THE

............
SUMMER 1996 . VOLUME 6, NUMBER 3
NATIONALABANDONEDINFANTSASSISTANCERESOURCECENTER
RESOURCE CENTER
Cultural Sensitivity and Diversity Awareness:
Bridging the Gap Between Families and Providers
Service providers across the United
States interact with children, families and
other professionals from an ever widening
variety of cultural, linguistic, and ethnic
backgrounds, suggesting a growing need
for cultural competency training. Many
staff deve]opment models that address
diversity emphasize the importance of
learning culturally specific information
including communication patterns, health
and illness beliefs and behaviors, religious
practices, symbols, and rituals (Stewart,
]991; Like, ]991; Nkongho, 1992). Gen-
erally, it has been assumed that knowing
about specific cultures and groups makes
it easier to respect and appreciate differ-
ences and to interact effectively with per-
sons from other cultures. However, one-
hour presentations and occasional classes
do not adequately address the growing
need for cultural education (Pahnos, 1992;
Marvel, Grow & Morphew, ]993). The
challenge of understanding diversity and
becoming culturally competent does not
stop with learning the "do's and don'ts" of
a specific cultural group.
The authors of this article came
together as a team by participating in a
CRAFT* (Culturally Responsive and
Family Focused Training) program
designed for early childhood professionals
and parents of children with special needs.
This training made it clear that developing
cultural sensitivity and diversity aware-
ness is extremely complex and an ongoing
process. The process begins with the
provider understanding his or her own
personal history and how it influences
his/her perceptions. Literature increasing-
ly reflects the importance of family
structure, gender roles, and beliefs and
The third step involves the process
of finding common ground between the
provider's and the client's perceptions
which allows the provider to start an
appropriate and effective intervention.
Thus it is important that cultural aware-
ness training programs offer insight into
how service providers can go beyond
the cultural chasm between their own
unique identity and the clients' distinctly
different identities. This article describes
a process that uses the Diversity Wheel
(a tool developed by the Oak]and CRAFT
team) to look at these three steps.
-
-.;
Diversity Wheel
From childhood, we Jearn to look at
people's differences primarily through
cultural or facia] identities-e.g., this is
an Asian family, she is African American,
they are Italian. Each cultural/ethnic iden-
tification suggests a set of generalized
expectations covering religion, styJes of
communication, attitudes about family
relationships, and types of careers or busi-
nesses. Culture can include how people
live, role expectations, child rearing
practices, attitudes about time or money,
definitions of achievement, concepts of
beauty, art, music, food, and a host of
other things. Nonetheless, culture is only
one element of who a person is.
values-not only as they relate to clients/
families, but also as factors that providers
bring to the encounter, and how this may
influence service delivery.
Second, the provider must begin the
process of understanding how similar
and/or different factors may influence the
perceptions of the client/family. This may
include, but is not limited to, becoming
more knowledgeable about specific cultur-
al norms and practices.
-
Please seepage2
. Continuedframpage 1
One way to help identify the myriad
factors which define an individual's
uniqueness is by using the Diversity
Wheel. This tool was developed to help
gain a better understanding of the many
factors which shape each unique individ-
ual. The Diversity Wheel (see Illustration
on p. 3) lists seventeen factors which may
influence values, behaviors, ideas, and
interpretations of situations. The user of
the Diversity Wheel can examine how
each of the sections on the Wheel pertains
to an individual. To use the Wheel effec-
tively to gain self understanding (or under-
standing of the client), the provider
should, for each section of the wheel, ask:
What are my (or my client's) significant
experiences, beliefs and emotional attach-
ments in this area? How do they affect
how I (my client) view the world and how
I (the client) interact with others? In what
ways might these experiences, beliefs, and
emotional attachments play an uncon-
scious role in how I (the client) perceive
others? This is a process that a provider
needs to do thoroughly once and then
periodically as shelhe goes through signif-
icant life experiences and changes.
Some factors on the wheel (e.g.,
education and class status) may change at
different points in life as a person gets
older and has different life experiences.
Identified areas on the wheel at age 20,
for instance, may look different at age 50.
Some factors (e.g., gender and race) are
dimensions we are born with and cannot
easily change.
Given the many spokes on the Diver-
sity Wheel, it would be limiting to see
either ourselves or others only through the
eyes of culture (one aspect of the wheel).
Other factors profoundly influence who
we are and contribute to our experiences
and perceptions of others. For example,
our socio-economic status not only influ-
ences our standard of living, but also the
neighborhood in which we live, our access
to health care and possibilities for future
planning. Although our cultural identity
may affect some of these, other factors,
like age, immigration status and primary
language, may also impact our experi-
ences and world view.
Self Awareness
Self perception plays a major role in our
ability to provide services. As providers of
service, particularly in diverse communi-
ties, it is critical that we have a clear
understanding of who we are as individu-
als. Experiences and life stories guide
interactions, expectations and biases. By
using the Diversity Wheel, we can begin
to identify our uniqueness and begin to
understand how we experience others.
With this process of self awareness, we
may identify personal beliefs underlying
our expected behaviors of others (Pope-
Davis, Prieto, Whitaker, & Pope-Davis,
1993). We each have individual reactions
based on our own histories and character-
istics. Recognizing this, we can then begin
to see others for their unique qualities and
the diversity within their group.
Uniqueness of the Client or Family
When meeting with professionals,
clients bring with them their values and
ideas based on their personal histories.
Even though two individuals may share a
cultural identity, other factors may cause
them to respond differently to the same
situation. To illustrate this point, a mem-
ber of our CRAFT team is a Jewish
woman from a small town in the eastern
United States. She had a friend who
attended the same elementary school,
worshipped at the same synagogue, and
whose family was from the same econom-
ic group. Their physical appearance was
similar, they wore similar clothes, and had
the same accents. The significant differ-
ence between these girls was that one was
from a family that was first generation in
the United States having survived World
War II in Europe. The other girl was sec-
ond generation; her parents were born in
this country. This fact shaped how the
families of both of these girls responded to
many life decisions including trust in the
government, familial relationships, and
faith in future endeavors. In this instance,
invisible differences shaped and differen-
tiated two girls who were otherwise very
similar.
