Primary Assessments Used in Counseling Settings Hays Review Question

Zhang Min, a 25-year-old start-generation Chinese woman, was referred to a counselor by her chief care physician because she reported having episodes of depression. The counselor who conducted the intake interview had received training in cultural competence and was mindful of cultural factors in evaluating Zhang Min. The referral noted that Zhang Min was born in Hong Kong, and then the therapist expected her to be hesitant to discuss her bug, given the prejudices attached to mental illness and substance corruption in Chinese civilization. During the evaluation, however, the therapist was surprised to detect that Zhang Min was quite forthcoming. She mentioned missing of import deadlines at work and calling in sick at least one time a week, and she noted that her coworkers had expressed concern after finding a bottle of wine in her desk. She admitted that she had been drinking heavily, which she linked to work stress and contempo discord with her Irish American spouse.

Further inquiry revealed that Zhang Min's parents, both Chinese, went to schoolhouse in England and sent her to a British schoolhouse in Hong Kong. She grew upwards shut to the British expatriate community, and her mother was a nurse with the British Army. Zhang Min came to the U.s. at the historic period of 8 and grew up in an Irish gaelic American neighborhood. She stated that she knew more than about Irish culture than about Chinese culture. She felt, with the exception of her physical features, that she was more than Irish than Chinese—a view accustomed by many of her Irish gaelic American friends. Most men she had dated were Irish Americans, and she socialized in groups in which booze consumption was non only accustomed merely expected.

Zhang Min kickoff started to drink in loftier schoolhouse with her friends. The counselor realized that what she had learned about Asian Americans was not necessarily applicable to Zhang Min and that knowledge of Zhang Min's unabridged history was necessary to capeesh the influence of civilisation in her life. The counselor thus adult treatment strategies more than suitable to Zhang Min'southward background.

Graphic: 3-D drawing of a cube, segmented. Along the Z axis is labeled

Multidimensional Model for Developing Cultural Competence: Clinical/Program Level

Zhang Min's case demonstrates why thorough evaluation, including assessment of the client'south sociocultural groundwork, is essential for treatment planning. To provide culturally responsive evaluation and treatment planning, counselors and programs must sympathise and incorporate relevant cultural factors into the process while avoiding a stereotypical or "i-size-fits-all" approach to treatment. Cultural responsiveness in planning and evaluation entails being open minded, asking the right questions, selecting appropriate screening and cess instruments, and choosing effective treatment providers and modalities for each client. Moreover, it involves identifying culturally relevant concerns and problems that should be addressed to improve the client's recovery process.

This chapter offers clinical staff guidance in providing and facilitating culturally responsive interviews, assessments, evaluations, and treatment planning. Using Sue'due south (2001) multidimensional model for developing cultural competence, this chapter focuses on clinical and programmatic decisions and skills that are important in evaluation and treatment planning processes. The chapter is organized around nine steps to exist incorporated past clinicians, supported in clinical supervision, and endorsed by administrators.

Step 1. Appoint Clients

Once clients are in contact with a treatment program, they stand on the far side of a withal-to-be-established therapeutic relationship. It is up to counselors and other staff members to bridge the gap. Handshakes, facial expressions, greetings, and small talk are uncomplicated gestures that institute a offset impression and begin building the therapeutic relationship. Involving ane'due south whole beingness in a greeting—thought, body, attitude, and spirit—is well-nigh engaging.

Fifty percent of racially and ethnically various clients terminate treatment or counseling afterward one visit with a mental health practitioner (Sue and Sue 2013e). At the outset of handling, clients can feel scared, vulnerable, and uncertain nearly whether treatment will really help. The initial meeting is often the outset encounter clients accept with the treatment system, so it is vital that they go out feeling hopeful and understood. Paniagua (1998) describes how, if a counselor lacks sensitivity and jumps to premature conclusions, the first visit can go the last:

Pretend that you are a Puerto Rican taxi driver in New York City, and at iii:00 p.m. on a hot summer day you realize that you take your first appointment with the therapist…later, you learned that the therapist fabricated a note that you were probably depressed or psychotic considering you dressed carelessly and had muddy nails and easily…would you return for a second date? (p. 120)

To engage the client, the advisor should try to establish rapport before launching into a series of questions. Paniagua (1998) suggests that counselors should draw attention to the presenting problem "without giving the impression that too much information is needed to empathize the problem" (p. 18). It is likewise of import that the client feel engaged with any interpreter used in the intake process. A mutual framework used in many healthcare grooming programs to highlight culturally responsive interview behaviors is the Larn model (Berlin and Fowkes 1983). The how-to box on the next page presents this model.

