Anything Goes? 10/23/13. Part One: Cultural Intelligence. Generalizations. Or Nobody s Wrong If Everybody s Right

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1 Anything Goes? Or Nobody s Wrong If Everybody s Right Part One: Cultural Intelligence Cultural Intelligence requires three key ingredients knowledge about one's own own culture and subconscious biases, and of the culture of the person one is dealing with, mindfulness about the differences, and skills to operate cross-culturally. It is not simple, and requires effort and reflexivity. Generalizations 1

2 Generalizations A type of mental shortcut for taking in, processing and retrieving information Based on a summary of common trends Are an open-ended starting point Needs more information to learn if an individual fits the group Center for Health Professions, 2007 Stereotypes Stereotypes Another type of mental shortcut for taking in, processing and retrieving information Used to assign an individual to a category based on what we believe about a general group to which they belong Based on limited personal knowledge and/or experience Are a closed-ended end point Center for Health Professions,

3 Positive Power of Diversity Between the population of Ireland fell from around eight million to about five million. As many as one million died from hunger and disease. Another two million were forced to emigrate Why? The Potato Famine one of the causes of which was an extreme lack of diversity in the potato crop of Ireland. Decision Making Decision Making Values Cognition Level (Daniel Kahneman, Thinking, Fast and Slow) System 1: Fast, automatic, frequent, emotional, stereotypic, subconscious System 2: Slow, effortful, infrequent, logical, calculating, conscious Cultural Context Experience 3

4 How Does Diversity Impact Ethics? Diversity challenges us to be ethically appropriate and identify our cultural ethics Challenges culturally-based ethics Personal ethics vs. communal/community ethics How Does Ethics Impact Diversity? Ethics challenges us to acceptance of diversity and working toward greater understanding Competence So we know what we are doing Can t just accept OUR culture as the only way Compromise Majority culture has to be flexible Minority cultures have to adapt How Does Ethics Impact Diversity? The provision of professional services to persons of culturally diverse backgrounds by persons not competent in understanding and providing professional services to such groups shall be considered unethical. (Korman, 1974, p. 105) A serious moral vacuum exists in the delivery of cross-cultural counseling and therapy services because the values of a dominant culture have been imposed on the culturally different consumer. Cultural differences complicate the definition of guidelines even for the conscientious and well-intentioned counselor and therapist 4

5 When Diversity and Ethics Collide Ethics and diversity can conflict when either is taken alone as The Good to be promoted Ethics and diversity can conflict when either personal values or professional values become absolute Ethics and diversity can conflict when the needs of the community take precedence over the needs of individuals or vice versa. When Ethics is Absolute You talk too much, Your life is safe in my hands I'm a man, no worse than any man. You are free, and there are no conditions, No bargains or petitions. There's nothing that I blame you for. You've done your duty, nothing more. There, out in the darkness A fugitive running Fallen from God Fallen from grace God be my witness I never shall yield Till we come face to face Till we come face to face He knows his way in the dark But mine is the way of the Lord Les Miserables Where Do Absolute Ethics Come From? Moral values Religious Values Cultural Values Law 5

6 In The End we work toward acceptance and diversity because it is ethical to do so from our own ethical codes we work toward ethics because our diversity can blind us to what others may be thinking and experiencing differently from ourselves we bring them together in order to be caring, compassionate, and competent counselors. Part Two: Levels of Awareness Ethical Counseling In the Midst of Diversity 6

7 Levels of Diversity Awareness and Cultural Understanding What Diversity Means to Me Management of Prejudices Gail Price-Wise- founder and president of the Florida Center for Cultural Competence Levels of Diversity Awareness Cultural Destructiveness acknowledges only one way of being and purposefully denies or outlaws any other cultural approaches. This is the most negative end of the continuum. Examples include forbidding the use of primary language. One of the most extreme examples is cultural genocide. Cultural Incapacity supports the concept of separate but equal; marked by an inability to deal personally with multiple approaches but a willingness to accept their existence elsewhere. This system or individual is extremely biased. Cultural Blindness fosters an assumption that people are all basically alike, so what works with members of one culture should work within all other cultures. Values and behaviors of the dominant culture are presumed to be universally applicable and beneficial. Source: Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care, volume 1. Washington, DC: CASSP Technical Assistance Center, Center for Child Health and Mental Health Policy, Georgetown University Child Development Center. 7

