Task: Commit to Cultural Competence

Counselors are typically a part of a larger organization or system, but the focus on and responsibility for developing culturally responsive services has historically fallen on individual practitioners rather than on organizations. Most literature on cultural competence addresses the cultural awareness, knowledge, and skills of the practitioner, but until recently, it has failed to apply these same concepts to agencies. Cultural competence among counselors is only as effective as their agencies' commitment to and support of cultural competence and ability to value diversity through culturally congruent administrative practices, including—but not limited to—policies and procedures, programming, staffing, and community involvement.

Counselors are unlikely to affect organizational change to the same degree as the agency's overall administration can. Hence, culturally responsive treatment cannot be sustained without an agency's commitment and support. In fact, the organization itself can prevent clients from receiving culturally responsive services or treatment opportunities. Organizations that are unaware of cultural issues can fail to recognize that diverse groups may have difficulty accessing and engaging in treatment. Also, counselors who attempt to use culturally responsive practices—such as the involvement of family members (as defined by the client) and traditional healers—can encounter insurmountable hurdles if their agencies' policies and resources do not support these practices. The system can actually impede efforts made by counselors invested and trained in cultural competence. Thus, the development of cultural competence begins at the top level of the organization, with an initial focus on systemic changes.

Cultural competence does not occur by accident. To maximize its effectiveness in working with diverse groups, the organization must first view diversity as an asset. As importantly, the organization must ensure that its process of developing cultural competence has the genuine, full, and lasting support of the organization's leadership. The chief executive officer (CEO), senior management, and board of directors play critical roles. A strong mandate from the board or CEO, coupled with a commitment to provide resources, can be a good motivator for staff and committees to undertake major organizational change. Support of cultural competence must be made clear throughout the organization and community in meaningful ways, in words and actions.

Leadership can make a difference in the implementation of culturally responsive practices by creating an organizational climate that encourages and supports such practices. This includes a willingness to discuss the importance of cultural competence, try new practices or approaches, tolerate the uncertainty that accompanies transitional periods during which practices and procedures are evolving, respond to unforeseen barriers, and revise innovations that are not working as intended. It is important that leadership be genuinely committed to the effort and that their support be tangibly apparent in the allocation of relevant resources. A strong commitment to improving organizational cultural competence should include the obligation to monitor procedures after they have been implemented, maintain and reevaluate new practices, and provide resources and opportunities for ongoing training and culturally competent supervision.

Task: Review and Update Vision, Mission, and Value Statements

The organization's mission, vision, and value statements are vitally important in creating a conceptual framework that promotes culturally responsive behavioral health services. Agencies should examine how these statements are developed. Are stakeholders involved in the development process? In what ways does the organization ensure that its values and mission reflect the community and populations that it serves? Does the organization see this task as a singular event, or has it planned for periodic review of its values and mission to ensure continued organizational responsiveness as needs, populations, or environments change?

Initially, the planning committee should determine how the culture of the organization as well as the surrounding community can support achievement of the mission and vision statements. Culturally responsive organizational statements cannot provide a tangible framework unless supported by community, referral, and client demographics; a needs assessment; and an implementation plan. Mission and vision statements need to be operationalized through identified goals as well as measurable indicators to track progress. The Hands Across Cultures Corporation of northern New Mexico, which serves Native peoples within pueblos (American Indians), the City of Española, Pojoaque Valley, and surrounding communities (predominantly Latino), addresses the importance of the cultural context of its work in its mission and philosophy statements (Exhibit 4-3).

Exhibit 4-3

Hands Across Cultures Mission Statement.

Task: Address Cultural Competence in Strategic Planning Processes

The strategic planning process provides an opportunity to reevaluate an agency's values, mission, and vision regarding cultural competence. A comprehensive process involves evaluating the organization's internal and external environments prior to holding planning meetings; this evaluation involves conducting staff, client, and community assessments. From assessing current needs to evaluating global factors that influence the direction and delivery of services (e.g., funding sources, treatment mandates, changes in health insurance), organizations can begin to gain insight into the demands and challenges of providing culturally responsive services. Moreover, strategic planning is an opportunity to explore and develop short- and long-term goals that focus on incorporating culturally responsive delivery systems while addressing issues of sustainability (i.e., how to provide resources and support the implementation of culturally responsive policies and procedures over time). A formal strategic planning meeting should be held to determine specific goals, objectives, and tasks that will ensure quality improvement in culturally responsive services. The development of timelines and methods to evaluate progress, obstacles, and directions for each goal are equally important. For organizations that do not have a specific cultural competence plan prior to the strategic planning meeting, this process can provide the forum for developing the steps needed to create a formal plan.

