Cultural Competence in Working with Kids and Families: Beyond Diversity in Systems and Practice Augu

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Cultural Competence in Working with Kids and
Families Beyond Diversity in Systems and
PracticeAugust, 2003
Zanda Hilger Francine Pratt
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Learning Objectives Through this workshop
participants will be able to

• Define cultural competence and related terms.
• State reasons that cultural competence is
  important.
• Identify possible values, characteristics, and
  communication styles of ethnic groups with a
  focus on mental health.
• Learn and practice culturally sensitive
  communication techniques.
• Assess and plan strategies and tactics for
  personal cultural competence.
• State at least one skill learned through the
  training experience.
• State a commitment to change one behavior as a
  result of participation in the workshop.

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Announcements

• Cell phones off.
• Location of bathrooms.
• Food and beverage.
• Breaks.
• Temperature.
• Facilitator role.
• Schedule and Agenda.

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Workshop Format

• Informal.
• Interactive.
• Mixture of lecture and activities.
• Skill building.

Dignity and Respect Connecting the head and the
heart Common sense into common practice
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Working Agreement/Ground Rules

• Do you agree to?
• Maintain confidentiality about specific people
  and situations, What is said here stays here.
• Demonstrate respect for one another.
• Accept other points of view.
• Be an active listener.
• Speak without blaming.
• Allow one person to speak at a time.
• Respect each person's contributions to the group.
• Realize that peoples opinions are not personal.
• Participate at a level where you are comfortable.
• Create a safe and supportive environment.
• Challenge yourself to step out of your comfort
  zone.

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Eggs, Bread Shoes
What do these items say about culture?
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What did we find out? Alike and Different

• In many ways we are different
• In many ways we are alike
• Some differences are visible and some are
  invisible.
• We share some experiences some experiences we
  cannot share.

• The strength of our community is in both our
  alike-ness and our different-ness.

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Hints for Effective Communication During
Activities1

• Begin with the word I when talking about
  thoughts and feelings.
• Mirror what you hear with phrases such as I
  heard you say (use speakers exact words or
  paraphrase them).
• Group members may respond to discussions by using
  such words as, I would like to respond to that
• Share only your own thoughts or from your own
  experiences speaking only for yourself.

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Introductions and Overview

• What is Cultural Competence?
• Why is Cultural Competence important?

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What is Cultural Competence"?

• According Dr. Terry Cross in a highly regarded
  publication, Towards a Culturally Competent
  System of Care"Cultural competence is a set of
  congruent behaviors, attitudes, and policies that
  come together in a system, agency, or among
  professionals and enable that system, agency, or
  professionals to work effectively in
  cross-cultural situations.

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How is Cultural Competence Different from
Diversity?
Cultural competence is not affirmative action
which is a law to ensure that employers take
positive steps to attract, promote, and retain
females, minorities, veterans, and people with
disabilities.

• Diversity is
• Differences in race, ethnicity, language, gender,
  age, physical abilities, sexual orientation,
  nationality, religion, education, and all the
  countless differences among people.
• Cultural awareness or sensitivity is
• An awareness of ones own cultural differences in
  relation to other cultures.

Cultural competence is beyond awareness into
action
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Cultural Competence is a Never-Ending Journey
Individuals and organizations have to ASK!
LISTEN!

• Valuing diversity.
• Acknowledging the importance of culture.
• Confronting discrimination and prejudice.
• Taking personal and organizational
  responsibility.
• Listening and responding to clients, families,
  and the community.
• Taking action as a person related to knowledge,
  skills, values, beliefs, and attitudes.
• Taking action as an organization in policies,
  procedures, skills, and training to change
  systems.

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Importance of Cultural Competence

• Population Statistics
• Health Access and Use
• Mental Health Services
• Juvenile Justice
• Language
• Disabilities

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FWISD Demographics 80,534 students

• Student ethnicity
• 24.2 African American
• 48.1 Hispanic
• 20 White/Anglo
• 1.9 Asian/Pacific Islander
• 0.2 Native American

• Profile
• 24.2 Bilingual/ESL
• 14.1Career Technology Education
• 60.1 Economically Disadvantaged
• 11.5 Gifted Talented Education
• 25.7 Limited English Proficient (LEP)
• 9.9 special Education

Source www. forthworthisd.org June, 2003
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Population Statistics Source US Census 2000
DataTarrant County

• Total Population 1,486,392
• Male 749,133
• Female 760,504
• Anglo 913,786
• Hispanic 323,877
• Black 198,949
• All Other 73,025

• of population less than 18 years of
  28.1Number of children and adolescents less
  than 18 years of age 417,676.15
• of population age 18 and over 71.9
• Number of residents age 18 and over 1,068,716

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Unmet Needs for Mental Health Services
White
Black
Latino
Other
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Culturally Competent Systems

• Likely to result in more successful outcomes.
• Treatment of the whole person including values,
  family structure, resources, etc.
• More likely to comply with health care and other
  public services.

