatment process.

1 2 3 4 5 

3. The staff here listens to me and my 

family when we talk to them. 1 2 3 4 5 

4. If I want, the staff will help me get 

services from clergy or spiritual leaders. 1 2 3 4 5 

5. The services I get here really help 

me work toward things like getting a

job, taking care of my family, going to 

school, and being active with my 

friends, family, and community.

1 2 3 4 5 

(Continued on the next page.)

273
Improving Cultural Competence

Iowa Cultural Understanding Assessment–Client Form (continued)

RESPONSE

STATEMENT

Strongly 

Disagree Disagree

Neither Agree 

Nor Disagree Agree

Strongly 

Agree

6. The staff here seems to understand the experiences and problems I 

have in my past life.

1 2 3 4 5 

7. The waiting room and/or facility 

has pictures or reading material that 

show people from my racial or ethnic 

group.

1 2 3 4 5 

8. The staff here knows how to use 

their knowledge of my culture to 

help me address my current day-today needs.

1 2 3 4 5 

9. The staff here understands that I 

might want to talk to a person from 

my own racial or ethnic group about 

getting the help I want.

1 2 3 4 5 

10. The staff here respects my religious or spiritual beliefs. 1 2 3 4 5 

11. Staff from this program comes to 

my community to let people like me 

and others know about the services 

they offer and how to get them.

1 2 3 4 5 

12. The staff here asks me, my family, 

or others close to me to fill out forms 

that tell them what we think of the 

place and services.

1 2 3 4 5 

13. Staff here understands that 

people of my racial or ethnic group 

are not all alike.

1 2 3 4 5 

14. It was easy to get information I 

needed about housing, food, clothing, child care, and other social 

services from this place.

1 2 3 4 5 

15. The staff here talks to me about 

the treatment they will give me to 

help me.

1 2 3 4 5 

16. The staff here treats me with 

respect. 1 2 3 4 5 

17. The staff seems to understand 

that I might feel more comfortable 

working with someone who is the 

same sex as me.

1 2 3 4 5 

(Continued on the next page.)

274
Appendix C—Tools for Assessing Cultural Competence

Iowa Cultural Understanding Assessment–Client Form (continued)

RESPONSE

STATEMENT

Strongly 

Disagree Disagree

Neither Agree 

Nor Disagree Agree

Strongly 

Agree

18. Most of the time, I feel I can trust 

the staff here who work with me. 1 2 3 4 5 

19. The waiting room has brochures 

or handouts that I can easily understand that tell me about services I 

can get here.

1 2 3 4 5 

20. If I want, my family or friends are 

included in discussions about the 

help I need.

1 2 3 4 5 

21. The services I get here deal with 

the problems that affect my day-today life such as family, work, money, 

relationships, etc.

1 2 3 4 5 

22. Some of the staff here understand the difference between their 

culture and mine.

1 2 3 4 5 

23. Some of the counselors are from 

my racial or ethnic group. 1 2 3 4 5 

24. Staff members are willing to be 

flexible and provide alternative 

approaches or services to meet my 

cultural/ethnic treatment needs.

1 2 3 4 5 

25. If I need it, there are translators 

or interpreters easily available to 

assist me and/or my family.

1 2 3 4 5 

Source: White et al. 2009. Reproduced with permission.

275
Appendix D—Screening and 

Assessment Instruments

Important Note: The following tables provide an overview of selected instruments that 

screen and assess for substance use disorders 

and mental disorders and symptoms. These 

tables only represent a sample of instruments. 

In reviewing the tables, do not assume that the 

instruments have normative data across race 

and ethnicities. The citations and information 

listed in this appendix serve only as a starting 

point for investigating the appropriateness of 

available instruments within specific populations. Citations reflect information about the 

effectiveness of the testing measurements as 

well as research that suggests modifications or 

reports testing discrepancies among racial and 

ethnic populations.

Screening and Assessment Instruments for Substance Use Disorders

Instrument Description Clinical Utility

Alcohol, Smoking, and 

Substance Involvement 

Screening Test (ASSIST; 

Humeniuk et al. 2010)

The ASSIST (version 

3.1) has eight items 

to screen for use of 

tobacco products, 

alcohol, and drugs 

ASSIST was developed by the World Health 

Organization (WHO) as a culturally neutral tool for 

use in primary and general medical care settings. 

This paper-pencil instrument takes 5 to 10 minutes 

to complete and is designed to be administered by 

a health worker. ASSIST determines a risk score for 

each substance; the score starts a discussion with 

clients about their substance use. For information 

about the instrument and its availability in other 

languages, see http://www.who.int/substance_ 

abuse/activities/assist/en/ 

Alcohol Use Disorders 

Identification Test 

(AUDIT; Babor et al. 1992; 

Saunders et al. 1993)

This 10-item screening questionnaire 

was developed to 

identify people 

whose alcohol 

consumption is 

hazardous or harmful to their health.

The AUDIT was developed by WHO for use in 

multinational settings—the original sample included subjects from Australia, Bulgaria, Kenya, Mexico, 

Norway, and the United States (Allen et al. 1997; 

Saunders et al. 1993).

Populations researched: Latinos (Cherpitel 1999; 

Cherpitel and Bazargan 2003; Cherpitel and Borges 

2000; Frank et al. 2008; Reinert and Allen 2007; Volk 

et al. 1997), northern (Asian) Indians (Pal et al. 2004); 

Vietnamese (Giang et al. 2005); Brazilians (Lima et al. 

2005), and Nigerians (Adewuya 2005).

(Continued on the next page.)

277
Improving Cultural Competence

 

Screening and Assessment Instruments for Substance Use Disorders (continued)

Instrument Description Clinical Utility

Languages available in: Numerous languages, 

including Spanish (de Torres et al. 2009; MedinaMora et al. 1998), French (Gache et al. 2005), 

Mandarin and Cantonese (Leung and Arthur 2000), 

Nigerian languages (Adewuya 2005), Russian, 

German, and Korean (Kim et al. 2008).

Addiction Severity Index 

(McLellan et al. 1980). 

Available online at 

http://www.tresearch.org/

index.php/tools/downloadasi-instruments-manuals/

Currently in its 5th 

edition, this instrument assesses the 

severity of substance 

use disorders. It has 

200 items distributed 

over seven subscales. 

Populations researched: African Americans (Drake 

et al. 1995; Leonhard et al. 2000; McLellan et al. 

1985), and Northern Plains American Indians (Carise 

and McLellan 1999).

Languages available in: Numerous languages, 

including Spanish (Sandí Esquivel and Avila Corrales 

1990; for multimedia version see Butler et al. 2009), 

French (Daeppen et al. 1996; Krenz et al. 2004), 

Japanese (Haraguchi et al. 2009), and Chinese 

(Liang et al. 2008). 

Alcohol Use Disorder and 

Associated Disabilities 

Interview Schedule 

(AUDADIS; Grant and 

Hasin 1990). Available 

online at 

http://pubs.niaaa.nih.gov/ 

publications/audadis.pdf

This structured interview is administered 

by nonprofessional 

interviewers to diagnose substance use 

disorders and assess 

some co-occurring 

mental disorders. It 

evaluates acculturation 

and racial/ethnic 

orientation. Currently 

in its 4th edition 

(AUDADIS-IV).

The AUDADIS has been found reliable in large 

general-population studies (Grant et al. 1995; Ruan 

et al. 2008).

Populations researched: African Americans,

Latinos, Asians, and Native Americans (Canino et al. 

1999; Chatterji et al. 1997; Grant et al. 1995; Ruan 

et al. 2008).

Languages available in: Chinese and Spanish 

(Canino et al. 1999; Horton et al. 2000; Leung and 

Arthur 2000).

CAGE (Ewing 1984; Mayfield et al. 1974)This is a set of four 

questions used to 

detect possible 

alcohol use disorder.

Populations researched: African Americans 

(Cherpitel 1997; Frank et al. 2008); Latino (Saitz et 

al. 1999).

Languages available in: Numerous languages, 

including Spanish, Creole, Chinese, and Japanese.

Composite International 

Diagnostic InterviewSubstance Abuse Module 

(CIDI-SAM; Cottler 2000)

This structured, 

detailed interview 

diagnoses substance 

abuse and dependence; it is an expanded version of the 

substance use section 

of the CIDI.

The instrument has been well evaluated with international populations from a variety of different 

nations and found to have good reliability for most 

substances of abuse (Ustün et al. 1997).

Populations researched: African Americans (Horton 

et al. 2000) and Brazilians (Quintana et al. 2004; 2007).

Languages available in: Numerous languages, 

including Portuguese, Spanish, Arabic, Japanese, 

Vietnamese, and Malay.

(Continued on the next page.)

278
Appendix D—Screening and Assessment Instruments

Screening and Assessment Instruments for Substance Use Disorders (continued)

Instrument Description Clinical Utility

Drug Abuse Screening 

Test (DAST; Skinner 

1982)

This self-report 

instrument (10- and 

20-item versions) 

identifies people who 

are abusing psychoactive drugs and 

measures degree of 

related problems.

No significant differences in DAST reliability 

across race or cultural background were found 

(Yudko et al. 2007).

Languages available in: Numerous, including 

Spanish for the 10-item DAST (DAST-10; Bedregal 

et al. 2006), Portuguese, Hebrew, Arabic, and 

Thai.

Rapid Alcohol Problems Screen (RAPS; 

Cherpitel 1995, 2000)

The RAPS is a fivequestion test (also 

available in a newer 

four-item version, 

the RAPS-4) that 

combines optimal 

questions from other 

instruments.

The RAPS has high sensitivity across both ethnicity 

and gender (Cherpitel 1997; 2002). It has also 

been found to work significantly better than the 

AUDIT for screening African American and Latino 

men and to be on par with the AUDIT for women 

(Cherpitel and Bazargan 2003).

Populations researched: Mexican Americans 

(Borges and Cherpitel 2001); residents of various 

countries (Argentina, Belarus, Brazil, Canada, 

China, Czech Republic, India, Mexico, 

Mozambique, Poland, South Africa, and Sweden; 

Cherpitel et al. 2005).

Languages available in: Numerous, including 

Spanish, Chinese, and Portuguese.

Short Michigan Alcohol 

Screening Test (SMAST; Selzer et al. 

1975)

The S-MAST screens 

for alcohol use 

disorder.

Populations researched: African Americans, Arab 

Muslims, American Indians, Asian Indians, and 

Thai (Al-Ansari and Negrete 1990; Pal et al. 2004; 

Nanakorn et al. 2000; Robin et al. 2004).

Languages available in: Numerous, including 

Spanish, French, Thai, and Asian Indian languages.

TWEAK (Russell 1994) TWEAK is a five-item 

screening instrument 

originally created to 

screen for risky 

drinking during 

pregnancy (but has 

been validated for a 

range of male and 

female populations).

Populations researched: Mexican Americans 

(Borges and Cherpitel 2001) and African 

Americans (Cherpitel 1997).

Languages available in: Spanish (Cremonte and 

Cherpitel 2008).

279
Improving Cultural Competence

Screening and Assessment Instruments for Mental Disorders and Symptoms

Instrument Description Clinical Utility With Specific Racial/Ethnic Groups

Beck Anxiety Inventory (BAI; Beck and 

Steer 1990)

The BAI is a 21-item 

scale that distinguishes 

anxiety from depression.

Populations researched: African Americans 

(Chapman et al. 2009). 

Languages available in: Numerous languages, 

including Spanish (Novy et al. 2001), Arabic, 

Chinese, Farsi, Korean, and Turkish.

Beck Depression 

Inventory (BDI) and 

Beck Depression 

Inventory, 2nd Edition (BDI-II; Beck et al. 

1996)

The BDI is a 21-item 

instrument used to 

assess the intensity of 

depression.

Several versions of the BDI are available with cultural specificity. 

Populations researched: African Americans (Dutton 

et al. 2004; Grothe et al. 2005; Joe et al. 2008), 

Asian Americans (Carmody 2005; Crocker et al. 

1994), Hmong (Mouanoutoua et al. 1991), Mexican 

Americans (Gatewood-Colwell et al. 1989), and 

Latinos (Contreras et al. 2004).

Languages available in: Numerous, including 

Spanish (Azocar et al. 2001; Bonilla et al. 2004; 

Carmody 2005; Wiebe and Penley 2005), Chinese 

(Yeung et al. 2002; Zheng and Lin 1991), French, 

Arabic (Abdel-Khalek 1998; Alansari 2006), Hebrew, 

and Farsi (Ghassemzadeh et al. 2005).

Center for Epidemiological StudiesDepression Scale

(CES-D; Radloff 1977)

The CES-D is a 20-item 

self-report scale designed to measure 

depressive symptoms.

May underestimate symptoms in African Americans 

(Bardwell and Dimsdale 2001; Cole et al. 2000).

Populations researched: Latinos (Batistoni et al. 

2007; Garcia and Marks 1989; Posner et al 2001; 

Reuland et al. 2009; Roberts et al.1990), Asian 

Indians (Diwan et al. 2004; Gupta et al. 2006), 

Native Americans (Chapleski et al. 1997), and 

African Americans (Canady et al. 2009; Makambi et 

al. 2009; Nguyen et al. 2004).

Languages available in: Numerous languages, 

including Spanish (Reuland et al. 2009), Chinese (Lin 

1989), Greek, Korean, and Portuguese.

Geriatric Depression 

Scale (Sheikh and 

Yesavage 1986)

Available in 30- and 15-

item forms, this instrument screens for depression in older adults.

Populations researched: Latinos (Reuland et al. 

2009) and Asians (Broekman et al. 2008; Nyunt et 

al. 2009).

Languages available in: Available in 30 languages 

and validated with a number of different populations (available online at http://www.stanford.edu/ 

~yesavage/GDS.html).

Millon Clinical Multiaxial Inventory-III 

(Millon et al. 2009)

Assesses 13 personality 

disorders (DSM-III-R 

Axis II disorders) and 9 

clinical syndromes 

(DSM-III-R Axis I disorders); includes scales to 

assess substance related problems.

Populations researched: African Americans (Calsyn 

et al.1991; Craig and Olson 1998) and Latinos 

(Fernández-Montalvo et al. 2006).

Languages available in: Multiple languages, including Spanish, Korean, Cantonese, and Portuguese.

(Continued on the next page.)

280
Appendix D—Screening and Assessment Instruments

 

Instruments To Screen and Assess Mental Disorders and Symptoms (continued)

Minnesota Multiphasic 

Personality Inventory, 

2nd Edition (MMPI-2) 

(Butcher et al. 1989)

The MMPI-2 

measures personality traits and symptom patterns.

Normed for Asian Americans, African Americans, 

Latinos, and American Indians (Hathaway et al.1989).

Populations researched: African Americans (Castro 

et al. 2008; McNulty et al. 2003; Monnot et al. 2009; 

Whatley et al. 2003) and Asian Americans (Tsai and 

Pike 2000; Tsushima and Tsushima 2009).

Languages available in: Numerous, including 

French, Hmong, and Spanish (Velasquez et al. 2000).

Mini International 

Neuropsychiatric Interview (M.I.N.I.; Sheehan 

et al. 1998)

This is a short, 

structured, diagnostic interview that 

assesses the most 

common mental 

disorders (including 

substance use 

disorders).

Populations researched: African Americans (Black 

et al. 2004).

The Major Depressive Episode and Posttraumatic 

Stress Disorder (PTSD) sections of the M.I.N.I. 

have been adapted for use in screening for PTSD 

in refugees, and found effective across cultures in 

a multinational sample (Eytan et al. 2007).

Languages available in: Over 43 languages, 

including French, Italian (Rossi et al. 2004), 

Japanese (Otsubo et al. 2005), Spanish, Italian, 

and Arabic (Amorim et al. 1998; Lecrubier et al. 