Task: Assign a Senior Manager To Oversee the Development of Culturally Responsive Practices and Services

From the outset, a senior staff member with the authority to implement change should be assigned to oversee the developmental process of planning, evaluating, and implementing culturally responsive administrative and clinical services. Key responsibilities include the ongoing development and facilitation of cultural competence committees and advisory boards, management of evaluative processes, facilitation of the development of a cultural competence plan and its implementation, and oversight of policies and procedures to ensure cultural competence within the organization and among staff. Cultural competence cannot come to fruition with only one voice being heard, but assigning a key person to oversee the process will more likely keep top-priority goals and objectives in view.

Task: Develop Culturally Competent Governing and Advisory Boards

Beyond having the foresight to plan for and develop culturally responsive services, it is vital that executive staff members on governing and advisory boards and committees are educated about and invested in the organization's mission and plan. For example, the board's human resources committee may be more invested in developing and reinforcing culturally responsive recruitment and hiring policies and practices if they are involved in the strategic planning process and educated about the organization's mission, values, and vision. At the same time, the organization should seek outside direction. Given that sharing information about the agency's activities with others outside the organization can create some hesitancy or be a potential barrier, the executive staff can frame the planning process as an opportunity for positive development and community involvement as a powerful resource. The organization should establish a community advisory board that includes stakeholders, specialists, and/or experts in multicultural behavioral health services along with key administrators and staff. This advisory board should consist of local community members from whom the organization can solicit valuable advice, input, and potential support for the development of culturally responsive treatment (Minnesota Department of Human Services 2004).

Representation should include clients, alumni, family members, and community-based organizations and institutions (e.g., community centers, faith communities, social service organizations). Developing an inclusive advisory board of community members can enhance and extend use of and referral from other community agencies. Moreover, this board can help identify community leaders and culturally appropriate resources for the client population to supplement treatment activities, such as traditional healing practices (Castro et al. 1999a). The advice box on the next page reviews strategies for engaging communities in the development of culturally responsive services.

Task: Establish a Cultural Competence Committee

By creating a committee within the organization to guide the process of becoming culturally competent and responsive, the organization ensures that a core group will provide oversight and direction. This committee should be inclusive not only in terms of the racial and ethnic composition of the population served, but also in terms of drawing from all levels of the organization (Whaley and Longoria 2008). Representatives of the advisory board should also be included. Program administrators should provide direction to the cultural competence committee. The person assigned to take the lead on cultural competence should chair the committee, and the CEO should be noticeably involved.

The cultural competence committee will oversee the organization's self-assessment process while also creating the demographic profile of the organization's community, developing a cultural competence plan, and formulating and monitoring procedures that evaluate the implementation and effectiveness of the organization's plan in developing culturally responsive services and practices. The committee should ensure that the organization's plans are continually updated . To succeed, this team must be empowered to influence, formulate, implement, and enforce initiatives on all levels and throughout every department of the organization (Constantine and Sue 2005; Fung et al. 2012), including, for example, presenting data and subsequent recommendations to the administration and boards based on employee feedback about their experiences with newly adopted, culturally responsive procedures in the organization. Exhibit 4-4 highlights key issues in behavioral health treatment that must be addressed in providing culturally responsive services.

Exhibit 4-4

Critical Treatment Issues To Consider in Providing Culturally Responsive Services.

Task: Engage Clients, Staff, and the Community in the Planning, Development, and Implementation of Culturally Responsive Services

Organizations can sometimes have the best intentions of creating culturally responsive services but miss the mark by operating in a vacuum. Initially, the vacuum approach can appear less time consuming, complex, and expensive, but it can also represent paternalism whereby organizations or administrators assume that they inherently know what is best for the program, clients, staff, and community. Instead, organizations and the services that they provide need to be congruent with the specific populations being served; clients and the community should have an opportunity to provide input on how services are delivered and the types of services that are needed. Otherwise, services may be poorly matched to clients, underused by the community, and detrimental to agency financial resources. For example, an agency could decide that family therapy is a culturally appropriate service and proceed to create a multifamily program (treating several families together in a group format) without considering that, for some cultural groups, family shame associated with seeking help can deter the use of such services.

Staff members are likely to have specific knowledge of client needs and to be able to identify potential obstacles or challenges in how an organization attempts to implement culturally responsive policies and procedures. A parallel process that can influence the potential success of staff involvement and commitment to the development of cultural competence is the organizational culture. Suppose, for example, that the staff perceives the organization's new commitment to cultural competence as another expectation of more work without training, adequate clinical supervision, or ongoing support. Maybe staff members have historically experienced frequent announcements, mandates, or excitement generated by the administration that fade quickly. Perhaps the organization arranges committees and meetings, purporting that they want staff input despite the fact that decisions have already been made.