Improving Cantankerous-Cultural Communication

Health disparities have multiple causes. One specific influence is cross-cultural communication between the counselor and the customer. Weiss (2007) recommends these six steps to improve communication with clients:

Boring downwards.
Use plain, nonpsychiatric language.
Show or draw pictures.
Limit the amount of information provided at one fourth dimension.
Use the "teach-back" method. Inquire the client, in a nonthreatening way, to explain or show what he or she has been told.
Create a shame-free environs that encourages questions and participation.

Footstep ii. Familiarize Clients and Their Families With Treatment and Evaluation Processes

Behavioral wellness treatment facilities maintain their own civilization (i.e., the handling milieu). Counselors, clinical supervisors, and agency administrators can easily become accepted to this culture and presume that clients are used to information technology every bit well. Even so, clients are typically new to handling language or jargon, program expectations and schedules, and the intake and treatment process. Unfortunately, clients from diverse racial and ethnic groups can feel more than estranged and disconnected from treatment services when staff members fail to educate them and their families nigh treatment expectations or when the clients are not walked through the treatment process, starting with the goals of the initial intake and interview. By taking the time to acclimate clients and their families to the treatment process, counselors and other behavioral wellness staff members tackle ane obstacle that could further impede handling date and retention among racially and ethnically diverse clients.

How To Employ the LEARN Mnemonic for Intake Interviews

Fiftyisten to each customer from his or her cultural perspective. Avert interrupting or posing questions earlier the client finishes talking; instead, discover creative ways to redirect dialog (or explicate session limitations if fourth dimension is brusk). Accept time to larn the client's perception of his or her bug, concerns about presenting bug and treatment, and preferences for treatment and healing practices.

Explain the overall purpose of the interview and intake process. Walk through the full general agenda for the initial session and talk over the reasons for asking well-nigh personal information. Remember that the client's needs come earlier the set up calendar for the interview; don't cover every intake question at the expense of taking time (usually brief) to accost questions and concerns expressed by the customer.

Acknowledge customer concerns and discuss the likely differences between you lot and your clients. Take time to understand each client'due south explanatory model of illness and wellness. Recognize, when appropriate, the client'south healing beliefs and practices and explore ways to comprise these into the treatment plan.

Recommend a course of activeness through collaboration with the client. The client must know the importance of his or her participation in the handling planning process. With client assistance, customer behavior and traditions tin serve every bit a framework for healing in treatment. However, not all clients have the same expectations of handling interest; some see the counselor as the skilful, desire a directive approach, and have piffling want to participate in developing the treatment plan themselves.

Negotiate a treatment programme that weaves the customer's cultural norms and lifeways into treatment goals, objectives, and steps. One time the treatment plan and modality are established and implemented, encourage regular dialog to gain feedback and appraise treatment satisfaction. Respecting the client's culture and encouraging communication throughout the process increases client willing to appoint in treatment and to adhere to the treatment plan and continuing care recommendations.

Sources: Berlin and Fowkes 1983; Dreachslin et al. 2013; Ring 2008.

Step 3. Endorse Collaboration in Interviews, Assessments, and Handling Planning

Almost clients are unfamiliar with the evaluation and treatment planning process and how they tin can participate in it. Some clients may view the initial interview and evaluation every bit intrusive if also much data is requested or if the content is a source of family dishonor or shame. Other clients may resist or distrust the process based on a long history of racism and oppression. Still others feel inhibited from actively participating because they view the counselor every bit the authority or sole expert.

The counselor tin can help decrease the influence of these bug in the interview procedure through a collaborative approach that allows fourth dimension to discuss the expectations of both counselor and client; to explain interview, intake, and treatment planning processes; and to constitute means for the client to seek description of his or her assessment results (Mohatt et al. 2008a). The counselor can encourage collaboration by emphasizing the importance of clients' input and interpretations. Client feedback is integral in interpreting results and tin can identify cultural issues that may affect intake and evaluation (Acevedo-Polakovich et al. 2007). Collaboration should extend to client preferences and desires regarding inclusion of family unit and community members in evaluation and treatment planning.

Footstep 4. Integrate Culturally Relevant Data and Themes

By exploring culturally relevant themes, counselors can more fully sympathise their clients and identify their cultural strengths and challenges. For example, a Korean woman's family may serve every bit a source of support and provide a sense of identity. At the same time, however, her family unit could be ashamed of her co-occurring generalized anxiety and substance use disorders and respond to her handling as a source of further shame because it encourages her to disclose personal matters to people outside the family. The post-obit section provides a brief overview of suggested strength-based topics to contain into the intake and evaluation process.