In looking at what creates the unique-
ness of individuals, it would be inaccurate
to allow anyone person to represent a
particular cultural group, or to allow our
experiences with an individual to create
expectations of what the next experience
will be like. For instance, a provider met a
client who was a single parent released
from prison a few years ago and living on
welfare with an abusive boyfriend. The
provider expected that this would be a
high risk situation, since her experience
with ex-convicts had always been discour-
aging. In her experience, people who had
been in prison were not well educated, had
low self-esteem, and did not make use of
available resources. She had difficult
times establishing regular visits with these
clients, and often felt she was being
conned by them. The provider's doubts
about this parent proved to be false. Not
only did this parent complete her AA
degree, but she ended the abusive relation-
ship, obtained a job, and maintained cus-
tody of her children.
,..
'-
Bridging the Gap
Bridging the gap between families and
providers starts with knowing what the
provider brings into the families' homes-
being aware of biases and agendas, and
being able to contain these issues while
remaining open for new perceptions. Bias-
es form the basis for expectations, and
these expectations influence judgments
about families or clients. For example, the
most common child rearing task of feed-
ing a baby is laden with cultural and indi-
vidual values: dependence vs. indepen-
dence, cleanliness vs. exploration, control
vs. choice. Someone who values indepen-
dence may feel it is important to use feed-
ing time as an opportunity for the child to
master the skill of feeding; wasted food
may not be a big issue. Self feeding may
be different for a family who is without
resources and does not have enough food
from month to month, or for a family who
is concerned about neatness or how much
food is consumed.
It is important to pay attention to
personal feelings, discomforts and uncer-
tainties when working with families.
These discomforts can be indications that
the provider is in fact experiencing value
differences with the family. Not attending
G
0)
AlA RESOURCE CENTER
VOLUME 6, NUMBER 3 2
.......
to these feelings may compromise the
quality of service and lose the family-
focused approach.
Part of forming a partnership with
families and working together is a dance,
learning when to lead, when to follow,
finding a rhythm, keeping in step. Some-
times toes get stepped on. Acknowledging
mistakes and learning to talk about them
with families is sometimes difficult for
professionals, but it is crucial if we are to
truly work together.
Bridging the gap is a complex process
that takes time. Do not be afraid to ask
questions. Many families may appreciate
the opportunity to talk about themselves.
Consider it a sign of progress when a fam-
ily can engage in conversation about cul-
tural and individual differences. It is criti-
cal, however, to not assume that there is a
clear understanding of each other because
the client has had a few discussions with
you.
Having a family focused approach is
crucial in supporting families and provid-
ing services. A tool like the Diversity
Wheel can help establish what is impor-
tant to a family and why. If health care,
food or unpaid bills are a family priority,
it may be difficult for parents to attend to
their child's speech therapy needs. Even
when providing interventions specific to
the child, parents may be more concerned
about their child's ability to self feed or
entertain him/herself than in the ability to
do puzzles or have good transitional
movements. Knowing how to listen to
what parents feel they need involves
knowing what issues you as a provider
bring into their home.
~
0
Conclusion
""
,
WOrking successfully with clients/
families requires a family focused
approach which includes being culturally
sensitive and having a heightened aware-
ness of diversity. Having culture specific
information is only a small part of
developing an alliance with clients and
families. Understanding the concept of
diversity is an ongoing, evolving process.
This process includes understanding
self, understanding the uniqueness of the
client/families, and finding a meeting
ground between the values and priorities
of the family and of the provider. There is
always much to learn, and in that learning
mistakes will be made. The process out-
lined in this article is just a starting place.
The integration of these concepts into
provider/client interactions forms a basis
for culturally sensitive, family focused
service delivery.
REFERENCES
Like, R. C, 1991. Culturally Sensitive Health Care
Recommendations for Family Practice Training.
Family Medicine. 23(3),180-181.
Marvel, M.K., Grow, M., & Morphew, P., 1993. Integrat-
ing Family and Culture into Medicine: A Family
Systems Block Rotation. Family Medicine. 25(7),
441-442.
Nkongho, N.O., 1992. Teaching Health Professionals
Transcultural Concepts. Holistic Nursing Practice.
6(3),29-33.
Pahnos, M.L, 1992. The Continuing Challenge of Multi-
cultural Health Education. Journal of School Health.
62(1),24-26.
Pope-Davis, D.B., Prieto, LR., Whitaker, CM., & Pope-
Davis, S.A., 1993. Exploring Multicultural Compe-
tencies for Occupational Therapists: Implications for
Education and Training. The American Journal of
Occupational Therapy. 47(9), 838-844.
Stewart, B., 1991. A Staff Development Workshop on
Cultural Diversity. Journal of Nursing Staff Devel-
opment. 2(4),190-194.
- Karen Tanner, M.A., Alfreda Turner
Ph.D., Susan Greenwald, L. c.S. W.,
Chela Rios Munoz, L. c.S. W,
Sonia Ricks
* CRAFT is a training program administered by
the Department of Special Education, Calij(,rnia
State University, Northridge
OiJlersity
Wheel
Chela Rios Munoz, Oakland CRAFT Team
THE SOURCE
VOLUME 6, NUMBER 3
3
TheLIVE& LEARNModel ForCulturally
CompetentFamilyServices
Working with families from diverse
cultural groups presents new challenges to
providers in community settings. Although
there are excellent materials and resources
available that deal with the theoretical and
technical aspects of family services, there
is very limited access to practical informa-
tion and assistance in conducting success-
ful interventions with families from
diverse cultural backgrounds.
Providers are often unaware of basic
principles of cross-cultural service deliv-
ery, including the definition and signifi-
cance of culture as a factor in service
interactions, the dominant cultural values
common to specific populations, and the
ways in which the dominant Euro-Ameri-
can provider culture influences the deliv-
ery of services and the attitudes toward
clients.
For the purposes of this discussion, I
will define culture as a stable pattern of
beliefs, attitudes and behaviors, transmit-
tedfrom generation to generation, for the
purpose of successfully adapting to other
group members and to the environment. In
using this definition of culture, we avoid
establishing hierarchies among diverse
cultures, and assume that all groups have
developed congruent approaches to issues
of social and environmental adaptation.
