Cultural Competence and Evidencebased Practices: Current State of Knowledge and Practice

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Cultural Competence and Evidence-based
Practices Current State of Knowledge and Practice

• Stanley Sue
• University of California, Davis

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What Know and Dont Know about Cultural Competency

• What is Cultural Competency?
• Is Cultural Competency Needed?
• What is the State of Evidence Based Practices
  with Ethnic Minority Populations?
• What are Different Ways of Viewing Cultural
  Competency?

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What is Cultural Competency?

• The integration and transformation of knowledge,
  information, and data about individuals and
  groups of people into specific clinical
  standards, skills, service approaches,
  techniques, and marketing programs that match the
  individuals culture and increase the quality and
  appropriateness of mental health care and
  outcomes (Davis, 1997).
• Cultural competence occurs in mental health
  service delivery when cultural issues are
  acknowledged and addressed at all levels of an
  organization Administration, service delivery,
  and clinician.
• At the clinician level, cultural competence
  impacts the therapeutic relationship between the
  clinician and client, supporting the clients
  participation in treatment. Clinician-level
  cultural competence is difficult to describe in
  terms of specific strategies. It is best
  understood as a stance. Whaley (2003) describes a
  culturally competent provider as someone who
• Recognizes the dynamic interplay between
  "heritage" and "adaptation" in shaping human
  behavior
• Heritage is the passing of tradition, beliefs,
  and values from older generations to younger
  generations
• Adaptation is the ability to change ones
  behaviors and attitudes to meet the  demands of
  ones environment
• Is able to utilize knowledge acquired about an
  individuals heritage and adaptation challenges
  to maximize the efficacy of assessment,
  diagnosis, and treatment and
• Internalizes this process of recognition,
  acquisition and utilization of cultural dynamics
  to routinely apply it to diverse groups.

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Little Research

• Chambless
• Surgeon General
• Recent Reviews

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How Know if Cultural Competency is Necessary?

• EBPs appear to be effective with ethnic minority
  populations
• Treatment-as-usual interventions often show no
  differences in outcomes (Lambert)
• Do we need to be cultural competent?
• Perhaps cultural competency is not effective,
  just illusory correlation
• Perhaps cultural competency as practiced not
  effective
• Perhaps cultural competency effective but need
  more conceptual clarity adequate,
  culturally-sensitive tests
• Perhaps cultural competency already being
  incorporated

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Challenges to Cultural Competency

• Multicultural counseling has not been put to
  any kind of test. I could find no controlled
  studies of patients wherein half are randomly
  assigned to multicultural counseling and half to
  conventional counseling. Such research, of
  course, would first require that multicultural
  counseling be defined and operationalized, a task
  its proponents have yet to undertake. (Satel,
  2000, p. 187)

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Conceptual Dilemmas

• Is it possible to know all cultures? How much
  knowledge is necessary and what are the contents
  of this knowledge?
• Is cultural competency a skill that can be
  manualized and scripted?
• Do different competencies exist for different
  groups or does cultural competency reside in
  individuals (e.g., clinicians) independent of
  groups? For example, if one is culturally
  competent, is he or she competent with all
  culturally diverse groups or are the skills
  specific to a particular ethnic group?
• Are different cultural competencies required at
  different times in the treatment process? In
  other words, can cultural competency be measured
  at one time and assumed to be in effect for all
  times?
• Is cultural competency a unidimensional versus
  multidimensional phenomenon? If it is
  multidimensional, are certain dimensions more
  important than others?

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Hard to Conduct Ethnic Minority Research

• Sampling small populations with
  cultural-psychological differences, convenience
  samples
• Little baseline research and theory
• Ethnocentric bias validity of assumptions,
  interpretations (sexual aggression)
• Equivalence/validity of measures and procedures
  (cultural and language differences)
• Use of race/ethnicity as proxy variable
• Costly

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Cultural Competency Necessary and Important

• U.S. Surgeon General
• APA Guidelines

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Need to Reconceptualize

• Law of Small Effects (Jackson)
• There is no one single factor that dramatically
  increases or decreases the effectiveness of
  treatment. Rather, there is a group of small
  differences which may accumulate over the life of
  treatment that affect the efficacy of treatment
  and account for differences in treatment
  effectiveness.
• Knowledge Understanding culture
• Skills Avoiding errors of commission
  omission culturally skilled
• Awareness Self, other, cultural context
• Law of Large Effects
• Language
• Culture-specific intervention program

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Orientation versus Specific Intervention (usually
still based on other EBP)

• 100
• Cultural
• Orientation
• 0
• Incorporate Specific Program
• Intervention

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Culturally Competent Process

• Good General Therapist (Especially
• Scientific Mindedness)
• Dynamic Sizing (Individualize-Generalize)
• Ethnic Specific Knowledge, Skills Attitudes

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General Steps (Content)
1. Assess own stimulus value, awareness, and
preparedness Take steps to prepare 2. Assess
client--culture and acculturation, experience
with minority group status gather information 3.
Assess own knowledge of clients
background--adequacy and deficiencies 4.
Pre-therapy intervention (what therapy is,
confidentiality, process involved) 5.
Hypothesize and test hypotheses using multiple
sources 6. Attend to credibility and giving 7.
Understand the nature of discomfort and
resistances 8. Understand from clients
perspective Goals, conceptions, means for
resolving problems 9. Strategy or plan for
intervention, incorporating understanding 10.
Assess session 11. Willingness to consult
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Conclusions

• Cultural competency needed at the three levels
  (administration, service delivery, and clinician)
• Difficult to study
• Conceptual confusion
• Research suggests EBPs are effective
• Cultural competency as form of orientation and
  treatment (Law of Small Effects)