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Improving Cultural Competence when Working with Alaskan Natives and Native American


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Improving Cultural Competence when Working with Alaskan Natives and Native American

  1. 1. Improving Cultural Competence Working with Native Americans and Alaskan Natives Instructor: Dr. Dawn-Elise Snipes, PhD, LPC-MHSP, LMHC Executive Director: Counselor education Podcast Host: Counselor Toolbox, Happiness Isn’t Brain Surgery AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 1
  2. 2. Objectives  Explore questions to consider when developing the case formulation and treatment plan  Examine demographics, prevalence of problems, health disparities, historical contributors to problems  Learn about specific Native American values, communication guidelines, worldview differences, differences in approaches to treatment, perspectives on health and healing, culture bound syndromes and approaches which may be helpful with this population.  Learn how mapping the client’s cultural views and influences can help clinicians (and clients) develop insights into current struggles and clarify culturally relevant goals AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 2
  3. 3. General Demographics and Information  There are 566 federally recognized American Indian Tribes, and their members speak more than 150 languages  Numerous other Tribes recognized only by states and others that still go unrecognized by government agencies of any sort.  Native Americans who belong to federally recognized Tribes and communities are members of sovereign Indian nations that exist within the United States. On lands belonging to these Tribes and communities, Native Americans are able to govern themselves  Health care is provided to many Native Americans on reservations by Indian Health Services (IHS),  Native Americans, by virtue of their membership in sovereign Tribal entities, have rights that are different from those of other Americans AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 3
  4. 4. Prevalence of Problems  28.3 percent of American Indians and Alaska Natives report having a mental illness, with approximately 8.5 percent indicating serious mental illness in the past year  Native Americans were nearly twice as likely to have serious thoughts of suicide as members of other racial/ethnic populations, and more than 10 percent reported a major depressive episode in the past year.  Common disorders include depression, anxiety, and substance use.  PTSD comparison rates taken from the AI-SUPER PFP study show that 12.8 percent of the Southwest Tribe sample met criteria for a lifetime diagnosis of PTSD compared with 4.3 percent of the general population  American Indians and Alaska Natives have the second highest infant mortality rate in the Nation (National Center for Health Statistics, 1999) and the highest rate of sudden infant death syndrome AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 4
  5. 5. Educational Problems  Less likely than other Americans to graduate high school or complete a college degree  American Indian students achieve on a par with or beyond the performance of non-Indian students in elementary school and show a decline in performance between fourth and seventh grades  AI children may have a culturally rooted way of learning at odds with teaching methods currently used in public education.  AI children are primarily visual learners, rather than auditory or verbal learners.  Academic crossover is paralleled by a similar trend in mental health status, as extrapolated from rates of child and adolescent outpatient treatment. AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 5
  6. 6. Poverty  The poverty rate for America as a whole is 14.3% (Center for Poverty Research), for Native Americans the rate is about 26%  Native Americans have the lowest employment rate of any racial or ethnic group in the United States (Bureau of Labor Statistics, 2012).  In the poorest Native counties, only about 1/3 of men in Native American communities have full-time, year- round employment. AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 6
  7. 7. Historical Contributors to MH/SA  Historical reasons for the development of binge drinking among Native Americans.  The existence of dry reservations (which can limit the times when individuals are able to get alcohol)  High levels of poverty  Lack of availability (e.g., In remote Alaskan native villages)  A history of trauma  The loss of cultural traditions AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 7
  8. 8. Historical Contributors to MH/SA  Issues impacting parenting & prevention which can lead to increased neglect and abuse:  Due to past separation from their families, when these children become parents themselves, they are not able to draw on experiences of growing up in a family to guide their own parenting  Poverty and demoralization  Rapid cultural change  These issues also increase the risk for domestic violence, spousal abuse, and family instability, with their attendant negative mental health effects  6 in 10 American Indian and Alaska Native families were headed by married couples vs. 8 in 10 of the Nation's other families AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 8
  9. 9. Health Disparities  Heart disease  Cancer  Unintentional injuries  Diabetes  Depression, anxiety, PTSD and suicide  Obesity  Substance abuse  Sudden infant death syndrome (SIDS)  Teenage pregnancy  Liver disease  Hepatitis.  60% higher infant mortality rate than Caucasians  5.8 tuberculosis rate compared to 2.0 for Caucasians (2010) AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 9
  10. 10. Health Disparities  Diabetes is increasing among Native Americans, and approximately 38 percent of elder Native Americans have diabetes  Diabetes is also associated with both substance use disorders and depression  In some Native American communities inhalants have been a major drug of abuse for adults as well as youth.  During the early 1990s, about 46 percent of the adult population on that reservation were thought to abuse inhalants  Native Americans are about 1.4 times more likely than White Americans to have a lifetime diagnosis of an alcohol use disorder  Illicit drug use is also more common for Native Americans than for members of other major racial/ethnic groups. AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 10
