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Cultural Competence In Clinical Practice


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Cultural Competence In Clinical Practice

  1. 1. CULTURAL DIVERSITY Presented by Lindsay Hutchins, LCSW
  2. 2. Culture <ul><li>A mix of values, norms, beliefs, religions, historical experiences, language that are manifested in experience, art, dress, style of worship, rites of passage and humor. </li></ul>
  3. 3. Incongruencies <ul><li>More clinical permission is given to speak of incest than the racial caste system. </li></ul><ul><li>If treatment is the place to deal with emotional pain, then the cultural pain associated with being a minority in this country is essential to providing ethical care. </li></ul>
  4. 4. In fact it is unethical not to deal with that pain. Peter Bell <ul><li>Cultural boundaries </li></ul><ul><ul><li>Use of chemicals: no impact on values and goals </li></ul></ul><ul><ul><li>Abuse: interferes with values and goals </li></ul></ul><ul><ul><li>Dependence: repeatedly interferes with values and goals </li></ul></ul>
  5. 5. Introduction Why this matters?
  6. 6. We bring ourselves to the work <ul><li>WASP, East Coast raised and educated, middle-child--perceived as different from siblings (dark haired and extroverted) woman’s education, sober 21 years in Alcoholic’s Anonymous, feminist, member of Al Anon, sister, daughter, aunt, step-mother, child of two parents with mental illness--father treated later in life. Restaurateur; entrepreneur; widow; divorcee. </li></ul>
  7. 7. Integration Work <ul><li>Psychotherapy </li></ul><ul><li>AA </li></ul><ul><li>Al Anon </li></ul><ul><li>Clinical Consultation </li></ul><ul><li>Continuing Education </li></ul><ul><li>Participation in White Ally organizations </li></ul>
  8. 8. “You don’t have to be a pig to work with pigs.” Morgan Yamanaka, MSW <ul><li>Use of self </li></ul><ul><li>Appropriate self-disclosure </li></ul><ul><li>Collaboration </li></ul><ul><li>Working with the client in the present moment </li></ul>
  9. 9. Erikson was the first psychoanalyst to articulate the interaction between the person and the environment and to consider the influence of cuture and society on identity formation. <ul><li>He sensed his difference and this sense of not belonging. Maintained his outsider staus within the psychoanalytic community. </li></ul>
  10. 10. Why is cultural competency so important and so challenging to us as service providers? <ul><li>“ ISM” always presents with rationalization, minimization, denial, shame, anger, perfectionism (both “walking on eggshells” along with the illusion that if I’m perfect than I will be protected from pain, projection, externalization, blame </li></ul>
  11. 11. We are so afraid of talking about differences <ul><li>Since those very differences may be used as excuses--service providers have obliterated the differences. </li></ul><ul><li>And, we have more similarities than differences </li></ul><ul><li>We must not deny these differences, by doing so, allowing a client to use them as a shield (preventing penetration of whatever we are assisting them with. </li></ul><ul><li>Whatever is unacknowledged cannot be transformed. </li></ul>
  12. 12. Self-disclosure <ul><li>Why doesn’t it work for a white clinician to identify with the “ism” of sexism when a person of color is speaking of their experience with racism? </li></ul><ul><ul><li>My wanting to move them through this. </li></ul></ul><ul><ul><li>My discomfort and cultural shame as a woman of white privilege </li></ul></ul><ul><ul><ul><li>What else? </li></ul></ul></ul>
  13. 13. Counter-transference and this work <ul><li>All the feelings the client may feel when there is a perception of judgment or other empathic failure, the clinician will need to also work through and negotiate all those feelings: shame, denial, rationalization, minimization, projection; externalizing the problem etc. Prepare to be uncomfortable. </li></ul>
  14. 14. Our training shows us what to look for. <ul><li>Am I willing to continue my training as I work with various populations? </li></ul><ul><li>Do I have a strong enough therapeutic alliance to allow for this? To in fact, encourage this? </li></ul>
  15. 15. 10 Effective Traits for a Counselor to Develop <ul><li>Becoming Naturally Therapeutic by Jacqueline Small </li></ul><ul><li>Empathy </li></ul><ul><li>Genuineness </li></ul><ul><li>Respect </li></ul><ul><li>Self-Disclosure </li></ul><ul><li>Warmth </li></ul>
