When counselors assume that one value system their own is superior and preferable to another it is known as?

As the 2000 census makes clear, the United States is a diverse multicultural society. Minority groups make up roughly one-third of the Nation's population, up from one-quarter in 1990. Minority groups are the fastest growing segment of the U.S. population (U.S. Census Bureau 2001). Foreign-born people now constitute more than 11 percent of the population—an alltime high (Schmidley 2003).

This chapter provides the consensus panel's recommendations on how to improve the cultural competence of treatment programs by

• Understanding cultural competence

• Learning about cultural competence in organizations

• Preparing for cultural competence assessment

• Understanding the stages of cultural competence

• Performing cultural competence assessment

• Implementing changes based on cultural competence assessment

• Developing a long-term, ongoing cultural competence process

• Undertaking program planning

Understanding Cultural Competence

What Is Cultural Competence?

Cultural competence is

• The capacity for people to increase their knowledge and understanding of cultural differences

• The ability to acknowledge cultural assumptions and biases

• The willingness to make changes in thought and behavior to address those biases

A culturally competent program demonstrates empathy and understanding of cultural differences in treatment design, implementation, and evaluation (Center for Substance Abuse Prevention 1994). According to Cultural Issues in Substance Abuse Treatment (CSAT 1999a), culturally competent treatment is characterized by

• Staff knowledge of or sensitivity to the first language of clients

• Staff understanding of the cultural nuances of the client population

• Staff backgrounds similar to those of the client population

• Treatment methods that reflect the culture-specific values and treatment needs of clients

• Inclusion of the client population in program policymaking and decisionmaking

It is important for administrators to understand that moving their program toward cultural competence requires a personal commitment and significant involvement from the entire staff. Cultural competence is an ongoing process of examination and change, not a goal to be attained once. To move toward cultural competence, staff members will have to contemplate on an ongoing basis what life is like for people different from themselves. Administrators should encourage program staff members to adopt an inquisitive and open-minded attitude toward other cultures.

Why Cultural Competence Matters

The Nation's diversity has important implications for treatment programs. The percentage of minority clients in substance abuse treatment is much greater than the percentage of minority treatment counselors (Mulvey et al. 2003). Administrators need to consider whether their organizations provide competent, sensitive treatment for individuals from minority groups. Following are compelling reasons for undertaking this effort:

• Individuals from minority groups can be a significant—even majority—sector of potential clients. In 2000, 59.0 percent of those admitted to treatment were Caucasian, 24.0 percent non-Hispanic African-American, 12.0 percent Hispanic, 2.3 percent American Indian and Alaska Native, and 0.8 percent Asian and Pacific Islander (Office of Applied Studies 2003b).

• Understanding and appreciating a client's cultural background expand treatment opportunities. Every culture has specific values that can be used in treatment, such as the support of extended families and of religious or spiritual communities. By appreciating a client's culture, staff can tap into the most effective treatment strategies—those based on the personal and social strengths of each individual.

• Enhancing the sensitivity and capacity to treat clients from other cultures improves a program's ability to treat all clients. The consensus panel believes that the competent handling of diversity is a basic issue underlying good treatment. The empathy and trust that a program's staff needs to practice to move toward cultural competence are an extension of the qualities that make a good counselor.

• Cultural competence is increasingly a requirement of funding and accreditation bodies. Attention to cultural competence is a requirement for accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). JCAHO currently is reviewing and is expected to adopt some form of the national standards for culturally and linguistically appropriate services (CLAS) in health care, developed by the U.S. Office of Minority Health. The CLAS standards were published in 2001 and are available at www.omhrc.gov.

• The ability to attract and serve ethnic clients is a financial issue. Improvements in cultural competence may contribute to improved client retention (Campbell and Alexander 2002).

Learning About Cultural Competence in Organizations

Administration's Attitude Toward Cultural Competence

Cultural competence starts with the program's administration. The more flexible and adaptable the program's organizational structure is, the more it will be able to incorporate the kind of changes cultural competence calls for. Rigidly hierarchical organizations are resistant to change and are hampered particularly when minority viewpoints need to be included (Administration for Children and Families 1994).

Cultural competence requires that people at all levels of the program learn to value diversity. The administration can demonstrate the seriousness of its commitment to cultural competence by investing human and financial resources in the effort and providing incentives for cultural competence training just as it would for other forms of continuing education. A culture of learning, where self-assessment and staff development are regular program activities, lends itself to cultural competence.

Becoming culturally competent means expanding the perceptions and the worldview of all staff members. The reassessment can result in fundamental changes for both individual staff members and program policy and structure. When staff members are asked to undergo serious self-examination and change, there may be resistance and varying degrees of success. Administrators should anticipate staff objections and reassure staff members that no one is being singled out for being insensitive—everyone can strive to be more culturally competent.