  11. 11. Cultural Considerations in Approaches AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 11
  12. 12. Specific Native American Values  Native Americans generally value the community’s best interests over their own interests (collectivistic).  When an individual is experiencing problems it interferes with his or her ability to fulfill his or her role in the community.  Many believe that addiction or mental health problems hurt and weaken the community.  This collectivistic role can increase motivation for change by inspiring clients to change for the good of the tribe and for the good of the next seven generations to come, even if they don’t want to change for themselves. AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 12
  13. 13. Worldview Differences in MH Treatment AIAN  Relational  Mind/Body/Spirit is one  Mysticism/Acceptance  Ceremonies/Rituals  Tribal Connectedness  Spirituality and Balance  Cooperation/Sharing  Patience/Respect  Present Orientation  Healing through Herbs, Plants, Nature Majority  Linear Point A to Point B  Psyche is the focus  Science/Verification  Psychotherapy  Individualism  Organized Religion  Competition/Winning  Assertiveness/Forcefulness  Future Orientation  Psychopharmacology AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 13
  14. 14. Communication Guidelines  You should know someone well before speaking to them for long periods of time or confiding in them  Children should not display themselves verbally in front of adults.  It is inappropriate to express emotions in public or around people you don't know very well, verbally or non-verbally.  Don’t ask direct questions or expect an immediate response from people you don't know very well.  It is inappropriate to verbally discipline or praise a child in public.  It is inappropriate to speak for someone else, no matter who that person is. Everyone is titled to their own opinion, even a child. AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 14
  15. 15. Communication Guidelines  "In Indian conversations, it is not the person who speaks first who necessarily controls the topic. This is because an immediate response to what someone ha said may be delayed. The respondent therefore has control over the topic by choosing when to speak and what to say.“  Do not signal someone out directly  Do not compete with answers, no answer can be said it is wrong  Do not look directly at someone the entire time they are talking. AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 15
  16. 16. Specific Native American Values  Be careful when bringing up the topic of spirituality, as there are sacred and secret traditional practices and spiritual leaders who have the role of providing guidance and healing.  Many Native communities have long histories of contact with missionaries. They may have adopted, rejected or blended Christian beliefs with their own Native beliefs.  In general, belief in the Creator, Grandfather, God, gods or a higher power is central to many Native people.  For some Native Americans, spirituality is an integral part of who they are and the world around them.  Native healers do not separate mind, body and spirit but see them all as connected. AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 16
  17. 17. Native Americans & Addiction Cause & Tx  Some believe that addiction is a spiritual entity that has its own voice. The spirit of addiction tries to seduce or tempt the person to drink or use other substances and sometimes is the only way people know how to cope with their problems. Eduardo and Bonnie Duran wrote about addiction as a spirit in their book, “Native American Postcolonial Psychology.”  Native American recovery movements viewed addictions as a result of cultural conflict between Native and Western cultures, seeing substances as weapons that have caused further loss of traditions  To best treat this population embrace a broader view that explores the spiritual, cultural, and social ramifications of substance abuse  Talking about how current behaviors interfere with their spirituality may help increase client’s motivation to make positive changes AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 17
  18. 18. Differences in Mental Health Approaches ANAI  Focus on health and positive words  Counseling ability may be an inborn gift, developed in dreams and visions and through apprenticeship  Egalitarian view that all people have challenges. Transference is uncommon  Oversight by the community  Humor  Healing accomplished through insight, interpretation, plant medicine, prayer, ceremony, and transpersonal help from spiritual powers Western Methods  Focus on diagnosis and disease  Counseling ability taught through internship and academics  Heirarchical view. Transference common.  Oversight by licensing boards  Interventions have a serious tone  Healing accomplished through insight, interpretation, and/or medication AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 18
  19. 19. Differences in Mental Health Approaches ANAI  Therapy practiced ion nature or a sanctified place  1-4 sessions on successive days  Advertising is unethical  Selfless generosity of healer and patient promotes healing and outcome  Sessions have no fixed length  Massage and laying of hands may be part of treatment  Focus on returning to a state of confidence, balance, beauty, well- being, and harmonious family and community relations Western  Therapy practiced in an office  Treatment is prolonged  Advertising is a key to success  Fixed fee for services  Fixed length sessions  No touching  Focus on coping with, managing, or curing mental disease AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 19