8 Levels of Diversity Awareness Cultural Pre-Competence encourages learning and understanding of new ideas and solutions to improve performance or services. There is a desire to provide fair and equitable treatment with appropriate cultural sensitivity. There may be a level of frustration because the person, or organization, does not know exactly what is possible or how to proceed. Cultural Competence involves actively seeking advice and consultation. It is a commitment to incorporating new knowledge and experiences into a wider range of practice. It is acceptance and respect for difference, continuing self-assessment regarding culture, careful attention to the dynamics of difference, continuous expansion of cultural knowledge and resources, and a variety of adaptations to belief system, policies, and practices. Cultural Proficiency involves holding cultural differences and diversity in the highest esteem, pro-activity regarding cultural differences, and promotion of improved cultural relations among diverse groups. There is a process of formally and informally increasing the knowledge of others and challenging or correcting inappropriate remarks and comments. Source: Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care, volume 1. Washington, DC: CASSP Technical Assistance Center, Center for Child Health and Mental Health Policy, Georgetown University Child Development Center. Clinical Cultural Competence Health care providers must: Be aware of social and cultural factors on health beliefs and behaviors Assess how these factors affect families and have tools and skills to manage these factors Empower patients to be active partners and to negotiate ethno-cultural beliefs and practices of the patient and those of the culture of biomedicine. Betancourt JR, Green, AR, Carillo, JE, 2002 American Academy of Pediatrics Committee on Pediatric Workforce, 1999 Pachter LM, 1996 Exploration Explore ways to discover our own level of diversity awareness and ways to expand that awareness to benefit our clients. 8

9 Stages Description Stage 1: Self-awareness Stage 2: Self-reflection Develop an awareness of one s personal worldview and the values that undergird that perspective Use self-reflection skills to examine the implications of and consequences of one s personal worldview on professional work Stage 3: Understanding and applying the Code of Ethics within a professional knowledge base Thoroughly examine the Code of Ethics to understand its meaning, historically and currently, as the basis for defining values and principles like diversity, social justice, self-determination, respect for human dignity, and other core elements articulated in the profession s literature Source: Stages Description Stage 4: Comparing Engage in a process of examining discrepancies between the Code of personal Ethics and one s personal worldview worldview with professional Code Stage 5: Professional Decision Making Make decisions about what needs to be done to remain faithful to the Code of Ethics (Decisions in practice should never be made solely based on one s personal worldview.) Stage 6: Professional Ethical Action Take action and monitor conformity to the Code of Ethics Source: Part Three: In Practice Tools to Help 9

10 In Practice DSM 5 Asking the right questions Cultural Humility DSM-5 and Culture A cultural formulation Understanding the cultural context of illness is essential for effective diagnostic assessment and clinical management. Culture, race and ethnicity are related to economic inequities, racism, and discrimination that result in health disparities. Outline for Cultural Formulation Cultural identity of the individual Cultural conceptualizations of distress Psychosocial stressor and cultural features of vulnerability and resilience Cultural features of the relationship between the individual and the clinician DSM-5 and Culture Cultural Formulation Interview (CFI) A set of 16 Questions that clinicians may use to obtain information in a mental health assessment about the impact of culture on key aspects of an individual s clinical presentation and care Cultural definition of the problem Cultural perceptions of cause, context and support Cultural factors affecting self-coping and past help seeking Cultural factors affecting current help seeking 10

11 From: Chapter 4. Cross-Cultural Aspects of Addiction The American Psychiatric Publishing Textbook of Substance Abuse Treatment, 4th Edition, 2008 Figure Legend: FIGURE 4 1. Cultural dynamics in clinical assessment. Date of download: 9/25/2013 Copyright American Psychiatric Association. All rights reserved. DSM-5 and Culture Essential features of culture include the following: It is learned. It refers to systems of meanings. It acts as a shaping template. It is taught and reproduced. It exists in a constant state of change. It includes patterns of both subjective and objective elements of human behavior. Cultural Questions Are there aspects of your race or culture that you think are important for me to know in working with you What traditions are important in your family and community? 11

12 Kleinman s Questions "What do you call the problem? What do you think has caused the problem? Why do you think it started when it did? What do you think the sickness does? How does it work? How severe is the sickness? Will it have a long or a short course? What kind of treatment do you think the patient should receive? What are the chief problems the sickness has caused? What do you fear most about the sickness?" Cultural Humility A lifelong process of self-reflection, respectful curiosity, inquiry, education and self-critique. Does not require learning to identify and respond to sets of culturally specific traits, but to develops and practice a process of self-awareness and reflection. A respectful partnership with each client through clientfocused interviewing, exploring similarities and differences between her/his own and each client's priorities, goals, and capacities. The most serious barrier is failure to develop self-awareness and a respectful attitude toward diverse points of view. Dr. Melanie Tervalon and Jann Murray-Garcia Resources Books: The American Psychiatric Publishing Textbook of Substance Abuse Treatment, 4th Edition (Chapter 4) ( The American Psychiatric Publishing Textbook of Psychiatry, 5th Edition (Chapter 40) ( Handbook of Psychotherapy and Religious Diversity, Edited by P. Scott Richards and Allen E. Bergin American Psychological Association 12

13 Resources Web Sites: Markkula Center for Applied Ethics ( Journal of Social Work Values and Ethics ( The Provider s Guide to Quality and Culture ( erc.msh.org/mainpage.cfm? file=1.0.htm&module=provider&language=english&ggroup=&mgroup=) 13