Defining Diversity

The consensus panel recommends that administrators define diversity broadly. Programs often assume that diversity applies only to specific ethnic and racial groups. But cultural diversity includes many groups of clients and many important factors that affect treatment—a client's gender, age, sexual preference, spiritual beliefs, socioeconomic status, physical and mental capacities, and geographic location. Program staff members should be aware of the many dimensions of diversity and how these factors can be used to motivate and assist clients in treatment—or how they can be barriers to engagement, treatment, and recovery.

The glossary in exhibit 4-1 defines common terms in the context of cultural competence.

Exhibit 4-1. Glossary of Cultural Competence Terms

Cultural diversity. Differences in race, ethnicity, nationality, religion, gender, sexual identity, socioeconomic status, physical ability, language, beliefs, behavior patterns, or customs among various groups within a community, organization, or nation.

Culture. Social norms and responses that condition the behavior of a group of people, that answer life's basic questions about the origin and nature of things, and that solve life's basic problems of human survival and development.

Discrimination. The act of treating a person, issue, or behavior unjustly or inequitably as a result of prejudices; a showing of partiality or prejudice in treatment; specific actions or policies directed against the welfare of minority groups.

Ethnicity. The beliefs, values, customs, or practices of a specific group (e.g., its characteristics, language, common history, and national origin). Every race has a variety of ethnic groups.

Ethnocentrism. The attitude that the beliefs, customs, or practices of one's own ethnic group, nation, or culture are superior; an excessive or inappropriate concern for racial matters.

Multiculturalism. Being comfortable with many standards and customs; the ability to adapt behavior and judgments to a variety of interpersonal settings.

Prejudice. Preconceived judgments, opinions, or assumptions formed without knowledge or examination of facts about individuals, groups of people, behaviors, or issues. These judgments or opinions usually are unfavorable and are marked by suspicion, fear, or hatred.

Race. The categorizing of major groups of people based solely on physical features that distinguish certain groups from others.

Background Resources

An administrator may want to explore materials and resources on cultural competence and organizational change. Information on how to support staff members in changing attitudes and behaviors is available in Thomas (1999). (See appendix 4-A for articles, books, and Web sites on educating staff and preparing programs for cultural competence.)

Federal agencies and academic centers offer information to assist administrators in determining the steps to take in planning, implementing, and evaluating culturally competent service delivery systems. One resource is the National Center for Cultural Competence at Georgetown University's Child Development Center (www.georgetown.edu/research/gucdc/nccc/index.html). The Health Resources and Services Administration (2001) also offers materials.

Research on treatment

Little research exists on practical ways for programs to deliver culturally competent substance abuse treatment to specific populations. Beutler and colleagues (1997) found that matching clients with counselors of the same race improved engagement and retention for some clients but for others it had no effect. Some ethnic groups (e.g., Asians) place such a strong emphasis on community that it is often easier for them to discuss problems with a counselor who is outside their group.

Further complicating the picture, clients' engagement with counselors and retention in programs also can be improved if such race-blind attributes as socioeconomic class, acculturation, and education are used to match clients with counselors (Chinman et al. 2000). Increased retention does not translate necessarily into increased client engagement in the treatment process (Chinman et al. 2000). In the mental health field, evidence that matching clients with counselors based on race improves treatment outcomes is inconclusive (Chinman et al. 2000). Administrators should not overlook the potential benefits of treating diverse clients together, where they can learn from one another across, instead of within, racial and cultural boundaries.

The Center for Substance Abuse Treatment's (CSAT's) forthcoming TIP Improving Cultural Competence in Substance Abuse Treatment (CSAT forthcoming b) provides both the latest research and expert advice from practitioners on clinical issues and treatment of diverse populations. Administrators also should consult TIP 29, Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities (CSAT 1998d), and Health Promotion and Substance Abuse Prevention Among American Indian and Alaska Native Communities: Issues in Cultural Competence (Center for Substance Abuse Prevention 2001). Cultural Issues in Substance Abuse Treatment (CSAT 1999a) contains population-specific discussions of treatment for Hispanics, African-Americans, Asian and Pacific Islanders, and American Indians and Alaska Natives, along with general guidelines on cultural competence.

Preparing for Cultural Competence Assessment

An administrator should consider the following issues before undertaking the various cultural competence assessments described below:

• Take advantage of staff knowledge. Counselors and nonclinical staff members should serve as resources; administrators should find out what staff members have learned from their experience with clients from diverse backgrounds.

• Educate and motivate staff. Staff members can learn from resource materials on substance abuse treatment and culturally diverse groups that the administrator has collected. Involving the entire staff in the cultural competence effort promotes self-assessment as a program priority and helps secure the staff's commitment and participation.