The organizational climate sets the stage for staff responsiveness and motivation in developing cultural competence and in implementing culturally responsive services. Without an organizational history and culture of supporting change across time, staff members will likely resent an increase in expectations without some means of compensating for additional work, perceive themselves as powerless over the proposed changes, or minimize the need to make any immediate changes. For example, staff members may view changes as temporary or a phase and believe that the organization will focus on other issues or new directions once the pressure or attention on this specific issue subsides.

Task: Develop a Cultural Competence Plan

To ensure the delivery of culturally responsive services, it is important to develop a cultural competence plan (see the “Criteria for Developing an Organizational Cultural Competence Plan” advice box on the next page) . Using demographic data and an organizational self-assessment (including community and advisory board input), the organization's cultural competence committee can begin writing an organizational plan for improving cultural competence. The committee will need to assign staff members to research and write each component of the plan, which should outline specific objectives, means of achieving these objectives, and recommend timelines and processes for evaluating progress. The plan should contain at least the following components:

• A narrative introduction that covers community demographics and history, organizational self-assessment and other evaluation tools, the rationale for providing culturally responsive services, and the organization's strengths and needs for improvement in providing services that are responsive to client cultural groups; a brief overview of current priorities, goals, and tasks to help the organization develop and improve culturally responsive clinical services and administrative practices is also advisable.
• Strategies for recruiting, hiring, retaining, and promoting qualified diverse staff.
• Resources and policies to support language services and culturally responsive services.
• Methods to enhance professional development (e.g., staff education and training, peer consultation, clinical supervision) in culturally responsive treatment services.
• Mechanisms for community involvement, beginning with the development of a community advisory board and cultural competence committee and including community participation in relevant treatment activities or in support of treatment services (e.g., spiritual direction).
• Approaches to amending facility design and operations to present a culturally congruent atmosphere.
• Identification of and recommendations for culturally and linguistically appropriate program materials.
• Programmatic strategies to incorporate culturally congruent clinical and ancillary treatment services.
• Fiscal planning for funding and human resources needed for priority activities
  (e.g., training, language services, program development, organizational infrastructure).
• Guidelines for implementation that describe roles, responsibilities, timeframes, and specific activities for each step.

The committee must determine how to oversee the plan (e.g., by tracking accomplishments, obstacles, and remediation strategies). Who will develop and revise guidelines for treatment planning, introduce new guidelines to the staff and provide counselor training, and coordinate revisions with the information technology specialist or department?

Task: Develop and Review Policies and Procedures To Ensure Culturally Responsive Organizational Practices

In essence, policies and procedures are the backbone of an organization's implementation of culturally responsive services. By creating, reviewing, and adapting clinical and administrative policies and procedures in response to the ever-changing needs of client populations, the agency is able to provide counselors and other workers with support and the means to respond in a consistent, yet flexible, manner. Programs are likely to have the foresight to develop relevant policies and procedures through the planning and evaluative processes outlined in this chapter, but it is unlikely that they will anticipate every situation. Thus, ongoing flexibility is paramount.

When putting together an organizational cultural competence plan, providers should be careful to follow the requirements set by state licensing boards, accreditation agencies, and professional organizations that oversee certification and licensing of treatment professionals. Much of the push for cultural competence throughout the healthcare field is in response to the mandates of accrediting agencies, funders, and managed care organizations. These entities have standards and guidelines that state minimum expectations for client rights, program structure, and staffing, along with treatment content and conditions. Behavioral health organizations, including substance abuse treatment programs, must meet these standards to be accredited by national organizations and compensated by funders.

Although many accrediting bodies require a cultural competence plan that is assessed as part of the accreditation process, their requirements can be minimal. Consequently, organizations should go beyond such requirements in their own thinking and planning to ensure that they are responding adequately to the needs of the communities they serve. Above all, are the policies, procedures, and systems of care suited to the served populations? Do policies reflect the organization's commitment to cultural competence in administrative practices? For example, are strategies for professional development, personnel recruitment, and retention of culturally competent staff members reflective of the populations and cultures that they serve?

If an organization fails to develop culturally responsive policies or procedures yet claims to endorse or support culturally responsive services, counselors and staff members will likely carry the entire burden of implementing these services and will face numerous obstacles that could prevent the delivery of responsive services. Take, for example, a counselor from a county-funded program who was directed by her supervisor to complement her counseling approach with the client's traditional healing beliefs and practices. The agency did not provide staff support, have policies or procedures consistent with this request, or exhibit a willingness to adapt current procedures to meet the client's needs. The counselor had difficulty following this direction because of barriers in finding an appropriate traditional practitioner in the local area, coordinating services, establishing and securing confidentiality for the client and with the practitioner (including educating the practitioner about confidentiality), arranging transportation for the client, obtaining a stipend for services, and discerning how and when to incorporate the traditional practice into the treatment milieu.