I dont want to be color blind. I want to
acknowledge the differences and what each person
can contribute not ignore that they are unique.
From materials of National Coalition Institute
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Why Is It Simple but Not Easy?

• Why cant we all just get along?
• Is discrimination and prejudice unique to the
  United States?
• Demographics show significant differences in
  ethnic culture, languages, ages, needs,
  economics.
• Common Sense Common sense into common
  practice.

Group Activity I dont ever want anyone to
treat, talk, or think about me like this.
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Guiding Principles

• Golden Rule Do unto others as you would have
  them do to you.
• Hillels Rule Do not do to others what is
  hateful to you.
• Platinum Rule Treat others as they wish to be
  treated.

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Culture Domains

• Language, Gender, Age, Ethnic Identification/ethni
  city, Culture, National Origin, Color, Sexual
  Orientation, Marital Status, Family Status,
  Political Belief, Religion, Language, Physical
  Size and Appearance, Education Level,
  Career/Experience, Mental or Physical Disability

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Primary Dimensions Secondary Dimensions

• Inborn characteristics.
• Affect how people socialize, self image, world
  view, and how someone is perceived.
• Usually do not change.

• Acquired characteristics usually learned in
  childhood.
• Less impact than the primary dimension but can
  have a major impact on a persons life.
• Can change or be modified.

Age Race
Ethnicity Physical abilities/qualities Gender
Sexual Orientation
Income Religion Geographic location
Education Work experience Marital
Status Military Experience Parental Status
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Cultural Context of Health Values that must be
recognized, understood, and used as source of
strength and empowerment

• How pain is experienced.
• What is labeled as a symptom.
• Communication of pain or symptoms.
• Causes of illness.
• Use of alternative treatment.
• Attitudes toward helpers.
• Desired or expected treatment.
• Relating pain intensity.
• Family involvement.

Integrate these principles into ongoing
assessment and intervention plans
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Culture and Values Influence Ways in Which People

• Make decisions.
• Explain events.
• Use terminology.
• Express their ideas.
• How they behave.

Culture gives us a sense of unity, of
connectedness, a vision of our identity.its
like a unity within the difference.
Wraparound training materials of Mary Grealish
quoting Latino Cultural Citizenship Claiming
Identify, Space and Rights.
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A Comparison of Differences in Western and
Eastern Practices

• Family.
• Education.
• Health care.
• Child development.
• Agreements and Contracts.
• Body Language.

• Silence.
• Time.
• Orientation.
• Communication.
• Value.
• Science.

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Examples of Possible Black or African American
Values

• Family.
• Descendent connected-ness.
• Closeness to community.
• Kinship care.
• Faith based connections.

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Focus on FWISD Mental Health Needs by Culture
within the Context of

• Parent conferences
• Home visits
• CPS reports
• Risk assessments
• Engaging families

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Examples of Possible Asian and Pacific Islander
Values

• Family and kin responsibility.
• Respect and loyalty.
• Hierarchical order.

Composed of more than 30 cultures, each group
unique.
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Examples of Possible Hispanic/Latino Values

• Children and family.
• Cooperation.
• Respect.
• Spirituality.
• Most but not all are of the Catholic faith.
• Includes use of non-traditional health
  practices.

• Diverse countries of origin with majority from
  Mexico but including Cuba, Central and South
  American countries.
• Common language with many dialects and street
  language differences.

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Examples of Possible Native American/American
Indian Values

• Tribal identity.
• Spirituality.
• Respect for elders.
• Present time anonymity.

• Composed of estimated 500 nations.
• Each nation is unique.

Question How do they refer to themselves?
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Diverse Communication Styles

• Research suggests that 55-95 of all
  communication is non-verbal.
• Significant differences between communication
  styles and culture.
• Country of origin.
• Region of the US.
• Ethnic preferences.
• Business, social, family settings.

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Gestures and Greetings
From Roger E. Axtell, Gestures The Dos and
Taboos Of Body Language Around the World
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Guidelines for Watching Your Multicultural Manners

• Touching the head.
• Hand signals.
• Eye contact.
• Use of red ink.
• Participation.
• Respect.
• Comments about characteristics.
• Forms of address.