• Establish a cultural competence task force. This group will lead the cultural competence assessment and will be responsible for planning, carrying out, and evaluating the program's cultural competence initiatives. It should have representation from throughout the program—board members, administrators, clinicians, nonclinical staff members, and clients. The task force can be divided into work groups to focus on different aspects of assessment (e.g., community, client, program; see “Performing Cultural Competence Assessment” below). An administrator also should try to involve members of the community in the self-assessment process.

• Network with other groups. It will be beneficial for the administrator to talk to other programs that have developed culturally competent service delivery systems and to solicit input from diverse groups in the community.

Understanding the Stages of Cultural Competence

The administrator and staff might find it useful to think of cultural competence occurring along a continuum that includes six stages, ranging from cultural destructiveness to cultural proficiency (see exhibit 4-2). Without attention to cultural issues, most organizations are at cultural incapacity (stage 2) or cultural blindness (stage 3). Agencies that begin to look at competence issues will be at cultural precompetence (stage 4). Even when a program reaches cultural proficiency (stage 6), there is still room for growth and improvement.

Exhibit 4-2. Stages of Cultural Competence for Organizations

Stage 1. Cultural Destructiveness

• Makes people fit the same cultural pattern; excludes those who do not fit (forced assimilation).

• Uses differences as barriers.

Stage 2. Cultural Incapacity

• Supports segregation as a desirable policy, enforces racial policies, and maintains stereotypes.

• Maintains a paternalistic posture toward “lesser races” (e.g., discriminatory hiring practices, lower expectations of minority clients, and subtle messages that they are not valued).

• Discriminates based on whether members of diverse groups “know their place.”

• Lacks the capacity or will to help minority clients in the community.

• Applies resources unfairly.

Stage 3. Cultural Blindness

• Believes that color or culture makes no difference and that all people are the same.

• Ignores cultural strengths.

• Encourages assimilation; isolates those who do not assimilate.

• Blames victims for their problems.

• Views ethnic minorities as culturally deprived.

Stage 4. Cultural Precompetence

• Desires to deliver quality services; has commitment to civil rights.

• Realizes its weaknesses; attempts to improve some aspect of services.

• Explores how to serve minority communities better.

• Often lacks only information on possibilities and how to proceed.

• May believe that accomplishment of one goal or activity fulfills obligations to minority communities; may engage in token hiring practices.

Stage 5. Cultural Competence

• Shows acceptance of and respect for differences.

• Expands cultural knowledge and resources.

• Provides continuous self-assessment.

• Pays attention to the dynamics of difference to meet client needs better.

• Adapts service models to needs.

• Seeks advice and consultation from minority communities.

• Is committed to policies that enhance services to diverse clientele.

Stage 6. Cultural Proficiency

• Holds all cultures in high esteem.

• Seeks to add to knowledge base.

• Advocates continuously for cultural competence.

Performing Cultural Competence Assessment

Agency self-assessment is valuable in planning for culturally competent service delivery. To capture all useful information relating to a program's cultural competence, the self-assessment must survey the community, the clients, and the program itself. This assessment has two key goals: to determine how culturally competent the program's services are and to provide information for a long-term improvement plan. Assessment focuses on the following questions:

• What is the composition of the local population? Are all those who need care being served in the program?

• What is the level of satisfaction with the program among clients from minority groups?

• How prepared and competent is the program to meet the treatment needs of the diverse groups in the community?

Community Assessment

An administrator needs to identify the culturally, linguistically, racially, and ethnically diverse groups in the program's locale. Appendix 4-B provides a matrix that can be used to determine the demographics of a local area, using 2000 census data. These data can be accessed at www.census.gov. The information is useful for assessing

• The percentage of minority and ethnic individuals residing in the catchment area

• The extent to which individuals from various ethnic groups are accessing services

• The underrepresented groups that may need targeted outreach

The census data also allow a program administrator to compare community demographics with those of the program staff. Does the staff reflect the makeup of the community? Does the board of directors include individuals who represent local population groups? Does the program have caseworkers, outreach workers, or other personnel who have links to all groups in the community?

Cultural competence has different emphases depending on the makeup of the local community. Each program establishes what cultural competence means with respect to the clients it serves. People from the community and members of the board and the staff who represent diverse groups can provide useful information about the program's level of cultural competence and needed services.

Assessment by Clients

Important information about a program's level of cultural competence can be supplied only by the clients it serves. How satisfied are clients with the services they receive? Surveys help determine the accessibility and sensitivity of the program and are an effective method of program assessment. It is recommended that a program survey clients at the time of discharge (or dropout) from the program. Programs then can analyze by gender, race, ethnicity, religion, and physical ability the feedback received from clients about services.