However, we can also infer that these
adaptations are group- and site-specific,
and that the relocation of persons adhering
to diverse cultures necessitates a long
period of re-adaptation to changing social
and physical environments. In this con-
text, it is important to note that, due to the
history of the United States, and the rela-
tively recent (the last 300 years) immi-
grant nature of the vast majority of its
population, there is-with the exception
of North American Indians residing in
ancestral lands-no perfectly adapted
cultural group at this time. This assertion,
of course, includes persons subscribing to
the dominant Euro-American culture. The
United States, thus, is overwhelmingly a
nation of immigrants, and its entire popu-
lation is currently seeking ways to adapt
socially and environmentally, regardless
of the fact that one particular cultural
group (Euro-Americans) is politically and
economically dominant.
Cross-Cultural Attitudes and
Client Reactions
Whenever a provider and a client from
different cultures meet, the former mani-
fests a cultural attitude and the latter
exhibits some reaction. I will briefly
examine what these cultural attitudes are,
and how they may determine to a great
extent the reaction that the client exhibits.
I will use a model of cross-cultural atti-
tudes and client reactions that range, on
the one hand, from superiority to cultural
competence, and on the other from resis-
tance to adaptation.
Because in our society the provider
usually controls important aspects of the
service relationship, including site, envi-
ronment, time of initiation, duration, and
type of intervention, the cross-cultural
attitude of the provider sets the tone for
the relationship. Possible cross-cultural
attitudes include:
. Superiority. The provider considers
the client's culture inferior or worthless,
and actively tries to impose his/her values
and world-view. The intervention attempts
to effectively dismiss the client's values
and replace them as a pre-condition for a
service relationship.
. Incapacity. The provider acknowl-
edges differences, but has no skills or
tools to address them effectively, and
therefore proceeds with a standard inter-
vention based on dominant cultural
values.
~)
. Universality. The provider considers
that all humans share basic values and
therefore treats all people alike, regardless
of their differences. Since behaviors are
culture-bound, this approach results in a
standard intervention based on the cultural
values of the provider.
. Sensitivity. The provider acknowl-
edges differences and tries to address them
by adopting external or formal cultural
expressions and presenting the standard
intervention within these parameters.
Cultural sensitivity usually is limited to
the use of the client's language and litera-
cy level, and limited deference to major
taboos.
. Competence. The provider identifies,
respects, incorporates and maintains the
values of the client in the design, delivery
and evaluation of the service. The inter-
vention is client-centered, as the provider
listens actively, elicits the client's world-
view, acknowledges the differences and
similarities, recommends approaches con-
gruent with the client's values, and negoti-
ates their implementation or adaptation.
t)
Faced with one of these cultural atti-
tudes, clients from a non-dominant culture
might exhibit one of the following reac-
tions:
. Resistance. Clients refuse to partici-
pate in the intervention, are unresponsive,
and may exhibit either hostility or passivi-
ty. In some cases, clients will purposely
minimize their understanding of the
provider's language.
. Accommodation. Clients reject their
native culture and attempt to adopt the
values, attitudes and behaviors that they
perceive to be dominant. Clients will often
aim to please the provider and agree to
~)
AlA RESOURCE CENTER VOLUME 6, NUMBER 3 4
recommendations that are impractical or
inappropriate.
-..... . Adaptation. Clients maintain their
values, attitudes and behaviors, adapting
them to new circumstances, while simulta-
neously adopting skills and strategies that
allow them to function effectively in the
dominant culture.
~
~
Cultural superiority allows for either
resistance or accommodation, but largely
elicits the latter. Incapacity and universali-
ty often are met with resistance or accom-
modation as well, although these attitudes
do not actively lead to the obliteration of
the client's culture. Cultural sensitivity is
met by clients with the entire spectrum of
reaction. When the intervention is so
superficially "sensitive" as to border on
blatant stereotyping, clients often respond
with passive resistance. More commonly,
clients accept the "sensitive" more formal
aspects of the intervention, and reject the
core, which is based on dominant cultural
values. Cultural competence encourages
and accepts adaptation in clients, as it
openly recognizes and respects the differ-
ences and similarities in world-view,
while incorporating client values in the
serVIcecore.
TheLIVE& LEARNModel
I n the LIVE and LEARN Model, each
letter of the acronym stands for an atti-
tude, strategy or activity that providers can
adopt to foster positive interactions with
their clients. This model has been culled
from the accumulated wisdom of diverse
sociologists, psychologists, social work-
ers, interpreters, medical providers (most
notably P.S. Adler, H.A. Bulhan, R. Cash-
man, A. Castaneda, L. Comas-Diaz, G.
Marin, J. Pares-Avila, M. Ramirez and T.
Tafoya), and the practical experiences of
the staff of the Latino Health Institute of
Massachusetts, which serves more than
10,000 clients through approximately 40
different programs, most of which are
offered through its Family Services
Division.
c
L stands for Like. If the provider does
not have a genuine liking for diverse
families and their cultural origins, no
amount of skill development will
make an iota of difference. If we
reflect on our personal experiences, it
will become evident that we are sel-
dom, if ever, competent at those
endeavors we dislike. For example,
children forced to take music lessons
against their will generally do not
become virtuosi; neither will providers
required to be culturally competent if
they lack the fundamental positive
predisposition for this work. It is far
more honest and productive to assess
whether diverse families would be
better served by other providers.
I
is for Inquire. As a certain tabloid
constantly reminds us at supermarket
check-out counters, "inquiring minds
want to know." Providers that habitu-
ally work with certain populations
have a responsibility to familiarize
themselves with the demographics,
history, beliefs, traditions, social
norms, family structures, discipline
strategies, and preferred forms of
address of their clients.
attempt to transact personally mean-
ingful business without the benefit of
interpreters. Another strategy is to
establish peer relationships with per-
sons from other cultures, and thus gain
an insider's view of that culture
through the eyes and the minds of our
peers. In this context, we may consider
establishing such peer relationships
with colleagues and even former
clients from the cultures of interest.