  16. 16. Tools for Effectiveness continued <ul><li>Immediacy </li></ul><ul><li>Concreteness </li></ul><ul><li>Confrontation </li></ul><ul><li>Potency </li></ul><ul><li>Self Actualization </li></ul>
  17. 17. Ethnicity should only be used as a tool for self-definition, not as a weapon for exclusion. Cecil Williams
  18. 18. Roland Williams says of the need for Culturally Specific Treatment <ul><li>Mental Illness & Chemical Dependency are Equal Opportunity Problems </li></ul><ul><li>Great diversity within various “cultural minorities” Use of themes. </li></ul><ul><li>A minority culture is always defined in relationship to the majority culture. </li></ul><ul><ul><li>Not helpful to minimize or deny that there are special issues that block initial entry into accessing services/recovery and that often lead to dropping out of recovery and relapsing (CD and MH) </li></ul></ul>
  19. 19. Imprisonment Rates in the US (1994) <ul><ul><li>Total Population: .37% </li></ul></ul><ul><ul><li>European Americans: .18% </li></ul></ul><ul><ul><li>Latino Americans: .69 (3.9 times higher than EA) </li></ul></ul><ul><ul><li>African Americans: 1.49% (8.5 times higher than EA) </li></ul></ul>
  20. 20. African Americans Account for <ul><li>12.5% of the US population </li></ul><ul><li>35% of arrests for drug possession </li></ul><ul><li>55% of convictions of drug-related charges </li></ul><ul><li>74% prison sentence </li></ul><ul><li>48% of the US prison populations </li></ul>
  21. 21. 1 out of every 4 black men will go to prison in their lifetime <ul><li>1992 more black men in prison (583,000) than in college (537,000) </li></ul><ul><li>In this context we can see that addicted African Americans have special problems that are not shared by the majority culture. </li></ul><ul><ul><li>Risk of long-term incarceration for possession, use and sale of small volume of illicit drugs. </li></ul></ul><ul><ul><li>Racist impact of crack cocaine laws disproportionately punish African Americans </li></ul></ul>
  22. 22. Race, Cocaine and Criminal justice <ul><li>1991: 52% of those reporting crack use were White </li></ul><ul><li>1992: 92.6% of those arrested for crack at the federal level were Black </li></ul><ul><li>1993: 88% of those convicted for federal crack distribution convictions were Black, 4.1% were White </li></ul>
  23. 23. Race, Cocaine and Criminal Justice <ul><li>5 grams of crack cocaine=5 yrs prison </li></ul><ul><li>500 grams of powder cocaine=5 yrs prison </li></ul>
  24. 24. War on Drugs and it’s disproportionate effect on communities of color <ul><li>According to the Department of Justice, from 1985 to 1995, 85% of the increase in the federal prison population was due to drug convictions. </li></ul>
  25. 25. Legacy of Tuskegee Study <ul><li>Lack of trust by dominant culture institutions </li></ul><ul><li>Although African Americans have a lower per capita consumption, they come with much higher levels of medical problems </li></ul>
  26. 26. African Americans <ul><li>Diagnose and intervene earlier </li></ul><ul><ul><li>Higher tolerance of emotional pain </li></ul></ul><ul><ul><li>Allows African Americans to survive in the face of brutalizing pain </li></ul></ul><ul><ul><li>Disproportionately to Whites, African Americans usually only see people who fail in treatment since many are encouraged to not return to the community </li></ul></ul>
  27. 27. African Americans in Treatment Hazeldon pamphlet 1990 <ul><li>“ As you enter a treatment facility for chemical dependency (or mental health) you will probably feel guilty and ashamed of the things you have done to yourself and others as a result of being addicted to either alcohol or other drugs, or both. These are the same feelings most addicted patients have. However as an African-American, you will also have to deal with a double-consciousness -- a sense of always looking at yourself through the eyes of others and trying to measure up to standards set by them. </li></ul>
  28. 28. Fears present accessing services <ul><li>Being misunderstood </li></ul><ul><li>White staff represents a system that cannot be trusted? </li></ul><ul><li>Fearful because you may be ashamed of being black(a woman, Latino, gay (M/F), Jewish, German, middle-eastern, poor, rich, transgender, person with disabilities, etc.) </li></ul>
  29. 29. White professionals must be educated by you about your needs if your are going to work together to get your needs met! <ul><li>Are you willing to do this? </li></ul><ul><li>Requires reciprocal honesty. </li></ul>