Counselors who feel that they have been left to go it alone can view implementation of culturally responsive practices as an insurmountable challenge when the agency provides limited support or fails to endorse adaptive policies that are congruent with the needs of the client population. Counselors may have high motivation to incorporate culturally responsive care but find themselves without appropriate agency resources, permission, or infrastructure to implement it. By developing and endorsing culturally responsive policies and procedures, an organization can provide carefully thought-out strategies and processes to help staff members provide real-time responsive services. Well-defined policies and procedures reinforce commitment to and expectations of cultural competence.

Task: Create a Demographic Profile of the Community, Clientele, Staff, and Board

Intake, admission, and discharge data provide a good starting point for determining the demographics of current populations being served. Programs would likely benefit from developing a demographic summary for each population served, consisting of age, gender, race, ethnic and cultural heritage, religion, socioeconomic status, spoken and written language preferences and capabilities, employment rates, treatment level, and health status (HHS 2003b). With adequate resources, the organization can generate reports dating back 5 years to determine program trends.

Agencies should also gather demographic information on groups in the agency's local community (Hernandez et al. 2009). This information can be easily obtained through census data and national centers (e.g., Bureau of Labor Statistics) or through local sources, including the library, city hall, or the county commissioner's office (Whealin and Ruzek 2008). Community demographics can provide a quick benchmark on how well an agency serves the local community and how the community is represented at all levels of the organization. A demographic profile should also summarize information about clinical, medical, and nonclinical staff members as well as board members. Other information can also be helpful for specific agencies, as can hiring a consultant to gather demographic information and conduct the organization's self-assessment of cultural competence to limit bias; however, lack of funding can prohibit this possibility.

Task: Conduct Organizational Self-Assessment of Cultural Competence

An organization must have an awareness of how it functions within the context of a multicultural environment, evaluating operational aspects of the agency as well as staff ability and competence in providing culturally congruent services to racially and ethnically diverse populations. Therefore, an agency should assess how well it currently provides culturally responsive treatment. An honest and thorough organizational self-assessment can serve as a blueprint for the cultural competence plan and as a benchmark to evaluate progress across time (National Center for Cultural Competence 2013). To review a sample assessment guide, refer to Appendix C.

The importance of organizational self-assessment cannot be overstated. Thorough, reliable, valid evaluations can gauge the effectiveness of an agency's services, structure, and practices (e.g., clinical services, governing practices, policy development, staff composition, and professional development) with culturally and racially diverse clients, staff, and communities. More and more, public and private funding sources—as well as accrediting bodies—use an organization's self-assessment as a means of measuring compliance, effectiveness, or quality improvement practices.

A self-assessment can seem intensive in terms of both labor and capital, but in the long run, it can guide an organization's quality improvement process more efficiently by helping it provide the most relevant services at the right time. Gathering feedback from many internal and external sources gives agencies considerable information needed to effectively evolve as a culturally responsive organization, including data on current performance, areas needing improvement, and development needs. In the initial self-assessment, an organization should obtain demographic information and seek feedback from key stakeholders—including community members, clients, families, and referral sources (e.g., probation and parole offices, family and child services, private practitioners)—and from all levels of the organization, including administrative, managerial, clinical, medical, and support staff. The following steps are recommended to help an agency gain the information necessary to guide and support the development of its cultural competence plan.

Step 1: With the advisory board and cultural competence committee, identify key stakeholders who can provide valuable feedback about current strengths and areas in need of improvement regarding the function of the organization and the needs of its community.

Step 2: Adopt a self-assessment guideline for organizational cultural competence (see Appendix C).

Step 3: Determine the feasibility of using consultants and/or external evaluators to select, analyze, and manage assessment.

For many organizations, hiring outside consultants is financially prohibitive. Nonetheless, the cultural competence committee could recommend hiring outside evaluators and consultants to help them plan, conduct, and assess the results of the organizational self-evaluation. The committee should ensure that consultants understand the population being served by the treatment facility. This means understanding the population's cultural groups across dimensions: language and communication, cultural beliefs and values, history, socio-economic status, education, gender roles, substance use patterns, spirituality, and other distinctive aspects. Candidates should be able to articulate a clear understanding of cultural competence (American Evaluation Association 2011). If consultants will train staff, they should have specific knowledge and proficiency in training development and delivery.