"&"
L stands for Listen. When we listen
attentively to our clients, we make a
special effort to discern not only the
content of their communication, but
the style which they employ. In the
dominant culture, this style tends to be
impersonal and to-the-point, focusing
more on verbal than on non-verbal
aspects. In many other cultures,
Continued on next page.
THE SOURCE
VOLUME 6, NUMBER 3
V is for Visit. When we perceive our-
selves as guests in someone else's
home, we naturally adopt an attitude
conducive to observation, respect, and
emulation of our hosts' social norms.
Conversely, if we maintain a provider
attitude, even when conducting home
visits, we tend to bring to our relation-
ships a clinical, business-like detach-
ment that inhibits the process of obser-
vation and emulation of client norms.
Adopting the attitude of a visitor when
interacting with persons from other
cultures, especially when meeting with
them in our own offices, is a strategy
that allows us easier access into the
client's world.
E is for Experience. This letter suggests
two useful strategies. The first is to
consciously put ourselves in situations
in which our culture is not dominant,
such as attending social events at
which our language and mores have a
marked minority status. For example,
when traveling in a country in which
another language is dominant (and
English is not universally understood
or spoken), it is most instructive to
5
. ContinuedfrOln page 5
however, styles tend to personalize
communications by referring to expe-
riences, interests and feelings, and
there is a greater focus on non-verbal
expression. Once we have discerned
the preferred communication style, it
wi]] not only be easier to understand
what is being said by clients, but we
will also know how to respond effec-
tively by matching their style.
E is for Evaluate. Although not often
used in this sense, the verb to evaluate
litera]]y means "to determine the
value(s)." Because a]] clients integrate
culture and personality in markedly
individual ways, it is important to
determine the specific beliefs, atti-
tudes and values to which they sub-
scribe, thus avoiding stereotypes. It is
also important to elicit the level of
acculturation of clients, which is
often-but not always-associated
with length of residence in the United
States. Thus, within the same family,
individuals may hold beliefs and
values that are different, according to
generation or date of immigration.
Often, it is useful to ask open-ended
questions such as "How would your
grandmother have addressed this
issue?" Clients will then be at liberty
to state the values of the culture of
origin, and will volunteer valuable
information about their own proximity
or distance to/from those values.
A is for Acknowledge similarities and
differences. Once we have ascertained
the values of interest, it becomes nec-
essary to clarify for the clients our
perception of the similarities and dif-
ferences among values of the family
members, and between those and the
dominant culture. While identifying
cultural similarities is always useful in
establishing rapport, and is highly
advisable, it is equally necessary to
inform clients in a non-judgmental
manner of any differences, particularly
when those differences might eventu-
a]]y arise in the service relationship. In
this regard, it is absolutely imperative
to inform clients if the legal require-
ments of our profession (i.e., mandat-
ed reporter) can lead us to use some
objective standards of behavior that
conflict with the stated client value
(i.e., harsh disciplining methods).
R is for Recommend. In addressing any
issue, there always are several possible
approaches, even though some may be
preferable to others. It is best to
describe for the client, while matching
their communication style, the entire
range of options and the consequences
associated with them. For this purpose,
we can i]]ustrate for the client several
approaches, from the least desirable to
the most desirable, and inquire from
them which approach seems to make
most sense, given their present situa-
tion and resources. This strategy wi]]
prevent us from recommending
impractical solutions, to which clients
may agree out of deference, but which
they have no intention, or insufficient
resources, to implement.
N is for Negotiate. Because, in most
cases, our interventions seek some
form of behavior modification, it is
important to reach an agreement-
preferably in the form of a contract-
between the client and the provider as
to which option(s) will be put into
practice, what measures wi]] be jointly
used to monitor progress, and the
timeline for implementation. Should
the client agree to an option that is not
considered tota]]y appropriate by the
provider, negotiation might also
include a timeline for adoption of
more desirable options in the future.
Important Considerations When
Using the LIVE& LEARNModel
When initiating work with persons
from diverse cultural orientations, stan-
dard assessment procedures should be
used in gathering data. Making assump-
tions solely on the basis of ethnicity is
both inaccurate and inappropriate. Howev-
er, there are several critical areas that must
be explored in order to insure the gather-
ing of a thorough psychosocial and devel-
opmental history that may result in accu-
rate formulation and service planning.
In work with J. Pan-:s-Avilaand our
co]]eagues at the Massachusetts General
Hospital, we have identified and discussed
certain critical considerations for engaging
clients in cross-cultural service relation-
ships. Some of the most applicable are
noted below.
t
. Time. Some persons with non-domi-
nant cultural orientations have flexible
understandings of punctuality and aver-
sion to a hurried pace, especia]]y within
the context of their expectation of close
social relations. Thus, emphasis on saving
time versus being cordial is viewed as
rudeness rather than efficiency.
. Personal Space. Some persons with
non-dominant cultural orientations require
less personal space than those with Euro-
American orientations. Additionally, some
persons with other cultural orientations
tend to touch more frequently, and hand-
shaking, hugging, knee- and backslapping,
rib-nudging and cheek-kissing are fre-
quently observed.
. Country of Origin. A first considera-
tion is the client's country of origin. In the
case of foreign-born persons with non-
dominant cultural orientations, it is impor-
tant to explore the client's migration histo-
ry. In the case of U.S.-born persons with
non-dominant cultural orientations, a simi-
lar migration history should be obtained
regarding the client's family, including a
determination of how many generations
ago the move occurred. Furthermore, the
provider should explore the client's expe-
riences in the U.S. relative to discrimina-
tion and/or racism.
f)\i
. Language Use and Dominance.
Assessment of language use and domi-
nance is another critical area. When the
client with a non-dominant cultural orien-
tation is seen by a monolingual dominant-
culture counselor and the client is fluent
in English, this is frequently overlooked.
When clients are not fluent in English,
providers often assume that they speak
only the language of their culture of ori-
gin. Language congruence is fundamental
to the effective delivery of services.
Among the approaches that can be used to
overcome language barriers, the most
t
Please see page 12 .