  30. 30. Looking for similarities while acknowledging differences <ul><li>We all hurt the people who love us the most. </li></ul><ul><li>We all did terrible things while using chemicals. </li></ul><ul><li>We all experienced a loss of control. </li></ul><ul><li>We all need some form of help from others. </li></ul><ul><li>We all desire to get help in recovery. </li></ul><ul><li>We all are no better than anyone else. </li></ul>
  31. 31. Maya Angelou: <ul><li>For centuries we had proved their faces, the angles of their bodies, the sounds of their voices and even their odors. Often our survival had depended upon the accurate reading of a white man’s chuckle or the disdainful wave of a white woman’s hand….Oh, but we knew them with the intimacy of a surgeon’s scalpel. </li></ul><ul><ul><li>The Heart of a Woman </li></ul></ul>
  32. 32. Tactical Vulnerability as Group Facilitator <ul><li>Special time going over our group guideline re: no racist, sexist, homophobia or ageist statements. </li></ul><ul><ul><li>“ It is my belief that we live in a culture where threads of these beliefs are woven into our cultural consciousness, and many of us are unaware that what we are saying is racist or sexist. If I hear something that registers in this way, I will ask you to re-state it in another fashion. </li></ul></ul>
  33. 33. If you notice something that I don’t, please bring it to my attention and I’ll have your back. <ul><li>This implicitly informs the group that I too live in the culture--and I’m willing to take a stand for the safety and self-expression of everyone in the group. </li></ul>
  34. 34. Culturally specific groups <ul><li>Many who are not clearly part of the dominant culture see treatment milieu’s as hostile environments </li></ul><ul><li>Allow people in specific communities to get to know each other. Even though they have different backgrounds and value systems that is a common thread that binds the group. </li></ul><ul><li>The groups are not designed to focus on the “ism” involved but on developing a healthy self-concept among group members, and communicating positive facts about their many important contributions to the world, especially to American society. </li></ul>
  35. 35. Culturally specific groups cont. <ul><li>Reality testing </li></ul><ul><li>Validation </li></ul><ul><li>Develop as role models for their community </li></ul><ul><li>Assistance related to communicating in mixed groups making it more effective and useful </li></ul><ul><li>Not having to deal with issues of other’s cultural shame </li></ul><ul><li>Opportunities to work through internalized “isms” with the group </li></ul>
  36. 36. Rudy L. <ul><li>38 y/o African American; longshoreman; long-term heroin user on methadone; history of domestic violence with his partner. Crack cocaine along with alcohol. </li></ul><ul><li>Importance of salutation and permission </li></ul><ul><li>Taking a stand for his recovery in the face of his attempt to use “racism” to justify his continued use and to silence me. </li></ul>
  37. 37. Christian S. <ul><li>14 y/o West African deaf young man presenting with behavioral problems in a SED setting. </li></ul><ul><ul><li>Use of self: basketball </li></ul></ul><ul><ul><ul><ul><ul><li>Tupac Shakur & Biggy Small </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Drums </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Humour </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Fun </li></ul></ul></ul></ul></ul>
  38. 38. Family work with Christian <ul><li>Mother immigrated from Sierra Leone (sp?) </li></ul><ul><li>Guilty since her son became deaf (meningitis) in her absence while trying to prepare her life to bring her children to this country. </li></ul><ul><li>The need to work collaboratively </li></ul>
  39. 39. Bea and Dorothy <ul><li>62 y/o African American woman moved here to be closer to her sister, unmarried, marginally employed by history, long history of alcohol dependence and multiple health problems; major depression, trauma history with periods of psychosis </li></ul><ul><li>66 y/o African American woman, married, NP, home owner, active in the African American community, CODEPENDENT </li></ul>
  40. 40. Collateral work <ul><li>Bea is six years sober today </li></ul><ul><li>I worked with the two of them for over three years </li></ul><ul><li>Dorothy’s codependency was maintaining her sister’s alcoholism--and effecting her health </li></ul><ul><li>Bea in recovery was able to loosen her dependency needs on Dorothy by joining a church and becoming very active in it. </li></ul>
