Culturally Competent Practice
Abstract and Keywords
This entry defines cultural competence and culturally competent practice and focuses on cultural awareness, knowledge acquisition, skill development, and inductive learning as key components. It traces the historical development of cultural competence in the disciplines of psychology and social work, pointing out how cultural competence has become a professional standard. Cultural competence has also been recognized on the federal and state health and human services levels. Cultural competence is viewed on the practitioner, agency, and community levels as well as the micro, meso, and macro dimensions. Among the implications for practice are the issues of cultural competence and cultural competencies, the ethics of cultural competence, social context, and biculturation and multiculturalization.
Keywords: biculturation, cultural awareness, cultural competence, cultural competencies, cultural identity, culturally competent practice, culture, ethics, inductive learning, knowledge acquisition, multiculturalization, skill development, social and economic justice, social context
Cultural competence has been defined as “a set of congruent practice skills, behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations. It is the ability to demonstrate skills and knowledge which enable a person to work effectively across cultures; the ability to provide mental health treatment within the cultural framework of the consumer; the ability to provide effective services to people of a specific cultural background, including one different from the provider” (Substance Abuse and Mental Health Services Administration, 1997, p. 1). Elsewhere Orlandi (1992, pp. 3–4) explained cultural competence as “a set of academic and interpersonal skills that allow individuals to increase their understanding and appreciation of cultural differences and similarities, within, among and between groups. This requires a willingness and ability to draw on community-based values, traditions, and customs and to work with knowledgeable persons of and from the community in developing focused interventions, communications, and other supports.” As a further step Lum (1999) coined the term culturally competent practice to integrate cultural competence into social work practice. Fong and Furuto (2001) and Fong (2004) also adopted this concept in their books. Thus, culturally competent practice has become an integral part of diversity and practice among social work educators and professional practitioners.
The focus of this entry is to provide an overview of culturally competent practice, review the history of this practice model, discuss different perspectives on this practice model, and specify implications for practice at all levels. It is hoped that the reader will be motivated to incorporate culturally competent practice in his or her helping repertoire.
An Overview of Culturally Competent Practice
Culturally competent practice has focused on the individual, professional education, practice model, and system levels. LaFromboise, Coleman, and Gerton (1993) state that a culturally competent individual possesses a strong personal identity, has knowledge of the beliefs and values of the culture, and displays sensitivity to the affective processes of the culture. Cultural competence is a part of a continuum of social skill and personality development. This concept encompasses an individual's sense of self-sufficiency and ego strength; cultural identity related to culture of origin and cultural context; and knowledge, appreciation, and internalization of basic beliefs of a culture.
From a practice perspective, cultural competence may also be understood as the development of academic and professional expertise and skills in the art of working with culturally diverse clients. A starting point is the fostering of cultural awareness. The social worker becomes culturally effective with the client when the worker develops cultural awareness through an exploration of his or her own ethnic identity, cultural background, and contact with ethnic clients. Furthermore the social worker must develop a knowledge acquisition perspective and a set of skills in order to work with multicultural clients. Knowledge acquisition provides a body of facts and principles that serve as guidelines to best assist the problems and cultural or ethnic dimensions of the particular client. Skill development applies knowledge acquisition to actual practice with clients from a culturally competent perspective. It also addresses the service delivery structure that ought to be in place for client services. Finally, culturally competent practice must constantly uncover new facts about multicultural clients through an inductive learning process (Lum, 2007).
How broad an understanding does culturally competent practice extend itself? Should it be used in a narrow sense to focus on ethnicity and culture or can it be applied in a broader sense that may encompass a general view of culture? Green and Hucles-Sanchez (1994) suggest that cultural competence should incorporate differential historical, political, socioeconomic, psychophysical, spiritual, and ecological realities, their interaction, and its impact on individuals or groups. Culture is understood in its broadest sense to include race, ethnicity, gender, and sexual orientation and other dimensions of individual or group experiences that are relevant to their understanding of the world and of themselves. Here culturally competent practice must be aware of its context as far as relevant individual or group characteristics are concerned and must highlight these unique differences as culturally appropriate. Adjusting the dimensions of cultural competence to fit the worker's and the client's perspectives and viewpoints are paramount to the helping process.
A Historical Review of Culturally Competent Practice
The fields of psychology and social work respectively have contributed much of the pioneering thinking about cultural competence. The American Psychological Association (APA) in 1980 adopted a professional competence practice requirement and recognized cultural competence as an essential element of competent practice (APA, 1980). In 1982 a major position paper on cross-cultural counseling competencies advocated that there be specified multicultural knowledge, awareness, and skill areas in counseling psychology (Casas, Ponterotto, & Gutierrez, 1986; Ibrahim & Arredondo, 1986). Green (1982) and Pinderhughes (1989) introduced the concept of cultural competence to social work. However, Terry Cross in 1989 developed the first full-scale organizational paradigm on cultural competence and is considered the father of cultural competence. Cross, a First Nation Peoples MSW social worker and the executive director of the National Indian Child Welfare Association, and others published a monograph (Cross, Bazron, Dennis, & Isaacs, 1989) formulating six anchor points along a cultural competence continuum regarding an organizational system of care, which is considered the first systematic treatment of cultural competence.