AlA RESOURCE CENTER VOLUME 6, NUMBER 3 6
EXCELLENCE IN ACTION
The Effectiveness of Indigenous Recovering
Outreach Counselors in Reaching Substance Abusing
Women of Color Within the Drug Culture
0
()
There is growing consensus that a more
comprehensive and systematic approach is
needed to respond to the complex needs of
substance abusing women and their fami-
lies. Drug addicted women come from
every social and economic class, race,
culture and religion. Virtually chained to
the close and perilous drug culture, vic-
tims typically look to other drug users for
the only social support they receive. They
rely on other addicts to guide them to safe
sellers, handouts, money and information
required to survive in the drug culture.
With rare exceptions, professional
outreach workers find it extremely diffi-
cult to gain acceptance from clients in the
drug culture. Ethnic and cultural influ-
ences on the client's life style, and clients'
interpretation of the environment, further
complicate the client/service provider
relationship. Drug addicted clients typical-
ly come from worlds significantly differ-
ent from the ones that shaped the belief
systems of most professional service
providers. As a result, professionals often
have difficulty gaining credibility because
they lack an understanding of the drug
culture and the ethnic and cultural back-
grounds frequently represented among
clients snared in this web.
The PEPProgram
Q
The PEP (Partnership to Empower
Parents) Program is an AlA project which
uses a consortium of consumers, commu-
nity members, family care agencies,
educators, family preservationists and
substance abuse treatment specialists to
provide intensive outreach and concrete
services to help families in South Dade
County, FL, break the cycle of addiction
and learn to parent their infants and young
children. To overcome the obstacles
described above, PEP selected and trained
some of the recovering clients, who had.
been drug-free for at least one year, to
serve as outreach workers for drug addict-
ed women in targeted communities. With
these recovering clients, PEP created what
is called a DART Team (Drug Addiction
Recovery Team). Team members are
trained in assessment and in carrying out
their roles and responsibilities as paid peer
counselors and outreach workers to drug
addicted women in their own neighbor-
hoods.
DARTTeam Members
PEP'S DART Team members come
from the same neighborhoods and share
ethnic and cultural backgrounds with
program participants. Having grown up
and/or shared drugs with many PEP
clients, DART members are uniquely
positioned to develop a basic support sys-
tem for clients' substance abuse recovery
efforts and family strengthening within the
context of their culture. They know the
environment, and they know what is going
on in the lives of their clients on a daily
basis. In those respects, DART team
members are more capable than "cultural
strangers" to communicate with the partic-
ipants through speech and action. To start
where the clients are means understanding
the clients' culture first.
The shared cultural background of the
DART team and the client population
shifts the diagnosis and intervention activ-
ities from a pathological orientation to an
ecological orientation. The barriers associ-
ated with cross-cultural interactions (e.g.,
PEP: Healthy Baby
miscommunication, stereotyping and
narrow parameters of one's own cultural
background) are significantly reduced.
DART members can easily understand
situations in the context of history and
culture of the clients because it is their
own history and culture as well. DART
members can be considered "cultural
interpreters" for substance abusing women
of eolor.
As recovering substance abusers
themselves, DART workers are better able
to engage clients, explain the service
options in the client's language, recognize
clinical symptoms in a cultural context,
confront a client who claims to be off
drugs, and serve as guides to help partici-
pants traverse the sometimes culturally
insensitive family care treatment and
Continued on next page.
THE SOURCE
VOLUME 6, NUMBER 3
7
. Continued from page 7
service systems. For example, the impor-
tance of the simple request by an African-
American client to "have her hair done"
before entering a residential treatment
center is understood and facilitated by
DART members. The request is culturally
significant and, once given the attention
needed, is removed as a barrier to the
recovery process.
DART team members also serve as
role models for clients. They are seen as
"scouts" who travel successfully outside
of the neighborhood, bringing their clients
information, ideas and resources necessary
to assist clients in the recovery process.
They stimulate participant interest in sub-
stance abuse rehabilitation and drug-free
life styles. Through models set by team
members, client participants begin to feel
that they, too, can achieve sobriety and
learn life management skills similar to
those exhibited by the recovering "sisters"
on the DART team. The following case
example illustrates the valuable contribu-
tions of indigenous counselors.
Staci, a PEPClient
Staci came to the PEP program in 1995,
addicted to both alcohol and crack. From
1988-1995, Staci exchanged sex for mon-
ey or drugs to support her habits. Staci
reported being in jail for one year on an
assault and battery charge that she says
was directly related to her addictions.
Staci has six children, three of whom
were prenatally exposed to drugs and
alcohol. She is currently receiving AFDC,
food stamps, Medicaid and Section 8
Housing. She is unemployed and has been
for 15 years due to her alcoholism and
drug addictions.
Staci says that she needed the DART
team members to help her realize that she
could actually get clean and sober and stay
that way. This message was conveyed in
an experiential manner; she knew one of
the DART members because she had
used drugs with her in the past. Staci says
that this same woman came to her house
and became an example to her, and that
the transformation she saw in her former
t
PEP Community Board Training
drug-using companion convinced her that
maybe there was hope for her.
With the help of the DART team,
Staci entered a residential treatment center
and reconnected with drug-free extended
family members. She is working toward
reunification with her children, and plans
to become a DART member in the future.
DARTMembers as Team Players
DART members are also a critical
source of information for the community
and professionals who work with PEP
clients. As recovering addicts, DART
members serve as communicators to com-
munity organizations regarding substance
abuse among women, and they provide the
community with information about ser-
vices available from PEP to help mothers
overcome substance abuse and its effects
on their children and families. The DART
team distributes information and
brochures, and reaches out to mothers and
their children in need of help to overcome
drug abuse.
Additionally, DART members pro-
vide PEP's professional staff, and other
community providers, with critical infor-
mation on the ethnic and cultural beliefs,
values and practices of their clients, and
help professionals to understand behaviors
which are characteristic of the drug cul-
ture. DART team members are included
in regularly scheduled staff meetings with
PEP's professional social workers to
review and discuss clients and their treat-
ment plans. DART members provide
information about clients from a different
cultural perspective, and offer their inter-
pretation and assessment of clients'
behavior. The entire staff works together,
respecting and integrating the perspectives
and assessments of both professional and
peer workers, to develop and revise client
intervention plans.