Program Self-Assessment

Self-assessment of the treatment program's cultural competence should include the following areas:

• Administration policies

• Physical facility

• Staff diversity

• Staff training

• Screening and assessment methods and tools

• Program design

To be effective, cultural competence self-assessment should be undertaken in a supportive environment; involve the entire program, including board members and volunteers; include a formal review in which all who were involved in the assessment learn the results; and culminate with the decision to take specific actions (Gonzalez Castro and Garfinkle 2003; McPhatter and Ganaway 2003).

The results of an agency self-assessment should be used to develop a long-term plan that includes measurable goals and objectives and may indicate changes to be made in the mission statement, policies, administration, staffing patterns, service delivery practices and approaches, and outreach and professional development activities.

Several assessment tools are listed in appendix 4-A.

Implementing Changes Based on Cultural Competence Assessment

Most programs can benefit from administrative-level changes that can be accomplished quickly. These changes can be made in program mission, program policy, board membership, community input, staff diversity, and facility appearance. The more attention the administration pays to diversity, the more positive and supportive all staff members will be about expanding their cultural competence.

Mission statement.The program should ensure that its mission statement incorporates cultural competence as a core value. The cultural competence committee should be involved in developing or modifying the statement.

Program policy.The program policy should endorse explicitly and respect the cultural diversity of program clients, staff members, and the community. Respect should be reflected in the development and enhancement of the program's philosophy, outreach activities, staffing, and client services.

Support for cultural competence should be included in staffing policies. Some suggestions follow:

• The ability to work sensitively with people from other cultures can be a criterion for evaluating staff performance.

• Program policy can encourage staff members to pursue continuing education in cultural competence, focused on groups served by the program.

A diverse board of directors.As a result of the agency assessment, an administrator may want to add board members from groups not represented. A diverse board is extremely important and can help provide a broader perspective. Having board members from diverse groups helps establish the program's credibility with members of those groups.

Input from diverse groups.An administrator can identify knowledgeable persons from the community and involve them in the program. Their advice can help develop new interventions and services that affirm and reflect the values of the various cultures in the community.

Diverse staff and management.The administrator needs to make clear, through policy and action, the value of recruiting staff members from diverse groups. Hiring ethnic or minority staff members to work in management, policymaking, and clinical positions is important for programs that serve diverse populations.

Facility appearance.The decor of a treatment facility can make an inclusive or exclusive statement. The program's walls should reflect cultural openness, with posters and pictures showing people representative of the client population. Clients feel welcome when they see pictures of people like themselves. (See appendix 4-A for Web sites that have appropriate posters.)

Developing a Long-Term, Ongoing Cultural Competence Process

To move toward cultural competence, programs need a long-term, ongoing commitment to change, including staff selection and training.

Steps To Take

Based on results of the cultural competence assessment, an administrator might take the following steps:

• Obtain new screening and assessment instruments. Identify and acquire screening and assessment materials for the diverse groups in the client population (e.g., translated or orally administered materials). Both foreign-born clients who are learning English and those with cognitive impairments may benefit from oral screening methods. Train staff to use these materials and methods.

• Open a dialog with staff. Convene brown-bag lunches to engage staff members in discussions and activities that offer an opportunity to explore attitudes, beliefs, and values related to cultural diversity and cultural competence.

• Explore staff development needs. Ask staff members what resources would help them serve culturally, linguistically, racially, and ethnically diverse groups. Use this information to develop ongoing staff training programs.

• Revise the budget. Allocate funds to support staff in attending conferences, seminars, and workshops on cultural competence and treatment issues relevant to the program.

• Investigate funding opportunities. Explore resources that are available to provide special services needed by potential clients. Many Federal grant programs are designed to fund services for underrepresented and underserved populations.

• Remove barriers. Address any special barriers to treatment for diverse groups identified in the assessment phase. For example, foreign-born clients may need vocational help, translation services, or English-as-a-second-language classes.

• Inform staff and clients of resources on diversity and substance use disorders. Provide information about the resources that are available to support clients from diverse groups.

Appendix 4-A contains population-specific information that can help staff better understand and treat clients from diverse backgrounds.

Staff Selection and Training

The program's openness to differences in background among clients and staff members should be communicated clearly both to potential clients and to referral sources in the surrounding community. The more diverse the staff is with respect to age, gender, physical ability, race, religion, and ethnicity, the more able the program will be to treat all types of clients. A program needs to make special efforts to hire culturally competent staff.

Selecting a diverse staff

Programs need to recruit staff members whose backgrounds are similar to those of the clients being treated. Unfortunately, the substance abuse treatment field has a shortage of trained counselors from diverse backgrounds. Administrators report that bicultural and bilingual counselors are hard to recruit. A recent survey done by CSAT showed serious disproportion between the demographic backgrounds of clients and those of treatment staffs (Mulvey et al. 2003). In this survey of 3,276 randomly selected facility directors, clinical supervisors, and counselors, only 6 percent of treatment providers were Hispanic and only 11 percent were African-American. Yet the survey showed that Hispanics made up 14 percent and African-Americans 25 percent of the treatment population.