If financially feasible, it can be useful for the agency to consider using more than one consultant and to invite each prospective consultant to present their qualifications to the board of directors and/or to a cultural competence committee so that the best match can be achieved between the agency's needs and the consultant based on his or her expertise, cost, and consulting style. If a consultant is hired, the organization should establish guidelines for working closely with that person, including reporting requirements to the cultural competence committee. The organization must retain ownership of the process and provide clear oversight and guidance.

Step 4: Select assessment tools suitable for each stakeholder group (e.g., clinical staff, agency referrals, clients). Several self-assessment tools are available, including checklists and surveys, for use in evaluation or as development guides. To date, most instruments available have limited empirical support (Delphin-Rittmon et al. 2012b; Shorkey et al. 2009).

More often than not, surveys and feedback questionnaires will need to be individually developed and tailored to the organization and stakeholder group depending upon setting; available resources; racial, ethnic, and cultural backgrounds; language preferences; and community accessibility (e.g., rural versus urban). Appendix C provides standards and lists the items that should be included in evaluating an agency and its services. Additional resources for provider and organizational assessment of cultural competence are available through the National Center for Cultural Competence (http://nccc.georgetown.edu/) and the Hogg Foundation for Mental Health (http://www.hogg.utexas.edu/index.php).

Step 5: Determine distribution, administration, and data collection procedures (e.g., confidentiality, participant selection methods, distribution time frames). Whatever methods are used to gather data for the self-assessment process, it is critical to explain the context of the assessment to all participants. They need to know why the assessment is being conducted and how the information they give will be used. Confidentiality can be a major concern for some respondents, especially staff members and clients, and every effort should be made to address this concern. Ideally, the evaluation instrument(s) should be administered by an objective third party, such as a consultant or a member of the cultural competence committee. Staff members should be asked about their attitudes toward cultural issues with the understanding that their attitudes are not necessarily indicative of the degree to which the staff mirrors the cultural groups served. In soliciting community feedback, the more credibility the organization has in the community, the higher the return rate will likely be. The lower the credibility, the more the organization needs to reassure respondents that it intends to listen to, and act on, what it hears. If many survey forms are to be distributed, the organization could consider hiring students or community members on a temporary basis to make follow-up or reminder calls.

Step 6: Compile and analyze the data. The process of reviewing and assessing data should be overseen by the cultural competence committee. Basic data analysis procedures should be used to ensure the accuracy of results and credibility of reported information. For most well-designed instruments, there are relatively simple and appropriate ways to present data. All available data should be assembled in a report, along with interpretive comments and recommended action steps. The report should note areas of strength and needed improvement and should offer possible explanations for any shortcomings. For example, if the community is 20 percent African American, but only 2 percent of the agency's clientele are African American, what are some possible explanations for this group's apparent underuse of services? It is also particularly important to share results with those who participated in the assessment process. Findings should be made available to staff, clients, community members, boards, and managers. This increases overall sense of ownership in the assessment and cultural competence development process and in implementing the changes that will be made based on the findings of and the priorities established through this assessment.

Step 7: Establish priorities for the organization and incorporate these priorities into the cultural competence plan. After obtaining the results of the self-assessment process, the organization—including boards, cultural competence committee, community stakeholders, and staff members—needs to establish realistic priorities based on the current needs of clients and the community. Significant consideration should be given to the level of influence any given priority could have in effecting organizational change that will improve culturally responsive services. Some priorities will require more planning to implement and can involve more financial and staff resources, whereas other priorities will be easier to implement from the outset (e.g., hiring culturally competent counselors who are bilingual versus translating intake and program forms). Therefore, long- and short-range priorities should be established at the same time to maintain the momentum of change in the organization.

Step 8: Develop a system to provide ongoing monitoring and performance improvement strategies. Similar to the clinical assessment process with clients, the organizational self-assessment is only valuable if it provides guidance, determines direction and priorities, and facilitates action. Assessment is not a one-time activity. It is important to continue monitoring to identify barriers that may impede the full implementation of the cultural competence plan, to evaluate progress and performance, and to identify new service needs. Establishing a system to monitor an organization's cultural responsiveness equips it with the information necessary to formulate strategies to meet new demands and to continuously improve quality of services.

Task: Plan for Language Services Proactively

An organization must anticipate the need for language services and the resources required to support these services, including funding, staff composition, program materials, and translation services. Assessing the language needs of the population to be served is essential. Upon determination, the foremost task is letting clients with limited English proficiency know that language services are available as a basic right for a client. Treatment providers need to plan for the provision of linguistically appropriate services, beginning with actively recruiting bicultural and bilingual clinical staff, establishing translation services and contracts, and developing treatment materials prior to client contact. Although it is not realistic to anticipate the language needs of all potential clients, it is important to develop a list of available resources and program procedures that staff members can follow when a client's language needs fall outside the organization's usual client demographics (The Joint Commission 2009).

