Cultural competence in mental health services: Theoretical orientations and practical strategies

doi:10.3724/SP.J.1042.2020.00661

Abstract

Abstract:

The cultural competence of mental health services has gradually developed as increasing attention has been paid to the cultural diversity of Europe and North America. There exist two differing theoretical orientations with similar practice strategies. The content-oriented approach emphasizes static, structured cultural competence, while the process-oriented approach stresses dynamic, unstructured cultural competence. The similarities and difficulties of the two orientations are manifestations of a balance between cultural specificity and generality in the studies and practices of cultural competence. The paper finally explores how to promote cultural competence in China based on experiences abroad and Chinese realities within the context of improving the system of public psychological services.

Key words: cultural competence, mental health services, counselling, psychotherapy, multiculturalism

CLC Number:

CHEN Zichen, JIANG He. Cultural competence in mental health services: Theoretical orientations and practical strategies[J]. Advances in Psychological Science, 2020, 28(4): 661-672.

Figures/Tables 1

References 85

1	国家卫生健康委员会疾病预防控制局. ( 2016. 关于加强心理健康服务的指导意见. 2019-12-16取自 http://www.nhc.gov.cn/cms-search/xxgk/getManuscriptXxgk.htm?id=6a5193c6a8c544e59735389f31c971d5 .