The study concludes that “treatment professionals are generally not from the same ethnic and racial backgrounds as the clients they serve. This situation presents a tremendous challenge for the field” (Mulvey et al. 2003, p. 56). The following planning approach may be helpful in increasing the number of counselors from different backgrounds:

• Target specific ethnic and cultural groups served by the program, and assess the barriers to finding and hiring clinical staff with the same backgrounds. In areas where these groups constitute a small percentage of the population, hiring qualified counselors from the same backgrounds may be difficult.

• Tap into State and national recruiting sources, such as the Single State Agency and job search and recruitment Web sites.

• Establish a file of recruitment resources, and seek their help.

• Develop a plan to encourage potential counselors to enter the treatment field through internships. Look at providing incentives for promising candidates, including training.

• Recruit diverse candidates from local colleges; consider granting fellowships to assist advanced students in completing their degrees.

Interviewing and hiring culturally competent staff

Cultural competence is not merely a set of skills; it is also a desire to use those skills to understand others. Programs will move more easily toward cultural competence if they hire individuals who have a genuine interest in cultural diversity. The process of hiring culturally competent staff need not differ much from hiring good counselors. The same qualities are common to each: empathy, use of individualized treatment approaches, willingness to look beyond assumptions, and ability to establish trust.

In interviews, applicants should be asked to discuss what diversity means to them. Administrators should rate more highly applicants who speak of diversity in terms that go beyond race to include religion, physical ability, sexual preference, age, and gender. Applicants also should be asked to speak in detail about their experiences working with diverse colleagues and clients. Administrators also may arrange for prospective counselors to run a group session to see how they interact with diverse clients.

Training staff

All counselors have cultural blind spots. It is important for counselors to acknowledge their beliefs and assumptions, even if they are misguided or based on stereotypes. Learning about the nuances of other cultures, particularly as they affect treatment, is not intuitive. Counselors should be willing to learn from their clients. Counselors should be trained to ask questions to learn what substance abuse and addiction mean in the client's culture. Staff members should not make assumptions about clients based on their physical ability, gender, ethnicity, or religion but approach and treat each client as an individual.

Training can be undertaken by the program itself, can focus on the particular groups being treated in the program, and can be done inexpensively. Knowledgeable people representing the diverse groups in the community can be invited to meet with staff and discuss issues affecting treatment. Training of staff members needs to focus on

• Self-assessment of cultural biases and attitudes

• Sources of cross-cultural misunderstanding

• Sources of social or psychological conflict for bicultural clients

• Strategies for clinical cultural assessment of individual clients

• Guidelines for clinical encounters

Appendix 4-A lists tools for cultural competence training and evaluation, including Web links to trainers and consultants.

Undertaking Program Planning

A core set of administrative and structural principles is important for every program providing treatment to diverse groups. Treatment planning and goal setting should be sensitive to the individual client's recovery goals. The client's values and cultural traditions should be accepted and respected in establishing expectations and making the treatment plan. Program staff members should be sensitive to cultural, ethnic, and regional variations in family structures and in the way that clients define their families.

Criteria for Types of Programming

What type of programming will be provided for clients from minority groups in the community? A program can decide to serve diverse clients

• Within a nonspecialized treatment program, providing one-on-one counseling as needed

• Within a nonspecialized treatment program, adding specialized group meetings or tracks

• In a specialized treatment program designed for members of a particular group

Programs should consider whether they can address diverse clients' needs within a nonspecialized treatment program or whether it would be preferable to set up a specialized program serving only these clients. If people are ill at ease outside their own culture, they generally are more comfortable and trusting with others who are like them. Specialized treatment programs consisting of clients from a particular group, such as immigrants from a particular country or women, offer the chance to design program strategies for individuals who share a common background and common concerns.

However, because treatment resources are limited, administrators may face difficult choices about integrating diverse clients into general programs. Some questions to answer include

• Is the potential volume of clients sufficient to support a specialized program?

• Is financial support available for these clients?

• Will treatment goals of the specialized services fit into the program?

• Are counselors available who are sensitive to the group?

• Will there be access to training regarding the special needs of this population?

• Are links and referrals to other service providers possible for this target population?

When the answers to these questions do not support the development of a separate specialized program, administrators may want to consider enhancing their program's general outpatient treatment services with special groups and tracks.

Administrative Support for Counselors

When clients from diverse groups are to be treated in a general program, the counselor who works with them should be experienced and supportive. Such clients may need additional time in individual counseling, as well as the counselor's help to integrate them into the treatment group.