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Terms Stereotypes and Prototypes

• Stereotypes
• Fixed image, exaggerated or distorted belief
  about a person or group of individuals that
  allows for no individuality or variation.
• Standardized mental picture held in common by
  members of a group represents an oversimplified
  opinion, prejudiced attitude, or uncritical
  judgment.
• Summary generalizations that obscure the
  differences within a group.
• Allow people to feel they are gaining a lot of
  information about a group in a short amount of
  time.
• Can get in the way of someone being able to see
  the real picture.
• Usually based on limited experience.
• Often lead to prejudice, and even hostility.2

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Prototypes

• Prototypes
• Idealized view of a person based on their
  cultural heritage or place in society.
• Set of attributes or criteria, which best
  characterize the members of a group.
• Allows people to feel they are gaining a lot of
  information about an individual.
• Provides the real picture.
• Usually based on in-depth experience, including
  personal contact.2

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Prototypes

• Jonah Salk
• Henry Ford
• Wright Brothers
• Amelia Earhart
• Oprah Winfrey
• Christopher Reeve

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The Family
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What is a Family?

• 1 a group of individuals living under one roof
  and usually under one head Household2 a a
  group of persons of common ancestry Clan b a
  people or group of peoples regarded as deriving
  from a common stock Race3 a a group of
  people united by certain convictions or a common
  affiliation Fellowship
• Merriam-Webster Online 3/03

• Nuclear.
• Blended.
• Extended.
• Extended and augmented.
• Single parent headed.
• Couples of same sex.

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Culture" of the Family

• Values.
• Family definition.
• Nature of family relationships, closeness.
• Beliefs shared by family members.
• Roles within the family.
• Rules that govern family relationships.
• Framework in which family interactions and
  behaviors take place.
• Definition of acceptable/unacceptable behavior.

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Dynamics Within The Family

• Emotional climate.
• Communication.
• Lines of authority.
• Division of labor.
• Attitudes, beliefs and values.
• Flexibility.
• Problem solving.
• Relationship to community.

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Skill Building
Challenges and Opportunities Wraparound
Philosophy/Model Communications Assessment
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Planning Ahead Considerations for Student
Service Teams in Working with Families

• Differences in culture, language and customs
  within groups.
• Variety of health beliefs, practices, and systems
  Differences in health wishes (individual versus
  family wishes).
• Adult children of immigrants Americanized and
  share different values, practices, and taboo
  subjects.
• Taboo subjects.

• Family involvement.
• Rich resources.
• Alternate ways to blend cultural practices and
  prescribed care.
• Improves compliance with recommended care.
• Ongoing cultural competence training for staff.

Modify your usual approach, as needed
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Use Concepts of Strengths Based and Wraparound
Processes

• Engage client and family member values, skills
  and knowledge.
• Build partnerships with everyone involved family
  members, schools, agencies, health care
  providers, and any stakeholder.
• In the wraparound process, we set out to learn
  each individual's and family's unique cultural
  norms. These are among the cornerstone strengths
  and assets on which wraparound plans are based.
• from training and other materials of Mary
  Grealish, MSW  

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Interviewing

• Presenting problem What is presented may not be
  the main issue.
• Listen to others and give them time to tell their
  story in their own way and words.
• Trust must develop before others share their
  vulnerability.
• Trust develops over time.
• Real issues may not surface for weeks, months, or
  even years.

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Interviewing

• Assume that many people do not trust the dominant
  culture.
• Acknowledge and accept differences and different
  experiences.
• I know how you feel is always untrue.
• Most ethnic minorities are more skilled in the
  dominant culture than members of the dominant
  cultures are skilled in the minorities cultures.

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Culturally Competent or Ethnographic
Interviewing

• Ethnographic
• Client assumes more control.
• First step is to establish grounds for the
  interview from the persons perspective.
• Professional is seeking information about the
  clients culture.

• Usual client-provider interaction
• Professional has control.
• Agenda is already set when the client makes
  appointment or meets with the professionals.
• Interaction is usually focused on professional
  giving information to the client.

the study and systematic recording of human
cultures, Merriam-Webster Online, 2003
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Skills of Ethnographic Interviewing

• Greeting.
• Opening questions
• How?
• Who?
• What
• Where?
• When?
• Expressing interest.

• Expressing ignorance.
• Avoiding repetition.
• Taking turns.
• Restating and incorporating.