Advice to Counselors: Asking About Civilization and Acculturation

A thoughtful exploration of cultural and indigenous identity issues will provide clues for determining cultural, racial, and ethnic identity. There are numerous clues that you may derive from your clients' answers, and they cannot all be covered in this TIP; this is simply one set of sample questions (Fontes 2008). Inquire these questions tactfully so they exercise non sound like an interrogation. Try to integrate them naturally into a conversation rather than asking ane after another. Not all questions are relevant in all settings. Counselors can adapt wording to suit clients' cultural contexts and styles of communication, considering the questions listed hither and throughout this chapter are only examples:

Where were y'all born?
Whom do y'all consider family unit?
What was the beginning language you learned?
Which other linguistic communication(s) do you speak?
What linguistic communication or languages are spoken in your dwelling?
What is your organized religion? How observant are y'all in practicing that faith?
What activities do you enjoy when yous are not working?
How do you identify yourself culturally?
What aspects of beingness ________ are most important to you? (Use the aforementioned term for the identified culture as the client.)
How would you draw your home and neighborhood?
Whom do you commonly turn to for aid when facing a trouble?
What are your goals for this interview?

Clearing History

Immigration history can shed light on customer support systems and place possible isolation or alienation. Some immigrants who live in ethnic enclaves have many sources of social support and resources. By contrast, others may be isolated, living apart from family, friends, and the support systems extant in their countries of origin. Culturally competent evaluation should always include questions about the client's country of origin, immigration status, length of time in the United States, and connections to his or her state of origin. Ask American-born clients most their parents' country of origin, the language(south) spoken at home, and affiliation with their parents' culture(south). Questions like these give the advisor important clues about the customer's caste of acculturation in early on life and at present, cultural identity, ties to civilisation of origin, potential cultural conflicts, and resources. Specific questions should elicit information nigh:

Length of fourth dimension in the United States, noting when immigration occurred or the number of generations who have resided in the United states of america.
Frequency of returns and psychological and personal ties to the state of origin.
Primary language and level of English proficiency in speaking and writing.
Psychological reactions to immigration and adjustments made in the process.
Changes in social condition and other areas as a outcome of coming to this country.
Major differences in attitudes toward alcohol and drug apply from the fourth dimension of immigration to now.

Advice to Counselors: Conducting Strength-Based Interviews

By nature, initial interviews and evaluations can overemphasize presenting problems and concerns while underplaying client strengths and supports. This list, although not exhaustive, reminds clinicians to acknowledge client strengths and supports from the showtime.

Strengths and supports

Pride and participation in one'south culture
Social skills, traditions, knowledge, and applied skills specific to the client'due south civilisation
Bilingual or multilingual skills
Traditional, religious, or spiritual practices, behavior, and religion
Generational wisdom
Extended families and nonblood kinships
Ability to maintain cultural heritage and practices
Perseverance in coping with racism and oppression
Culturally specific ways of coping
Community involvement and support

Source: Hays 2008.

Cultural Identity and Acculturation

Equally shown in Zhang Min's case at the outset of this affiliate, cultural identity is a unique characteristic of each client. Counselors should baby-sit against making assumptions almost client identity based on general indigenous and racial identification by evaluating the degree to which an individual identifies with his or her civilization(s) of origin. As Castro and colleagues (1999b) explain, "for each group, the level of inside-group variability can be assessed using a core dimension that ranges from high cultural involvement and acceptance of the traditional civilisation'southward values to low or no cultural involvement" (p. 515). For African Americans, for case, this dimension is called "Afrocentricity." Scales for Afrocentricity take been adult in an endeavour to provide an indicator of an individual's level of involvement within the traditional or core African-oriented culture (Baldwin and Bell 1985; Cokley and Williams 2005; Klonoff and Landrine 2000). Many other instruments based on models of identity evaluate acculturation and identity. A detailed discussion of the theory backside such models is beyond the scope of this Treatment Improvement Protocol (TIP); withal, counselors should have a full general agreement of what is being measured when administering such instruments. The "Asking About Culture and Acculturation" communication box at correct addresses exploration of civilization and acculturation with clients. For more data on instruments that measure out acculturation and/or identity, see Appendix B.

Other areas to explore include the cross-cutting factors outlined in Chapter 1, such as socioeconomic status (SES), occupation, education, gender, and other variables that can distinguish an individual from others who share his or her cultural identity. For instance, a biracial client could identify with African American culture, White American culture, or both. When a client has two or more racial/indigenous identities, counselors should assess how the client cocky-identifies and how he or she negotiates the different worlds.

Membership in a Subculture

Clients oftentimes identify initially with broader racial, indigenous, and cultural groups. Yet, each person has a unique history that warrants an agreement of how culture is expert and has evolved for the person and his or her family; accordingly, counselors should avoid generalizations or assumptions. Clients are often part of a culture within a culture. In that location is not just one Latino, African American, or Native American culture; many variables influence culture and cultural identity (see the "What Are the Cross-Cutting Factors in Race, Ethnicity, and Culture" department in Affiliate 1). For example, an African American customer from East Carroll Parish, LA, might describe his or her culture quite differently than an African American from downtown Hartford, CT.