Clients from diverse groups may need ongoing, long-term social support. The available peer support groups in the community may not serve some of these clients adequately. Programs should identify and maintain a list of local mutual-help groups. If appropriate support groups cannot be identified for a particular group (e.g., Hispanic clients who abuse alcohol), the treatment program should consider sponsoring a specialized alumni support group. Bonding with a long-term support group can be a significant factor in recovery.

Specialized Treatment Programs

If a specialized program is deemed necessary, administrators should be aware that the program must follow mandatory State requirements and meet the same licensure regulations as other treatment programs. These requirements need not hamper treatment of minority clients. Directors of ethnocentric treatment programs note that, although State and accreditation requirements are the same for all programs, culturally sensitive treatment can deploy the required program elements to serve culturally diverse clients.

Identified special client populations

Clients for whom specialized programs are highly recommended include

• Foreign-born clients. The special language needs of some immigrant groups may be met best through specialized programming. Bilingual counselors need to be available when treating clients who speak a language other than English. Specialized programs for recent immigrants also may require focusing on U.S. laws that pertain to substance abuse and on available social support systems. For clients with limited English-language skills, important documents (e.g., confidentiality, grievance, and complaint forms) need to be translated or explained.

• Clients benefiting from an ethnocentric approach. Individuals from minority groups may have problems with identity, self-esteem, and cultural alienation. Ethnocentric programs that build on the individual's strengths and ethnic roots can be empowering. Treatment programs developed for Native Americans and Alaska Natives—using both Western and traditional healing methods—represent an example of the enhanced effectiveness that ethnocentric programs can achieve.

• Clients who are disabled, including those from the Deaf community.

Components of specialized programs

Specialized programs for a particular group should include

• Staff members, supervisors, and administrators representing backgrounds similar to those of the clients. Although it is important that program staff members reflect the diversity of the client population, it should not be assumed that counseling staff members will be competent simply because they share the clients' ethnicity or culture. For example, middle-class African-American counselors may not share the life experiences of African-American clients who live in inner-city poverty. Native-American programs may find that their Western-trained Native counselors need training and support before they can treat clients effectively using Native healing ceremonies and traditions.

• Staff training and supervision. Cultural training is important for counselors in an ethnocentric program. Programs serving foreign-born clients need to employ staff members who are multilingual and multicultural. It is important to be aware that a counselor from the same culture as the client may still need cultural sensitivity training. Culture changes within a country over time. A counselor whose family immigrated during his or her childhood may not be attuned to the culture of the recent immigrant. Also, the level of acculturation can change drastically between immigrants and their children born in this country.

• Unbiased assessment tools. Program staff should be sensitive to issues of cultural bias in assessment procedures. To ensure appropriate test interpretation, programs should use standardized and program-based instruments that have norms for the ethnic or cultural groups that are being treated.

• Special programming components. Treatment programs that serve a particular group should be culturally relevant for the particular group in content, delivery of services, and philosophy. Before designing a specialized program, administrators should seek help and advice from other providers who have developed programs for the same population. Focus groups comprising recovering members of a specific minority population, drawn from program alumni, also can be valuable.

Clients With Disabilities

Clients who are deaf

One-half of one percent of the American population is deaf, but people who are deaf are underrepresented among the population that seeks treatment (McCrone 1994). It is important for administrators to be aware of potential barriers to treatment, some of which come from within the close-knit Deaf community. Because people who are deaf socialize primarily with one another, a fear exists that personal information shared in treatment will become public via the Deaf community's communication grapevine. The Deaf community's desire to present a positive image also may deter some members from admitting to substance use problems (Guthmann and Blozis 2001).

Individuals who are deaf are reluctant to enter treatment if they think they will encounter barriers to communication. For this reason, most people who are deaf and seeking treatment for a substance use disorder prefer to be in a program with other people who are deaf (CSAT 1998d). Because having a separate group often is not feasible, most programs treat individuals who are deaf with hearing clients.

Deafness is defined as a disability by the Americans with Disabilities Act (ADA) of 1990; clinics are required to provide accommodations to individuals who are deaf and seek treatment. In most cases, the accommodation will consist of hiring an individual fluent in American Sign Language (ASL) to interpret during sessions. Family members of the individual who is deaf should not be used as interpreters. Administrators should not assume that all individuals who are deaf are proficient in ASL; some use other manual languages. Written materials might be difficult to understand for some individuals who are deaf; the average adult who is deaf reads at the fourth grade level (Crone et al. 2003).