2	吕小康, 汪新建 . ( 2018). 中国社会心理服务体系的建设构想. 心理科学, 41( 5), 1026-1030.
3	王俊秀 . ( 2020). 多重整合的社会心理服务体系:政策逻辑、建构策略与基本内核. 心理科学进展, 28( 1), 55-61.
4	王铭, 江光荣, 闫玉朋, 周忠英 . ( 2015). 我国心理咨询师与治疗师职业资格认证办法. 中国心理卫生杂志, ( 7), 503-509.
5	Aggarwal N. K., Cedeño K., Guarnaccia P., Kleinman A., & Lewis-Fernández R . ( 2016). The meanings of cultural competence in mental health: An exploratory focus group study with patients, clinicians, and administrators. SpringerPlus, 5, 384.
6	Aggarwal N. K., Desilva R., Nicasio A. V., Boiler M., & Lewis-Fernández R . ( 2015). Does the cultural formulation interview for the fifth revision of the diagnostic and statistical manual of mental disorders (DSM-5) affect medical communication? A qualitative exploratory study from the New York site. Ethnicity & Health, 20( 1), 1-28.
7	Aggarwal N. K., Lam P., Castillo E. G., Weiss M. G., Diaz E., Alarcón R. D., Lewis-Fernández R . ( 2016). How do clinicians prefer cultural competence training? Findings from the DSM-5 cultural formulation interview field trial. Academic Psychiatry, 40( 4), 584-591.
8	Aggarwal N. K., Nicasio A. V., DeSilva R., Boiler M., & Lewis-Fernández R . ( 2013). Barriers to implementing the DSM-5 cultural formulation interview: A qualitative study. Culture Medicine and Psychiatry, 37( 3), 505-533.
9	American Psychiatric Association . ( 2000). Diagnostic and statistical manual of mental disorders, fourth edition, text revision. Washington, DC: American Psychiatric Association.
10	American Psychiatric Association . ( 2013). Diagnostic and statistical manual of mental disorders, fifth edition. Arlington, VA: American Psychiatric Association.
11	American Psychological Association . ( 2003). Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. American Psychologist, 58( 5), 377-402.
12	American Psychological Association. ( 2015). Standards of accreditation for health service psychology. Retrieved July, 2018, from https://www.apa.org/ed/accreditation/about/policies/standards-of-accreditation.pdf.
13	American Psychological Association ( 2017a. Multicultural guidelines: An ecological approach to context, identity, and intersectionality. Retrieved December, 2018, from: http://www.apa.org/about/policy/multicultural-guidelines.pdf.
14	American Psychological Association ( 2017b. Ethical principles of psychologists and code of conduct. Retrieved July, 2018, from http://www.apa.org/ethics/code/.
15	Arredondo, P., & Toporek, R . ( 2004). Multicultural counseling competencies = ethical practice. Journal of Mental Health Counseling, 26( 1), 44-55.
16	Azevedo K. J., Mendoza S., Fernández M., Haydel K. F., Fujimoto M., & Tirumalai E. C., .. Robinson T. N . ( 2013). Turn off the TV and dance! Participation in culturally tailored health interventions: Implications for obesity prevention among Mexican American girls. Ethnicity & Disease, 23( 4), 452-461.
17	Benuto L. T., Singer J., Newlands R. T., Casas J. B . ( 2019). Training culturally competent psychologists: Where are we and where do we need to go? Training and Education in Professional Psychology, 13( 1), 56-63.
18	Bernal G., Bonilla J., & Bellido C . ( 1995). Ecological validity and cultural sensitivity for outcome research: Issues for the cultural adaptation and development of psychosocial treatments with Hispanics. Journal of Abnormal Child Psychology, 23( 1), 67-82.
19	Bernal G., Jiménez-Chafey M. I., & Domenech Rodríguez M. M . ( 2009). Cultural adaptation of treatments: A resource for considering culture in evidence-based practice. Professional Psychology: Research and Practice, 40( 4), 361-368.
20	Bradley J. M., Werth J. L., & Hastings S. L . ( 2012). Social justice advocacy in rural communities: Practical issues and implications. The Counseling Psychologist, 40( 3), 363-384.
21	Brown R. C., Southam-Gerow M. A., Mcleod B. D., Wheat E. B., Tully C. B., & Reise S. P., Weisz J. R . ( 2017). The global therapist competence scale for youth psychosocial treatment: Development and initial validation. Journal of Clinical Psychology, 74( 4), 649-664.
22	Burrow-Sanchez J. J., Minami T., & Hops H . ( 2015). Cultural accommodation of group substance abuse treatment for Latino adolescents: Results of an RCT. Cultural Diversity and Ethnic Minority Psychology, 21( 4), 571-583.
23	Castro F. G., Barrera M. Jr., Holleran Steiker L. K . ( 2010). Issues and challenges in the design of culturally adapted evidence-based interventions. Annual Review of Clinical Psychology, 6( 6), 213-239.
24	Chu J., Leino A., Pflum S., & Sue S . ( 2016). A model for the theoretical basis of cultural competency to guide psychotherapy. Professional Psychology: Research & Practice, 47( 1), 18-29.
25	Cross T., Bazron B., Dennis C., Isaacs M. R . ( 1989). Towards a culturally competent system of care: A monograph on effective services for minority children who are severely emotionally disturbed. Washington, DC: Georgetown University Child Development Center/CASSP Technical Assistance Center.
26	Dansereau D. F., Joe G. W., Dees S. M., & Simpson D. D . ( 1996). Ethnicity and the effects of mapping-enhanced drug abuse counseling. Addictive Behaviors, 21( 3), 363-376.
27	Edge D., Degnan A., Cotterill S., Berry K., Drake R., & Baker J., .. Abel K . ( 2016). Culturally-adapted family intervention (CaFI) for African-Caribbeans diagnosed with schizophrenia and their families: A feasibility study protocol of implementation and acceptability. Pilot & Feasibility Studies, 2( 1), 39.
28	Fuller, K . ( 2002). Eradicating essentialism from cultural competency education. Academic Medicine, 77( 3), 198-201.