1997; Sheehan et al. 1997, 1998).

Schedules for Clinical 

Assessment in Neuropsychiatry, 2nd Version 

(SCAN-2; Wing et al. 

1998)

The SCAN-2 is a set 

of instruments that 

measure psychopathology and 

behavior associated 

with major mental 

disorders.

Populations researched: The SCAN-2 was developed by WHO with an international sample that 

included participants from Turkey, Greece, India, 

the United States, Nigeria, Romania, Mexico, 

Spain, and South Korea and is intended to be 

cross-culturally appropriate (Room et al. 1996). 

Languages available in: Chinese (Cheng et al. 

2001), Danish, Dutch, English, French, German, 

Greek, Italian, Kannada, Portuguese, Spanish, 

Thai, Turkish, and Yoruba.

Symptom Checklist-90-

R (SCL-90R; Derogatis 

1992)

This 90-item checklist evaluates psychiatric symptoms 

and their intensity in 

nine different categories and screens 

for a broad range of 

mental disorders.

The SCL-90R has been normed for adult inpatient 

and outpatient psychiatric patients and adult and 

adolescent nonpatients across a number of ethnic 

groups (Derogatis 1992).

Populations researched: Latinos (Martinez et al. 

2005) and African Americans (Ayalon and Young 

2009).

Languages available in: Spanish, French, 

Armenian, and Persian.

281
Appendix E—Cultural Formulation 

in Diagnosis and Cultural Concepts 

of Distress

Cultural Formulation in 

Diagnosis

Clinicians need to consider the effects of culture when diagnosing clients. The following 

cultural formulation adopted by the American 

Psychiatric Association (APA) in the Diagnostic 

and Statistical Manual of Mental Disorders, Fifth 

Edition (DSM-5; 2013, pp. 749–759) provides 

a systematic outline for incorporating culturally 

relevant information when conducting a multiaxial diagnostic assessment. Whether or not 

they are credentialed to diagnose disorders, 

counselors and other clinical staff can use the 

main content areas listed below to guide the 

interview, initial intake, and treatment planning 

processes. (For review, see Mezzich and Caracci 

2008; for Native American application, specifically Lakota, refer to Brave Heart 2001.) 

1. Cultural identity of the person. Note the 

person’s ethnic or cultural reference groups. For 

immigrants and ethnic minorities, also note

degree of involvement with culture of origin 

and host culture (where applicable). Also note 

language ability, use, and preference (including 

multilingualism).

2. Cultural explanations of the person’s 

illness. Identify the following: the predominant idioms of distress through which symptoms or the need for social support are communicated (e.g., “nerves,” possessing spirits, 

somatic complaints, inexplicable misfortune), 

the meaning and perceived severity of the 

individual’s symptoms in relation to norms of 

the cultural reference group, any local illness 

category used by the individual’s family and 

community to identify a condition (see the 

“Cultural Concepts of Distress” section of this 

appendix), the perceived causes or explanatory 

models that the individual and the reference 

group use to explain the illness, and current 

preferences for and past experiences with 

professional and popular sources of care.

3. Cultural factors related to psychosocial 

environment and level of functioning. Note 

culturally relevant interpretations of social 

stressors, available social supports, and levels of 

functioning and disability, including stresses in 

the local social environment and the role of 

religion and kin networks in providing emotional, instrumental, and informational support.

4. Cultural elements of the relationship 

between client and clinician. Indicate differences in culture and social status between 

client and clinician, as well as any problems 

these differences may cause in diagnosis and 

283
Improving Cultural Competence

treatment (e.g., difficulty communicating in 

the client’s first language, eliciting symptoms 

or understanding their cultural significance, 

negotiating an appropriate relationship or level 

of intimacy, determining whether a behavior is 

normative or pathological).

5. Overall cultural assessment for diagnosis 

and care. Conclude cultural formulation by 

discussing how cultural considerations specifically influence comprehensive diagnosis and 

care.

Cultural Concepts of 

Distress

Just as standard screening instruments can 

sometimes be of limited use with culturally 

diverse populations, so too are standard diagnoses. Expressions of psychological problems 

are, in part, culturally specific, and behavior 

that is aberrant in one culture can be standard 

in another. For example, seemingly paranoid 

thoughts are to be expected in clients who 

have migrated from countries with oppressive 

governments. Culture plays a large role in 

understanding phenomena that might be 

construed as mental illnesses in Western 

medicine. These cultural concepts of distress 

may or may not be linked to particular DSM5 diagnostic criteria (APA 2013). The table 

that follows lists DSM-5 cultural concepts of 

distress; other concepts exist that are not

recognized in DSM-5. 

DSM-5 Cultural Concepts of Distress 

Syndrome Description Populations

Ataque de 

nervios

Commonly reported symptoms include uncontrollable shouting, 

attacks of crying, trembling, heat in the chest rising into the head, 

and verbal or physical aggression. Dissociative experiences, seizurelike or fainting episodes, and suicidal gestures are prominent in 

some attacks but absent in others. A general feature of an ataque 

de nervios is a sense of being out of control. Ataques de nervios 

frequently occur as a direct result of a stressful event relating to the 

family (e.g., death of a close relative, separation or divorce from a 

spouse, conflict with spouse or children, or witnessing an accident 

involving a family member). People can experience amnesia for 

what occurred during the ataque de nervios, but they otherwise 

return rapidly to their usual level of functioning. Although descriptions of some ataques de nervios most closely fit with the DSM-IV 

description of panic attacks, the association of most ataques with a 

precipitating event and the frequent absence of the hallmark symptoms of acute fear or apprehension distinguish them from panic 

disorder. Ataques range from normal expressions of distress not 

associated with a mental disorder to symptom presentations associated with anxiety, mood dissociative, or somatoform disorders.

Caribbean, 

Latin 

American, 

Latin 

Mediterranean

Dhat (jiryan 

in India, skra 

prameha in 

Sri Lanka,

shen-k’uei in 

China)

A folk diagnosis for severe anxiety and hypochondriacal concerns 

associated with the discharge of semen, whitish discoloration of 

the urine, weakness, and exhaustion.

Asian Indian

(Continued on the next page.)

284
Appendix E—Cultural Formulation in Diagnosis and Cultural Concepts of Distress

DSM-5 Cultural Concepts of Distress (continued)

Nervios Refers both to a general state of vulnerability to stress and to a 

syndrome evoked by difficult life circumstances. Nervios includes a 

wide range of symptoms of emotional distress, somatic disturbance, and inability to function. Common symptoms include headaches and “brain aches,” irritability, stomach disturbances, sleep 

difficulties, nervousness, tearfulness, inability to concentrate, 

trembling, tingling sensations, and mareos (dizziness with occasional vertigo-like exacerbations). Nervios tends to be an ongoing 

problem, although it is variable in the degree of disability manifested. Nervios is a broad syndrome that ranges from cases free of 

a mental disorder to presentations resembling adjustment, anxiety, depressive, dissociative, somatoform, or psychotic disorders. 

Differential diagnosis depends on the constellation of symptoms, 

the kind of social events associated with onset and progress, and 

the level of disability experienced.

Latin 

American

Shenjing 

shuairuo

A condition characterized by physical and mental fatigue, headaches, difficulty concentrating, dizziness, sleep disturbance, and 

memory loss. Other symptoms include gastrointestinal problems, 

sexual dysfunction, irritability, excitability, and autonomic nervous 

system disturbances.

Chinese

Susto 

(espanto, 

pasmo, tripa 

ida, perdida 

del alma, or 

chibih) 

An illness attributed to a frightening event that causes the soul to 

leave the body and results in unhappiness and sickness. Individuals 

with susto also experience significant strains in key social roles. 

Symptoms can appear days or years after the fright is experienced. In extreme cases, susto can result in death. Typical symptoms include appetite disturbances, inadequate or excessive 

sleep, troubled sleep or dreams, sadness, lack of motivation, and 

feelings of low self-worth or dirtiness. Somatic symptoms accompanying susto include muscle aches and pains, headache, stomachache, and diarrhea. Ritual healings focus on calling the soul 

back to the body and cleansing the person to restore bodily and 

spiritual balance. Susto can be related to major depressive disorder, posttraumatic stress disorder, and somatoform disorders.

Similar etiological beliefs and symptom configurations are found in 

many parts of the world.

Latino 

American, 

Mexican, 

Central and 

South 

American

Taijin 

kyofusho

This syndrome refers to an individual’s intense fear that his or her 

body, its parts, or its functions displease, embarrass, or are offensive to other people in appearance, odor, facial expressions, or 

movement. This syndrome is included in the official Japanese 

diagnostic system for mental disorders.

Japanese

Source: APA 2013. Used with permission.

285
.

Appendix F—Cultural Resources

General Resources

Addiction Technology Transfer 

Centers 

http://www.nattc.org

The Addiction Technology Transfer Centers 

Network identifies and advances opportunities 

for improving substance abuse treatment. The 

Network comprises 14 regional centers as well 

as a national office serving the United States 

and its territories. Regional centers cater to

unique needs in their areas while supporting 

national initiatives. Improving cultural competence is a major focus for the Network, which 

seeks to improve substance abuse treatment by 

identifying standards of culturally competent 

treatment and generating ways to foster their 

adoption in the field. 

Agency for Healthcare Research 

and Quality–Minority Health

http://www.ahrq.gov/research/findings/factsh

eets/minority/index.html

This site provides research findings, papers, and 

press releases related to minority health.

American Translators Association

http://www.atanet.org

The American Translators Association (ATA)

offers a certification program that evaluates 

the competence of translators according to 

guidelines that reflect current professional 

practice. The ATA also has online directories 

available. The Directory of Translation and 

Interpreting Services is an online directory of 

individual translators and interpreters. The 

Directory of Language Services Companies is 

a directory of companies that offer translating 

or interpreting services.

Center for Research on Ethnicity, 

Culture, and Health

http://www.crech.org

Established in 1998 in the University of 

Michigan’s School of Public Health, the Center

provides a forum for basic and applied public 

health research on relationships among ethnicity, culture, socioeconomic status, and 

health. It develop new interdisciplinary 

frameworks for understanding these relationships while promoting effective collaboration 

among public health academicians, healthcare 

providers, and communities to reduce racial 

and ethnic disparities in health care.

Community Toolbox: Cultural 

Competence in a Multicultural 

World

http://ctb.ku.edu/en/table-ofcontents/culture/cultural-competence

The cultural competence section of this Web 

site provides information (including examples 

and links) on a number of relevant topics, such 

287
Improving Cultural Competence

as how to build relationships with people from 

different cultures, reduce prejudice and racism, 

build organizations and communities that are 

responsive to people from diverse cultures, and 

heal the effects of internalized oppression.

The Cross Cultural Health Care 

Program 

http://www.xculture.org

Since 1992, the Cross Cultural Health Care 

Program (CCHCP) has been addressing 

broad cultural issues that affect the health of 

individuals and families in ethnic minority 

communities in Seattle and nationwide. 

Through a combination of cultural competency trainings, interpreter trainings, research 

projects, community coalition building, and 

other services, CCHCP serves as a bridge 

between communities and healthcare institutions to ensure full access to quality health care 

that is culturally and linguistically appropriate.

Cultural Competence Standards in 

Managed Care Mental Health 

Services

Western Interstate Commission for Higher 

Education. Cultural Competence Standards in 

Managed Mental Health Care for Four Underserved/Underrepresented Racial/Ethnic Groups.

Boulder, CO: Western Interstate Commission 

for Higher Education, 1998. 

The Center for Mental Health Services 

(CMHS) presents cultural competence standards for managed care mental health services to 

improve the availability of high-quality services 

for four underserved and/or underrepresented

racial and ethnic groups—African Americans, 

Latinos, Native Americans, and Asian/Pacific 

Islander Americans. With help from the 

Western Interstate Commission for Higher 

Education Mental Health Program, CMHS 

convened national panels representing each 

major racial/ethnic group. Mental health 

professionals, families, and consumers on the 

panels prepared the document.

http://www.diversityrx.org

This Web site offers resources relating to 

cross-cultural communication issues in 

healthcare settings and information on interpreter practice, legal issues relating to language 

barriers and access to linguistically appropriate 

services, and the ways language and culture 

can affect the use of healthcare services.

Health Resources and Services 

Administration Culture, Language 

and Health Literacy Page

http://www.hrsa.gov/culturalcompetence/

The Health Resources and Services 

Administration Culture, Language and Health 

Literacy Web site provides links to various

online resources relating to cultural competence in general and to providing culturally 

competent health care to a number of specific 

cultural/ethnic groups.

Instruments for Measuring 

Acculturation, University of 

Calgary

http://www.ucalgary.ca/~taras/_private/Accult

uration_Survey_Catalogue.pdf

This document gives information on acculturation and cultural identity measures, presenting many in full. It does not always include 

scoring information but typically provides

questions from each instrument.

Minority Health Project

http://www.minority.unc.edu/

The Minority Health Project (MHP) of the 

University of North Carolina’s Gillings School 

of Global Public Health seeks to improve the 

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Appendix F—General Resources

quality of racial and ethnic population data, to 

expand the capacity for conducting statistical 

research and developing research proposals on 

minority health, and to foster a network of 

researchers in minority health. MHP collaborates with the Center for Health Statistics 

Research, the University of North Carolina, the 

National Center for Health Statistics, and the 

Association of Schools of Public Health to 

conduct educational programs and provide 

information on minority health research and 

data sources.

National Center for Cultural 

Competence 

http://nccc.georgetown.edu

The National Center for Cultural Competence’s (NCCC) mission is to increase the 

capacity of health and mental health programs 

to design, implement, and evaluate culturally 

and linguistically responsive service delivery 

systems. NCCC conducts training, technical 

assistance, and consultation; participates in 

networking, linkages, and information exchange; and engages in knowledge and product development and dissemination.

The National Center on Minority 

Health and Health Disparities

http://www.ncmhd.nih.gov

The Center’s mission is to promote minority 

health and reduce health disparities. It is 

particularly useful as a resource for information about health disparities and the best 

methods to address them.

International MultiCultural 

Institute

http://www.imciglobal.org/

The International MultiCultural Institute 

(iMCI) works with individuals, organizations, 

and communities to create a society that is 

strengthened and empowered by its diversity.

iMCI’s initiatives aim to increase communication, understanding, and respect among people 

of diverse backgrounds and address systemic 

cultural issues facing our society. The Institute 

accomplishes this through its conferences, 

individualized organizational training and 

consulting interventions, publications, and 

leading-edge projects. 

Office of Civil Rights

http://www.hhs.gov/ocr/civilrights/resources/s

pecialtopics/lep/

The Office of Civil Rights of the U.S. 

Department of Health and Human Services 

investigates complaints, enforces rights, develops policies, and promulgates regulations to 

ensure compliance with nondiscrimination 

and health information privacy laws. The 

agency offers technical assistance and public 

education to ensure understanding of and 

compliance with these laws, including the 

provision of resources and tools to improve 

services for individuals with limited English 

proficiency. 

Office of Minority Health 

Resource Center 

http://minorityhealth.hhs.gov/

The Office of Minority Health (OMH) was 

established by the U.S. Department of Health 

and Human Services in 1985 to advise the 

Secretary and the Office of Public Health and 

Science on public health policies and programs 

affecting Native Americans, African Americans, Asian Americans, Latinos, and Native 

Hawaiians and other Pacific Islanders. The 

mission of OMH is to improve and protect the 

health of racial and ethnic minority populations 

through the development of policies and programs that will eliminate health disparities.

The OMH Resource Center (OMHRC) is a 

national resource and referral service for 

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Improving Cultural Competence

minority health issues. It collects and distributes information on various health topics,

including substance abuse, cancer, heart disease, violence, diabetes, HIV/AIDS, and 

infant mortality. OMHRC also facilitates 

information exchange on minority health 

issues, and offers customized database searches, publications, mailing lists, referrals, and 

the like regarding Native American, African 

American, Asian American, Pacific Islander, 

and Latino populations. 