Behavior About Wellness, Healing, Assist-Seeking, and Substance Use

Just as civilisation shapes an individual's sense of identity, it also shapes attitudes surrounding health practices and substance use. Cultural acceptance of a beliefs, for instance, can mask a problem or deter a person from seeking treatment. Counselors should be aware of how the client's civilisation conceptualizes bug related to health, healing and handling practices, and the use of substances. For instance, in cases where alcohol use is discouraged or frowned upon in the customs, the client can experience tremendous shame about drinking. Chapter 5 reviews health-related beliefs and practices that can affect help-seeking behavior across various populations.

Trauma and Loss

Some immigrant subcultures have experienced violent upheavals and have a higher incidence of trauma than others. The theme of trauma and loss should therefore be incorporated into general intake questions. Specific issues under this general theme might include:

Migration, relocation, and emigration history—which considers separation from homeland, family, and friends—and the stressors and loss of social back up that can accompany these transitions.
Clients' personal or familial experiences with American Indian boarding schools.
Experiences with genocide, persecution, torture, war, and starvation.

Communication to Counselors: Eliciting Client Views on Presenting Issues

Some clients do not come across their presenting concrete, psychological, and/or behavioral difficulties equally problems. Instead, they may view their presenting difficulties as the result of stress or another effect, thus defining or labeling the presenting problem equally something other than a physical or mental disorder. In such cases, word the following questions using the clients' terminology rather than using the word "problem." These questions aid explore how clients view their behavioral health concerns:

I know that clients and counselors sometimes have different ideas near illness and diseases, and so can you lot tell me more about your idea of your problem?
Do you consider your use of booze and/or drugs a trouble?
How do you characterization your problem? Do yous call back information technology is a serious trouble?
What do y'all recall caused your problem?
Why do you lot think information technology started when it did?
What is going on in your torso as a consequence of this problem?
How has this problem affected your life?
What frightens or concerns you virtually about this problem and its treatment?
How is your problem viewed in your family unit? Is information technology adequate?
How is your problem viewed in your community? Is it acceptable? Is information technology considered a disease?
Do yous know others who have had this problem? How did they care for the problem?
How does your trouble touch your stature in the community?
What kinds of treatment do you think will aid or heal you?
How have you treated your drug and/or booze problem or emotional distress?
What has been your experience with treatment programs?

Sources: Lynch and Hanson 2011; Tang and Bigby 1996; Taylor 2002.

How To Use a Multicultural Intake Checklist

Some clients do not meet their presenting concrete, psychological, and/or behavioral difficulties as problems. Instead, they may view their presenting difficulties as the result of stress or another issue, thus defining or labeling the presenting problem as something other than a physical or mental disorder. In such cases, word questions nearly the following topics using the client'southward terminology, rather than using the word "trouble." Asking questions about the post-obit topics can help you explore how a client may view his or her behavioral health concerns:

□: Immigration history
□: Relocations (current migration patterns)
□: Losses associated with clearing and relocation history
□: English linguistic communication fluency
□: Bilingual or multilingual fluency
□: Individualistic/collectivistic orientation
□: Racial, ethnic, and cultural identities
□: Tribal affiliation, if appropriate
□: Geographic location
□: Family and extended family concerns (including nonblood kinships)
□: Acculturation level (e.g., traditional, bicultural)
□: Acculturation stress
□: History of bigotry/racism
□: Trauma history
□: Historical trauma
□: Intergenerational family history and concerns
□: Gender roles and expectations
□: Birth order roles and expectations
□: Relationship and dating concerns
□: Sexual and gender orientation
□: Wellness concerns
□: Traditional healing practices
□: Help-seeking patterns
□: Beliefs about health
□: Beliefs most mental illness and mental wellness handling
□: Beliefs most substance use, abuse, and dependence
□: Beliefs well-nigh substance corruption handling
□: Family views on substance use and substance abuse handling
□: Treatment concerns related to cultural differences
□: Cultural approaches to healing or treatment of substance employ and mental disorders
□: Educational activity history and concerns
□: Piece of work history and concerns
□: SES and fiscal concerns
□: Cultural grouping affiliation
□: Electric current network of back up
□: Community concerns
□: Review of confidentiality parameters and concerns
□: Cultural concepts of distress (DSM-five^*)
□: DSM-5 culturally related 5-codes

Sources: Comas-Diaz 2012; Constantine and Sue 2005; Sussman 2004.

*

Step 5. Gather Culturally Relevant Collateral Information

A client who needs behavioral health treatment services may exist unwilling or unable to provide a full personal history from his or her own perspective and may not recall certain events or exist enlightened of how his or her beliefs affects his or her well-being and that of others. Collateral information—supplemental information obtained with the customer'southward permission from sources other than the client—can exist derived from family members, medical and court records, probation and parole officers, community members, and others. Collateral data should include culturally relevant data obtained from the family, such as the organizational memberships, behavior, and practices that shape the customer'southward cultural identity and understanding of the world.