29	Gillem A. R., Bartoli E., Bertsch K. N., McCarthy M. A., Constant K., Marrero-Meisky S., … Bellamy S . ( 2016). Validation of a standardized multiple-choice multicultural competence test: Implications for training, Assessment, and practice. Journal of Multicultural Counseling and Development, 44( 3), 209-224.
30	Gomes M. F., Chowdhary N., Vousoura E., & Verdeli H . ( 2016). “When grief breaks your heart”: A case study of interpersonal psychotherapy delivered in a primary care setting. Journal of Clinical Psychology, 72( 8), 807-817.
31	Gone, J. P . ( 2015). Reconciling evidence-based practice and cultural competence in mental health services: Introduction to a special issue. Transcultural Psychiatry, 52( 2), 139-149.
32	González R. C., Biever J. L., & Gardner G. T . ( 1994). The multicultural perspective in therapy: A social constructionist approach. Psychotherapy: Theory Research Practice Tranining, 31( 3), 515-524.
33	Good, M. J. D., & Hannah, S. D . ( 2015). “Shattering culture”: Perspectives on cultural competence and evidence-based practice in mental health services. Transcultural Psychiatry, 52( 2), 198-221.
34	Hannah, S. D . ( 2011). Clinical care in environments of hyperdiversity. In M. J. D. Good, S. S. Willen, S. D. Hannah, K. Vickery, & L. T. Park (Eds.) Shattering culture: American medicine responds to cultural diversity (pp. 35-69). New York, NY: Russell Sage Foundation.
35	Hinton D. E., Rivera E. I., Hofmann S. G., Barlow D. H., & Otto M. W . ( 2012). Adapting CBT for traumatized refugees and ethnic minority patients: Examples from culturally adapted CBT (CA-CBT). Transcultural Psychiatry, 49( 2), 340-365.
36	Huey Jr S. J., Tilley J. L., Jones E. O., & Smith C. A . ( 2014). The contribution of cultural competence to evidence-based care for ethnically diverse populations. Annual Review of Clinical Psychology, 10( 10), 305-338.
37	Hwang, W. C . ( 2006). The psychotherapy adaptation and modification framework: Application to Asian Americans. American Psychologist, 61( 7), 702-715.
38	Hwang, W. C . ( 2009). The formative method for adapting psychotherapy (FMAP): A community-based developmental approach to culturally adapting therapy. Professional Psychology Research & Practice, 40( 4), 369-377.
39	Hwang W. C. ( 2012). Integrating top-down and bottom-up approaches to culturally adapting psychotherapy: Application to Chinese Americans. In: G.Bernal & M. M. D. Rodríguez (Eds.) Cultural adaptations: Tools for evidence-based practice with diverse populations (pp. 179-198). Washington, DC: American Psychological Association.
40	Hwang W. C., Myers H. F., Chiu E., Mak E., Butner J. E., Fujimoto K., … Miranda J . ( 2015). Culturally adapted cognitive-behavioral therapy for Chinese Americans with depression: A randomized controlled trial. Psychiatric Services, 66( 10), 1035-1042.
41	Johnson, A., & Williams, D. J . ( 2015). White racial identity, color-blind racial attitudes, and multicultural counseling competence. Cultural Diversity and Ethnic Minority Psychology, 21( 3), 440-449.
42	Kananian S., Ayoughi S., Farugie A., Hinton D., & Stangier U . ( 2017). Transdiagnostic culturally adapted CBT with Farsi-speaking refugees: A pilot study. European Journal of Psychotraumatology, 8( sup2), 1390362.
43	Kirmayer, L. J . ( 2012). Rethinking cultural competence. Transcultural Psychiatry, 49( 2), 149-164.
44	Kirmayer L. J., Fung K., Rousseau C., Lo H. T., Menzies P., Guzder J., .. Mckenzie K . ( 2012). Guidelines for Training in Cultural Psychiatry. The Canadian Journal of Psychiatry, 57( 3), S1-S16.
45	Kleinman A. M. ( 1980). Patients and healers in the context of culture . Berkeley, CA: University of California Press.
46	Kleinman A., Estrin G. L., Usmani S., Chisholm D., Marquez P. V., & Evans T. G., & Saxena S . ( 2016). Time for mental health to come out of the shadows. Lancet, 387( 10035), 2274-2275.
47	Kohrt B. A., Jordans M. J. D., Rai S., Shrestha P., Luitel N. P., Ramaiya M. K., … Patel V . ( 2015). Therapist competence in global mental health: Development of the enhancing assessment of common therapeutic factors (ENACT) rating scale. Behaviour Research and Therapy, 69, 11-21.
48	Kopelowicz A., Zarate R., Wallace C. J., Liberman R. P., Lopez S. R., & Mintz J . ( 2015). Using the theory of planned behavior to improve treatment adherence in Mexican Americans with schizophrenia. Journal of Consulting and Clinical Psychology, 83( 5), 985-993.
49	Kuah-Pearce K. E., Kleinman A., & Harrison E . ( 2014). Social suffering and the culture of compassion in a morally divided China. Anthropology & Medicine, 21( 1), 1-7.
50	Lakes K., López S. R., & Garro L. C . ( 2006). Cultural competence and psychotherapy: Applying anthropologically informed conceptions of culture. Psychotherapy: Theory, Research, Practice, Training, 43( 4), 380-396.
51	Lau, A. S . ( 2006). Making the case for selective and directed cultural adaptations of evidence-based treatments: Examples from parent training. Clinical Psychology Science & Practice, 13( 4), 295-310.
52	Lau A. S., Chang D. F., Okazaki S., & Bernal G . ( 2016). Psychotherapy outcome research with ethnic minorities: What is the agenda? In N. Zane, G. Bernal, & F. Leong (Eds.), Evidence-based psychological practice with ethnic minorities(pp. 31-53). Washington, DC: American Psychological Association.
53	Lewis-Fernández R., Aggarwal N. K., Lam P. C., Galfalvy H., Weiss M. G., Kirmayer L. J., … Vega-Dienstmaier J. M . ( 2017). Feasibility, acceptability and clinical utility of the Cultural Formulation Interview: Mixed-methods results from the DSM-5 international field trial. The British Journal of Psychiatry, 210( 4), 290-297.
54	López, S. R . ( 1997). Cultural competence in psychotherapy: A guide for clinicians and their supervisors. In C. E. Watkins, Jr.(Ed.), Handbook of psychotherapy supervision (pp. 570-588). Hoboken, NJ, US: John Wiley & Sons Inc.