Substance Abuse and Mental 

Health Services Administration 

http://store.samhsa.gov/

The Substance Abuse and Mental Health 

Services Administration (SAMHSA) is the 

Nation’s one-stop resource for information 

about substance abuse and mental illness 

prevention and behavioral health treatment. 

The SAMHSA Store Web site provides information on behavioral health topics such as 

cultural competence, healthcare-related laws, 

and mental health and substance abuse.

Surgeon General’s Report on 

Mental Health: Culture, Race, and 

Ethnicity

U.S. Department of Health and Human 

Services. Mental Health: Culture, Race, and 

Ethnicity. A Supplement to Mental Health: A 

Report of the Surgeon General. HHS Pub. No. 

SMA 01-3613. Rockville, MD: U.S. 

Department of Health and Human Services, 

Substance Abuse and Mental Health Services 

Administration, Center for Mental Health 

Services, 2001.

This report highlights the roles that culture 

and society play in mental health, mental 

illness, and the types of mental health services 

people seek. The report finds that, although 

effective, well-documented treatments for 

mental illnesses are available, minorities are 

less likely to receive quality care than the general population. It articulates the foundation for 

understanding relationships among culture, 

society, mental health, mental illness, and 

services, and also describes how these issues 

affect different racial and ethnic groups.

Stanford University Curriculum in 

Ethnogeriatrics

http://www.stanford.edu/group/ethnoger/

This online curriculum explores healthcare 

issues for older adults from a variety of cultural groups (with modules on African 

Americans, Latinos, Native Americans, and 

several Asian American populations).

African and Black

American Resources

Congressional Black Caucus 

Foundation Health

http://www.cbcfinc.org/what-wedo/researchandpolicy.html 

Congressional Black Caucus Foundation 

Health’s mission is to empower people of 

African descent to make better decisions 

about their health and that of their communities. The Web site provides information about 

public health issues, key legislation on public 

policy issues, health initiatives, and local 

events directly and indirectly relating to the 

health of people of African descent worldwide. It includes a section on substance abuse. 

National Black Alcoholism and 

Addictions Council, Inc. 

http://www.nbacinc.org

The National Black Alcoholism and Addictions 

Council, Inc. (NBAC) is a nonprofit, taxexempt organization of Black individuals 

concerned about alcoholism and drug abuse. 

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Appendix F—General Resources

NBAC educates the public about the prevention of alcohol and drug abuse and alcoholism 

and is committed to increasing services for 

persons who are dependent upon alcohol and 

their families, providing quality care and treatment, and developing research models designed 

for Blacks. NBAC helps Blacks concerned with 

or involved in the field of alcoholism and drugrelated issues to exchange ideas, offer services, 

and facilitate substance abuse treatment programs for Black Americans.

National Medical Association

http://www.nmanet.org

A professional and scientific organization 

representing the interests of more than 25,000 

physicians and their patients, the National 

Medical Association (NMA) is the collective 

voice of African American physicians and a 

leading force for parity and justice in medicine 

and health. Established in 1895, NMA aims 

to prevent diseases, disabilities, and adverse 

health conditions that disproportionately or 

differentially affect African American and 

underserved populations; improve quality and 

availability of health care for poor and underserved populations; and increase representation and contributions of African Americans 

in medicine. NMA provides educational 

programs and opportunities for scholarly 

exchange, conducts outreach to promote improved public health, and establishes national 

health policy agendas in support of African 

American physicians and their patients.

Asian American, Native 

Hawaiian, and Other 

Pacific Islander Resources

Asian and Pacific Islander 

American Health Forum

http://www.apiahf.org

The Asian and Pacific Islander American 

Health Forum (APIAHF) is a national advocacy organization that promotes policy, program, and research efforts to improve the 

health of Asian and Pacific Islander Americans.

APIAHF established the Asian and Pacific 

Islander Health Information Network 

(APIHIN) in 1995. APIHIN was developed 

as an integrated telecommunications infrastructure that gives Asians and Pacific Islanders access to health information and 

resources through local community access 

points and key provider intermediaries. The 

organization supports two mailing lists: APIHealthInfo, which concentrates on Asian and 

Pacific Islander American health, and APISAMH, which deals with issues related to 

behavioral health of special interest to the 

Asian and Pacific Islander community. 

National Asian American Pacific 

Islander Mental Health 

Association 

http://www.naapimha.org

The National Asian American Pacific Islander 

Mental Health Association (NAAPIMHA) 

evolved from an Asian American Pacific 

Islander Mental Health Summit sponsored by 

SAMHSA. NAAPIMHA focuses on five 

interrelated areas: enhancing collection of 

appropriate and accurate data; identifying 

current best practices and service models;

capacity building, including provision of technical assistance and training of service 

providers, both professional and paraprofessional; conducting research and evaluation; and 

working to engage consumers and families.

National Asian Pacific American 

Families Against Substance Abuse

http://www.napafasa.org

The National Asian Pacific American Families 

Against Substance Abuse is a nonprofit 

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Improving Cultural Competence

membership organization that addresses the 

alcohol, tobacco, and drug issues of Asian 

American and Pacific Islander populations; it 

involves providers, families, and youth in 

reaching Asian American and Pacific Islander 

communities to promote health and social 

justice and reduce substance abuse and related 

problems.

Psychosocial Measures for Asian 

American Populations: Tools for 

Direct Practice and Research

http://www.columbia.edu/cu/ssw/projects/pmap

This Web site presents information on psychosocial measures (including some related to 

substance abuse) found to be reliable and valid 

with Asian Americans (in general group or for 

a specific subgroup).

The Vietnamese Community 

Health Promotion Project

http://www.suckhoelavang.org/main.html

This project’s mission is to improve the health 

of Vietnamese Americans. A part of the University of California–San Francisco School of 

Medicine, the Web site provides information 

in Vietnamese and English, along with links 

to Vietnamese Web sites related to health 

issues.

Hispanic and Latino

Resources

Hispanic/Latino Portal to Drug 

Abuse Prevention

http://www.latino.prev.info

The Indiana University Prevention Resource 

Center created this trilingual Web site to serve 

the growing Latino population and those who 

work with Latinos. Many Latinos face a language barrier, as do many prevention professionals trying to address their needs. This Web 

site helps bridge the communication barrier by 

offering information about and links to resources for substance abuse prevention, general 

health information, building cultural pride, and 

research tools, such as databases and bibliographies.

National Alliance for Hispanic 

Health

http://www.hispanichealth.org

The National Alliance for Hispanic Health is 

the nation’s oldest and largest network of 

Hispanic health and human service providers. 

Alliance members deliver quality services to 

more than 12 million persons annually. As the 

nation’s action forum for Hispanic health and 

well-being, the programs of the Alliance 

inform and mobilize consumers, support 

providers in the delivery of quality care, promote appropriate use of technology, improve 

the science base for accurate decisionmaking, 

and promote philanthropy.

National Council of La Raza 

Institute for Hispanic Health

http://www.nclr.org/index.php/issues_and_pr

ograms/health_and_nutrition/hispanic_health

The Institute for Hispanic Health (IHH)

works closely with National Council of La 

Raza affiliates, government partners, private 

funders, and Latino-serving organizations to 

deliver quality health interventions and improve access to and use of quality health promotion and disease prevention programs. 

IHH provides culturally responsive and linguistically appropriate technical assistance and 

science-based approaches that emphasize 

public health, rather than disease-specific, 

themes. Themes include behavior change 

communication, healthy lifestyle promotion, 

improving access to quality services, and 

292
Appendix F—General Resources

increasing the number and level of Latinos in 

health fields.

National Hispanic Medical 

Association

http://www.nhmamd.org

Established in 1994, the National Hispanic 

Medical Association (NHMA) is a nonprofit 

association representing 36,000 licensed Hispanic physicians in the United States. Its 

mission is to improve the health of Latinos 

and other underserved populations. NHMA 

provides policymakers and healthcare providers with expert information and support in 

strengthening health service delivery to Latino 

communities across the Nation. Its agenda 

includes expanding access to quality health 

care; increasing medical education, cultural 

competence, and research opportunities for 

Latinos; and developing policy and education 

to eliminate health disparities for Latinos.

Native American

Resources

Centers for American Indian and 

Alaska Native Health

http://www.ucdenver.edu/academics/colleges/

PublicHealth/research/centers/ 

CAIANH/Pages/caianh.aspx

The Centers for American Indian and Alaska 

Native Health (CAIANH) at the University 

of Colorado, Denver promote the health and 

well-being of American Indians and Alaska 

Natives by pursuing research, training, continuing education, technical assistance, and information dissemination in a biopsychosocial 

framework that recognizes the unique cultural 

contexts of this special population. The site 

provides online access to the group’s journal, 

American Indian and Alaska Native Mental 

Health Research, as well as information about 

ongoing research projects.

Indian Health Service

http://www.ihs.gov

The Indian Health Service (IHS) is the principal federal healthcare provider and advocate 

for Native Americans; it ensures that comprehensive, culturally acceptable personal and 

public health services are available and accessible to Native peoples. Its Web site provides a 

tour of the IHS and its service areas, administrative reports, legislative news, IHS job opportunities, and healthcare resources targeted 

to this group.

National Indian Child Welfare 

Association

http://www.nicwa.org

The National Indian Child Welfare Association (NICWA), a comprehensive source of 

information on American Indian child welfare, 

works on behalf of Indian children and families to provide public policy, research, and 

advocacy; information and training on Indian 

child welfare; and community development 

services to Tribal governments and programs, 

State child welfare agencies, and other organizations, agencies, and professionals interested 

in Indian child welfare. NICWA addresses 

child abuse and neglect through training, 

research, public policy, and grassroots community development. NICWA also supports 

compliance with the Indian Child Welfare Act 

of 1978, which seeks to keep American Indian 

children with American Indian families.

One Sky Center 

http://www.oneskycenter.org

One Sky Center aims to improve prevention 

and treatment of substance abuse for Native 

peoples by identifying, promoting, and disseminating effective, evidence-based, culturally 

293
Improving Cultural Competence

appropriate substance abuse prevention and 

treatment services and practices for application across diverse Tribal communities. It also 

provides training, technical assistance, and 

products to expand the capacity and quality of 

substance abuse prevention and treatment 

services for this population. SAMHSA created, designed, and funds One Sky Center to 

work with all federal and state agencies 

providing services to Native Americans.

SAMHSA’s Tribal Training and 

Technical Assistance Center 

http://beta.samhsa.gov/tribal-ttac

The Tribal Training and Technical Assistance 

(TTA) Center uses a culturally relevant, evidence-based, holistic approach to support 

Native communities in their selfdetermination efforts through infrastructure

development and capacity building, as well as 

program planning and implementation. The 

Center provides TTA on mental and substance use disorders, bullying and violence, 

suicide prevention, and the promotion of 

mental health. It offers TTA to federally 

recognized tribes, other American Indian and 

Alaska Native communities, SAMHSA Tribal 

grantees, and organizations serving Indian 

Country. The Web site provides resources 

across behavioral health topics relevant to 

Native peoples. 

White Bison

http://www.whitebison.org/

This Web site offers resources related to the 

Wellbriety self-help movement for Native 

Americans, including a discussion board and 

access to the Wellbriety online magazine.

294
.

Appendix G—Glossary

Acculturation typically refers to the socialization process through which people from one 

culture adopt certain elements from the dominant culture in a society.

American Indian and Alaska Native people 

include those “having origins in any of the 

original peoples of North and South America 

(including Central America), and who maintain tribal affiliation or community attachment” (Grieco and Cassidy 2001, p. 2).

Asians are defined in the United States (U.S.)

Census as “people 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 (Grieco and 

Cassidy 2001, p. 2).

Biculturalism is “a well-developed capacity to 

function effectively within two distinct cultures based on the acquisition of the norms, 

values, and behavioral routines of the dominant culture” and one’s own culture (Castro 

and Garfinkle 2003, p. 1385).

Biracial individuals have two distinct racial 

heritages, either one from each parent or as a 

result of racial blending in an earlier generation (Root 1992).

Blacks/African Americans are, according to 

the U.S. Census Bureau (2000) definition, 

people whose origins are “in any of the black 

racial groups of Africa” (p. A-3). The term 

includes descendants of African slaves brought 

to this country against their will and more 

recent immigrants from Africa, the Caribbean, 

and South or Central America (many individuals from these latter regions, if they come 

from Spanish-speaking cultural groups, identify or are identified primarily as Latino). The 

term Black is often used interchangeably with 

African American, although for some, the 

term African American is used specifically to 

describe those individuals whose families have 

been in this country since at least the 19th 

century and thus have developed distinctly 

African American cultural groups. Black can 

be a more inclusive term describing African 

Americans as well as for more recent immigrants with distinct cultural backgrounds.

Confianza means trust or confidence in the 

benevolence of the other person.

Conformity in Helms’s model of racial identity development refers to the tendency of 

members of a racial group to behave in congruence with the values, beliefs, and attitudes 

of their own culture to which they have been 

exclusively exposed. 

Cultural competence is “a set of congruent 

behaviors, attitudes, and policies that . . . enable a system, agency, or group of professionals

to work effectively in cross-cultural situations” 

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Improving Cultural Competence

(Cross et al. 1989, p. 13). It refers to the 

ability to honor and respect the beliefs, languages, interpersonal styles, and behaviors of 

individuals and families receiving services, as 

well as staff members who are providing such 

services. “Cultural competence is a dynamic, 

ongoing developmental process that requires a 

long-term commitment and is achieved over 

time” (U.S. Department of Health and 

Human Services [HHS] 2003a, p. 12).

Cultural competence plans are strategic 

plans that outline a systematic organizational 

approach to providing culturally responsive 

services to individuals and to increasing cultural competence among staff at each level of 

the organization. 

Cultural diffusion is the process of cultural 

intermingling. 

Cultural humility “incorporates a lifelong 

commitment to self-evaluation and critique” 

(Tervalon and Murray-García 1998, p. 123) to

redress the power imbalances in counselor–

client relationships. 

Cultural norms are the spoken or unspoken 

rules or standards for a cultural group that 

indicate whether a certain social event or 

behavior is considered appropriate or inappropriate. 

Cultural proficiency involves a deep and rich 

knowledge of a culture—an insider’s view—

that allows the counselor to accurately interpret the subtle meanings of cultural behavior 

(Kim et al. 1992).

Culture is the conceptual system that structures the way people view the world—it is the 

particular set of beliefs, norms, and values that 

influence ideas about the nature of relationships, the way people live their lives, and the 

way people organize their world.

Ethnicity refers to the social identity and 

mutual belongingness that defines a group of 

people on the basis of common origins, shared 

beliefs, and shared standards of behavior 

(culture).

Ethnocentrism is “the tendency to view one’s 

own culture as best and to judge the behavior 

and beliefs of culturally different people by 

one’s own standards” (Kottak 1991, p. 47). 

Health disparity is a particular type of health 

difference that is closely linked with social, 

economic, and/or environmental disadvantage. 

Health disparities adversely affect groups of 

people who have systematically experienced 

greater obstacles to health based on their racial 

or ethnic group; religion; socioeconomic 

status; gender; age; mental health; cognitive, 

sensory, or physical disability; sexual orientation or gender identity; geographic location; or 

other characteristics historically linked to 

discrimination or exclusion (HHS 2011a).

Hembrismo refers to female strength, endurance, courage, perseverance, and bravery 

(Falicov 1998).

Latinos are those who identify themselves in 

one of the specific Hispanic or Latino Census 

categories—Mexican, Puerto Rican, or 

Cuban—as well as those who indicate that 

they are “other Spanish, Hispanic, or Latino.” 