As families can be a vital source of information, counselors are likely to attain more than support past engaging families earlier in the handling procedure. Although counselor interactions with family members are often limited to a few formal sessions, the families of racially and ethnically diverse clients tend to play a more than significant and influential role in clients' participation in treatment. Consequently, special sensitivity to the cultural background of family unit members providing collateral information is essential. Families, like clients, cannot be easily defined in terms of a generic cultural identity (Congress 2004; Taylor et al. 2012). Fifty-fifty families from the same racial background or ethnic heritage can be quite different, thus requiring a multidimensional approach in agreement the function of civilization in the lives of clients and their families. Using the culturagram tool on the side by side page in preparation for counseling, treatment planning, or clinical supervision, clinicians can larn about the unique attributes and histories that influence clients' lives in a cultural context.

Stride 6. Select Culturally Appropriate Screening and Assessment Tools

Discussions of the complexities of psychological testing, the interpretation of assessment measures, and the ceremoniousness of screening procedures are outside the scope of this TIP. However, counselors and other clinical service providers should be able to use assessment and screening information in culturally competent ways. This section discusses several instruments and their appropriateness for specific cultural groups. Counselors should continue to explore the availability of mental health and substance corruption screening and cess tools that have been translated into or adjusted for other languages.

Culturally Advisable Screening Devices

The consensus panel does not recommend any specific instruments for screening or assessing mental or substance utilise disorders. Rather, when selecting instruments, practitioners should consider their cultural applicability to the customer being served (AACE 2012; Jome and Moody 2002). For instance, a screening instrument that asks the respondent about his or her guilt near drinking could exist ineffective for members of cultural, indigenous, or religious groups that prohibit whatever consumption of alcohol. Al-Ansari and Negrete'south (1990) research supports this point. They found that the Short Michigan Alcoholism Screening Test was highly sensitive with people who use alcohol in a traditional Arab Muslim society; however, one question—"Practise you always feel guilty about your drinking?"—failed to distinguish between people with alcohol dependency disorders in treatment and people who drank in the community. Questions designed to measure out conflict that results from the utilize of alcohol can skew test results for participants from cultures that wait complete abstinence from alcohol and/or drugs. Appendix D summarizes instruments tested on specific populations (eastward.g., availability of normative information for the population beingness served).

Culturally Valid Clinical Scales

As the literature consistently demonstrates, co-occurring mental disorders are common in people who accept substance use disorders. Although an assessment of psychological issues helps lucifer clients to appropriate treatment, clinicians are cautioned to proceed carefully. People who are abusing substances or experiencing withdrawal from substances tin exhibit behaviors and thinking patterns consequent with mental illness. After a catamenia of abstinence, symptoms that mimic mental disease can disappear. Moreover, clinical instruments are imperfect measurements of equally imperfect psychological constructs that were created to organize and understand clinical patterns and thus better treat them; they practice not provide absolute answers. As research and science evolve, so does our understanding of mental disease (Benuto 2012). Cess tools are by and large developed for particular populations and can be inapplicable to diverse populations (Blume et al. 2005; Suzuki and Ponterotto 2008). Appendix D summarizes research on the clinical utility of instruments for screening and assessing co-occurring disorders in various cultural groups.

How To Use a Culturagram for Mapping the Role of Civilisation

The culturagram is an cess tool that helps clinicians understand culturally diverse clients and their families (Congress 1994, 2004; Congress and Kung 2005). Information technology examines 10 areas of inquiry, which should include not but questions specific to clients' life experiences, but as well questions specific to their family histories. This diagram can guide an interview, counseling, or clinical supervision session to elicit culturally relevant multigenerational data unique to the customer and the client's family. Requite a copy of the diagram to the client or family for utilise equally an interactive tool in the session. Throughout the interview, the client, family unit members, and/or the counselor tin can write brief responses in each box to highlight the unique attributes of the client's history in the family context. This diagram has been adapted for clients with co-occurring mental and substance use disorders; sample questions follow.

Values about family unit structure, ability, myths, and rules

Are at that place specific gender roles and expectations in your family?
Who holds the ability within the family?
Are family needs more than of import than, or equally every bit of import every bit, individual needs?
Whom do you lot consider family?

Reasons for relocation or migration

Are you and your family unit able to return home?
What were your reasons for coming to the United States?
How practice y'all now view the initial reasons for relocation?
What feelings do you have virtually relocation or migration?
Do you move back and forth from one location to another?
How often practice y'all and your family return to your homeland?
Are you living apart from your family?