Planning for language services is crucial, and the need for these services must be assessed by staff members who have initial contact with clients, their family members, and/or other individuals in their support systems (American Psychological Association [APA] 1990, 2002). If frontline administrative and clinical staff members are bilingual, the initial screening and assessment process can begin uninterrupted. If this is not the case, receptionists or frontline clinical staff members should at least be familiar with some rudimentary phrases in the preferred languages of their client base. The conversation can be scripted so that they can convey their limited ability to speak the client's language, obtain contact information and inquire about language service needs, and inform the client that someone who can speak the language more fluently will be made available to facilitate the initial screening process. Most importantly, procedures should be in place to provide pretreatment contact and follow-up in the client's language to bridge the gap between initial contact and subsequent arrangement of language services.

Written and illustrated materials or a video about the program in the languages spoken by the client population should be available to answer frequently asked questions. All materials given to clients, family members, and community members should be available in their primary languages. It is preferable to develop the materials initially in those languages rather than simply translating materials from one language to another. Along with language, one should also consider the level of literacy of the group in question. Some clients may be functionally illiterate even in their native languages. Materials should graphically reflect the population served through pictures or photographs, using ethnic themes and traditional elements familiar to the target audience. Also, materials should be tested with the populations with whom they will be used, perhaps through focus groups, to ensure that they communicate effectively.

Task: Establish Practice and Training Guidelines for the Provision of Language Services

Key issues to consider in implementing and overseeing language services within an organization include staff monitoring of language proficiencies, selection of translators and interpreters, confidentiality issues, and training needs. First, agencies need to assess language proficiencies among staff members and encourage them to learn a language relevant to the population served. At a minimum, staff members should acquire in the given language some basic terminology and phrases that are commonly used in the treatment setting.

In recruiting and hiring translators and interpreters, administrative staff members should consider experience, motivation, skill level, mastery of English, and fluency in the language in need of interpretation (OMH 2000; American Translators Association 2011). Be aware, however, that there can be considerable variation in dialects and levels of proficiency within the language, and these must be determined in the selection process. To supplement hiring practices, administrative policies should provide a means for determining the credentials of any language services organizations (Appendix F lists American Translators Association credentialing information).

Other important hiring issues revolve around potential ethical dilemmas. In particular, care should be taken in using interpreters from the local community, which can create potential challenges with confidentiality and dual relationships (e.g., the interpreter may also be client's cousin or neighbor). Policies should place the burden on language service providers to identify and disclose dual relationships to supervisors immediately and on supervisors to assess and determine the appropriateness of using certain translator. Once a selection has been made, a confidentiality agreement should be signed. Organizations need to provide information routinely to clients about their confidentiality rights in using language services. Implementing a procedure for handling client grievances is also recommended.

In planning for the use of language services, organizations should initially provide training for staff on how to incorporate these services and should familiarize translators and interpreters with the clinical setting, terminology, behavioral expectations, a n d content related to behavioral health (see the “Training Content for Language Service Personnel” advice box on the next page). The language of mental health and substance abuse services requires an additional degree of specialization. Experienced translators and interpreters who are unfamiliar with concepts of addiction, illness, and recovery could convey information adequately from a linguistic perspective but not accurately convey the intent or meaning of clinically oriented information or dialog. Various training approaches can be used, including role-plays mirroring intakes, evaluations, and counseling sessions; indirect exposure to client sessions through audio or video recordings of sessions or viewing from an observation room; direct observation by sitting in on a session, if appropriate; and consultation with other experienced language service providers and clinical staff. Using other experienced translators and interpreters for training and/or for consultations, as well as sharing experiences in a peer support format, can be very beneficial for new language service providers.

Organizations must also create opportunities for translators and interpreters to inquire about and clarify clinical content and meaning. Language service providers often attempt to convey terminology or concepts that do not exactly match the words or meaning of the client's language or culture by becoming more descriptive, taking longer to deliver the message in an effort to match the intent of a specific word or concept in English.

Task: Develop Staff Recruitment, Retention, and Promotion Strategies That Reflect the Populations Served

To determine whether it adequately reflects the population it serves, an organization has to assess its personnel, including counselors, administrators, and board of directors. According to a 10-year study that collected data on treatment admissions, racial and ethnic composition of treatment populations has not significantly changed. Racially diverse groups (excluding non-Latino Whites) represent approximately 40 percent of treatment admissions (Substance Abuse and Mental Health Services Administration [SAMHSA] 2011c), yet 80 percent of counselors are non-Latino Whites (Duffy et al. 2004). In striving to improve cultural responsiveness, staff composition should be a major strategic planning consideration. As much as possible, the staff should mirror the client population.