In April 1992 the Association for Multicultural Counseling and Development (AMCD) was an influential group, which lobbied for multicultural content, and the Professional Standards Committee of the American Association for Counseling and Development proposed 31 multicultural counseling competencies to the APA (Sue, Arredondo, & McDavis, 1992). Also in 1992 a paradigm model of the characteristics of a culturally competent counselor and the dimensions of cultural competence was constructed (Sue et al., 1992). By 1993 the APA had committed itself to multicultural competence (APA, 1993).
On the federal and state levels, cultural competence has been recognized as an essential ingredient in the health and human services arena. The U. S. Public Health Service Office for Substance Abuse Prevention has published a series of monographs that integrated cultural competence, alcohol and drug abuse treatment programs, and ethnic groups and community. (Orlandi, Weston, & Epstein, 1992). The Title IV-E child welfare training grant under the auspices of the California Social Work Education Center at the University of California (CalSWEC), Berkeley (1996) identified 14 cultural competencies according to population groups, child welfare knowledge, and practice skills. Such states as California (1997) and New York (1998) have articulated cultural competence plans on the state and county levels. California was concerned about planning culturally competent mental health services, while New York developed cultural competence performance measures for managed behavioral health care programs. New Jersey (Adams, 2005) passed a 2005 law requiring physicians to take cultural competency training as a part of licensure. The 2005 CalSWEC II Mental Health Initiative identified two sets of mental health competencies at the foundational and advanced levels with sections on culturally and linguistically competent practice competencies in accordance with the 2004 California Mental Health Services Act and the 2003 California Mental Health Master Plan: A Vision for California.
The National Association of Social Workers (NASW) has a section on cultural competence (1.05 a, b, c) in their NASW 1999Code of Ethics and issued in 2001 ten Standards for Cultural Competence in Social Work Practice covering ethics and values, self-awareness, cross-cultural knowledge, cross-cultural skills, service delivery, empowerment and advocacy, diverse workforce, professional education, language diversity, and cross-cultural leadership. Thus, there is steady growth in the development of culturally competent practice.
Different Perspectives on Culturally Competent Practice
One might view culturally competent practice based on levels and dimensions. Miley, O'Melia, and DuBois (1998) discuss three levels: practitioner, agency, and community. On the practitioner level, the worker must know about self-awareness in terms of personal values and cultural heritage, value differences and conflicts regarding assimilation and cultural pluralism, and awareness of the cultures of others, especially clients. In terms of agency level cultural competence, workers should be trained in the skills necessary for diversity-sensitive practice, and multicultural awareness and functioning are promoted in organizational structure and program delivery. For example, Kaiser Permanente (2004) has published an educational monograph on cultural competence and has established Centers of Excellence in Cultural Competence targeting specific populations, while BlueCross BlueShield of Florida (2004) has instituted internal diversity training and cultural competence education for providers. The community level is concerned about the promotion of a context of pluralism, celebration of diversity, promotion of cross-cultural interaction, and social justice. Cultural competence in health care services has sought to provide interpreter services; recruit and retain minority staff; provide training to increase cultural awareness, knowledge, and skills; coordinate with traditional healers; use community health workers; incorporate culture-specific attitudes and values into health promotional tools; include family and community members in health care decision making; locate clinics in geographic areas that are easily accessible for certain populations; expand hours of operation; and provide linguistic competency beyond the clinical encounter to the appointment desk, advice lines, medical billing, and other written materials.
Cultural competence can be viewed on the micro, meso, and macro dimensions. Micro cultural competence involves the client and the social worker. The client acquires cultural competence from personal background and development. The client has the task of sorting out his or her culture of origin and elements of the dominant culture to achieve bicultural integration and bicultural competence. Likewise, the worker develops expertise and skills through education and through working with culturally diverse clients. Meso cultural competence addresses the organizational level to determine whether an organization has a culturally competent system of care. Cross et al. (1989) create a cultural competence continuum for an organizational system of care: (a) cultural destructiveness (attitudes, practices, and policies that promote the superiority of the dominant culture and attempt to eradicate the inferior and different culture); (b) cultural incapacity (attitudes, practices, and policies that adhere to separate but equal treatment and tend toward segregated institutional practices); (c) cultural blindness (attitudes, practices, and policies that have an unbiased view of undifferentiated elements of culture and people and treat all people as assimilated); (d) culturally open organization (attitudes, practices, and policies that are receptive to the improvement of cultural services through staff hiring practices, training on cultural sensitivity, and minority board representation); (e) culturally competent agency (attitudes, practices, and policies that demonstrate respect for different cultures and people by seeking advice and consultation from ethnic and racial communities and by being committed to incorporating these practices into the organization); and (f) cultural proficiency (attitudes, practices, and policies that are sensitive to cultural differences and diversity, improve cultural quality of services through cultural research, disseminate research findings, and promote diverse group cultural relations). A culturally competent organization and service delivery system should value diversity, have the capacity for cultural self-assessment, be conscious of the dynamics of cultural interaction, institutionalize cultural knowledge, and develop programs and services that promote diversity between and within cultures. Macro cultural competence refers to large system efforts to address cultural competence issues and programs. On the national level the National Center for Cultural Competence (NCCC) has been a leadership force at the Georgetown University Child Development Center. Its mission is to increase the capacity of health care programs to design, implement, and evaluate culturally competent service delivery systems. The center serves as the clearinghouse for planning, policy, and programs related to cultural competence (see http://gucchd.georgetown.edu/nccc/pa.html).