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Communication within Families and with
Individuals Setting the Tone

• Determine if a trained interpreter is needed and
  arrange for that service.
• Determine reading ability if using printed
  materials.
• Ask how the person wishes to be addressed.
• Allow the person to choose seating for
  comfortable personal space.
• Let the person guide eye contact.
• Avoid body language that may be offensive. Avoid
  judgment and stay objective.
• Avoid disagreeing or initial conflicting
  perception.
• 4

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Communication within Families and with
Individuals Tools

• Speak directly to the person whether an
  interpreter is present or not.
• Ask open-ended questions.
• Avoid jargon.
• Avoid complex sentences.
• Ask one question at a time.
• Use open-ended questions.
• Use language familiar to the person/family.
• Choose a speech rate and style that reflects need
  of the person and family.

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Assessing Family Structure and Decision Making

• What is the first language of the client and
  family? 
• When a decision has to be made about health or
  services who needs to be included in the
  discussion?
• What types of healing practices does the person
  or person's family practice?
• What is the belief regarding the cause of illness
  and/or suffering?
• Does immigrant or refugee status have impact on
  the person and family's actual or perceived
  access to services?

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Acknowledge Lack of Understanding

• Ignorance or lack of experience can be seen as an
  opening instead of a roadblock.
• Focus on similarities or common ground including
  work, families, leisure,and basic human
  concerns.
• Be aware of differences in non-verbal
  communication patterns
• Eye contact.
• Space.
• Touching.
• Tone of voice.
• Facial expressions.

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Self Assessment The Person in the Mirror

• Cultural competence begins with personal
  awareness through self assessment
• Own personal cultural heritage and the context in
  which a person grew up.
• Context and community where a person lives.
• Messages received through families of origin.
• Personal experiences.

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Personal Cultural Competence

• Self assessment.
• Staying aware of your own behavior.
• Participating in training and education and
  integrating new skills and knowledge.
• Taking the initiative to interact with people
  from backgrounds and beliefs different than your
  own.
• Committing to continuing improvement.

Changing your behavior
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Levels of Cultural CompetenceIndividual and
personal level

• Providers should work in ways that are not just
  politically correct, but are compassionate for
  healing and social justice.
• Individuals should be aware of how we have been
  impacted by historical and societal inequities
  (either having or lacking power), and the effect
  on our work with students in the larger school
  and societal system.
• Providers should consider an intervention stance,
  at least during the early period of
  cross-cultural counseling, of humility, naivete
  and respectful curiosity.
• Like a good healer, counselors in SBMH
  (school-based mental health) centers should avoid
  having a solely Eurocentric or monocular
  viewpoint but instead be culturally empathic
  using a continuously refocusing multicultural
  lens.
• Adapted from On the Move With School-Based Mental
  Health, Center for Mental Health Assistance, Fall
  2002.

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Personnel Cultural Competence

• Continuously addressing cultural competence.
• Continually assessing the ability to serve and
  empower multicultural clients, students and
  families being served.
• Shaping interventions to meet culturally special
  unmet needs, I.e., culturally specify groups,
  support groups for specific issues and problems.
• Striving for greater effectiveness.
• As quoted in On the Move With School-Based Mental
  Health, Center for Mental Health Assistance, Fall
  2002.

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Cultural Competence Commitment by Community
Solutions

• Childrens Voices, Family Choices, Community
  Solutions Building Blocks for Healthy Families.
  6 year cooperative agreement through the Center
  for Mental Health Services to create an
  accessible, culturally competent and seamless,
  child and family driven system of care for
  families impacted by severe emotional disturbance
  in Fort Worth. http//mhctc.org/cs/cs.htm
• Administered by The City of Fort Worth Public
  Health Department
• In partnership with the Mental Health Connection
• Mission Connecting mental health for Tarrant
  County
• Vision No wrong doors to the right mental
  health resources
• In partnership with Fort Worth Independent School
  District
• Diversity Mission to exemplify the character
  of a diverse, democratic society by respecting
  and celebrating our commonalties and differences
  of culture, experience, and opinion.
• Lena Pope Home, Catholic Charities, United Way,
  Mental Health Association, MHMR of Tarrant County
  and member agencies and individuals of the Mental
  Health Connection of Tarrant County.
• Contracted position of Cultural Competence
  Manager during first year of planning.

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But What Can I Really Do?
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Whose job is it anyway? What difference can I
make?

• Make a commitment to make a difference.
• Stay aware of our own biases.
• Accept that not everyone has the same beliefs or
  behavior.
• Communicate an attitude of respect for
  differences.
• Confront disrespectful behavior and talk.
• Participate in ongoing education and training.
• Take the initiative to get to know someone
  different from you.
• Acknowledge that every person and organization
  has a responsibility to create the environment
  that recognizes and values the unique potential
  of everyone.