This is not an easy process. Along
with the undeniable benefits of using peer
workers, there are always challenges to
managing a staff which is culturally, eth-
nically, economically and educationally
diverse. DART team members often need
support in their own recovery process, and
assistance drawing the line between client
and peer/friend. Despite these challenges,
PEP attributes much of its success in
reaching substance using women of color
to the culturally competent work of the
DART team-peer workers who share the
clients' ethnic, racial and socioeconomic
background and who have experienced the
drug culture first-hand.
t)11
- Shirley Pinder Cook &
Scott Briar, DSW
tl
AlA RESOURCE CENTER VOLUME 6, NUMBER 3 8
rO
Culturally Competent Program Evaluation
It
I n recent years, family support programs
have increasingly recognized the impor-
tance of cultural competency in providing
services tofamilies with children affected
by substance abuse and HIV. However,
cultural competence principles are just
beginning to be considered in the evalua-
tion (~fprograms and systems which serve
these families. Andres Pumariega (1996)
points out that "the cultural 'blindness'
approach which has characterized the
field of evaluation has kept [evaluators}
from identifying important differences in
needs and orientation to service utilization
across ethnic groups" (p. 1). In order to
make programs more effective in reaching
and improving outcomes offamilies with
different cultural, racial and socioeco-
nomic backgrounds, process and outcome
evaluations must consider and reflect
cross-cultural differences. Thefollowing
information, excerptedfrom Pumariega
(1996)*, offers practical guidelinesfor
designing culturally competent evalua-
tions.
Defining Program Characteristics
,
An evaluation for either a program or a
system of care begins with defining con-
sumer/population, process, and outcome
characteristics. This gives the evaluation
the data it needs to answer the key ques-
tions of which interventions work, for
whom, and how.
Consumer/population characteristics
include information about race and ethnic-
ity as well as other demographic character-
istics that often interact with culture, e.g.,
gender, age, socioeconomic status, and
urbanicity. Relating these characteristics
to the geographic region being served
sheds light on factors that influence ser-
vice delivery, e.g., the proximity of the
population to natural stressors and physi-
cal access to services. If there are signifi-
cant culturally diverse populations, it is
useful to know how the target populations
compare to the prevailing community
population.
Program characteristics are also key
in designing an evaluation. The philoso-
phy of the program or system determines
the service model and the associated
process characteristics to be examined.
Process characteristics can include type
and frequency of interventions, length of
stay, attainment of individual treatment
goals in care plans, staff involved in inter-
ventions, and behaviors that change as a
result of applying interventions. Culturally
relevant process questions include:
. How does program philosophy relate to
staffing composition, including the distrib-
ution of professional disciplines and their
ethnic composition?
. Is effective cultural competence train-
ing available for statl and how does it
impact program philosophy?
. How does program philosophy com-
pare and interact with the cultural values
of the target population, e.g., emphasis on
spirituality, individual versus family ori-
entation, and assignment of clients to
different therapeutic modalities? This may
include traditional healing approaches
(religious ceremonies, rituals, specific
cultural interventions such as sweat
lodges, or community intervention), and
which clients benefit from such interven-
tions as opposed to Western approaches.
. What are the points of entry into the
program and the barriers to accessing
care? How do those relate to the clients'
cultural and socioeconomic needs?
Outcome characteristics in evaluation
usually involve symptom change, func-
tional change, safety, cost, community
tenure and level ofrestrictiveness, and
consumer/family burden and satisfaction.
Culturally related outcome questions
include:
. How do outcomes differ across cultur-
al, racial or ethnic groups?
. What outcomes are expected from the
program and how do they compare to the
functional expectations of individuals of
the cultures/ethnicities/socioeconomic
status being served? (For example, if
emotional separation and autonomy is an
important program outcome, is this appro-
priate for a cultural group for which multi-
generational closeness is the norm?)
. How does the program relate to the
community organizations/leadership that
represent minority groups served?
(Windle, Jacobs & Sherman, 1986)
Participation by the Community
and Providers/Agencies
Staff, child, and family participation
must be fostered in order to evaluate a
program or system of care. Minority com-
munity members often are not enthusiastic
about evaluation because of prior negative
experiences. There is also mistrust about
whether research will be used as a tool of
government agencies, immigration, social
services/child welfare agencies for cus-
tody termination or termination of bene-
fits. Research methodology sometimes
conflicts with cultural values, tradition,
and accepted means of communication of
sensitive information. Staff may fear that
evaluation might frighten families away
from services.
A number of approaches can be used
to engage the cooperation of minority
children and families. Seeking out advice,
input, and endorsement from leaders and
elders in the minority community is quite
effective, both in building trust and in
Continued on next page.
THE SOURCE
VOLUME 6, NUMBER 3
9
. Continued from page 9
informing the selection of instruments,
methods, and procedures. Recruiting
evaluation assistants from the community
builds in community involvement and
expertise. Cultural competence training
for staff as outcome evaluation is intro-
duced can heighten awareness for the need
to examine cultural diversity issues.
Informed consent procedures must also
be easily understood and should involve
appropriate family members indicated.
Evaluation Design and Sampling
The nature of the actual design
chosen has significant implications for
culturally diverse groups.
. Pre-post or multiple baseline designs
are commonly used. However, culturally
diverse populations served frequently
change over time for reasons other than
interventions provided, e.g., exposure to
mainstream culture, generational change,
and signal events in the life of the commu-
nity (Szapocznik, Scopetta & King, 1978).
It is important to monitor such intervening
changes when using these designs.
. Single case methodology, which tracks
ratings of selected target behaviors before
and after intervention to determine effects,
is useful in evaluations involving groups
which have only small numbers of people
available.
. Experimental designs, where clients are
randomly assigned to different interven-
tions, are often consider the "gold stan-
dard" scientifically. However, these stud-
ies are hard to implement in the real world
of service provision. Ethical questions
may come up when one group is receiving
an intervention that is obviously less
worthwhile, and this reinforces suspicions
in ethnic minority clients.
. Longitudinal designs following a
cohort of clients over time to measure
outcome can be useful. Their drawback is
that some behavioral changes may be
specific to certain "cohort" groups if they
share many life experiences in common,
and may be hard to generalize to other
groups.