  41. 41. Elmer F. <ul><li>65 y/o single, African American social worker, polysubstance dependent, sex addiction, codependency </li></ul><ul><li>Use of time in the session--negotiation to 40/10 </li></ul><ul><li>Wondered about SA (sex addiction) after working with patient for close to two years </li></ul><ul><li>Worked with him in private practice for 2 more years around his SA. </li></ul><ul><li>Attempted to get him to start “Playa'holic’s Anonymous” prior to leaving for the South. </li></ul>
  42. 42. Richard L <ul><li>40 something EurAsian male, cannabis dependent, major depressive disorder, recurrent, codependent, r/o Sex Addiction </li></ul><ul><li>“ You obviously don’t know how it is in my culture?” </li></ul><ul><li>Cruise Control by Robert Weiss, MSW, CAS </li></ul>
  43. 43. Richard L <ul><li>Tell me about how it works for you? </li></ul><ul><li>Gay male screening tool. </li></ul><ul><li>How is it working for you? </li></ul><ul><li>Is it giving you the connection/feelings of intimacy that you are looking for? </li></ul><ul><li>Self-identity development for gay men has components of both chemical use as well as sexing. </li></ul>
  44. 44. Patrick Carnes, PhD <ul><li>The experience of oppression generates self-doubt, fear, and shame in the lives of those affected by it. These internal psychological dynamics are at the core of addictive disease and compulsive behavior in general. And they become even more deeply rooted when the focus of oppression is human sexuality. </li></ul>
  45. 45. Carnes on affects of homophobia <ul><li>… sexual oppression is really another form of sexual abuse. In that sense, homophobia is about more than just prejudice. The oppressing culture is actually damaging to a gay man’s emerging sexual self--a natural human process that’s difficult even under the best of circumstances. </li></ul>
  46. 46. Not a surprise… <ul><li>As science helps us to understand the nature of addiction, it becomes increasingly apparent that obth heterosexist oppression and reactive notions of sexual freedome account for the persistence of sexually addictive behavior among gay people. </li></ul>
  47. 47. Homophobia and Shame by R.Weiss <ul><li>Shame is a core emotion underlying and driving much addictive behavior. </li></ul><ul><li>It is hard to learn to trust and intimacy when you feel you have to hide parts of yourself in order to feel safe and survive. </li></ul>
  48. 48. Specific type of shame…. <ul><li>The fear of discovery and/or rejection for being homosexual--is at the root of internalized homophobia, which influences the later development of self-esteem, self-worth, and the ability to be intimate and genuine with others. </li></ul>
  49. 49. The pressure of growing up feeling different… <ul><li>In an unacceptable way and having to learn to hide that difference is an emotional stressor with which most heterosexual children do not have to contend. This, in part, accounts for the higher levels of multiple addictions and emotional problems that we see among adult gay men. </li></ul>
  50. 50. Children of other minority groups… <ul><li>Often also experience this kind of stress, and its negative influence on adult emotional life, self-esteem, and social relationships is well documented. </li></ul>
  51. 51. Object relations Theory <ul><li>Helps the clinician to understand the powere of the situation in the person. In other words, what is outside often gets inside and shapes the way a person grows, thinks and feels. </li></ul>
  52. 52. Object relations theory <ul><li>… inner loneliness is due to the lack of soothing introjects. Introjects are the result of what one has taken in from others. They are the inner people we all carry within us. Their quality and quantity can vary tremendouly. They can be helpful or harful or absent or any complex combination thereof. </li></ul>
  53. 53. When the “badness” of the other is “taken in”… <ul><li>In an attempt to control and master the situation, in an an attempt not to feel so powerless and to preserve the positive image of the needed other. </li></ul><ul><li>… this helps explain why the victims of abuse (“isms”), crime or brutality often end up by hating themselves. </li></ul>
  54. 54. Object relations theory <ul><li>How can we provide a “good-enough” holding environment as Winnicott stated was imperative for growth and development to proceed well. </li></ul><ul><ul><li>Loosely put, the capacity to create a space/connection where there is a level of safety, and protection from dangers without and protected as well from the danger of emotions within. Taken in perspective, it can help the clinician to appreciate the kind of closeness and attachment that needs to occur at least some ot the time in treatment. </li></ul></ul>