Origin can be viewed as the heritage, nationality, group, lineage, or country of birth of the 

person or the person’s parents or ancestors 

before their arrival in the United States.

Immersion–emersion is a stage in the identity development models of both Cross and 

Helms during which a transition takes place 

from satisfaction with the old self to commitment to personal change: from immersion in 

one’s old identity to emerging with a more 

mature view of one’s identity (Cross 1995b).

Indigenous peoples are those people native 

to a particular country or region. In the case 

of the United States and its territories, this 

296
Appendix G—Glossary

includes Native Hawaiians, Alaska Natives, 

Pacific Islanders, and American Indians.

Institutional racism generally “refers to the 

policies, practices, and norms that incidentally

but inevitably perpetuate inequality,” resulting 

in “significant economic, legal, political and 

social restrictions” (Thompson and Neville 

1999, p. 167).

Language is a culture’s communication system and the vehicle through which aspects of 

race, ethnicity, and culture are communicated.

Machismo is the traditional sense of responsibility Latino men feel for the welfare and 

protection of their families. 

Marianismo is the traditional belief that 

Latinas should be self-sacrificing, endure 

suffering for the sake of their families, and 

defer to their husbands in all matters. The 

Virgin Mary is held up as the model to which 

all women should aspire.

Motivational interviewing is a counseling 

style characterized by the strategic therapeutic 

activities of expressing empathy, developing 

discrepancy, avoiding argument, rolling with 

resistance, and supporting self-efficacy. In 

motivational interviewing, the counselor’s 

major tool is reflective listening.

Multiracial individuals are any racially mixed 

people and include biracial people, as well as 

those with more than two distinct racial heritages (Root 1992).

Native Hawaiians and other Pacific Islanders include those with “origins in any of 

the original peoples of Hawaii, Guam, Samoa, 

or other Pacific Islands” (Grieco and Cassidy 

2001, p. 2). Other Pacific Islanders include 

Tahitians; Northern Mariana Islanders; 

Palauans; Fijians; and cultural groups like 

Melanesians, Micronesians, or Polynesians.

Nguzo saba are the seven African American 

principles celebrated during Kwanzaa:

• Umoja is unity with family, community, 

nation, and race.

• Kujichagulia means self-determination to 

define collective selves, create for collective 

selves, and speak for collective selves.

• Ujima refers to collective responsibility to 

build and maintain community and solve 

problems together.

• Ujamaa refers to cooperative economics to 

build and maintain businesses and to profit from them together.

• Nia is a sense of purpose to collectively 

build and develop community to restore 

people to their traditional greatness.

• Kuumba is creativity to always do as much 

as possible to leave the community more 

beautiful and beneficial than it was.

• Imani refers to belief in the community’s 

parents, teachers, and leaders and in the 

righteousness and victory of the struggle.

Organizational cultural competence and 

responsiveness refers to a set of congruent 

behaviors, attitudes, and policies that enable a 

system, agency, or group of professionals to 

work effectively in cross-cultural situations 

(Cross et al. 1989). It is a dynamic, ongoing 

process.

Orgullo means pride and dignity.

Personalismo is the use of positive personal 

qualities to accomplish a task.

Race is a social construct that describes people 

with shared physical characteristics.

Racism is an attitude or belief that people 

with certain shared physical characteristics are 

better than others.

Reculturation occurs when individuals return 

to their countries of origin after a prolonged 

period in other countries and readapt to the 

dominant culture.

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Improving Cultural Competence

Respeto can be translated as respect but also

includes elements of both emotional dependence and dutifulness (Barón 2000).

Selective perception is, in Helms’s model of 

racial identity development, the tendency of 

people early in the process to observe their 

environment in ways that generally confirm 

their pre-existing beliefs.

Simpatía is an approach to social interaction 

that avoids conflict and confrontation. One 

who is simpático is agreeable and strives to 

maintain harmony within the group.

Syncretism is the result of combining differing systems, such as traditional and introduced 

cultural traits.

Transculturation is the acceptance of a part 

or a trait of one culture into another culture. 

White privilege is a form of ethnocentrism 

and refers to a position of entitlement based 

on a presumed culturally superior status. 

Whites/Caucasians are people “having origins in any of the original peoples of Europe, 

the Middle East, or North Africa.” This 

category includes people who indicate their 

race as White or report entries “such as Irish, 

German, Italian, Lebanese, Near Easterner, 

Arab, or Polish” (Grieco and Cassidy 2001, 

p. 2).

298
. 

Appendix H—Resource Panel

Note: Information given indicates each participant’s affiliation during the time the panel was 

convened and may no longer reflect the individual’s current affiliation.

Ana Anders, M.S.W., LICSW 

Senior Advisor 

Special Populations Office 

National Institute on Drug Abuse 

National Institutes of Health

Bethesda, MD

Candace Baker, Ph.D. 

Clinical Affairs Manager

Lesbian, Gay, Bisexual, and Transgender 

Special Interest Group 

National Association of Alcoholism and Drug 

Abuse Counselors 

Alexandria, VA

Carole Chrvala, Ph.D. 

Senior Program Officer 

Board on Neuroscience & Behavioral Health 

Institute of Medicine 

Washington, DC 

Christine Cichetti 

Drug Policy Advisor 

United States Department of Health and 

Human Services 

Washington, DC

Cathi Coridan, M.A. 

Senior Director for Substance Abuse 

Programs 

National Mental Health Association 

Alexandria, VA

Edwin M. Craft, Dr.P.H. 

Program Analyst 

Practice Improvement Branch 

Division of Services Improvement 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, MD

Christina Currier 

Public Health Analyst 

Practice Improvement Branch 

Division of Services Improvement 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, MD

Dorynne Czechowicz, M.D. 

Medical Officer 

Treatment Development Branch 

Division of Treatment Research and Development 

National Institute on Drug Abuse

National Institutes of Health 

Bethesda, MD

Janie B. Dargan 

Senior Policy Analyst 

Office of National Drug Control Policy 

Executive Office of the President 

Washington, DC

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Improving Cultural Competence

James (Gil) Hill, Ph.D. 

Director 

Office of Rural Health and Substance Abuse 

American Psychological Association 

Washington, DC 

Hendree E. Jones, M.A., Ph.D. 

Assistant Professor 

CAP Research Director 

Department of Psychiatry and Behavioral 

Sciences 

Johns Hopkins University Center 

Baltimore, MD

Guadelupe Pacheco, M.P.A. 

Special Assistant to the Deputy Assistant 

Secretary 

Office of Minority Health 

Department of Health and Human Services 

Rockville, MD

Cecilia Rivera-Casale, Ph.D. 

Senior Project Officer 

Center for Mental Health Services 

Substance Abuse and Mental Health Services 

Administration 

Rockville, MD

Deidra Roach, M.D. 

Health Science Administrator 

National Institute on Alcohol Abuse and 

Alcoholism 

Bethesda, MD

Kevin Shipman, M.H.S., LPC 

Deputy Chief 

Grants and Program Management Division 

Special Population Services 

Washington, DC

Richard T. Suchinsky, M.D. 

Associate Chief for Addictive Disorders and 

Psychiatric Rehabilitation 

Mental Health and Behavioral Sciences 

Services 

Department of Veterans Affairs 

Washington, DC

Jan Towers, Ph.D. 

Director 

Health Policy 

American Academy of Nurse Practitioners 

Washington, DC

Jose Luis Velasco 

Project Director 

National Hispanic Council on Aging 

Washington, DC 

Karl D. White, Ed.D. 

Public Health Analyst 

Practice Improvement Branch 

Division of Services Improvement 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, MD

Jeanean Willis, D.P.M., CDR, USPHS 

Public Health Analyst 

Office of Minority Health 

Health Resources and Services 

Administration 

Rockville, MD

300
.

Appendix I—Cultural Competence 

and Diversity Network Participants

Note: Information given indicates each participant’s affiliation during the time the network was 

convened and may no longer reflect the individual’s current affiliation.

Elmore T. Briggs, CCDC, NCAC II 

President/CEO

SuMoe Partners

Germantown, MD

African American Workgroup Member

Deion Cash 

Executive Director 

Community Treatment and Correction 

Center, Inc. 

Canton, OH

African American Workgroup Member

Magdalen Chang, Ph.D. 

Center Manager

Haight Ashbury Free Clinics, Inc.

San Francisco, CA

Asian/Pacific Islander Workgroup Member

Diana Yazzie Devine, M.B.A. 

Executive Director

Native American Connections, Inc.

Phoenix, AZ

Native American Workgroup Member

Terry S. Gock, Ph.D. 

Director

Pacific Clinics Asian Pacific Family Center

Rosemead, CA

Asian/Pacific Islander Workgroup and Lesbian/

Gay/Bisexual/Transgender Workgroup Member

Renata J. Henry, M.Ed. 

Director

Delaware Health and Social Services

New Castle, DE

African American Workgroup Member

Adelaida F. Hernandez, M.A., LCDC 

Youth OSR Services Program Director

S.C.A.N., Inc.

Laredo, TX

Hispanic/Latino Workgroup Member

Ford H. Kuramoto, D.S.W. 

President

National Asian Pacific American Families 

Against Substance Abuse

Los Angeles, CA

Asian/Pacific Islander Workgroup Member

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Improving Cultural Competence

Victor Leo, M.S.W., LCSW 

Board Chair

Asian/Pacific American Consortium on Substance Abuse

Portland, OR

Aging Workgroup Member and Asian/Pacific 

Islander Workgroup Member

Harry Montoya, M.A. 

President/CEO

Hands Across Cultures

Espanola, NM

Hispanic/Latino Workgroup Member

Michael E. Neely, Ph.D., MFCC 

Administrator

Integrated Care System

Los Angeles, CA

African American Workgroup Member

Tam Khac Nguyen, M.D., CCJS, LMSW 

President

Vietnamese Mutual Association, Inc.

Polk City, IA

Asian/Pacific Islander Workgroup Member

Rick Rodriguez 

Manager/Counselor

Services United

Santa Paula, CA

Hispanic/Latino Workgroup Member

Mariela C. Shirley, Ph.D. 

Assistant Professor

University of North Carolina at Wilmington

Wilmington, NC

Hispanic/Latino Workgroup Member

302
.

Appendix J—Field Reviewers

Note: Information given indicates each participant’s affiliation during the time the review was 

conducted and may no longer reflect the individual’s current affiliation.

Alan J. Allery, M.Ed., M.H.A. 

Director 

Student Health Services 

University of North Dakota 

Grand Forks, ND

Deborah Altschul, Ph.D. 

Assistant Professor/Psychologist 

Mental Health Services Research and 

Evaluation Unit 

Adult Mental Health Division 

Hawaii Department of Health 

University of Hawaii 

Honolulu, HI

Diana S. Amodia, M.D. 

Medical Director 

Substance Abuse Treatment Services 

Haight Ashbury Free Clinics, Inc.

San Francisco, CA

Ronald G. Black 

Director, Residential Group 

Drug Abuse Foundation 

Del Ray Beach, FL

Patricia T. Bowman 

Probation Counselor 

Fairfax Alcohol Safety Action Program 

Fairfax, VA

Rodolfo T. Briseno, M.D., M.P.H. 

Facilitator 

Worker’s Assistance Program–Youth 

Advocacy 

Austin, TX

Stephanie Brooks, M.S.W. 

Interim Director & Assistant Professor 

Programs in Couple & Family Therapy 

College of Nursing and Health Professions 

Drexel University 

Philadelphia, PA

Jutta H. Butler, B.S.N., M.S. 

Public Health Advisor 

Practice Improvement Branch 

Division of Services Improvement 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, MD

Flanders Byford, M.S.W., LCSW 

Licensed Clinical Social Worker 

Oklahoma City County Health Department 

Oklahoma City, OK

Maria J. Carrasco, M.P.A 

Director

Multicultural Action Center 

Arlington, VA

303
Improving Cultural Competence

Gerhard E. Carrier, Ph.D. 

Chair, Mental Health & Addiction Studies 

Department of Mental Health 

Alvin Community College 

Alvin, TX

Carol J. Colleran, CAP, ICADC 

National Director of Older Adult Services 

Center of Recovery for Older Adults 

Hazelden Foundation/Hanley-Hazelden 

West Palm Beach, FL

Cynthia C. Crone, APN, MNSC 

Executive Director 

Center for Addictions Research, Education, 

and Services 

College of Medicine, Department of 

Psychiatry and Behavior Health

University of Arkansas for Medical Sciences 

Little Rock, AR

John P. de Miranda, Ed.M. 

Executive Director 

National Association on Alcohol, Drugs, and 

Disability, Inc.

San Mateo, CA

Efrain R. Diaz, Ph.D., LCSW 

Program Supervisor 

Connecticut Department of Mental Health 

and Addiction Services 

Hartford, CT

Dedric L. Doolin, M.P.A. 

Deputy Director 

Area Substance Abuse Council, Inc. 

Cedar Rapids, IA

Donna Doolin, LCSW 

Director 

Division of Health Care Policy, Addiction & 

Prevention Services 

Kansas Department of Social and 

Rehabilitation Services 

Topeka, KS

Lynn Dorman, Ph.D., J.D. 

President 

Creating Solutions 

Portland, OR

Gayle R. Edmunds 

Director 

Indian Alcoholism Treatment Services 

Wichita, KS

Michele J. Eliason, Ed.S., Ph.D. 

Associate Professor 

The University of Iowa 

Iowa City, IA

Jill Shepard Erickson, M.S.W., ACSW 

Public Health Advisor 

Child and Family Branch 

Center for Mental Health Services 

Substance Abuse and Mental Health Services 

Administration 

Rockville, MD

Elena Flores, M.A., Ph.D. 

Associate Professor 

School of Education 

Counseling and Psychology Department 

University of California, San Francisco 

San Francisco, CA

Jo Ann Ford, M.R.C. 

Assistant Director 

Substance Abuse Resources and Disability 

Issues 

School of Medicine

Wright State University

Dayton, OH

Maria del Mar Garcia, M.S.W., M.H.S. 

Continuing Education Coordinator 

Caribbean Basin and Hispanic Addiction 

Centro de Estudios en Adicción

Universidad Central del Caribe

Bayamon, PR

304
Appendix J—Field Reviewers

Virgil A. Gooding, Sr., M.A., M.S.W., 

LISC 

Clinical Director 

Foundation II, Inc. 

Cedar Rapids, IA

Maya D. Hennessey, CRADC 

Women’s Specialist 

Supervisor, Quality Assurance, Technical 

Assistance & Training 

Office of Special Programs 

Division of Substance Abuse 

Illinois Department of Human Services and 

Substance Abuse 

Chicago, IL

Michael W. Herring, LCSW 

Wayne Psychiatric Associates, P.A. 

Goldsboro, NC

Deborah J. Hollis, M.A. 

Administrator

Office of Drug Control Policy 

Division of Substance Abuse and Gambling 

Services 

Michigan Department of Community Health 

Lansing, MI 

Ruth Hurtado, M.H.A. 

Public Health Advisor 

Center for Substance Abuse Treatment

Division of Pharmacologic Therapies

Substance Abuse and Mental Health Services

Administration 

Rockville, MD

Ting-Fun May Lai, M.S.W., CASAC 

Director 

Chinatown Alcoholism Center

Hamilton-Madison House

New York, NY

Tom Laws 

Talihina, OK

Susan F. LeLacheur, M.P.H., PA-C 

Assistant Professor of Health Care Sciences 

The George Washington University 

Washington, DC

Jeanne Mahoney 

Director 

Provider’s Partnership-Women’s Health Issues 

American College of Obstetricians and 

Gynecologists 

Washington, DC

Michael Mobley, Ph.D., M.Ed. 