  20. 20. Beliefs About Illness and Healing  Native American medicine is a complete system that addresses both healing and cure.  Health requires balance in every sphere of one’s life, from the most personal inner world to lifestyle and social connections.  Disease is not defined by physical pathology, but viewed from an expanded context that includes body, mind, spirit, emotions, social group, and lifestyle.  Native American medicine works by returning the individual to a state of balance both within himself and in relationship to the outer world.  Native medicine places the roots of any imbalance in the world of spirit. Spiritual interventions are thus seen as critical to the success of any treatment plan. AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 20
  21. 21. Beliefs About Illness and Healing  This holistic approach seeks to create a change not only in pathology, but also in:  The patient’s understanding  Attitude towards healthier self-concept  Appreciation of the world around him.  Such growth supports the patient in necessary behavior modifications.  The healer’s intention is that the person be not simply cured of a disease, but transformed through the experience of disease.  Someone in need of healing looks for a practitioner who has been successful in similar situations.  The healing elder is the culture’s primary access to healing power. In a system without technology and standardized practice, the responsibility for treatment failure falls squarely on the practitioner AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 21
  22. 22. Examples of Opening Ceremonies  Although indigenous people differ greatly from one another, these examples of ceremonies emphasize similarities in creating a safe space where everyone feels respected and honored.  It was suggested that if we provided a prayer, song and ceremony for MI, that Native people might have an easier time deciding whether to adopt it. (Example is provided in the MI Guideline)  Pueblo Example Opening Ceremony  The “ceremony” is an attempt to bring sacredness to the healing process when initially meeting with your clients, acknowledging that we are entering a special space. As we enter this space we leave all of our bad feelings and anger on the outside. We enter this space, where we will be interacting, with a clear mind and heart. We say our prayers asking our ancestors for their wisdom and help so that we may have a successful gathering. We ask the Ancient Ones to bring good energy, healing energy, into our space and our time together. We put our thoughts and healing feelings together and become one. ~Based on Nadine Tafoya’s experience AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 22
  23. 23. Examples of Opening Ceremonies cont…  Maori (Aboriginals of New Zealand)  When Maori people invite outsiders (even other Maori communities) into their Marai (special building for spiritual and community activities), they use a ceremony that reminds everyone that we are all one, that everyone is safe within the Marai, and that we all have the same goals.  Each group introduces themselves and lets the other know that they come in peace. There is a specific process of talking back and forth and singing. Near the end of this welcoming ceremony, each person from each group greets the other. The men touch noses, thereby breathing the same air and signifying that they are one. The women usually kiss the cheek. Then everyone goes to have tea and eat together. ~Based on Kamilla Venner’s experience AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 23
  24. 24. Examples of Opening Ceremonies cont…  Northwest Canadian Tribe (De Cho)  Everyone is asked to stand up and form a circle. The leader addresses the people and emphasizes the importance of greeting and honoring each other and acknowledging that we are all one in the world. The circle evolves into two circles that are connected. The person in the inner circle is the introducer while those in the outer circle listen. After you introduce yourself, you move into the outer circle. The first person begins to show the others what to do while music plays (in this case, a CD playing the song, “O Siem”, translated “We are all family”, by Susan Aglukark, an Inuit woman). AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 24
  25. 25. Adaptations Example AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 25
  26. 26. Culture Bound Syndromes  Most “culture-bound” syndromes associated w/ Native Americans eliminated from DSM V  Ghost Sickness (Navajo)  People that are preoccupied and possessed by the deceased are considered to have Ghost Sickness. Its symptoms include general weakness, loss of appetite, feeling suffocated, having recurring nightmares, and an everlasting feeling of terror. It is believed that if the deceased did not get proper burial rights, their spirit would be doomed to remain on the living plane, staying to torture the living.  Windigo Psychosis  “The Windigo is a figure in Northern Algonquin mythology, a fierce supernatural cannibal able to infect humans and make them into cannibalistic creatures by turning their hearts into ice. Windigo Psychosis occurs when a person becomes filled with anxiety that they are becoming a Windigo, and may increasingly view those around them as edible. The person also complains of poor appetite, nausea and vomiting, and may become suicidal or homicidal.” 26
  27. 27. Culture Bound Syndromes  Heartbreak Syndrome  Pibloktoq (arctic hysteria)  Soul loss  iich’ aa (moth madness (Navajo))  “Frenzy” witchcraft (Navajo)  Fatigue from thinking too much  From Thomason, T. (2014). “Issues in the Diagnosis of Native American Culture Bound Syndromes. Arizona Counseling Journal AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 27
  28. 28. Barriers to Treatment  American Indian women listed mistrust as one of the primary barriers for seeking treatment. This is due, in part, to the women's belief that they would encounter people they knew among treatment agency staff; they also doubted the confidentiality of the treatment program.  Many Native Americans believe that recovery cannot happen for individuals alone and that their entire community has become sick.  Coyhis calls this the “healing forest” model: one cannot take a sick tree from a sick forest, heal it, and put it back in the same environment expecting that it will thrive. Instead, the community must embrace recovery.  Access. IHS is only on reservations, where about 20% of the AI/NA live.  Lack of AI/NA/AN as service providers  Culturally insensitive practices AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 28