55	Mattingly, C . ( 2008). Reading minds, telling tales and creating dramas in a cultural borderland. Ethos, 36( 1), 136-154.
56	Meissner, F., & Vertovec, S . ( 2015). Comparing super-diversity. Ethnic and Racial Studies, 38( 4), 541-555.
57	Mezzich J. E., Caracci G., Fabrega H., & Kirmayer L. J . ( 2009). Cultural formulation guidelines. Transcultural Psychiatry, 46( 3), 383-405.
58	Mills S., Xiao A. Q., Wolitzky-Taylor K., Lim R., & Lu F. G . ( 2017). Training on the DSM-5 cultural formulation interview improves cultural competence in general psychiatry residents: A pilot study. Transcultural Psychiatry, 54( 2), 179-191.
59	Moradi, B., & Grzanka, P. R . ( 2017). Using intersectionality responsibly: Toward critical epistemology, structural analysis, and social justice activism. Journal of Counseling Psychology, 64( 5), 500-513.
60	Motulsky S. L., Gere S. H., Saleem R., & Trantham S. M . ( 2014). Teaching social justice in counseling psychology. The Counseling Psychologist, 42( 8), 1058-1083.
61	Naeem F., Gul M., Irfan M., Munshi T., Asif A., Rashid S., … Ayubk M . ( 2015). Brief culturally adapted CBT (CaCBT) for depression: A randomized controlled trial from Pakistan. Journal of Affective Disorders, 177, 101-107.
62	Nanda, S., & Warms, R. L . ( 2017). Culture counts: A concise introduction to cultural anthropology (fourth edition). Boston, US: Cengage Learning.
63	Patterson, C. H . ( 2004). Do we need multicultural counseling competencies? Journal of Mental Health Counseling, 26( 1), 67-73.
64	Pedersen, P . ( 1988). A handbook for developing multicultural awareness. Alexandria, VA, US: American Counseling Association.
65	Pon, G . ( 2009). Cultural competency as new racism: An ontology of forgetting. Journal of Progressive Human Services, 20( 1), 59-71.
66	Psychology Board of Australia . ( 2017). Guidelines for the 4+2 internship program. Retrieved July, 2018, from https://www.psychologyboard.gov.au/Standards-and-Guidelines/Codes-Guidelines-Policies.aspx.
67	Rathod S., Gega L., Degnan A., Pikard J., Khan T., Husain N., …Naeem F . ( 2018). The current status of culturally adapted mental health interventions: A practice-focused review of meta-analyses. Neuropsychiatric Disease and Treatment, 14, 165-178.
68	Ratts M. J., Singh A. A., Butler S. K., Nassar-McMillan S., & Rafferty McCullough J . ( 2016). Multicultural and social justice counseling competencies: Practical applications in counseling. Counseling Today, 58( 8), 40-45.
69	Schouler-Ocak M., Graefcalliess I. T., Tarricone I., Qureshi A., Kastrup M. C., & Bhugra D . ( 2015). EPA guidance on cultural competence training. European Psychiatry, 30( 3), 431-440.
70	Sempértegui G. A., Knipscheer J. W., & Bekker M. H. J . ( 2018). Development and evaluation of diversity-oriented competence training for the treatment of depressive disorders. Transcultural Psychiatry, 55( 1), 31-54.
71	Soto A., Smith T. B., Griner D., Rodriguez M. D., & Bernal G . ( 2018). Cultural adaptations and therapist multicultural competence: Two meta-analytic reviews. Journal of Clinical Psychology. 74( 11) SI, 1907-1923.
72	Spanierman L. B., Poteat V. P., Whittaker V. A., Schlosser L. Z., & Arévalo Avalos M. R . ( 2017). Allies for life? Lessons from white scholars of multicultural psychology. The Counseling Psychologist, 45( 5), 618-650.
73	Sue, D. W . ( 2001). Multidimensional facets of cultural competence. Counseling Psychologist, 29( 6), 790-821.
74	Sue D. W., Arredondo P., & McDavis R. J . ( 1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Counseling & Development, 70( 4), 477-486.
75	Sue D. W., Bernier J. E., Durran A., Feinberg L., Pedersen P., Smith E. J., & Vasquez-Nuttall E . ( 1982). Cross-cultural counseling competencies. The Counseling Psychologist, 10( 2), 45-52.
76	Sue, S . ( 1998). In search of cultural competence in psychotherapy and counseling. American Psychologist, 53( 4), 440-448.
77	Sue, S., & Zane, N . ( 1987). The role of culture and cultural techniques in psychotherapy: A critique and reformulation. American Psychologist, 42, 37-45.
78	Sue S., Zane N., Hall G. C. N., & Berger L. K . ( 2009). The case for cultural competency in psychotherapeutic interventions. Annual Review of Psychology, 60, 525-548.
79	Watson P., Raju P., & Soklaridis S . ( 2017). Teaching not-knowing: Strategies for cultural competence in psychotherapy supervision. Academic Psychiatry, 41, 55-61.
80	Wendt, D. C., & Gone, J. P . ( 2012). Rethinking cultural competence: Insights from indigenous community treatment settings. Transcultural Psychiatry, 49( 2), 206-222.
81	Wendt D. C., Gone J. P., & Nagata D. K . ( 2015). Potentially harmful therapy and multicultural counseling: Bridging two disciplinary discourses. The Counseling Psychologist, 43( 3), 334-358.
82	Whaley, A. L., & Davis, K. E . ( 2007). Cultural competence and evidence-based practice in mental health services: A complementary perspective. American Psychologist, 62( 6), 563-574.
83	Wilkinson I., Kleinman A., & . ( 2016). A passion for society: How we think about human suffering Oakland, US: University of California Press How we think about human suffering. Oakland, US: University of California Press.
84	Windsor L. C., Alexis J., & Alessi E. J . ( 2015). Cognitive behavioral therapy: A meta-analysis of race and substance use outcomes. Cultural Diversity & Ethnic Minority Psychology, 21( 2), 300-313.
85	Yeung A., Shyu I., Fisher L., Wu S., Yang H., & Fava M . ( 2010). Culturally sensitive collaborative treatment for depressed Chinese Americans in primary care. American Journal of Public Health, 100( 12), 2397-2402.