Sampling from culturally diverse
groups must assure that the racial/ethnic,
socioeconomic, age, and gender composi-
tion of any sample reflects the service
population. Oversampling or stratification
of samples may be necessary if the sam-
ples of culturally diverse individuals are
too few in number to be representative.
Measurement Strategies
Selection of instruments and measure-
ment strategies introduces many cultural
considerations. Few instruments are
appropriate for use across different cultur-
al groups, and some have subtle but dis-
tinct cross-cultural biases (Pumariega,
Holzer & Swanson, 1991). Instruments
being used or compared across cultural
groups should have these characteristics:
. Conceptual equivalence: the same theo-
retical construct is being measured across
different cultures (e.g., parental role func-
tion is defined the same in all the groups
being studied).
. Semantic equivalence: both translation
across language as well as idioms and
expressions of the groups being studied
are accounted for (e.g., the Anglo term
feeling "blue" does not have meaning for
Hispanics, and has a historical context for
African-Americans).
. Content equivalence: the content of
each item in the instrument is relevant to
the phenomenon being studied in that
culture. For example, the concept of being
"put-upon" may not have an equivalent
expression in another culture. Lack of
familiarity with clinical jargon and differ-
ent understanding of symptoms and cul-
turally-bound syndromes (e.g., schizo-
phrenia versus being possessed) must be
taken into account. It may be necessary to
include descriptors of illness or behaviors
in questions.
. Criterion equivalence: the variable
measured is interpreted based on the
norms for that culture (e.g., the level of
depression and the cut-off for significant
depression is based on the normative
response for that culture). Measures of
symptoms or behaviors need to account
for culturally determined thresholds of
dysfunction within the community. It may
be necessary to develop different cut-off
scores for different ethnic groups using
culturally-specific normative samples.
~I
. Methodological equivalence: methods
of assessment and data collection yield
comparable responses across culture. For
example, it is a problem if some groups
are more open in self-administered ques-
tionnaires, while others prefer interaction
with,an interviewer.
A problem which periodically arises
is whether to use instruments specific to
one culture or cross-cultural instruments.
Mono-cultural instruments may be neces-
sary when specific aspects of a culture are
being evaluated as a variable in the impact
of a program, e.g., ethnic pride/ethnic
identification in a particular culture.
Instruments that can measure constructs
across cultures are necessary when mak-
ing comparisons across cultural/ethnic
groups. It may be necessary to develop
parallel versions of instruments that are
specific for different groups.
Qualitative approaches, e.g., open-
ended questions, interviews, or observa-
tions, may be useful in eliciting important
perceptions or attitudes without the limits
imposed by rating instruments. These
approaches often are very compatible with
cultural values and means of transmission
of information in communities.
The measurement of cultural identifi-
cation and cultural value orientation pre-
sents particular challenges. The construct
most commonly endorsed in the cross-
cultural mental health field is that of
biculturality or multiculturality, i.e., cul-
turally diverse individuals by necessity are
bi-cultural or multi-cultural in order to
adapt successfully. The domain of cultur-
al/ethnic identification must allow for this
construct, and must take into account a
number of domains, e.g., self-identifica-
tion, relational patterns (friends, intimate
relations, etc.), culturally related traditions
and preferences (clothing, foods, tradi-
tions, language, media, etc.), and cultural
value orientation. For many children and
tJ
{I
AlA RESOURCE CENTER VOLUME 6, NUMBER 3 10
(0
families, the measure of concrete behav-
iors or activity orientations are a valuable
means of assessing cultural identification.
These include simple activities such as the
amount of time spent with family, reli-
gious activity, and time spent exposed to
the media (Pumariega, et aI., 1992).
Use of Databases and
Clinical Records
(t
Clinical or agency databases may be
important information sources for out-
come evaluation. However, there are often
problems with the rating of ethnic/racial
identification in databases. Often clini-
cians do not ask race/ethnicity directly,
but infer it from appearance or surnames!
Problems often occur with the coding
categories used for cultural and ethnic
groups, with insufficient or unclear cate-
gories (e.g., a single Hispanic category or
Asian/Pacific Islander combined). There
are also problems with the coding of
much culturally-related information in
databases, such as socioeconomic status,
diagnosis, and service utilization informa-
tion. It may be important to develop
rational coding categories for clinical
database information, with instruction for
clinical staff or other staff entering infor-
mation. Racial/ethnic bias in clinical diag-
nosis is well documented, especially by
clinicians not familiar with the culture
(Kilgus, Pumariega, & Cuff, 1995), so that
these data might have limited utility. It
may be more valuable to have clinicians
rating the presence of symptoms reported
by the base of objectivity and not contami-
nated by the biases of classification sys-
tems.
Conclusion
f
The practice of culturally competent
outcome evaluation needs to be greatly
developed given the culturally diverse
nation in which we live and the different
needs of culturally diverse children and
their families. Such evaluation is crucial
in supporting the need for an effectiveness
of culturally competent programs and
for special programs with a focus on
particular cultural populations. The imper-
atives for cost effectiveness and clinical
effectiveness which have been promoted
by the transition to managed systems of
care may actually promote the develop-
ment of higher levels of cultural compe-
tence in community-based systems of
care. Culturally competent care may well
be the most cost-effective and clinically-
effective care.
Behavioral Symptomatology. Proceedings of the
Annual Meeting of the American Academy of Child
& Adolescent Psychiatry. Volume VB, NR-1l9.
Pumariega, A., Swanson, J., Holzer, c., Linskey, A. &
Quintero-Salinas, R. (1992). Cultural Context and
Substance Abuse iu Hispanic Adolescents. Journal
of Child and Family Studies, 1(1): 75-92.
Szapocznik, 1., Scopetta, M., & King, O. (1978). Theory
and practice in matching treatment to the specific
characteristics and problems of Cuban immigrants.
Journal of Community Psychology, 6, 112-122.
Windle, c., Jacobs, J.H. & Shennan, P.S. (1986). Mental
Health Program Performance Measurement,
Rockville, MD: ADAMHA, NIMH, Division of
Biometry and Applied Sciences.