Recovery can be particularly difficult for individuals who are deaf. Because there may be few people who are deaf in the area, people who are deaf and in recovery who want to sever ties with substance-using friends may have to turn their backs on nearly everyone they know. Also, support groups that include ASL interpreters are rare (Guthmann and Blozis 2001). Programs should maintain a list of resources that can be accessed by individuals who are deaf and in recovery (Guthmann and Sandberg 1998). The Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals offers resources and training for treating this population. Its Web site (www.mncddeaf.org) includes articles on assessment and treatment, as well as information for ordering manuals for individuals in recovery and videotapes of mutual-help programs interpreted in ASL.

Other clients with disabilities

Individuals who are disabled have higher rates of substance use disorders than the general population (Moore and Li 1998). The higher rates can be attributed to increased risk factors, such as chronic pain, a feeling of entitlement to drugs, and access to prescription drugs. Administrators should know that the presence of a physical or mental disability may conceal signs of substance use (Li and Ford 1998).

ADA guarantees equal access to treatment for clients with disabilities. If the building that houses the program does not permit equal access to people with disabilities, administrators should consider making the necessary changes. Physical barriers include not just stairs, but narrow hallways, conventional doorknobs that prevent access to people with limited manual dexterity, deep pile carpet that interferes with wheelchairs or crutches, and water fountains and telephones that are located too high on walls (CSAT 1998d). People who use wheelchairs or crutches may need help arranging transportation to and from the treatment facility. While there, they may require extra time to get from place to place.

Administrators should be aware of local programs and services that are equipped to help individuals with disabilities. TIP 29, Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities (CSAT 1998d), contains information about screening and treating this population; chapter 5 of TIP 29 focuses on administrative tasks, appendix B lists resources, and appendix D discusses the implications of ADA.

Designing Ongoing Outreach Efforts

Community involvement and outreach are critical parts of any long-term, cultural competence plan. Providers need to think about how they can recruit clients from cultures not adequately reached by the program. Programs should reach out to minority individuals who are in need of treatment but may be reluctant to seek it.

Programs will benefit greatly from drawing on the cultural experience and expertise of diverse members of the community. Administrators should involve the diverse groups in developing program goals, designing networking, and ensuring client entry and retention.

The following steps can be taken:

• Network with appropriate organizations. Contact organizations concerned with the culturally diverse groups the program serves. Solicit their involvement and input in the design and implementation of service delivery initiatives with these groups.

• Work to identify and remove barriers to treatment for diverse groups. Address clients' need for transportation services, limited free time to participate in treatment, and the need for childcare services.

Although there is widespread agreement that understanding of and sensitivity to the increasingly diverse cultural groups in the United States are positive developments, it is unclear how these developments should affect treatment. McFadden (1996) observes that “simply knowing about a culture is not sufficient. The counselor must use this new information obtained through experience and incorporate it into the counseling process” (p. 234). Studies conducted to date on the implementation of culturally specific elements in substance abuse treatment have been inconclusive.

The consensus panel believes that cultural competence is a worthwhile goal for programs and recommends that it involve the entire program—from the board of directors to the part-time staff members, from the mission statement to outreach efforts. When administrators commit program resources to train and support staff members in their efforts to improve their cultural competence, the program as a whole benefits.

Appendix 4-A. Cultural Competence Resources

Background Information on Diversity and Cultural Competence

• The Substance Abuse and Mental Health Services Administration's (SAMHSA's) National Clearinghouse for Alcohol and Drug Information (NCADI) (www.ncadi.samhsa.gov)—The NCADI Web site provides access to publications on specific populations. Click on Audience to access information on African-Americans, American Indians, Alaska Natives, Asians and Pacific Islanders, disabled individuals, Hispanic and Latino populations, and lesbian, gay, and bisexual individuals.

• Hawaii AIDS Education and Training Center (www.hawaii.edu/hivandaids/links_culture.htm)—This Web site provides links to resources on clients who are homeless, have disabilities, or are members of minority groups. The information and links provided discuss more than just HIV/AIDS and health care.

• “Effective Therapies for Minorities: Meeting the Needs of Racially and Culturally Different Clients in Substance-Abuse Treatment” (Beatty September/October 2000; www.counselormagazine.com)—This journal article includes basic steps that programs can take to move toward cultural competence.

• Cultural Competence in Substance Abuse Treatment, Policy Planning, and Program Development (www.attc-ne.org/pubs/ccsat.pdf)—This annotated bibliography of resources has sections on African-Americans, Asian and Pacific Islanders, Native Americans, and Latinos, compiled by the Addiction Technology Transfer Center of New England, at Brown University's Center for Alcohol and Addiction Studies.

• The Provider's Guide to Quality and Culture (erc.msh.org/mainpage.cfm?file=1.0.htm&module=provider&language=English)—This Web site provides descriptions of attributes and beliefs of many cultural groups, with links and references, as well as information on cultural diversity and self-assessment tools.