  29. 29. Approaches  Community approaches often lead to:  A reduction of substance use.  Breaking intergenerational cycles of alcohol abuse.  Increased community support.  The strengthening of individual and group cultural identity.  Leadership development.  Increased interpersonal and inter-Tribal problem-solving skills and solidarity.  Native American cultural groups generally believe that health is nurtured through balance and living in harmony with nature and the community  They also, for the most part, have a holistic view of health that incorporates physical, emotional, and spiritual elements, individual and community healing, and prevention and treatment activities AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 29
  30. 30. Approaches  Culture is the path to prevention and treatment.  Culturally responsive treatment should involve community events, group activities, and the ability to participate in ceremonies to help clients achieve balance and find new insight  Recommend Motivational Interviewing, CBT and social learning approaches for Native American clients, which have  Less cultural bias  Focus on problem-solving and skill development  Emphasize client strengths and empowerment  Recognize the need to accept personal responsibility for change  Make use of learning styles that many native americans find culturally appropriate AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 30
  31. 31. Approaches  many traditional healing activities and ceremonies have been made accessible during treatment or effectively integrated into treatment settings  See The Book of Ceremonies: a Native Way of Honoring and Living the Sacred for some techniques  These practices include  Sacred dances  The four circles (a model for conceptualizing a harmonious life)  Navajo: Hozhq encompasses the notions of connectedness, reciprocity, balance, and completeness that underpin contextually oriented views of health and well-being  The talking circle  Medicine Wheel (See Dancing with the Wheel: a Medicine Wheel Workbook ) AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 31
  32. 32. Approaches  Practices cont…  Sweat lodges  the sweat is intended as a religious ceremony – it is for prayer and healing, and the ceremony is only to be led by elders with many years of training who know the associated language, songs, traditions, and safety protocols.  The ceremony can be dangerous if performed improperly.  Sweat lodges have also been used by some non-natives resulting in responses from Indigenous Elders declaring that it is dangerous and disrespectful  Indigenous cultures of Mexico and Central America have similar practices  Other purification practices AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 32
  33. 33. Approaches: Family Therapy  Family Therapy: American Indians place high value on family and extended family networks; restoring or healing family bonds can be therapeutic  The Native American concept of family can include elders, others from the same clan, or individuals who are not biologically related. In many Tribes, all members are considered relatives.  Family therapy models such as network therapy, which makes use of support structures outside the immediate family and which were originally developed for Native American families living in urban communities, can be particularly effective with Native clients AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 33
  34. 34. Approaches: Group Therapy  Many Native American Tribes have traditional healing practices that involve groups and healing needs to occur within the context of the group or community (e.g., in talking circles).  Thus, if properly adapted to incorporate NA traditions, group therapy can be very beneficial and culturally congruent.  The talking circle is a Native tradition easily adapted for behavioral health treatment. In this tradition, the members of the group sit in a circle. An eagle feather, stone, or other symbolic item is passed around, and each person speaks when he or she is handed the item.  Earn support or permission from Tribal authorities before organizing group therapy, and consult with Native professionals.  If group members consent, invite respected Tribal members (e.g., traditional healers or elders) to participate in sessions. AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 34
  35. 35. Mutual Help and Support  More Alaska Natives in recovery reported participation in 12-Step groups than in substance abuse treatment.  84 percent of respondents had attended some mutual-help meetings. AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 35
  36. 36. Mutual Help and Support  The Lakota Tribe has adapted the 12 Steps 1. I admit that because of my dependence on alcohol, I have been unable to care for myself and my family. 2. I believe that the Great Spirit can help me to regain my responsibilities and model the life of my forefathers (ancestors). 3. I rely totally on the ability of the Great Spirit to watch over me. 4. I strive every day to get to know myself and my position within the nature of things. 5. I admit to the Great Spirit and to my Indian brothers and sisters the weaknesses of my life. 6. I am willing to let the Great Spirit help me correct my weaknesses. AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 36  Traditional 12 Steps 1. We admitted we were powerless over alcohol—that our lives had become unmanageable. 2. Came to believe that a Power greater than ourselves could restore us to sanity. 3. Made a decision to turn our will and our lives over to the care of God as we understood Him. 4. Made a searching and fearless moral inventory of ourselves. 5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs. 6. Were entirely ready to have God remove all these defects of character.