  55. 55. Object relations theory… <ul><li>Winnicott believed that attachment needed to be flexible and genuine enough to nurture what he called the “True Self,” which is at the core of the personality. </li></ul>
  56. 56. The “True Self”… <ul><li>Is the repository of individuality, uniqueness, difference. In relationships characterized by genuine attachment, the separate individuality of both person is seen, respected and encouraged to flourish. The highly individuated True Self will not emerge when the environment fails to be genuinely attuned to the person’s uniqueness. </li></ul>
  57. 57. False self as accomodation <ul><li>What happens instead is that the child may develop a False Self, one that seeks to suppress individuality and molds itself to the needs of others. </li></ul><ul><li>“isms” fertile ground for codependency or loss of crucial self-identity development </li></ul>
  58. 58. This False Self, <ul><li>Trying so hard to be responsive and to take care of others, ultimately becomes overly compliant. Uniqueness, vibrancy, idiosyncrasy, difference are all submerged. In this debilitating, constricting process the energy, the power, the “wildness” of the True Self is lost. </li></ul>
  59. 59. Klein, Fairbairn and Guntrip <ul><li>Speak to the usefulness of understanding the internal world--which is comprised of representations of self and other, representations formed by ideas, memories and experiences with the external world. </li></ul><ul><li>A representation has an enduring existence, and although it begins as a cognitive construction, it ultimately takes on a deep emotional resonance. </li></ul>
  60. 60. The usefulness of externalizing <ul><li>Cruella exercise and it’s usefulness with CD, depression, anxiety, ED’s, addressing painful experiences due to racism, sexism, homophobia, etc. that are internalized in order to “take the edge off” </li></ul><ul><ul><li>How potent the positive and negative internalizations of others can be, how they can rule the internal world and how they can change through new object experiences and the growth of consciousness. </li></ul></ul>
  61. 61. The belief system offered by object relations theorists… <ul><li>Connection is highly valued, whereas absolute independence is seen as unhealthy and psychologically sound. Mature dependence is considered to be the ideal. Having achieved mature dependence a person could survive for a while without dependence on others, but would not actually want to. </li></ul>
  62. 62. Issues/Info Gay-Identified Men at CDRP feel you should know about their sexuality and/or their chemical dependency compiled by R. Bulger, CADC <ul><li>Growing up Gay is traumatic </li></ul><ul><li>Don’t assume all Gay men are sexually promiscuous </li></ul><ul><li>Drug use in the Gay community is seen as OK -- normalized </li></ul><ul><li>Methamphetamine and Sex addiction are often intertwined </li></ul>
  63. 63. What gay men want you to know continued <ul><li>Not all Gay men are meth addicts </li></ul><ul><li>You need to know the lingo of the community </li></ul><ul><li>Sex act-wise, there’s no difference between what two men do and what a heterosexual couple do </li></ul><ul><li>The culture is identified by it’s music </li></ul>
  64. 64. More of what gay men want you to know… <ul><li>The existence of internalized homphobia and denial </li></ul><ul><li>Drug and alcohol use is used to deal with shame about sex and sexuality </li></ul><ul><li>There is a different set of rules and norms in the Gay community </li></ul><ul><li>Not all Gay men know each other </li></ul><ul><li>The popular drugs and their effects: poppers, meth, GHB, XTC, Viagra, testosterone and other sexual performance enhancers </li></ul>
  65. 65. And more….. <ul><li>Gay men come in all shapes and sizes </li></ul><ul><li>Prejudice still exists </li></ul><ul><li>Understand the bar culture -- go to the Castro </li></ul><ul><li>Myth regarding Gay men </li></ul>
  66. 66. Cultural competence with poverty
  67. 67. In closing…. <ul><ul><li>On strength I bring to this work </li></ul></ul><ul><ul><li>One thing I am going to take away from this training, and one thing I will leave behind </li></ul></ul><ul><ul><li>One thing I do to take care of myself in this work </li></ul></ul><ul><ul><li>Thank you for being such powerful change agents in the lives of the people that you will serve. I appreciate it so much. </li></ul></ul>