• Cultural Competence Standards in Managed Mental Health Services: Four Underserved/Underrepresented Racial/Ethnic Groups (Center for Mental Health Services 1997; www.mentalhealth.org/publications/allpubs/SMA00-3457)—This book discusses guiding principles for cultural competence in the context of treatment for African-Americans, Asians and Pacific Islanders, Hispanic populations, Native Americans, Alaska Natives, and Native Hawaiians.

• “Develop Your ‘Ethnocultural Competence’ and Improve the Quality of Your Practice” (Straussner November/December 2002; www.counselormagazine.com)—This journal article provides a good introduction to ethnicity and culture and how both affect treatment.

• Cultural Diversity in Health and Illness (Spector 2003)—This book includes chapters on traditional views of health in African-American, Hispanic, American Indian, and Asian and Pacific Islander communities and appendixes that list population-specific resources.

Preparing for Cultural Competence Assessment

• Managing Multiculturalism in Substance Abuse Services (Gordon 1994)—This book focuses on developing a multicultural framework for treatment, program evaluation, and leadership. It includes tools to evaluate the needs of the community and the effectiveness of cultural competence training.

• Planning, Implementing and Evaluating Culturally Competent Service Delivery Systems in Primary Health Care Settings: Implications for Policymakers and Administrators (http://www.mchgroup.org/nccc/documents/Getting_Started.html)—This checklist from the National Center for Cultural Competency helps organizations implement policies and practices that support cultural competence.

• “Evaluating Outcomes in a Substance Abuse Training Program for Southeast Asian Human Service Workers” (Amodeo and Robb 1998)—This journal article explores the challenges that cross-cultural substance abuse training programs face.

• Culture, Race, and Ethnicity in Performance Measurement (Philips et al. 1999)—This is a compilation of resources and readings on providing and evaluating culturally competent mental health care.

Assessment

• A Guide to Enhancing the Cultural Competence of Runaway and Homeless Youth Programs (Administration for Children and Families 1994; www.ncfy.com/pubs/culguide.htm)—This guide presents tools for assessing and enhancing cultural competence in youth-serving organizations. Assessment questionnaires that focus on the community, clients, and the program itself are included in appendix A. The tools and information can be adapted for drug treatment programs.

• Cultural Competence Self-Assessment Instrument (Child Welfare League of America 1993; www.cwla.org/pubs)—This resource provides tools for assessing cultural competence of policies, programs, and staff and guidelines for strengthening cultural competence.

• Health Resources and Services Administration. Study on Measuring Cultural Competency in Health Care Delivery Settings: A Review of the Literature (www.hrsa.gov/culturalcompetence/measures)—This report details a comprehensive review of the cultural competence theoretical and methodological literature.

Training

• Cultural Competency Tool (order forms at www.ahaonlinestore.com)—Available from the Society for Social Work Leadership in Health Care for $15 for members and $20 for nonmembers, this instrument assists in evaluating the cultural competence of staff and can be used for performance assessment, evaluation of prediversity and postdiversity efforts, or compliance with Medicaid/Medicare conditions or JCAHO cultural competence standards.

• Toolkit for Cross-Cultural Communication (www.awesomelibrary.org/multiculturaltoolkit.html)—These materials compare patterns of communication across diverse groups and discuss myths that impair cultural competence, including a table of communication norms and values across cultures.

• Handbook for Developing Multicultural Awareness, 3d edition (Pedersen 2000)—This book employs a three-stage model of multicultural training, focusing on culturally learned assumptions, accurate information, and counseling skills; it also discusses ethical dilemmas and conflict management.

• Developing Intercultural Awareness: A Cross-Cultural Training Handbook (Kohls and Knight 1994)—This book contains training activities, including preplanned 1- and 2-day workshops.

• Figuring Foreigners Out: A Practical Guide (Storti 1999)—This workbook focuses on interactions with people from outside the United States. Lessons can be used for group training or self-instruction and are designed to teach new attitudes and behaviors for interacting with people from diverse cultures.

• Culture and the Clinical Encounter: An Intercultural Sensitizer for the Health Professions (Gropper 1996)—This book presents cross-cultural health care scenarios with possible outcomes from which the reader chooses. Each choice is discussed in a separate answer key. The question-and-answer format makes this a useful training tool.

• Intercultural Communication Institute (www.intercultural.org)—This organization conducts an annual Summer Institute for Intercultural Communication.

• Diversity Training Associates of Portland, OR (800-484-9711, ext. 8250)—This organization provides consultants and trainers.

Posters

SAMHSA's NCADI stocks posters and office materials that can be viewed and ordered at www.ncadi.samhsa.gov.

Population-Specific Information

For information and resources that address specific populations, see TIP 47, Substance Abuse: Clinical Issues in Intensive Outpatient Treatment (CSAT 2006b).

Appendix 4-B. Community Diversity Form

Total City Population: ________________

Total County Population: ________________