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It is your choice To see things differently
and to do things differently.
Call to Commitment
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Personal Commitment Action Plan
As a result of participating in this program, I
commit to the following
Action________________________________________ _
_______________________________________
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• Cultural Competence is a never ending journey
  to find and use the best talents and resources of
  everyone to build better communities and
  healthier families.
• End of Workshop
• Thank You for Coming

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• Written by Zanda Hilger, M.Ed., LPC, Cultural
  Competence Manager, Community Solutions, 2003.
• In collaboration with
• Charles Hoffman, Director of Community Services,
  Fort Worth Independent School District
• John Isom, MHMR of Tarrant County
• Daniel Reimer, Director, Public Health
  Department, City of Fort Worth
• Francine Pratt, Catholic Charities of Fort Worth
• Includes materials adapted from National Center
  for Cultural Competence, National Coalition
  Institute, the web site of the Mental Health
  Connection of Tarrant County, and Community
  Solutions noted in these materials
• 1. Common Ground, Fort Worth Independent School
  District
• 2. Never-Ending Journey, Texas Department of
  Health HIV/STD Health Resources as adapted by
  City of Fort Worth Health Department
• 3. Diversity Training, MHMR of Tarrant County

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Resources

• Anderson, P. and Fenichel, E., Serving Culturally
  Diverse Families of Infants and Toddlers with
  Disabilities, National Center for Clinical Infant
  Programs, Washington, DC, 1989.
• Cross, T., Bazron, B., Dennis, K., and Isaacs,
  M., Towards a Culturally Competent System of
  Care A Monograph on Effective Services for
  Minority Children Who are Severely Emotionally
  Disturbed, CASSP Technical Assistance Center,
  Georgetown University Development Center,
  Washington, DC, 1989.Harwood, A., Ethnicity and
  Medical Care, Harvard University Press,
  Cambridge, MA, 1981.
• Henderson, G. and Primeaux, M. (Eds.),
  Transcultural Health Care, Addison-Wesley
  Publishing Company, Menlo Park, CA, 1981.
• Malach, R., Segel, N, and Thomas, T., Overcoming
  Obstacles and Improving Outcomes Early
  Intervention Services for Indian Children with
  Special Needs, Southwest Communication Resources,
  Bernallilo, NM, 1989.
• Miranda, M. and Kitano, H., (Eds.), Mental Health
  Research and Practices in Minority Communities
  Development of Culturally Sensitive Training
  Programs, National Institute of Mental Health,
  Rockville, MD, 1986.

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Resources

• Nelkin, V. and Hubbell, R., Evaluation of
  Communication-Based Services for Children with
  Special Health Care Needs, CSR, Inc. and Bear
  Enterprises, Ltd., Washington, DC, 1989.
• Randall-David, E., Strategies for Working with
  Culturally Diverse Communities and Clients,
  Comprehensive Hemophilia Program, Bowman Gray
  School of Medicine. Published by the Association
  for the Care of Children Health, Bethesda, MD,
  1989.Roberts, R., et al., Developing Culturally
  Competent Programs for Children with Special
  Needs, Georgetown University Child Development
  Center, Washington, DC, 1990. (Monograph)
• Roberts, R., et al., Developing Culturally
  Competent Programs for Children with Special
  Needs, Georgetown University Child Development
  Center, Washington, DC, 1990. (Workbook)
• Watkins, E.L. and Johnson, A.E. (Eds.), Removing
  Cultural and Ethnic Barriers to Health Care,
  National Maternal and Child Health Clearinghouse,
  Washington, DC, 1985.

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Internet Links

• Mental Health Connection of Tarrant
  County http//www.mhtc.org and then link to
  Community Solutions
• Center for Mental Health Services Substance Abuse
  Mental Health Services Administration SAMHSA
  http//www.mentalhealth.org/publications/allpubs/C
  A-0015/default.asp
• Center for Cultural competence http//www.georgeto
  wn.edu/research/gucdc/nccc/
• Publications List http//www.georgetown.edu/resear
  ch/gucdc/document.html
• Links related to Cultural Competence
  http//www.georgetown.edu/research/gucdc/nccc/link
  s.html
• Frequently Asked Questions about the National
  Center for Cultural competence http//www.georgeto
  wn.edu/research/gucdc/nccc/faqs.html
• Diversity and Health Care on the Internet
  http//cecp.air.org/cultural/resources.htm
   http//www.library.miami.edu/netguides/ethnopsy.h
  tml