Legal status and SES

Has your SES improved or worsened since coming to this country?
Has at that place been a change in socioeconomic status across generations?
What is the family history of documentation? (Note: Clients oft need to develop trust before discussing legal status; they may come from a place where confidentiality is unfamiliar.)

Time in the customs

How long have you and your family members been in the country? Community?
Are you and your family unit actively involved in a culturally based community?

Languages spoken in and outside the home

What languages are spoken at home and in the customs?
What is your and your family unit's level of proficiency in each language?
How dependent are parents and grandparents on their children for negotiating activities surrounding the utilise of English? Have children become the family interpreters?

Health beliefs and beliefs about help-seeking

What are the family behavior about drug and alcohol use? Mental illness? Handling?
Do you and your family uphold traditional healing practices?
How do help-seeking behaviors differ across generations and genders in your family?
How practice you and your family define illness and wellness?
Are at that place whatever objections to the apply of Western medicine?

Impact of trauma and other crisis events

How has trauma affected your family beyond generations?
How accept traumas or other crises affected yous and/or your family?
Has in that location been a specific family crisis?
Did the family feel traumatic events prior to migration—war, other forms of violence, displacement including refugee camps, or like experiences?

Oppression and discrimination

Is there a history of oppression and bigotry in your homeland?
How have you and your family experienced discrimination since immigration?

Religious and cultural institutions, food, vesture, and holidays

Are there specific religious holidays that your family unit observes?
What holidays practise you gloat?
Are at that place specific foods that are important to you?
Does clothing play a pregnant cultural or religious role for you?
Practice you belong to a cultural or social society or system?

Values about educational activity and work

How much importance exercise you place on piece of work, family, and educational activity?
What are the educational expectations for children within the family unit?
Has your work status inverse (e.g., level of responsibility, prestige, and power) since migration?
Do you or does anyone in your family piece of work several jobs?

Sources: Comas-Diaz 2012; Congress 1994, 2004; Singer 2007.

Diagnosis

Counselors should consider clients' cultural backgrounds when evaluating and assessing mental and substance use disorders (Bhugra and Gupta 2010). Concerns surrounding diagnoses of mental and substance use disorders (and the cross-cultural applicability of those diagnoses) include the ceremoniousness of specific test items or questions, diagnostic criteria, and psychologically oriented concepts (Alarcon 2009; Room 2006). Inquiry into specific techniques that address cultural differences in evaluative and diagnostic processes so far remains limited and underrepresentative of diverse populations (Guindon and Sobhany 2001; Martinez 2009).

Does the DSM-5 accurately diagnose mental and substance utilise disorders among immigrants and other ethnic groups? Caetano and Shafer (1996) found that diagnostic criteria seemed to identify alcohol dependency consistently across race and ethnicity, but their sample was limited to African Americans, Latinos, and Whites. Other research has shown mixed results.

In 1972, the Globe Health Organization (WHO) and the National Institutes of Health (NIH) embarked on a joint study to test the cross-cultural applicability of nomenclature systems for various diagnoses, including substance apply disorders. WHO and NIH identified factors that appeared to exist universal aspects of mental and substance apply disorders and then developed instruments to measure them. These instruments, the Composite International Diagnostic Interview (CIDI) and the Schedules for Clinical Assessment in Neuropsychiatry (Browse), include some DSM and International Statistical Nomenclature of Diseases and Related Health Problems criteria. Studies written report that both the CIDI and SCAN were by and large accurate, just the investigators urge caution in translation and interview procedures (Room et al. 2003).

Advice to Counselors and Clinical Supervisors: Culturally Responsive Screening and Assessment

Assess the client'southward primary linguistic communication and language proficiency prior to the administration of any evaluation or utilize of testing instruments.
Determine whether the assessment materials were translated using specific terms, including idioms that correspond to the client's literacy level, culture, and language. Practise not assume that translation into a stated linguistic communication exactly matches the specific linguistic communication of the client. Specifically, the client may not understand the translated language if it does not match his or her ways of thinking or speaking
Educate the client on the purpose of the assessment and its application to the development of the treatment program. Remember that testing tin generate many emotional reactions.
Know how the examination was developed. Is normative information available for the population existence served? Examination results can be inflated, underestimated, or inaccurate due to differences within the customer's population.
Consider the role of acculturation in testing, including the influence of the client's worldview in responses. Unfamiliarity with mainstream U.s. culture tin can touch on estimation of questions, the client-evaluator relationship, and behavior, including participation level during evaluation and verbal and behavioral responses.

Sources: Association for Cess in Counseling and Education (AACE) 2012; Saldaña 2001.