Assistant Professor in Counseling Psychology 

Department of Educational, School and 

Counseling Psychology 

University of Missouri–Columbia 

Columbia, MO

Valerie Naquin, M.A. 

Vice President 

Planning and Development 

Cook Inlet 

Anchorage, AK

Paul C. Purnell, M.S. 

President 

Social Solutions, LLC 

Potomac, MD

Laura Quiros, M.S.W. 

Program Associate

Program Planning & Development Department 

Palladia, Inc. 

New York, NY

Melissa V. Rael, USPHS 

Senior Program Management Officer 

Co-Occurring and Homeless Branch 

Division of State and Community Assistance 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, MD

305
Improving Cultural Competence

Susanne R. Rohrer, R.N. 

Nurse Consultant 

Practice Improvement Branch

Division of Services Improvement 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, MD

Laurie J. Rokutani, Ed.S., NCC, CPP, 

MAC 

Training Coordinator 

Virginia Commonwealth University 

Mid-America Addiction Technology Transfer 

Center 

Richmond, VA

LaVerne R. Saunders, B.S.N., R.N., M.S. 

Training Specialist and Consultant 

Dorrington & Saunders and Associates 

Framingham, MA

Gary Q. Tester, MAC, CCDC III-E, OCPS 

II 

Director 

Ohio Department of Alcohol and Drug 

Addiction Services 

Columbus, OH

Ralph Varela, M.S.W. 

Chief Executive Officer 

Pinal Hispanic Council 

Eloy, AZ

Ming Wang, L.C.S.W. 

Program Manager 

Division of Substance Abuse and Mental 

Health 

Utah Department of Human Services 

Salt Lake City, UT

Mike Watanabe, M.S.W. 

President and CEO 

Asian American Drug Abuse Program, Inc. 

Los Angeles, CA

Debbie A. Webster 

Community Program Coordinator 

Best Practice Team 

Division of Mental Health, Developmental 

Disabilities, and Substance Abuse Services

North Carolina Department of Health and 

Human Services

Raleigh, NC

Melvin H. Wilson, M.B.A., LCSW-C 

High Intensity Drug Trafficking Area

Coordinator 

Maryland Division of Parole and Probation 

Baltimore, MD

Ann S. Yabusaki, M.Ed., M.A., Ph.D. 

Director 

Coalition for a Drug-Free Hawaii 

Honolulu, HI

306
.

Appendix K—Acknowledgments

Numerous people contributed to the development of this Treatment Improvement Protocol 

(TIP), including the TIP Consensus Panel (page vii), the Knowledge Application Program 

(KAP) Expert Panel and Federal Government Participants (page ix), the Resource Panel 

(Appendix H), the Cultural Competence and Diversity Network Participants (Appendix I), and 

the Field Reviewers (Appendix J). 

This publication was produced under KAP, a Joint Venture of The CDM Group, Inc. (CDM), 

and JBS International, Inc., for the Substance Abuse and Mental Health Services 

Administration’s Center for Substance Abuse Treatment. 

CDM KAP personnel included Rose M. Urban, M.S.W., J.D., LCSW, CCAC, CSAC, KAP 

Executive Project Director; Jessica L. Culotta, M.A., KAP Managing Project Co-Director and 

former Managing Editor; Susan Kimner, Former Managing Project Co-Director; Raquel 

Witkin, M.S., former Deputy Project Manager; Claudia A. Blackburn, Psy.D., Expert Content 

Director; Shel Weinberg, Ph.D., Senior Research/Applied Psychologist; J. Max Gilbert, M.A.,

Ph.D., Senior Editor/Writer; Deborah Steinbach, M.A., and Janet G. Humphrey, M.A., former 

Senior Editors/Writers; Claudia Askew, Catalina Bartlett, M.A., Angela Cross, Timothy 

Ferguson, M.A., Randi Henderson, and Susan Hills, Ph.D., Writers; Angela Fiastro, Junior 

Editor; Sonja Easley, former Editorial Assistant; Virgie D. Paul, M.L.S., Librarian; and Maggie 

Nelson, former Project Coordinator.

307
Index

A

AA (Alcoholics Anonymous), 113, 114, 136, 

137, 147, 155–156, 173, 174

ACA (American Counseling Association) 

Counselor Competencies, 46, 47, 56

acceptance, culturally competent counselors 

showing, 49

access to care. See also health insurance coverage

by African Americans, 106–108

by Asians and Asian Americans, 120

as critical treatment issue, 80

by Hispanics and Latinos, 132

by Native Americans, 142–143

outreach strategies, 96–98, 97–98

for White Americans, 153

acculturation, 24–27

asking clients about, 62

defined, 24, 295

five-level model for, 25

generational gap in, 23

tools for identifying and measuring, 27,

253, 254–257, 288

acupuncture, 126

adapting intervention strategies to clients’

cultural needs, 50, 55, 56, 71–72

Addiction Technology Transfer Centers, 287

Addressing the Specific Behavioral Health Needs 

of Men (TIP 56), 20

advisory and governing boards, 79

affective/mood disorders, 105–106, 153

Affordable Care Act, 7

African Americans, 14, 103–116

Afrocentricity of, 62

CODs of, 105–106, 107, 108

cultural identification by, 27

cultural resources for, 290–291

defined, 14, 103–104, 295

evaluation and treatment planning, 109–

116, 110, 112, 115

families, concepts of and attitudes about, 

19

gender issues, 19, 104, 107, 111

health disparities, 20

health, illness, and healing, attitudes toward, 108–109

as high-context cultural group, 17

historical trauma of, 28, 108, 109–110

incarceration rates, 108

Kwanzaa, seven principles of, 297

mental disorders suffered by, 105–106

organizational cultural competence and, 

73

power and trust issues, 109–110

recovery and relapse prevention, 115–116

religion and spirituality, 114, 115

substance use and abuse and drug cultures, 27, 104–105

traditional/alternative healing practices 

and, 114–115

treatment patterns, 106–108

Agency Cultural Competence Checklist, 264–

265

Agency for Healthcare Research and Quality 

(AHRQ), 20, 85, 287

AI-SUPER PFP (American Indian Services 

Utilization and Psychiatric Epidemiology 

309
Improving Cultural Competence

Risk and Protective Factors Project), 140, 

141, 142, 147

Alaskan Natives. See Native Americans

Alcoholics Anonymous (AA), 113, 114, 136, 

137, 147, 155–156, 173, 174

alcohol abuse. See drug cultures; substance 

abuse

alcohol flushing response, 119

alternative healing practices. See traditional/alternative healing practices

American Counseling Association (ACA) 

Counselor Competencies, 46, 47, 56

American Indian Services Utilization and 

Psychiatric Epidemiology Risk and Protective Factors Project (AI-SUPER PFP), 140, 

141, 142, 147

American Indians. See Native Americans

American Psychiatric Association (APA), 69, 

283

American Religious Identification Survey, 30

American Translators Association, 287

anxiety disorders, 61, 72, 105, 107, 109, 124, 

126, 142, 153

APA (American Psychiatric Association), 69, 

283

APIs (Asians and Pacific Islanders), 14. See 

also Asians and Asian Americans; Pacific 

Islanders

appreciation, as stage in racial and cultural 

identity development, 40

Arab Americans, 32, 65, 150, 152

Asian Indians, 14, 116. See also Asians and 

Asian Americans

Asians and Asian Americans, 14, 116–128. See 

also immigrants

adopted into White families, 117

client–counselor matching, 71

CODs, 119–120

community fairs, 98

complex cultural problems, counselors allowing for, 51

in criminal justice system, 120

cultural resources for, 291–292

defined, 295

educational factors, 22

emotional expression and, 69, 119, 123

evaluation and treatment planning for, 

121, 121–128, 123

families, role of, 1, 19, 61, 72, 124

gender issues, 122–123

geographic factors, 18

health, illness, and healing, attitudes toward, 119, 120–121

language and communication issues, 17,

54

mental disorders, 57, 119–120

recovery and relapse prevention among, 

128

religion and spirituality, 126–128

shame and guilt, 1, 117, 119, 121, 122

structured approach to counseling often 

preferred by, 55

substance use and abuse and drug cultures, 1, 57, 117–119

traditional/alternative healing practices 

used by, 126–128

trauma, personal or historical, 119–120

treatment patterns, 120

assessment. See evaluation and planning; 

measurement; self-assessment

assimilation, 24

Association for Multicultural Counseling, 37, 

45

ataque de nervios, 284

attitudes and behaviors of culturally competent counselors, 49–50

avoidance of certain counselor behaviors, 51

B

Baltimore Epidemiologic Catchment Services 

Area study (1980s), 106

behavioral health

critical treatment issues for culturally responsive services, 80

cultural knowledge about, as core competency, 48, 48–49

defined, 3

Behavioral Health Services for American Indians 

and Alaska Natives (planned TIP), 139

310
Index

behavioral health service providers and counselors. See also core competencies; selfassessment; self-knowledge, as core competency

behaviors to avoid, 51

on continuum of cultural competence, 

10–11

diversity of, 4–5, 8

evaluation and monitoring of staff performance, 95–96, 96

importance of cultural competence for, 2

matching clients with, 71

organizational staff development, 75, 90–

96, 92–96

professional development tool for supervisor-supervisee discussions, 95

in Sue’s multidimensional model for developing cultural competence, 6, 6–7

behaviors and attitudes of culturally competent counselors, 49–50

biculturalism and mixed cultural identity, 5, 

24, 57–58, 62, 116–117, 295

bipolar disorders, 41, 69, 153

biracial or multiracial people, 5, 13, 14, 62, 

295, 297

Blacks. See African Americans

boards, governing and advisory, 79

Brief Interventions and Brief Therapies for 

Substance Abuse (TIP 34), 157

Buddhists and Buddhism, 32–33, 123, 128, 

156

C

cabellerismo, 19

Cambodians, 117, 118, 119, 123, 128. See also

Asians and Asian Americans

cao gio, 126

Caribbeans, 104, 106, 113, 128, 284. See also

African Americans; Hispanics and Latinos

case management, culturally responsive, 70, 

70–71, 71

Case Management Society of America, 71

case studies

core competencies (Gil), 35

drug cultures (Lisa), 159–161

evaluation and treatment planning 

(Zhang Min), 57–58, 62

group clinical supervision case study 

(Beverly), 72

Hispanics and Latinos (Anna), 136

importance of cultural competence 

(Hoshi), 1

Native Americans (John), 101–102

organizational cultural competence 

(Cavin), 73–74

racial and cultural identity, 41

Caucasians. See White Americans

CBT. See cognitive–behavioral therapy

CCHCP (Cross Cultural Health Care Program), 288

Census Bureau, U.S., racial and ethnic groups, 

xvi, 13

Center for Integrated Health Solutions 

(CIHS), 98

Center for Mental Health Services (CMHS), 

288

Center for Research on Ethnicity, Culture, 

and Health, 287

Center for Substance Abuse Treatment 

(CSAT)

Targeted Capacity Expansion Program, 

98

TIPs. See Treatment Improvement Protocols

Central and South Americans, 32, 129, 131, 

135, 285. See also Hispanics and Latinos

change, determining readiness and motivation 

for, 69–70

chibih, 285

Chinese, 14, 32, 51, 57, 98, 117, 118, 123, 124, 

125, 126, 285. See also Asians and Asian 

Americans

Christians and Christianity, 31, 101, 115, 128, 

138, 149, 156

CIDI (Composite International Diagnostic 

Interview), 68

CIHS (Center for Integrated Health Solutions), 98

circles, in Native American philosophy, 147, 

148

311
Improving Cultural Competence

cirrhosis, 105, 140, 141

Civil Rights Movement, 38

clinical issues, culturally framing, 49

clinical/program attributes. See evaluation and 

treatment planning

clinical scales and CODs, 65–68

clinical supervisors and clinical supervision. 

See also core competencies

diversity of, 4–5, 8

evaluation and monitoring of staff performance, 95–96, 96

group clinical supervision case study 

(Beverly), 72

importance of cultural competence for, 2, 

93–95, 94

mapping racial and cultural identity development and, 42

professional development tool for supervisor-supervisee discussions, 95

training content for language services personnel, 90

clinical worldview, 43

CMHS (Center for Mental Health Services), 

288

co-occurring disorders (CODs)

of African Americans, 105–106, 107, 108

of Asians and Asian Americans, 119–120

clinical scales, culturally valid, 65–68

counselor knowledge of cultural distribution of, 48–49

of Hispanics and Latinos, 131–132

immigrants and, 26

of Native Americans, 141–142

Substance Abuse Treatment for Persons With 

Co-Occurring Disorders (TIP 42), 20, 

157

of White Americans, 153

cognitive–behavioral therapy (CBT)

for African Americans, 111

for Asians and Asian Americans, 123–124

for Hispanics and Latinos, 135

for Native Americans, 145

for White Americans, 155

collaborative approach, 60–61, 109, 111

collateral information of cultural relevance, 64,

64–65, 66–67

committees, organizational, for cultural competence, 79–80

communication. See language and communication

Community-Defined Solutions for Latino Mental Health Care Disparities (Aguilar-Gaxiola 

et al., 2012), 98

community involvement and awareness

demographic profiles, 84

environmental appropriateness for populations served, 96

feedback, gathering, 86

as key culturally responsive practice, 8

Native American treatment planning and, 

101–102, 143, 144

outreach programs, 96–98, 97–98

strategies for engaging, 80, 80–81

Community Toolbox, 287

complementary healing practices. See traditional/alternative healing practices

complex cultural problems, counselors allowing for, 51

Composite International Diagnostic Interview 

(CIDI), 68

confianza, 295

confidentiality issues, 134, 144

conformity, as stage in racial and cultural 

identity development, 40, 295

Consumer Assessment of Healthcare Providers and Systems Cultural Competence Item 

Set, 85

contingency management approaches, 111, 

135

continuum of cultural competence, 9–11, 10–

11

core assumptions of cultural competence, xvii, 

4–5

core competencies, xvii–xviii, 3, 36–56. See also

self-knowledge, as core competency

adapting intervention strategies to clients’

cultural needs, 50, 55, 56

attitudes and behaviors of culturally competent counselors, 49–50

312
Index

behavioral health, cultural knowledge 

about, 48, 48–49

behaviors to avoid, 51

case studies, 35, 41

clinical issues, framing in culturally relevant ways, 49

complex cultural problems, allowing for, 

51

cross-cutting factors affecting, 46–47

knowledge of other cultural groups, 44–

47, 45, 47

personal space issues, dealing with, 51–52

power and trust issues, 44, 52

self-assessment tools, 55, 259–63

skill development, 49–50, 49–55, 51, 53–

54

in Sue’s multidimensional model for developing cultural competence, 6, 36, 37

touch, awareness of culturally specific 

meanings of, 52

counselors. See behavioral health service providers and counselors

criminal justice system

African Americans in, 108

Asians and Asian Americans in, 120

Native Americans in, 143

Substance Abuse Treatment for Adults in the 

Criminal Justice System (TIP 44), 157

cross-cultural applicability of diagnostic systems, 68–69

cross-cultural communication, 59

Cross Cultural Health Care Program 

(CCHCP), 288

cross-cutting factors, xvii, 16–33, 46–47, 62–

63, 150

CSAT. See Center for Substance Abuse 

Treatment

Cubans and Cuban Americans, 129, 130, 131. 