Nevertheless, providers should avoid hiring “ethnic representatives,” which means hiring a single person from an ethnic or cultural group and expecting him or her to serve as the cultural resource on that group for the entire staff. This can be burdensome, if not offensive, to that person. Belonging to a group does not ensure cultural responsiveness toward, knowledge of, or skill in working with members of that group, nor does it guarantee that the person culturally identifies with that cultural group or its heritage. Hiring ethnic representatives undermines the expansion of diversity at all organizational levels and the importance of developing opportunities for all staff members to gain awareness and improve their ability to effectively work with clients.

Some organizations struggle to find multicultural staff members that represent the diversity of their communities and clienteles. If recruitment is perceived as an immediate short-term goal, ongoing difficulties are likely in hiring, promoting, and retaining a diverse staff. Instead, recruitment strategies need to embrace a more comprehensive and long-term approach that includes internships, marketing to those interested in the field at an early age, mentoring programs for clinical and administrative roles, support networks, educational assistance, and training opportunities.

Task: Create Training Plans and Curricula That Address Cultural Competence

The primary purpose of training is to increase cultural competence in the delivery of services, beginning with outreach and extending to continuing care services that support behavioral health. Training should increase staff self-awareness and cultural knowledge, review culturally responsive policies and procedures, and improve culturally responsive clinical skills (Anderson et al. 2003; Brach and Fraser 2000; Lie et al. 2011). The organization should be prepared to offer relevant professional development experiences consistent with counselors' personal goals and assigned responsibilities as well as the organization's goals for culturally responsive services. Board members, volunteers, and interpreters should all receive appropriate training.

A professional development training plan details the frequency, content, and schedule for staff training and continuing education. Because becoming culturally competent is a process, training and support for engaging in culturally responsive services can be more appropriate when delivered across a period of time involving follow-up sessions rather than through a single session. Outcome research that evaluates the effectiveness of cultural competence training materials, format, and content in mental health services, including treatment for substance use disorders (Bhui et al. 2007; Lie et al. 2010), is limited. Nonetheless, numerous resources have suggested that effective cultural training does feature certain qualities (Exhibit 4-5).

Exhibit 4-5

Qualities of Effective Cultural Competence Training.

Sometimes, staff members will express resistance to participation in training activities aimed at promoting cultural competence—they may feel forced to learn about cultural competence, or they may feel unable to take the time away from their clients to attend the trainings. Others might object on the grounds that they treat everyone equally, thus ignoring their own cultural blindness.

The organization's leadership needs to address staff reluctance and concerns regarding training through initial education on the rationale for cultural competence. Assume that staff members are invested in creating the best opportunities for their clients to achieve success, and use this premise to introduce the need for training centered on culturally responsive care. Some staff members may respond to incentives or predetermined objectives and criteria reflected in employee performance evaluations. Others may be more motivated by opportunities that arise from the organization's commitment to culturally responsive services or by other factors, such as specialized training and supervision, the desire to be perceived by other staff members as team players, or their roles as agents of change with other staff members.

Opportunities for cultural competence training abound. National organizations, agencies dedicated to multicultural learning, academic institutions, government agencies, and information clearinghouses offer training or have information about training opportunities and curricula on cultural competence on their Web sites. In addition to OMH guidelines on staff education and training (Exhibit 4-6), guidelines are available from psychological and counseling associations (APA 2002). To review sample training modules, see Cultural Competence for Health Administration and Public Health (Rose 2011).

Exhibit 4-6

OMH Staff Education and Training Guidelines.

Task: Provide Culturally Congruent Clinical Supervision

Little research is available that measures cultural competence among clinical supervisors or evaluates the effects of supervision on cultural competence among counselors (Colistra and Brown-Rice 2011; Constantine and Sue 2005). Not much is known about the effectiveness of clinical supervision in enhancing culturally competent behavior among counselors, although some research with a multicultural focus has measured counselor self-efficacy after receiving supervision and has examined the dynamics of supervisee–supervisor relationships. Even though educational institutions have developed curricula and standards to reinforce the need for a multicultural perspective in training, many clinical supervisors lack sufficient training in this area (e.g., avoid cultural topics in supervision, have difficulty giving culturally appropriate consultations or direction, fail to guide/reinforce timely implementation of policies or procedures that support culturally responsive services with their supervisees). This can significantly impede organizations attempting to introduce or improve culturally responsive clinical services.