  37. 37. Mutual Help and Support  The Lakota Tribe has adapted the 12 Steps 7. I pray daily to the Great Spirit to help me correct my weaknesses. 8. I make an effort to remember all those that I have caused harm to and, with the help of the Great Spirit, achieve the strength to try to make amends. 9. I do make amends to all those Indian brothers and sisters that I have caused harm to whenever possible through the guidance of the Great Spirit. 10. I do admit when I have done wrong to myself, those around me, and the Great Spirit. 11. I seek through purification, prayer, and meditation to communicate with the Great Spirit as a child to a father in the Indian way. 12. Having addressed those steps, I carry this brotherhood and steps to sobriety to all my Indian brothers and sisters with alcohol problems and together we share all these principles in all our daily lives. AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 37  Traditional 12 Steps 7. Humbly asked Him to remove our shortcomings. 8. Made a list of all persons we had harmed, and became willing to make amends to them all. 9. Made direct amends to such people wherever possible, except when to do so would injure them or others. 10. Continued to take personal inventory, and when we were wrong, promptly admitted it. 11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out. 12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.
  38. 38. Advice to Counselors  Avoid interrupting, extensive note-taking or excessive questioning  Refrain from asking about family or personal matters unrelated to the presenting issue without first asking the client's permission to inquire about these areas.  Pay attention to the client's stories, experiences, dreams, and rituals and their relevance to the client.  Remember that Native Americans are often visual learners, so provide handouts and visual explanations  Accept extended periods of silence during sessions.  Allow time during sessions for the client to process information.  Greet the client with a gentle (rather than firm) handshake and show hospitality (e.g., by offering food and/or beverages). AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 38
  39. 39. Advice to Counselors  Give the client ample time to adjust to the setting at the beginning of each session.  Keep promises.  Offer suggestions instead of directions (preferably more than one to allow for client choice)  If you are not Native or are from a different tribe, you might invite your client to share what it is like for him or her to be working with you as their counselor.  Cultural differences in the expression and reporting of distress are well established among American Indians and Alaska Natives. These often compromise the ability of assessment tools to capture the key signs and symptoms of mental illness. Words such as "depressed" and "anxious" are absent from some American Indian and Alaska Native languages ( Cultural Formulation Interview DSM V) AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 39
  40. 40. LEARN at Intake  Listen to each client from his or her cultural perspective, including perception of the problem and treatment preferences  Explain the overall purpose of the interview and intake process.  Acknowledge client concerns and discuss the probable differences between you and your clients. Take time to understand each client's explanatory model of illness and health.  Recommend a course of action through collaboration with the client including how much involvement he or she has in the planning process  Negotiate a treatment plan that weaves the client's cultural norms and lifeways into treatment goals, objectives, and steps. AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 40
  41. 41. RESPECT Clients  Respect—Understand and reflect how respect is shown within given cultural groups through verbal and nonverbal communications.  Explanatory model—Devote to understanding how clients perceive their presenting problems issues, their origin, impact and treatment  Sociocultural context—Recognize how class, race, ethnicity, gender, education, socioeconomic status etc. affect care.  Power—Acknowledge the power differential between clients and counselors.  Empathy—Express, verbally and nonverbally, the significance of each client's concerns so that he or she feels understood by the counselor.  Concerns and fears—Elicit clients' concerns and apprehensions regarding help-seeking behavior and initiation of treatment.  Therapeutic alliance/Trust—Commit to behaviors that enhance the therapeutic relationship; recognize that trust is not inherent but must be earned by counselors. • Check-in • Walking to office • Intake process A client or consumer is a person who chooses to use your services/businessAllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 41
  42. 42. Summary  Clinicians have to consider the impact of their “Clinical Worldview” as well as their personal worldview on treatment  The culturally aware counselor will reflect on the impact of everything from the décor in the lobby to clinic procedures and treatment selection have on the client and make every effort to respect and empower the client to achieve wellness as he or she defines it.  It is important to consider the client’s worldview when developing the case formulation  Mapping the client’s cultural views and influences can help clinicians (and clients) develop insights into current struggles and clarify culturally relevant goals AllCEUs Counselor Education $59 Unlimited CEUs | $89 Specialty Certificates 42