See also Hispanics and Latinos

culturagrams, 65, 66–67

cultural awareness, 38

cultural blindness, 10–11

cultural competence, xv–xxi, 1–33

core assumptions of, xvii, 4–5

core competencies for counselors and 

clinical staff, xvii–xviii, 3, 35–56. See 

also core competencies

cross-cutting factors, xvii, 16–33, 46–47, 

62, 63, 150

defined, xv, 5–7, 11, 295–296

development of, xvi, 9–11, 10–11

diversity aiding, 4–5, 8

drug cultures, xxi, 3, 159–175. See also

drug cultures; substance abuse

in evaluation and treatment planning, 

xviii–xix, 3, 57–72. See also evaluation 

and treatment planning

importance to behavioral health field, xv–

xvi, 1–2, 7–9

at multiple levels of operation, 4

in organizations, xix–xx, 73–99. See also

organizational cultural competence

public advocacy of, 5

purpose and objectives of pursuing, 2

for specific racial and ethnic groups, xx–

xxi, 3, 101–57. See also racial and ethnic 

groups; specific groups

Sue’s multidimensional model for developing, xv, 5–7, 6, 36, 37, 58, 74, 102, 

103, 160, 161

terminology used in discussing, 3

Cultural Competence for Health Administration and Public Health, 93

cultural competence plans, 81–82, 82, 84, 87, 

296

cultural concepts of distress, 30, 69, 284–285

cultural destructiveness, 10

cultural diffusion, 296

cultural formulation, 69, 283–284

cultural humility, 50, 296

cultural identity, 24–27

asking clients about, 62

case study, 41

defined, xvii, 16

diagnosis, cultural formulation in, 283

drug culture, as alternative to, 173

mapping, 41, 42

mixed, 57–58, 62, 116–117

models of, 39, 40

313
Improving Cultural Competence

for Native Americans, 26–27, 144–145

self-knowledge of counselors regarding, 

38, 38–41, 40, 41

subcultures, 62–63

terminology of, 24

tools for measuring and identifying, 253, 

254–257, 288

for White Americans, 39, 154

cultural incapacity, 10

cultural norms, xvi, 12, 45, 48, 52, 60, 296

Cultural Orientation Resource Center, 23

cultural precompetence, 11

cultural proficiency, 296

culture, defined, xvi, 11–13, 12, 296

Culture Matters: The Peace Corps Cross-Cultural 

Workbook (2012), 52

culture of recovery, xxi, 173, 173–175, 174, 175

Cup’ik Eskimo, 148

curanderismo, 138

D

daily routines and rituals of substance abusers, 

assessing, 172

dances,sacred, 148

demographic profiles, developing, 84

Departments, U.S. See entries at U.S.

depression, 21, 49, 51, 57, 69, 72, 107, 109, 

119, 124, 131, 141, 142, 153

development of cultural competence, xvi, 9–11, 

10–11

dhat, 284

diabetes, 49, 141, 290

diagnosis, 68–69, 283–285

Diagnostic and Statistical Manual of Mental 

Disorders, Fifth Edition (DSM-5), 30, 68, 

283, 284–285

dissonance, as stage in racial and cultural 

identity development, 40

distress, cultural concepts of, 30, 69, 284–285

diversity

at developmental and organizational levels, 4–5, 8, 90–91

within racial and ethnic groups, 17–18, 

103

Diversity Rx, 288

drug cultures, xxi, 3, 159–175. See also substance abuse

of African Americans, 104–105

of Asians and Asian Americans, 117–119

attraction of, 165–169

case study (Lisa), 159–161

cultural identity as alternative to, 173

culture of recovery replacing, xxi, 173,

173–175, 174, 175

daily routines and rituals, assessing, 172

defined, 161–164

differences between, 161, 162

evaluation and treatment planning addressing, 171–175, 172

exercise on benefits, losses, and the future, 170–171

families and, 169

geographical variations, 161, 162

of Hispanics and Latinos, 129–131, 130

identifying key characteristics of, 162–163

as initiating and sustaining force for substance abuse, 167, 169

language and terminology of, 164

mainstream culture, relationship to, 164–

165

music and, 165, 166–167

of Native Americans, 139–141

online, 169–171

rituals of, 167, 168

SES and, 162, 169

skills required for certain drug use, 

transmitting, 167, 168

as subcultural phenomenon, 160, 161–162

Sue’s multidimensional model for developing cultural competence and, 160,

161

of White Americans, 150–152

worldviews, values, and traditions of, 165, 

166

DSM-5 (Diagnostic and Statistical Manual of 

Mental Disorders, Fifth Edition), 30, 68, 

283, 284–285

314
Index

E

East Harlem Protestant Parish, 138

EBP. See evidence-based practices

educational factors, 21–22, 22, 67

emotional expression, 54–55, 69, 119, 123

enculturation, 24

engaging clients, 59, 59–60

Engaging Moms, 113

Enhanced National Standards for Culturally and 

Linguistically Appropriate Services in Health 

and Health Care (OMH, 2013), 8, 75, 265–

266

Enhancing Motivation for Change in Substance 

Abuse Treatment (TIP 35), 69, 70, 157

environmental appropriateness for populations 

served, 96

epicanthic eye fold, 13

equality, commitment to, 40, 50

ESI (Ethnic-Sensitive Inventory), 262–263

espanto, 285

espiritismo, 138

ethnic groups. See racial and ethnic groups

Ethnic-Sensitive Inventory (ESI), 262–263

ethnocentrism, 9, 40, 296, 298

ethnogeriatrics, 290

evaluation and monitoring

of organizational cultural competence, 74, 

75, 84–87, 85, 86, 264–273

of staff performance, 95–96, 96

evaluation and treatment planning, xviii–xix, 3, 

57–72

adapting intervention strategies to clients’

cultural needs, 50, 55, 56, 71–72

for African Americans, 109–116, 110,

112, 115

benefits of cultural competency for, 4

case management, 70, 70–71, 71

case studies, 57–58, 62, 72

change, determining readiness and motivation for, 69–70

collaborative approach to, 60–61

collateral information of cultural relevance, 64, 64–65, 66–67

cross-cutting factors affecting, 62, 63

culturagram, 65, 66–67

cultural identity and acculturation, determining, 62

diagnosis, 68–69, 283–285

distress, cultural concepts of, 30, 69, 284–

285

diversity of population developing, 4–5

drug cultures, addressing, 171–175, 172

eliciting client views on their problems, 

63

engaging clients at initial meeting, 59, 

59–60

familiarization of client with process, 59–

60

families, inclusion of, 1, 59–60, 61, 64–65

health, illness, and healing, different cultural attitudes toward, 60, 61, 63, 64

for Hispanics and Latinos, 133–138

immigration history, taking, 23, 61, 66

integration of culturally relevant issues, 

61–63, 61–64

matching clients and counselors, 71, 134

motivational interviewing, 70

multicultural intake checklist, 64

for Native Americans, 143, 143–150, 145

one-size-fits-all approach, importance of 

avoiding, 58

for Pacific Islanders, 127

screening and assessment tools, 65–69, 

68, 277, 277–81

strength-based interviews, 61

subcultures, 62–63

in Sue’s multidimensional model for developing cultural competence, 6, 6–7, 

58

traumatic experiences, 63

for White Americans, 154–156

evidence-based practices (EBPs)

counselors’ cultural sensitivity and, 37

health disparities, reducing, 20

for Hispanics and Latinos, 134

F

families

in Asian culture, 1, 19, 61, 72, 124

315
Improving Cultural Competence

counselor’s worldview of, 72

culturagrams, 66

cultural variations regarding, 19

drug cultures and, 169

gathering culturally relevant collateral information from, 64–65

health, illness, and healing, cultural attitudes toward, 30, 60, 61

in Hispanic and Latino culture, 129–130, 

135

immigration and migration issues, 22, 23

inclusion in evaluation and treatment 

process, 1, 59–60, 61, 64–65

in Native American culture, 145–146

family therapy, 19, 49

for African Americans, 111–113, 113

for Asians and Asian Americans, 124,

124–125

for Hispanics and Latinos, 135–136, 136,

137

for Native Americans, 145–146

Substance Abuse Treatment and Family 

Therapy (TIP 39), 19, 146, 157

for White Americans, 155

feedback, gathering, 85, 85–87, 86, 273–275

fetal alcohol syndrome, 141

Filipinos, 14, 118. See also Asians and Asian 

Americans

fiscal support of organizational cultural competence, 96

flexibility, culturally competent counselors 

showing, 50, 55

four circles, 158

G

gender, 19–20

acculturation and, 26

Addressing the Specific Behavioral Health 

Needs of Men (TIP 56), 20

African Americans and, 19, 104, 107, 111

for Asians and Asian Americans, 122–

123

client–counselor matching for, 71, 134

in Hispanic and Latino culture, 19–20, 

129, 134

mental disorders and substance abuse issues, 20

Substance Abuse Treatment: Addressing the 

Specific Needs of Women (TIP 51), 20, 

123, 157

White Americans and, 19

genetics and race, 13

geographical factors in cultural competence, 

17–18, 62–63, 161, 162

governance, of organizations, 75, 78–80, 80

governing and advisory boards, 79

group clinical supervision case study (Beverly), 

72

group therapy

for African Americans, 113

for Asians and Asian Americans, 125

exercise on benefits, losses, and the future, 170–171

for Hispanics and Latinos, 136

Ho’oponopono (used by Native Hawaiians), 127

for Native Americans, 146

Substance Abuse Treatment: Group Therapy

(TIP 41), 155, 157

for White Americans, 155

H

Hands Across Cultures Corporation, New 

Mexico, 77–78, 78

Hawaiians. See Pacific Islanders

health disparities

causes of, 20

cultural competence reducing, 7

defined, 7, 296

National Center on Minority Health and 

Health Disparities, 289

SES and, 21

health, illness, and healing

African American attitudes toward, 108–

109

Asian and Asian American attitudes toward, 119, 120–121

core competency, cultural knowledge of 

behavioral health as, 48, 48–49

316
Index

culturagrams, 67

different cultural attitudes toward, 29–30, 

60, 61, 63, 64

Hispanic and Latino attitudes toward, 

133

Native American attitudes toward, 143, 

147–148

Pacific Islanders’ attitudes toward, 127

White American attitudes toward, 153–

154

health insurance coverage

for African Americans, 107

for Asians and Asian Americans, 120

for Hispanics and Latinos, 132, 137

for Native Americans and Pacific Islanders, 142

SES and treatment access, 20, 22

Health Resources and Services Administration (HRSA)

Administration Culture, Language and 

Health Literacy Page, 288

CIHS (Center for Integrated Health Solutions), 98

domains of organizational cultural competence, 75, 75–76, 266–268

Organizational Cultural Competence Assessment Profile, 266–268

Healthy People 2020, 21

Health and Human Services (HHS). See U.S. 

Department of Health and Human Services

Helms’s model of racial identity development, 

298

hembrismo, 296

heritage. See history and heritage

HHS (Health and Human Services). See U.S. 