Overall, psychological concepts that are appropriate for and easily translated by some groups are inappropriate for others. In some Asian cultures, for example, feeling refers more to a concrete than an emotive state; questions designed to infer emotional states are not easily translated. In most cases, these issues can be remedied by using culture-specific resources, measurements, and references while also adopting a cultural formulation in the interviewing process (come across Appendix Eastward for the A PA'due south cultural formulation outline). The DSM-5 lists several cultural concepts of distress (encounter Appendix E), all the same in that location is little empirical literature providing data or handling guidance on using the APA'southward cultural formulation or addressing cultural concepts of distress (Martinez 2009; Mezzich et al. 2009).

Step 7. Determine Readiness and Motivation for Change

Clients enter treatment programs at different levels of readiness for change. Fifty-fifty clients who present voluntarily could accept been pushed into it by external pressures to accept treatment before reaching the action phase. These different readiness levels crave unlike approaches. The strategies involved in motivational interviewing tin help counselors prepare culturally various clients to modify their behavior and go along them engaged in treatment. To sympathise motivational interviewing, it is offset necessary to examine the process of change that is involved in recovery. See TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (Center for Substance Abuse Handling [CSAT] 1999b), for more data on this technique.

Stages of Change

Prochaska and DiClemente's (1984) archetype transtheoretical model of change is applicative to culturally diverse populations. This model divides the change process into several stages:

Precontemplation. The private does non see a need to change. For instance, a person at this stage who abuses substances does not encounter whatever demand to alter use, denies that there is a problem, or blames the trouble on other people or circumstances.
Contemplation. The person becomes enlightened of a problem but is clashing about the course of action. For instance, a person struggling with low recognizes that the depression has affected his or her life and thinks about getting help simply remains ambivalent on how he/she may practice this.
Preparation. The private has adamant that the consequences of his or her behavior are too swell and that change is necessary. Training includes small steps toward making specific changes, such as when a person who is overweight begins reading about wellness and weight direction. The client nonetheless engages in poor health behaviors merely may be altering some behaviors or planning to follow a nutrition.
Action. The private has a specific plan for change and begins to pursue it. In relation to substance abuse, the customer may make an appointment for a drug and booze assessment prior to condign abstemious from booze and drugs.
Maintenance. The person continues to appoint in behaviors that support his or her decision. For example, an individual with bipolar I disorder follows a daily relapse prevention plan that helps him or her assess warning signs of a manic episode and reminds him or her of the importance of engaging in help-seeking behaviors to minimize the severity of an episode.

Progress through the stages is nonlinear, with movement back and forth among the stages at different rates. It is important to recognize that change is not a 1-time process, but rather, a series of trials and errors that eventually translates to successful alter. For example, people who are dependent on substances often effort to abstain several times earlier they are able to learn long-term abstinence.

Motivational Interviewing

Motivational interventions appraise a person's stage of change and utilize techniques likely to move the person forward in the sequence. Miller and Rollnick (2002) adult a therapeutic style chosen motivational interviewing, which is characterized by the strategic therapeutic activities of expressing empathy, developing discrepancy, avoiding statement, rolling with resistance, and supporting self-efficacy. The advisor's major tool is cogitating listening and soliciting change talk (CSAT 1999c).

This nonconfrontational, customer-centered approach to treatment differs significantly from traditional treatments in several means, creating a more welcoming relationship. TIP 35 (CSAT 1999c) assesses Project MATCH and other clinical trials, last that the prove strongly supports the apply of motivational interviewing with a wide variety of cultural and ethnic groups (Miller and Rollnick 2013; Miller et al. 2008). TIP 35 is a good motivational interviewing resource. For specific awarding of motivational interviewing with Native Americans, see Venner and colleagues (2006). For comeback of handling compliance among Latinos with low through motivational interviewing, come across Interian and colleagues (2010).

Step 8. Provide Culturally Responsive Case Management

Clients from various racial, indigenous, and cultural populations seeking behavioral health services may confront additional obstacles that tin can interfere with or forestall admission to treatment and ancillary services, compromise appropriate referrals, impede compliance with handling recommendations, and produce poorer treatment outcomes. Obstacles may include clearing status, lower SES, language barriers, cultural differences, and lack of or poor coverage with health insurance.

Case direction provides a single professional contact through which clients gain access to a range of services. The goal is to help assess the demand for and coordinate social, wellness, and other essential services for each client. Case direction tin can exist an immense help during treatment and recovery for a person with limited English literacy and knowledge of the treatment system. Case management focuses on the needs of individual clients and their families and anticipates how those needs will be affected as handling proceeds. The case manager advocates for the customer (CSAT 1998a; Summers 2012), easing the way to constructive treatment by assisting the client with disquisitional aspects of life (e.g., nutrient, childcare, employment, housing, legal issues). Like counselors, case managers should possess self-knowledge and basic knowledge of other cultures, traits conducive to working well with diverse groups, and the ability to utilize cultural competence in applied ways.