REFERENCES
Kilgus, M., Pumariega, A. & Cuffe, S. (1995). Race and
Diagnosis in Adolescent Psychiatric Inpatients.
Journal of the Academy of Child and Adolescent
Psychiatry. 34(1): 67-72.
Pumariega, AJ. (1996). Culturally Competent Evaluation
of Outcomes in Systems of Care for Children!s
Mental Health. TABrief, 2(2): 1,3-5*
Pumariega, A., Holzer, c., & Swansou, J. (1991).
Cross-Ethnic Comparisou of Youth Self Report of
*TABrielis a newsletter published by the
Technical Assistance Centerfor the Evaluation of
Children's Mental Health Systems, located at
Judge Baker Children's Center, 295 Longwood
Ave., Boston, MA 02115. Ph (617) 232-8390,
x2139; Fax (617) 232-4125.
THE SOURCE
VOLUME 6, NUMBER 3
11
. Continued from page 6
appropriate, in descending order of effec-
tiveness are: (1) providing the service with
bilinguallbicultural staff; (2) using trained
interpreters (simultaneous or consecutive)
and providing effective training to inter-
preters and service providers in the prefer-
able modes of interpretation, team build-
ing, and communication strategies; and (3)
teaching monocultural providers the
language(s) of the clients.
Providers should determine whether
clients are English-dominant, language of
origin-dominant, or bilingual. Even for
English-dominant clients, it is important
to assess what language is spoken at home
and what type of schooling the clients had
(bilingual or English-only programs).
Providers should be aware that original
language-dominant or bilingual clients
speaking English may invest more energy
in correct expression, thus giving prece-
dence to the cognitive aspect of communi-
cation over the affective component of
language. Thus, these clients may appear
more constricted or flat.
Clients may also use bilingualism as a
defensive structure, utilizing one language
to communicate and reserving another as
the emotional language. Clients may dis-
cuss certain emotionally charged topics in
their non-dominant language as a way of
gaining some emotional distance. At other
times, clients may use their dominant
language in order to access meaningful
memories or experiences. Even if the
provider is monolingual, it is useful to
allow clients to think out loud in their
dominant/emotional language to facilitate
their access to and organization of mean-
ingful material.
. Natural Support Systems. Another
area to consider is the client's natural
support systems. The availability of such
support will be crucial in helping clients to
cope with their family issues. An assess-
ment of the social network should include
a list of friends and acquaintances indicat-
ing their ethnic background. The current
state of relationships with the extended
family is particularly important. In this
regard, both family meetings and geno-
grams are useful assessment and interven-
tion techniques that should be considered.
When it is not possible to interview the
family due to geographic and/or emotional
distance, use of a genogram is highly rec-
ommended in gaining an understanding
of family dynamics and relations. The
provider should also establish whether the
client has attributed family status to non-
blood-related individuals, as this is fre-
quently done by persons with non-domi-
nant cultural orientations. If such is the
case, the provider should treat these fami-
ly members accordingly, and include
them in the assessment and intervention
process. Gathering a history of intimate
relationships is also crucial. If the client
(parent) is currently in a relationship, it is
important to explore whether the partner
is from the same or a different cultural
group. If the partner is not from the same
cultural group, the provider should assess
how the couple deals with their cultural
differences, and how these differences
affect the couple's and the family's
dynamics.
. Provider Selection and Transfer-
ence Issues. The social network data will
provide useful information that may help
in anticipating potential transference
issues that may emerge in a service rela-
tionship. How the client deals with racism,
ethnocentrism, and other issues may be
seen in the client's interpersonal relations
and choice of friends and partners.
This will also become apparent in the
client's selection of a provider, when a
choice is available. Given the scarcity of
providers from matching cultural origins,
for example, clients will most likely be
forced to choose according to age, gender,
or language fluency. Some will give prior-
ity to language, while others will favor
gender or age. Still others may choose
providers with considerable expertise in
the area of their basic presenting issue or
problem, regardless of ethnic background.
This forced choice should be explored in
the assessment process, as it may illustrate
meaningful psychosocial information. It
will also have significant intervention
implications.
When the selection results in a cultur-
ally discordant service relationship, the
dynamics that occur in the client's social
network will be played out in the interven-
tion. Then, more than ever, providers must
be aware of and sensitive to the power of
differentials that exist between them and
their clients.
. Other Considerations. It is always
important to consider specific values,
attitudes, norms, and expectations in
designing service plans. For example,
providers should be aware that reliance on
Euro-American relationship models where
women are assertive and independent
might be uncomfortable and culturally
inappropriate for other women. Most
importantly, interventions should assist all
women in translating knowledge and
awareness of coping skills into successful
verbal and behavioral repertoires. For
some women the emphasis may lie more
with nonverbal than verbal skills.
Possible negative impacts on the fam-
ily, especially on children, may increase
the motivation of more traditionally-ori-
ented men and women to accept service.
Male-dominant traditions may provide
useful intervention strategies with men
because cultural values emphasizes their
role in assuming responsibility for and
protection of the family. Finally, if at all
possible, providers should offer clients a
choice of either or both English and their
preferred language. If providers have
limited command of other languages, they
should avoid literal translations. Monocul-
turallbilingual providers also should avoid
regionalisms in language and consider the
educational level and socioeconomic sta-
tus of clients in their choice of words,
images, and metaphors.
The LIVE & LEARN Model presents
providers with a practical, phased
approach to cross-cultural service delivery
that respects client centrality, avoids
stereotyping, and leads to the adoption of
mutually acceptable objectives-and mea-
sures-for behavior change. It is simple
and straightforward, and accommodates
varying degrees of provider cross-cultural
experience, always leaving room for
improvement.
f)
~
- Nicolas Carhalleira, ND, MPH, DSc
Latino Health Institute of
Massachusetts
~)
AlA RESOURCE CENTER
VOLUME 6, NUMBER 3
12
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Richard Barth, Ph.D.
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Senior Research Associate
Amy Price, M.P.A., B.S.W.
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Gwen Edgar-Miles, B.A.
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Research Assistants
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The Source
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Karen Tanner, Alfreda Turner
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