It is essential for organizations to provide counselors with clinical supervisors who are culturally aware, have engaged in multicultural training, and model culturally competent behaviors in clinical supervision sessions (e.g., allowing or engaging in discussions centered on race, ethnicity, and cultural groups in the session). Clinical supervision is the glue that reinforces culturally competent behavior, and it is often the only avenue of ongoing clinical training and follow-up after specific workshops or trainings are offered by the organization.

Clinical supervisors should adopt a multicultural framework to guide the supervision process (e.g., Sue's [2001] multidimensional model for developing cultural competence). Endorsement of a model for developing and enhancing cultural competence helps both supervisors and supervisees understand how to address cultural issues in supervision and pursue personal and professional development that supports culturally responsive clinical services. (For a specific example, see Field and colleagues' [2010] Latina–Latino multicultural developmental supervisory model.) The model guides supervision and reinforces the premise that cultural variables influence each aspect of supervision: the relationship between supervisors and supervisees, the supervisors' and supervisees' perceptions and assessments of clients' presenting issues, the interactions between supervisees and their clients, and the treatment recommendations and directions that evolve from supervision.

Task: Evaluate Staff Performance on Culturally Congruent and Complementary Attitudes, Knowledge, and Skills

Organizations committed to endorsing and implementing culturally responsive services need policies and procedures that reflect this commitment in job descriptions and staff evaluations across all levels of the organization. By incorporating specific goals, expectations, and tasks into performance evaluations, staff members will receive an important and consistent message from the organization that culturally competent behavior and responsive services are valued and rewarded.

Task: Plan Long-Range Fiscal Support of Cultural Competence

An organization's commitment to providing culturally responsive treatment services will only succeed if resources are consistently dedicated to supporting the plan. Realistically, treatment program funds may be insufficient to initially meet the goals outlined in the organization's self-assessment. More often than not, the committee, executive staff, and board will have to prioritize the specific changes that are financially feasible. However, this necessity does not preclude the organization from soliciting help from the community, finding creative and inexpensive ways to make organizational changes, and using strategic and financial planning to build resources designated for culturally responsive services.

Task: Create an Environment That Reflects the Populations Served

The self-assessment process should include an environmental review of the organization's physical facilities in which barriers to access are examined. The plan should address identified deficits. For example, signage should be written in all primary languages spoken by the clients served; it should be written at an appropriate level of literacy in those languages. When possible, signs should use pictures and graphics to replace written instructions. The design of the facility, including use of space and décor, should be inviting, comfortable, and culturally sensitive. The plan should establish how to make facilities more accessible and culturally appropriate. In addition, the organization should create an environment that reflects the culture(s) of its clients not only within the facility, but through business practices, such as using local and community vendors.

Task: Develop Outreach Strategies To Improve Access to Care

The best-laid plans for providing culturally competent treatment are futile if clients cannot access treatment. Providers should develop outreach plans for diverse ethnic and racial communities, particularly those whose members may find it difficult to seek services on their own. For example, see Community-Defined Solutions for Latino Mental Health Care Disparities (Aguilar-Gaxiola et al. 2012). From the outset, effective outreach and improved access to care should include formal and informal contacts with community organizations, spiritual leaders, and media. Providers can learn from these contacts about the behavioral health concerns in the community, special considerations for working with members of the community, cultural impediments to treatment, and cultural resources to aid treatment and recovery.

Unfortunately, many providers lack sufficient funding to offer the level of outreach services needed by the communities they serve. Because they are overwhelmed already, the issue of outreach to underserved populations is often seen as a low priority, which can cause these providers to send people in need of treatment away, disappointed and disheartened. However, thoughtful and strategic use of community resources can result in more members of underserved populations receiving the treatment they need and deserve. A t minimum, outreach enables providers to offer accurate information and referral to appropriate mutual-help or community groups.

Regarding fiscal planning and funding opportunities, some HHS initiatives support outreach through integrated care. For example, the Health Resources and Services Administration (HRSA) Center for Integrated Health Solutions (CIHS) promotes the development of integrated primary and behavioral health services to better address the needs of individuals with mental health and substance use concerns. Resources are available to help physicians screen for behavioral health problems and refer individuals to appropriate treatment. SAMHSA's Center for Substance Abuse Treatment has a Targeted Capacity Expansion Program that offers grants in support of outreach to specific populations.

The challenges outlined in this chapter are burdensome but can be overcome. Many organizations have been able to develop cultural competence over time (for a historical perspective of one organization's journey, see Exhibit 4-7). A well-defined and organized plan, coupled with a consistent organizational commitment, will enable organizations to initiate and accomplish the tasks necessary to promote culturally responsive services.

Exhibit 4-7

Cultural Competence Initiative Across Time in One Organization.