Department of Health and Human Services

high-context versus low-context cultural 

groups, 17, 54

Hispanics and Latinos, 15, 128–138. See also

immigrants

CODs of, 131–132

cultural resources for, 292–293

distress, cultural concepts of, 284–285

evaluation and treatment planning for, 

133–138

family role in culture of, 129–130, 135

gender roles, 19–20, 129, 134

geographic factors, 18

health, illness, and healing, attitudes toward, 133

language and communication issues, 17

mental disorders, 131–132

recovery and relapse prevention, 138

religion and spirituality of, 137, 138

sexual identity and orientation, 29

substance use and abuse and drug cultures, 35–36, 129–131, 130

traditional/alternative healing practices, 

137–138

treatment patterns for, 132

history and heritage, 27–29. See also trauma, 

personal or historical

of counselors, 43–44

of organizational cultural competence, 98, 

99

HIV/AIDS, 105, 290

Hmong, 18, 30, 52, 126

Hogg Foundation for Mental Health, 86

Holocaust, 28

homosexuality, 29, 162–163

Ho’oponopono, 127

Hopi, 139–140

HRSA. See Health Resources and Services 

Administration

humility, culturally competent counselors 

showing, 50, 296

I

IHS (Indian Health Service), 139, 142, 293

iMCI (International MultiCultural Institute), 

289

immersion, as stage in racial and cultural 

identity development, 40, 296

immigrants, 22–27

acculturation and cultural identification, 

23, 24, 24–27, 25, 27

culturagrams, 66

Cultural Orientation Resource Center, 23

317
Improving Cultural Competence

evaluation and treatment planning for, 

23, 61, 66

family issues, 22, 23

history and heritage, effects of, 27–28

initial interview and assessment questions, 23

legal status of, 22, 66–67, 134

mental disorders and, 22–23

migrant/seasonal workers, 24

refugees, 23, 28, 52

substance abuse issues, 23, 25–26, 130

incarceration. See criminal justice system

Indian Health Service (IHS), 139, 142, 293

Indians. See Asian Indians; Native Americans

indigenous peoples, 52, 297. See also Native 

Americans; Pacific Islanders

individual counselors. See behavioral health 

service providers and counselors

infrastructure, organizational, 75, 96–98, 97–

98, 99

initial meeting, engaging clients at, 59, 59–60

institutional racism, 46, 297

Instruments for Measuring Acculturation 

(University of Calgary), 288

integration of culturally relevant issues into 

evaluation and treatment planning, 61–63, 

61–64

integrative awareness, as stage in racial and 

cultural identity development, 40

International MultiCultural Institute (iMCI), 

289

International Statistical Classification of 

Diseases and Related Health Problems, 68

interviews. See evaluation and treatment planning

introspection, as stage in racial and cultural 

identity development, 40

Iowa Cultural Understanding Assessment, 86, 

273–275

Islam, 32, 115, 156

J

jail. See criminal justice system

Japanese, 1, 14, 32, 126, 285. See also Asians 

and Asian Americans

Jews and Judaism, 28, 30, 31–32, 156

jiryan, 284

Journey Mental Health Center ( JMHC), 

Wisconsin, 76

K

Kickapoo Reservation, Texas, 141

Kiowa gourd dance, 148

Koreans, 14, 16, 19, 61, 98, 117, 118, 120, 124,

126, 128. See also Asians and Asian Americans

Kung San bushmen, 13

Kwanzaa, seven principles of, 297

L

Lakota version of the 12 Steps, 147

language and communication, 16–17

assessing cultural differences in, 53–54

counselor adjustment of communication 

style, 52–54

culturagrams, 67

defined, 297

drug cultures, 164

emotional expression, 54–55, 69, 119

examples of cultural differences, 17

high-context versus low-context cultural 

groups, 17, 54

improving cross-cultural communication, 

59

informing clients about language services, 

88

nonverbal communication, 16–17, 54

organizational language services (translators), 75, 88, 88–90, 90

translators, 88, 88–90, 90, 287

White Americans’ issues with, 155

Laotians, 118. See also Asians and Asian 

Americans

Latinos. See Hispanics and Latinos

LEARN mnemonic, 59, 60

legal status of immigrants, 22, 66–67, 134

LGBT community, 29, 162–163

Living in the Balance intervention, 111

318
Index

low-context versus high-context cultural 

groups, 17, 54

M

machismo, 19, 137, 297

marianismo, 19, 297

matching clients, counselors, and programs, 

71, 134

measurement

acculturation and cultural identity, 27,

253, 254–257, 288

communication styles, cultural differences 

in, 53–54

drug cultures, 162–163

Medicare, 22, 265

mental disorders. See also co-occurring disorders; specific conditions

of African Americans, 105–106

of Asians and Asian Americans, 57, 119–

120

cultural differences in understanding of, 

30

diagnosis, 68–69

gender roles and, 20

geographic factors, 18

of Hispanics and Latinos, 131–132

immigrants and, 22–23, 26

of Native Americans, 141–142

religion and spirituality, 31

SES and, 21

trauma-induced, 28–29

of White Americans, 153

Mental Health: Culture, Race, and Ethnicity

(Surgeon General’s report, 2001), 290

methadone programs, 111, 132, 135

Mexicans and Mexican Americans, 18, 25, 26, 

35–36, 128–129, 130, 131, 133, 134, 135, 

137, 138, 167, 285. See also Hispanics and 

Latinos

MHP (Minority Health Project), 288–289

migrant/seasonal workers, 24

Minority Health Project (MHP), 288–289

mission statements, 77–78, 78

mixed cultural identity/biculturalism, 5, 24, 

57–58, 62, 116–117, 295

models of racial identity, 38

monitoring and evaluation

of organizational cultural competence, 74, 

75, 84–87, 85, 86, 264–273

of staff performance, 95–96, 96

Monitoring the Future Study, 131

mood and affective disorders, 105–106, 153

motivation for change

determining, 69–70

Enhancing Motivation for Change in Substance Abuse Treatment (TIP 35), 69, 

70, 157

motivational interviewing, 70

for African Americans, 110

defined, 297

for Hispanics and Latinos, 135

for Native Americans, 145

Multicultural Counseling Self-Efficacy Scale, 

259

multicultural intake checklist, 64

Multiculturally Competent Service System 

Assessment Guide, 268–273

multiracial or biracial people, 5, 13, 14, 62, 

295, 297

music and drug cultures, 165, 166–167

Muslims, 32, 115, 156

mutual-help groups. See also 12-Step programs, under T

for African Americans, 113–114

for Asians and Asian Americans, 125–126

for Hispanics and Latinos, 136–137

for Native Americans, 146–147, 147

for White Americans, 155–156

N

NA (Narcotics Anonymous), 113, 160, 174

Na Wahine Makalapua Project, 127

naiveté, as stage in racial and cultural identity 

development, 40

narcocorridos, 167

Narcotics Anonymous (NA), 113, 160, 174

National Alliance on Mental Illness, 156

National Ambulatory Medical Care Survey, 

106

319
Improving Cultural Competence

National Association of Social Workers, 71

National Center for Cultural Competence 

(NCCC), 86, 259, 289

National Center on Minority Health and 

Health Disparities, 289

National Comorbidity Study, 142

National Congress of American Indians, 141

National Epidemiologic Survey on Alcohol 

and Related Conditions (NESARC), 114, 

115, 154

National Institute on Minority Health and 

Health Disparities, 20

National Institutes of Health (NIH), 20, 68

National Latino and Asian American Study 

(NLAAS), 118, 120

National Survey on Drug Use and Health 

(NSDUH) data

on African Americans, 104, 108, 114

on Asians and Asian Americans, 117, 

119, 120, 121, 125

on Hispanics and Latinos, 132, 133

on Native Americans, 139, 140, 142

on Pacific Islanders, 127

on racial and ethnic groups, 18, 21, 117

on White Americans, 152, 154

Native Americans, 14–15, 138–150

Behavioral Health Services for American Indians 

and Alaska Natives (planned TIP), 139

case study (John), 101–102

CODs of, 141–142

community involvement, importance of, 

101–102, 143, 144

complex cultural problems, counselors allowing for, 51

confidentiality issues, 144

in criminal justice system, 143

cultural identification, importance of, 26–

27, 144–145

cultural resources for, 293–294

defined, 295

evaluation and treatment planning for, 

143, 143–50, 145

family in culture of, 145–146

geographic factors, 18

health, illness, and healing, attitudes toward, 143, 147–148

historical trauma of, 28, 140, 142

IHS and Tribal service providers, 139, 

142, 293

language and communication issues, 17

mental disorders of, 141–142

monthly newsletters, 98

motivational interviewing, 70

personal space, cultural differences regarding, 51

recovery and relapse prevention, 148, 

149–150

religion and spirituality, 102, 144, 149

substance use and abuse and drug cultures, 26–27, 139–141

traditional/alternative healing practices, 

72, 102, 144, 147–149, 148

treatment patterns, 142–143

Wellbriety movement, 49, 147

Navajo, 140

NCCC (National Center for Cultural Competence), 86, 259, 289

nervios, 285

NESARC (National Epidemiologic Survey on 

Alcohol and Related Conditions), 114, 115,

154

nguzo saba, 297

NIH (National Institutes of Health), 20, 68

NLAAS (National Latino and Asian American Study), 118, 120

node-link mapping, 111, 135

nonverbal communication, 16–17, 54

NSDUH. See National Survey on Drug Use 

and Health (NSDUH) data

O

Office of Civil Rights, 289

Office of Minority Health (OMH), 289

definition of cultural competence, 5

Enhanced National Standards for Culturally and Linguistically Appropriate Services 

in Health and Health Care (2013), 8,

75, 265–266

Resource Center (OMHRC), 289–290

320
Index

staff education and training guidelines, 

93, 94

online drug cultures, 169–171

openness, culturally competent counselors 

showing, 50

organizational cultural competence, xix–xx, 

73–99

basic requirements for, 74, 75

benefits to organization, 8

case study (Cavin), 73–74

commitment to, throughout organization, 

76–77, 77

community involvement in, 8, 80, 80–81, 

84, 86, 96

continuum of cultural competence, organizations on, 10–11

defined, 297

diversity necessary for, 4–5, 90–91

engagement of all parties in, 80, 80–81

evaluation and monitoring of, 74, 75, 84–

87, 85, 86, 264–273

feedback, gathering, 85, 85–87, 86, 273–

275

fiscal support for, 96

governance, 75, 78–80, 80

historical perspective on, 98, 99

HRSA domains of, 75, 75–76

importance of organizational commitment, 2, 4

infrastructure supporting, 75, 96–98, 97–

98, 99

language services, 75, 88, 88–90, 90

mapping racial and cultural identity development and, 42

planning, 75, 80–83, 82, 87

self-assessments, 84–87, 85, 86, 264–273

senior management in charge of, 78–79

strategic planning, 78

in Sue’s multidimensional model for developing cultural competence, 6, 6–7, 

74

values of organization and, 75, 76–78, 77,

78

workforce and administrative staff development, 75, 90–96, 92–96

Organizational Cultural Competence Assessment Profile (HRSA), 266–268

orgullo, 297

orientation sessions, 134

outreach strategies and access to care, 96–98, 

97–98

P

Pacific Islanders, 14, 116–117, 127. See also

Asians and Asian Americans

access to care, 142

client–counselor matching, 71

cultural resources for, 291–292

defined, 297

evaluation and treatment planning for, 

127

health, illness, and healing, attitudes toward, 121, 127

substance abuse by, 127

pasmo, 285

peer-supported interventions and strategies, 

110, 113–114. See also group therapy; mutual-help groups

pelea nonga, 133–134

People Awakening Project, 150

perdida del alma, 285

performance evaluation

of organizational cultural competence, 74, 

75, 84–87, 85, 86, 264–273

of staff performance, 95–96, 96

personal space, 51–52

personalismo, 17, 133, 138, 297

Pew Forum on Religion and Public Life 

(2008), 30

planning. See also evaluation and treatment 

planning

cultural competence plans, 81–82, 82, 84, 

87, 296

fiscal support of organizational cultural 

competence, 96

organizational cultural competence, 75,

80–83, 82, 87

plática, 17

policies and procedures, organizational review 

of, 82–83

321
Improving Cultural Competence

posttraumatic stress disorder (PTSD), 105, 

106, 119, 142

power and trust issues, 44, 52, 109–110

prejudices, of counselors, 43–44, 44

prison. See criminal justice system

procedures and policies, organizational review 

of, 82–83

professional development programs, 91, 94

Prohibition, 151

Project MATCH, 70

promotion strategies for workforce and staff, 

90–91

A Provider’s Introduction to Substance Abuse 

Treatment for Lesbian, Gay, Bisexual, and 

Transgender Individuals (CSAT, 2001), 29

psychoeducation, 9, 111, 113, 125, 157, 170–

171

PTSD (posttraumatic stress disorder), 105, 

106, 119, 142

public advocacy of cultural competence, 5

Puerto Ricans, 59, 129, 130, 131, 132, 135, 

136, 138. See also Hispanics and Latinos

purification ceremonies, 72, 148

R

R/CID (racial/cultural identity development) 

model, 39, 40, 41, 42

racial and ethnic groups, xx–xxi, 3, 101–157. 

See also African Americans; Asians and 

Asian Americans; Hispanics and Latinos; 

Native Americans; Pacific Islanders; White 

Americans

Buddhists, 32

case studies, 41, 101–102

client–counselor matching, 71, 134

definitions of race and ethnicity, xvi, 13–

16, 15, 296, 297

diversity within, 17–18, 103

ethnic or token representatives, 90–91

families, concepts of and attitudes about, 

19

gender roles, 19

geographical variations in, 17–18

global differences in, 13

health disparities among, 20

health, illness, and healing, cultural attitudes toward, 29–30

Jewish, 31

language and communication issues, 16–

17, 17

mapping racial and cultural identity development, 41, 42

models of racial identity, 38, 39, 40

Muslims, 32

self-knowledge of counselor regarding racial, ethnic, and cultural identities, 38,

39–41, 40, 41

sexual identity and orientation, 29

sizes and percentages, 13

in Sue’s multidimensional model for developing cultural competence, 5–6, 6,

102, 103

U.S. Census Bureau groupings, xvi, 13

worldviews, values, and traditions, differences in, 18–19

racial/cultural identity development (R/CID) 

model, 39, 40, 41, 42

racism, 21, 28, 39, 40, 46, 50, 52, 56, 60, 109–

110, 119, 297

readiness and motivation for change, determining, 69–70

recovery and relapse prevention

for African Americans, 115–116

for Asians and Asian Americans, 128

culture of recovery, xxi, 173, 173–175, 

174, 175

for Hispanics and Latinos, 138

for Native Americans, 148, 149–150

Relapse Prevention and Recovery Promotion 

in Behavioral Health Services (planned 

TIP), 128, 157, 173–174

for White Americans, 156–157

recovery camps, Native American, 149

recruitment strategies for workforce and staff, 

90–91

reculturation, 297–298

refugees, 23, 28, 52

relapse prevention. See recovery and relapse 

prevention

322
Index

religion and spirituality, 30–33. See also rituals

of African Americans, 114, 115

of Asians and Asian Americans, 126–128

Buddhists and Buddhism, 32–33, 123, 

128, 156

Christians and Christianity, 31, 101, 115, 

128, 138, 149, 156

culturagrams, 67

of Hispanics and Latinos, 137, 138

Islam, 32, 115, 156

Jews and Judaism, 28, 30, 31–32, 156

of Native Americans, 102, 144, 149

of Pacific Islanders, 127

substance abuse and mental illness, treating, 31

syncretistic, 138, 298

Taoist version of CBT, 124

of White Americans, 151, 152

resistance, as stage in racial and cultural identity development, 40

respect, culturally competent counselors showing, 49

RESPECT mnemonic, 44

respeto, 134, 298

retention strategies for workforce and staff, 

90–91

rituals

of cultures of recovery, 174

of drug cultures, 167, 168

Rural Hawai’i Behavioral Health Program, 

127

S

SAMHSA. See Substance Abuse and Mental 

Health Services Administration

Santería, 138

Save Our Selves, 156

Schedules for Clinical Assessment in Neuropsychiatry (SCAN), 68

schizophrenia, 18, 21, 105–106, 119

screening and assessment tools, 65–69, 68,

277, 277–281

seasonal/migrant workers, 24

Secular Organizations for Sobriety, 156

segmented assimilation, 24

selective perception, 298

self-assessment

of core competencies, 55, 259–263

for counselor training, 93

of organizational cultural competence, 

84–87, 85, 86, 264–273

Self-Assessment Checklist for Personnel 

Providing Services and Supports to Children and Youth with Special Health Needs 

and Their Families, 55, 259–262

self-knowledge, as core competency, 37–45

ACA Counselor Competencies, 46

benefits of, 4, 8–9, 37–38

case management and, 70

cultural awareness, 38

limitations and abilities, understanding, 

44–45

racial, ethnic, and cultural identities, 

identifying, 38, 39–41, 40, 41, 42

RESPECT mnemonic, 44

stereotyping, prejudices, and history, 43–

44, 44

trust and power issues, 44

worldviews, individual and clinical, 42–

43, 43, 72

Self-Management and Recovery Training, 156

sensitivity, culturally competent counselors 

showing, 50

SES. See socioeconomic status

sexual identity and orientation, 29

shame, 1, 32, 60, 61, 117, 119, 121, 122

shen-k’uei, 284

shenjing shuairuo, 285

silence, cultural comfort with, 17

simpatía, 17, 253, 298

skra prameha, 284

social constructs

gender as, 19

race as, 13

socioeconomic status (SES), 20–22

acculturation and substance abuse, 26

culturagrams, 66–67

drug cultures and, 162, 169

education and, 21–22, 22

health disparities and, 20

323
Improving Cultural Competence

health, social determinants of, 21

solution-focused interventions, 123

South and Central Americans, 32, 129, 131, 

135, 285. See also Hispanics and Latinos

spirituality. See religion and spirituality

Standards of Practice for Case Management

(Case Management Society of America, 

2010), 71

Standards on Cultural Competence in Social Work 

Practice (National Association of Social 

Workers, 2001), 71

Stanford University Curriculum in Ethnogeriatrics, 290

Star Trek terminology and crack cocaine use, 

164

stereotyping, by counselors, 43–44, 44

strategic planning, by organizations, 78

strength-based interviews, 61

Subanun people, 30

subcultures, 62–63, 160, 161–162

substance abuse. See also co-occurring disorders; drug cultures; Treatment Improvement Protocols; 12-Step programs, under T

acculturation and, 25

by African Americans, 27, 104–105

by Asians and Asian Americans, 1, 57, 

117–119

Buddhism and, 32–33

cultural identification and, 26–27

culture of recovery and, xxi, 173, 173–

175, 174, 175

defined, 3

diagnosing, 68–69

educational factors, 21–22

exercise on benefits, losses, and the future, 170–171

gender roles and, 20

geographic factors, 18

by Hispanics and Latinos, 35–36, 129–

131, 130

historical trauma leading to, 28

immigrants and, 23, 25–26, 130

Islam and, 32

Judaism and, 31–32

by Native Americans, 26–27, 139–141

by Pacific Islanders, 127

religion and spirituality, 31

SES and, 21, 22, 26

sexual identity and orientation, 29

by White Americans, 150–152, 155

Substance Abuse and Mental Health Services 

Administration (SAMHSA), 290. See also

Health Resources and Services Administration; National Survey on Drug Use and 

Health (NSDUH) data; Treatment Improvement Protocols

guiding principles of recovery, 175

Targeted Capacity Expansion Program, 

CSAT, 98

TTA (Tribal Training and Technical Assistance) Center, 293

Sue’s multidimensional model for developing

cultural competence, xv, 5–7, 6, 36, 37, 58,

74, 102, 103, 160, 161

suicide, 3, 141, 143

sun dance, 148

supportive-expressive psychotherapy, 111

surveys of clients, staff, and community members, 85, 85–87, 86, 273–275

susto, 285

sweat lodges, 102, 148

syncretistic religions, 138, 298

T

taijin kyofusho, 285

talking circle, 158

Taoist version of CBT, 124

Targeted Capacity Expansion Program, 

CSAT, 98

TEDS (Treatment Episode Data Sets; 2001-

2011), 107

Temperance Movement, 151

terapia dura, 137

TIPs. See Treatment Improvement Protocols

touch, culturally specific meanings of, 52

traditional/alternative healing practices

acupuncture, 126

adapting intervention strategies to, 72

African Americans and, 114–115

Asian Americans and, 126–128

324
Index

cao gio, 126

circles, in Native American philosophy, 

147, 148

complex cultural problems, counselors allowing for, 51

counselor attitudes to, 37

counselor awareness of, 49

dances, sacred, 148

in Hispanic and Latino culture, 137–138

mainstream attitudes to, 10

of Native Americans, 72, 102, 144, 147–

149, 148

organizational attitudes to, 10

purification ceremonies, 72, 148

sweat lodges, 102, 148

White Americans and, 156

yin/yang balance, 126

traditions and values. See worldviews, values, 

and traditions

training

exercise on benefits, losses, and the future, 170–171

in language services, 89–90

of workforce and staff, 91, 91–93, 92, 93

transculturation, 298

translators, 88, 88–90, 90, 287

trauma, personal or historical, 28–29

African American, 28, 108, 109–110

Asian or Asian American, 119–120

in evaluation and treatment planning, 63, 

67

Native American, 28, 140, 142

PTSD, 105, 106, 119, 142

of racial and ethnic groups, 28–29, 106

Trauma-Informed Care in Behavioral 

Health Services (TIP 57), 23, 28, 157

treatment, attitudes toward. See health, illness, 

and healing

Treatment Episode Data Sets (TEDS; 2001-

2011), 107

Treatment Improvement Protocols (TIPs)