	内容取向	过程取向
出发点	解决少数族群的心理健康不平等问题	关注影响心理健康问题的普遍性社会文化动力
关注点	文化胜任力的“内容”	实现文化胜任力的“过程”
文化胜任力的界定	服务提供者或服务活动满足特定多元文化群体需求的能力和特征	根据普遍性的文化原则为具体个案提供文化胜任服务的能力
文化视角	基于群体(族群)的文化特征	基于个体或跨群体的文化特征
实践策略	建构服务提供者的能力指标和培训体系(技能模型)	培养关于服务动力过程的文化意识和技巧(个案中心的策略)
实践策略	对干预方法或服务系统进行文化改编(适应模型)	用针对服务过程的通用文化工具支持文化胜任的服务(通用文化工具的策略)

	内容取向	过程取向
出发点	解决少数族群的心理健康不平等问题	关注影响心理健康问题的普遍性社会文化动力
关注点	文化胜任力的“内容”	实现文化胜任力的“过程”
文化胜任力的界定	服务提供者或服务活动满足特定多元文化群体需求的能力和特征	根据普遍性的文化原则为具体个案提供文化胜任服务的能力
文化视角	基于群体(族群)的文化特征	基于个体或跨群体的文化特征
实践策略	建构服务提供者的能力指标和培训体系(技能模型)	培养关于服务动力过程的文化意识和技巧(个案中心的策略)
实践策略	对干预方法或服务系统进行文化改编(适应模型)	用针对服务过程的通用文化工具支持文化胜任的服务(通用文化工具的策略)

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