Cultural competence begins with self-knowledge; counselors and instance managers should be aware of and responsive to how their culture shapes attitudes and beliefs. This understanding will augment as they gain noesis and directly experience with the cultural groups of their client population, enabling them to better frame client issues and interact with clients in culturally specific and appropriate ways. TIP 27, Comprehensive Case Management for Substance Corruption Treatment (CSAT 1998a), offers more data on constructive case management.

Showroom 3-1 discusses the cultural matching of counselors with clients. When counselors cannot provide culturally or linguistically competent services, they must know when and how to bring in an interpreter or to seek other help (CSAT 1998a). Case direction includes finding an interpreter who communicates well in the customer's linguistic communication and dialect and who is familiar with the vocabulary required to communicate finer most sensitive subject thing. The case director works inside the system to ensure that the interpreter, when needed, can be compensated. Example managers should also have a list of appropriate referrals to meet assorted needs. For example, an immigrant who does not speak English may need legal services in his or her linguistic communication; an undocumented worker may need to know where to become for medical aid. Culturally competent case managers build and maintain rich referral resources for their clients.

The Case Management Society of America'southward Standards of Practice for Case Management (2010) state that case management is primal in coming together client needs throughout the course of handling. The standards stress understanding relevant cultural information and communicating effectively by respecting and being responsive to clients and their cultural contexts. For standards that are also applicable to case management, refer to the National Clan of Social Workers' Standards on Cultural Competence in Social Piece of work Practice (2001).

Footstep 9. Incorporate Cultural Factors Into Treatment Planning

The cultural adaptation of treatment practices is a burgeoning area of interest, yet inquiry is limited regarding the process and effect of culturally responsive treatment planning in behavioral health handling services for diverse populations. How do counselors and organizations respond culturally to the diverse needs of clients in the handling planning procedure? How effective are culturally adaptive handling goals? (For a review, encounter Bernal and Domenech Rodriguez 2012.) Typically, programs that provide culturally responsive services approach treatment goals holistically, including objectives to better physical health and spiritual strength (Howard 2003). Newer approaches stress implementation of strength-based strategies that fortify cultural heritage, identity, and resiliency.

Treatment planning is a dynamic process that evolves along with an agreement of the clients' histories and treatment needs. Foremost, counselors should be mindful of each customer'southward linguistic requirements and the availability of interpreters (for more detail on interpreters, see Chapter 4). Counselors should be flexible in designing treatment plans to see client needs and, when appropriate, should draw upon the institutions and resources of clients' cultural communities. Culturally responsive handling planning is accomplished through agile listening and should consider client values, beliefs, and expectations. Client health beliefs and handling preferences (eastward.m., purification ceremonies for Native American clients) should be incorporated in addressing specific presenting problems. Some people seek assist for psychological concerns and substance abuse from alternative sources (e.g., clergy, elders, social supports). Others prefer handling programs that use principles and approaches specific to their cultures. Counselors can suggest appropriate traditional handling resources to supplement clinical handling activities.

In sum, clinicians demand to incorporate culture-based goals and objectives into treatment plans and establish and support open up client–counselor dialog to become feedback on the proposed plan'south relevance. Doing so can better client date in treatment services, compliance with treatment planning and recommendations, and handling outcomes.

Grouping Clinical Supervision Instance Report

Beverly is a 34-year-old White American who feels responsible for the tension and dissension in her family. Beverly works in the lab of an obstetrics and gynecology practice. Since early childhood, her younger brother has had problems that have been diagnosed differently by various medical and mental wellness professionals. He takes several medications, including one for attention arrears disorder. Beverly'southward father has been out of work for several months. He is seeing a psychiatrist for low and is on an antidepressant medication. Beverly's female parent feels burdened past family problems and ineffective in dealing with them. Beverly has always helped her parents with their problems, but she now feels bad that she cannot better their situation. She believes that if she were to work harder and be more astute, she could lessen her family's distress. She has had trouble sleeping. In the past, she secretly drank in the evenings to relieve her tension and anxiety.

Most counselors agree that Beverly is too submissive and think assertiveness training volition help her put her needs commencement and move out of the family home. However, a female person Asian American advisor sees Beverly's priorities differently, saying that "a morally responsible daughter is duty-bound to care for her parents." She thinks that the family needs Beverly's assistance, and so it would be selfish to leave them.

Discuss

How does the counselor's worldview affect prioritizing the client's presenting issues?
How does the counselor's individualistic or collectivistic culture touch treatment planning?
How might a advisor approach the initial interview and evaluation to minimize the influence of his or her worldview in the evaluation and treatment planning process?

Sources: The Part of Nursing Practice and Professional person Services, Center for Addiction and Mental Health & Faculty of Social Piece of work, Academy of Toronto 2008; Zhang 1994.

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Source: https://www.ncbi.nlm.nih.gov/books/NBK248423/