Addressing the Specific Behavioral Health 

Needs of Men (TIP 56), 20

Behavioral Health Services for American 

Indians and Alaska Natives (planned 

TIP), 139

Brief Interventions and Brief Therapies for 

Substance Abuse (TIP 34), 157

Enhancing Motivation for Change in Substance Abuse Treatment (TIP 35), 69, 

70, 157

Relapse Prevention and Recovery Promotion 

in Behavioral Health Services (planned 

TIP), 128, 157, 173–174

Substance Abuse: Clinical Issues in Intensive 

Outpatient Treatment (TIP 47), 157

Substance Abuse Treatment: Addressing the 

Specific Needs of Women (TIP 51), 20, 

123, 157

Substance Abuse Treatment and Family 

Therapy (TIP 39), 19, 146, 157

Substance Abuse Treatment for Adults in the 

Criminal Justice System (TIP 44), 157

Substance Abuse Treatment for Persons With 

Co-Occurring Disorders (TIP 42), 20, 

157

Substance Abuse Treatment: Group Therapy

(TIP 41), 155, 157

Trauma-Informed Care in Behavioral 

Health Services (TIP 57), 23, 28, 157

treatment planning. See evaluation and treatment planning

Tribal service providers, 139, 142

Tribal Training and Technical Assistance 

(TTA) Center, SAMHSA, 293

tripa ida, 285

trust and power issues, 44, 52, 109–110

TTA (Tribal Training and Technical Assistance) Center, SAMHSA, 293

12-Step programs

for African Americans, 111, 113–114

for Asians and Asian Americans, 125

culture of recovery and, 174

for Hispanics and Latinos, 136–137

for Jewish people, 32

Lakota version, 147

for Native Americans, 49, 102, 146–147, 

147

for White Americans, 155, 156

325
Improving Cultural Competence

U

undocumented immigrants, 22, 66–67, 134

Urban Indian Health Institute, 140

U.S. Census Bureau racial and ethnic groups, 

xvi, 13

U.S. Department of Health and Human Services (HHS). See also Office of Minority 

Health

definition of cultural competence, xv

health disparities, defined, 7

Healthy People 2020, 21

Mental Health: Culture, Race, and Ethnicity (Surgeon General’s report, 2001), 

290

Office of Civil Rights, 289

U.S. Department of Veterans Affairs, 116

V

value statements, of organizations, 77–78, 78

values. See worldviews, values, and traditions

Veterans Affairs, U.S. Department of, 116

veterans, Native American, 142

Vietnamese, 14, 22, 118, 119, 126, 292. See also

Asians and Asian Americans

Village Sobriety Project, 148

vision statements, 77–78, 78

W

Wellbriety movement, 49, 147

White Americans, 13–14, 150–157. See also

immigrants

CODs, 153

cultural identities of, 39, 154

defined, 298

evaluation and treatment planning for, 

154–156

families, concepts of and attitudes about, 

19

gender roles, 19

health, illness, and healing, attitudes toward, 153–154

language and communication issues, 17

mental disorders, 153

personal space, cultural differences regarding, 51

power and trust issues, 52

recovery and relapse prevention for, 156–

157

religion and spirituality, 151, 152

substance use and abuse and drug cultures, 150–152, 155

traditional/alternative healing practices, 

156

treatment patterns, 153

White Bison program, 147, 294

White privilege, 298

White racial identity development (WRID) 

model, 39, 40, 41, 42

WHO (World Health Organization), 68

Women for Sobriety, 156

World Health Organization (WHO), 68

worldviews, values, and traditions

clinical worldview, 43

of counselors, 42–43, 43, 72

culturagrams, 66–67

cultural differences in, 18–19

of culture of recovery, 174

of drug cultures, 165, 166

organizational cultural competence and, 

75, 76–78, 77, 78

WRID (White racial identity development) 

model, 39, 40, 41, 42

Y

yin/yang balance, 126

Yup’ik Eskimo, 148

326
327

SAMHSA TIPs and Publications Based on TIPs

What Is a TIP?

Treatment Improvement Protocols (TIPs) are the products of a systematic and innovative process that 

brings together clinicians, researchers, program managers, policymakers, and other federal and non-federal 

experts to reach consensus on state-of-the-art treatment practices. TIPs are developed under the Substance 

Abuse and Mental Health Services Administration’s (SAMHSA’s) Knowledge Application Program (KAP) 

to improve the treatment capabilities of the Nation’s alcohol and drug abuse treatment service system.

What Is a Quick Guide?

A Quick Guide clearly and concisely presents the primary information from a TIP in a pocket-sized 

booklet. Each Quick Guide is divided into sections to help readers quickly locate relevant material. Some 

contain glossaries of terms or lists of resources. Page numbers from the original TIP are referenced so providers can refer back to the source document for more information.

What Are KAP Keys?

Also based on TIPs, KAP Keys are handy, durable tools. Keys may include assessment or screening instruments, checklists, and summaries of treatment phases. Printed on coated paper, each KAP Keys set is 

fastened together with a key ring and can be kept within a treatment provider’s reach and consulted frequently. The Keys allow you, the busy clinician or program administrator, to locate information easily and 

to use this information to enhance treatment services.

Ordering Information

Publications may be ordered or downloaded for free at http://store.samhsa.gov. To order over the phone, 

please call 1-877-SAMHSA-7 (1-877-726-4727) (English and Español). 

TIP 1 State Methadone Treatment Guidelines—

Replaced by TIP 43

TIP 2 Pregnant, Substance-Using Women—

Replaced by TIP 51 

TIP 3 Screening and Assessment of Alcohol- and 

Other Drug-Abusing Adolescents—Replaced 

by TIP 31 

TIP 4 Guidelines for the Treatment of Alcoholand Other Drug-Abusing Adolescents—

Replaced by TIP 32 

TIP 5 Improving Treatment for Drug-Exposed 

Infants 

TIP 6 Screening for Infectious Diseases Among 

Substance Abusers—Archived 

TIP 7 Screening and Assessment for Alcohol and 

Other Drug Abuse Among Adults in the 

Criminal Justice System—Replaced by TIP 44 

TIP 8 Intensive Outpatient Treatment for Alcohol 

and Other Drug Abuse—Replaced by TIPs 46 

and 47 

TIP 9 Assessment and Treatment of Patients With 

Coexisting Mental Illness and Alcohol and 

Other Drug Abuse—Replaced by TIP 42 

TIP 10 Assessment and Treatment of CocaineAbusing Methadone-Maintained Patients—

Replaced by TIP 43 

TIP 11 Simple Screening Instruments for Outreach 

for Alcohol and Other Drug Abuse and 

Infectious Diseases—Replaced by TIP 53 

TIP 12 Combining Substance Abuse Treatment 

With Intermediate Sanctions for Adults in 

the Criminal Justice System—Replaced by 

TIP 44

TIP 13 Role and Current Status of Patient 

Placement Criteria in the Treatment of 

Substance Use Disorders 

Quick Guide for Clinicians 

Quick Guide for Administrators 

KAP Keys for Clinicians

TIP 14 Developing State Outcomes Monitoring 

Systems for Alcohol and Other Drug Abuse 

Treatment 

TIP 15 Treatment for HIV-Infected Alcohol and 

Other Drug Abusers—Replaced by TIP 37
Improving Cultural Competence

328

TIP 16 Alcohol and Other Drug Screening of 

Hospitalized Trauma Patients 

Quick Guide for Clinicians 

KAP Keys for Clinicians 

TIP 17 Planning for Alcohol and Other Drug 

Abuse Treatment for Adults in the Criminal 

Justice System—Replaced by TIP 44

TIP 18 The Tuberculosis Epidemic: Legal and 

Ethical Issues for Alcohol and Other Drug 

Abuse Treatment Providers—Archived

TIP 19 Detoxification From Alcohol and Other 

Drugs—Replaced by TIP 45

TIP 20 Matching Treatment to Patient Needs in 

Opioid Substitution Therapy—Replaced by 

TIP 43

TIP 21 Combining Alcohol and Other Drug Abuse 

Treatment With Diversion for Juveniles in 

the Justice System 

Quick Guide for Clinicians and 

Administrators 

TIP 22 LAAM in the Treatment of Opiate 

Addiction—Replaced by TIP 43 

TIP 23 Treatment Drug Courts: Integrating 

Substance Abuse Treatment With Legal 

Case Processing 

Quick Guide for Administrators 

TIP 24 A Guide to Substance Abuse Services for 

Primary Care Clinicians 

Concise Desk Reference Guide 

Quick Guide for Clinicians 

KAP Keys for Clinicians 

TIP 25 Substance Abuse Treatment and Domestic 

Violence 

Linking Substance Abuse Treatment and 

Domestic Violence Services: A Guide for 

Treatment Providers 

Linking Substance Abuse Treatment and 

Domestic Violence Services: A Guide for 

Administrators 

Quick Guide for Clinicians 

KAP Keys for Clinicians

TIP 26 Substance Abuse Among Older Adults 

Substance Abuse Among Older Adults: A 

Guide for Treatment Providers 

Substance Abuse Among Older Adults: A 

Guide for Social Service Providers 

Substance Abuse Among Older Adults: 

Physician’s Guide 

Quick Guide for Clinicians 

KAP Keys for Clinicians

TIP 27 Comprehensive Case Management for 

Substance Abuse Treatment 

Case Management for Substance Abuse 

Treatment: A Guide for Treatment Providers 

Case Management for Substance Abuse 

Treatment: A Guide for Administrators 

Quick Guide for Clinicians 

Quick Guide for Administrators

TIP 28 Naltrexone and Alcoholism Treatment—

Replaced by TIP 49 

TIP 29 Substance Use Disorder Treatment for 

People With Physical and Cognitive 

Disabilities 

Quick Guide for Clinicians

Quick Guide for Administrators 

KAP Keys for Clinicians 

TIP 30 Continuity of Offender Treatment for 

Substance Use Disorders From Institution 

to Community 

Quick Guide for Clinicians

KAP Keys for Clinicians

TIP 31 Screening and Assessing Adolescents for 

Substance Use Disorders 

See companion products for TIP 32.

TIP 32 Treatment of Adolescents With Substance 

Use Disorders 

Quick Guide for Clinicians 

KAP Keys for Clinicians 

TIP 33 Treatment for Stimulant Use Disorders 

Quick Guide for Clinicians

KAP Keys for Clinicians

TIP 34 Brief Interventions and Brief Therapies for 

Substance Abuse

Quick Guide for Clinicians 

KAP Keys for Clinicians 

TIP 35 Enhancing Motivation for Change in 

Substance Abuse Treatment

Quick Guide for Clinicians 

KAP Keys for Clinicians 

TIP 36 Substance Abuse Treatment for Persons 

With Child Abuse and Neglect Issues 

Quick Guide for Clinicians 

KAP Keys for Clinicians

Helping Yourself Heal: A Recovering Woman’s 

Guide to Coping With Childhood Abuse 

Issues 

Also available in Spanish

Helping Yourself Heal: A Recovering Man’s 

Guide to Coping With the Effects of 

Childhood Abuse 

Also available in Spanish
SAMHSA TIPs and Publications Based on TIPs

 329

TIP 37 Substance Abuse Treatment for Persons 

With HIV/AIDS 

Quick Guide for Clinicians

KAP Keys for Clinicians 

Drugs, Alcohol, and HIV/AIDS: A Consumer 

Guide 

Also available in Spanish

Drugs, Alcohol, and HIV/AIDS: A Consumer 

Guide for African Americans

TIP 38 Integrating Substance Abuse Treatment and 

Vocational Services 

Quick Guide for Clinicians 

Quick Guide for Administrators 

KAP Keys for Clinicians 

TIP 39 Substance Abuse Treatment and Family 

Therapy 

Quick Guide for Clinicians

Quick Guide for Administrators

Family Therapy Can Help: For People in 

Recovery From Mental Illness or Addiction

TIP 40 Clinical Guidelines for the Use of 

Buprenorphine in the Treatment of Opioid 

Addiction 

Quick Guide for Physicians 

KAP Keys for Physicians 

TIP 41 Substance Abuse Treatment: Group 

Therapy 

Quick Guide for Clinicians 

TIP 42 Substance Abuse Treatment for Persons 

With Co-Occurring Disorders

Quick Guide for Clinicians 

Quick Guide for Administrators 

KAP Keys for Clinicians 

TIP 43 Medication-Assisted Treatment for Opioid 

Addiction in Opioid Treatment Programs 

Quick Guide for Clinicians 

KAP Keys for Clinicians 

TIP 44 Substance Abuse Treatment for Adults in 

the Criminal Justice System

Quick Guide for Clinicians

KAP Keys for Clinicians 

TIP 45 Detoxification and Substance Abuse 

Treatment 

Quick Guide for Clinicians

Quick Guide for Administrators

KAP Keys for Clinicians 

TIP 46 Substance Abuse: Administrative Issues in 

Outpatient Treatment 

Quick Guide for Administrators

 

TIP 47 Substance Abuse: Clinical Issues in 

Outpatient Treatment 

Quick Guide for Clinicians 

KAP Keys for Clinicians 

TIP 48 Managing Depressive Symptoms in 

Substance Abuse Clients During Early 

Recovery 

TIP 49 Incorporating Alcohol Pharmacotherapies 

Into Medical Practice 

Quick Guide for Counselors 

Quick Guide for Physicians 

KAP Keys for Clinicians 

TIP 50 Addressing Suicidal Thoughts and 

Behaviors in Substance Abuse Treatment

 Quick Guide for Clinicians 

Quick Guide for Administrators

TIP 51 Substance Abuse Treatment: Addressing the 

Specific Needs of Women

 Quick Guide for Clinicians

Quick Guide for Administrators

KAP Keys for Clinicians

TIP 52 Clinical Supervision and Professional 

Development of the Substance Abuse 

Counselor 

Quick Guide for Clinical Supervisors

Quick Guide for Administrators

TIP 53 Addressing Viral Hepatitis in People With 

Substance Use Disorders 

Quick Guide for Clinicians and 

Administrators

KAP Keys for Clinicians 

TIP 54 Managing Chronic Pain in Adults With or 

in Recovery From Substance Use Disorders 

Quick Guide for Clinicians 

KAP Keys for Clinicians

You Can Manage Your Chronic Pain To Live a 

Good Life: A Guide for People in Recovery 

From Mental Illness or Addiction

TIP 55 Behavioral Health Services for People Who 

Are Homeless 

TIP 56 Addressing the Specific Behavioral Health 

Needs of Men 

TIP 57 Trauma-Informed Care in Behavioral 

Health Services 

TIP 58 Addressing Fetal Alcohol Spectrum 

Disorders (FASD) 

TIP 59 Improving Cultural Competence 

 
HHS publication no. (SmA) 14-4849 

First printed 2014

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and mental Health Services Administration

center for Substance Abuse Treatment