Implications for Practice
Culturally competent practice is emerging as an integral part of social work practice and education. It offers a new complementary orientation and standard to culturally diverse social work practice. Cultural competence is the subject area that relates to the cultural awareness of the worker and the client and their mutual backgrounds, knowledge acquisition about historical oppression, and related theories of understanding the multiple dimensions of the human person; skill development to deal effectively with the needs of the culturally diverse client; and inductive learning, which heuristically processes new information about emerging new populations. Cultural competencies involve turning culturally competent areas and concepts into specific and measurable statements. Leung and Cheung (2001) identify five clusters of competencies, which are useful in categorizing: (a) informational competencies (ethnic differences, family history, minority identity development); (b) intellectual competencies (information gathering, assessment, goal setting); (c) interpersonal competencies (relationship building, communication skills); (d) intrapersonal competencies (values and attitudes; personal qualities and characteristics); and (e) intervention competencies (family and cultural expectations, support systems, family acculturation, termination). In this sense there is a need to develop a conversation between measure-seeking cultural competencies and evidence-based practice.
The ethics of cultural competence reaffirms that social work ethics has a connection to cultural competence. Ethics are based on the values that we have as individuals and as professionals, which guide our choices based on our sense of right and wrong and on ideals such as the highest good, the promotion of fairness, or the moral duty and obligation that we have to ourselves, others, our profession, our community, and to a higher being. At times our ethical guidelines force us to make a tragic moral choice where we must choose the lesser of the two evils because the two or more available selections are less than ideal. Along with the cultural competence components of the NASW Code of Ethics and the Standards for Cultural Competence in Social Work Practice, which were previously mentioned, are some ethical moral guidelines and cultural beliefs and practices that comprise an ethical notion of cultural competence: the acknowledgement of the importance of culture in people's lives; the respect for cultural differences; the minimization of any negative consequences of cultural differences, which has a discriminatory effect on persons or groups; the assessment of personal cultural values, acknowledging the existence of a cultural lens that shapes our interpretations of the world; the understanding and acknowledgement of the historical relationship between your own culture and other cultural groups; and the creation and dissemination of institutional cultural knowledge, which recognizes and honors diversity (Lum, 2007, p. 22). The highest ethical value and the striving goal of the social work profession is social and economic justice. Social justice governs how social institutions deal fairly or justly with the social needs of people as far as opening access to what is good for individuals and groups. Economic justice encompasses moral principles of how to design economic institutions, policies, programs, and practices so that a person can earn a living, enter into social and economic contracts, and exchange goods and services in order to produce an independent material foundation for economic sustenance. How we articulate and shape our personal and professional ethics and our sense of social and economic justice have implications for how we practice cultural competence.
Social context is an important factor in culturally competent practice. Contextual social work practice is concerned with the person and the environment or situational setting. Lum (2007) discusses person-centered context and environmental-centered context. The former is concerned about the unique characteristics of diverse people, that is, what makes a person similar to and different from another person, while the latter explores the social environmental issues of racism, sexism, homophobia, discrimination, and oppression. The term context implies the “joining and weaving together” of textures that are surrounding or immediately next to parts that create how a situation, background, or environment is structured or put together. In social work we discuss the social context in terms of the person and the environment or the psychosocial perspective. That is, we are concerned about understanding the important characteristics of the person and the environment as well as the interaction between the person and the environment. This is the core meaning of social context.
Finally there has been a major paradigm shift to biculturation and multiculturalization. Fong (2001) called for the recognition of the interracial interblending of cultures in a single ethnic group and the need for assessments and interventions to deal with multiethnic identities and the differing environments of clients. This is a timely shift away from a static description of various people of color ethnic groups, particularly as we recognize the multiple identities of people and the intersectionality of their backgrounds (Guadalupe & Lum, 2005). That is, a growing number of people are multiracial in ethnic identity and understand themselves along ethnic, gender, social class, and sexual orientation lines. The question then becomes: What is the particular set of individual, family, group multicultural variables that must be identified in order to understand the client? Can we then make a case for a broad and new sense of cultural identity? Fong (2001) goes on to state that values and belief systems comprising traditions and cultural norms are central to understanding the ethnic client's functioning.
The starting point is the indigenous culture itself, particularly the ethnic social environment of the client and the parallel use of Euro-American norms as a complement to the client's ethnic reality. One might call this a multicultural social construction approach. That is, to fully understand and work with a client, the worker must start with the client's cultural context (the culture of the client and his or her surrounding environment) and find useful cultural helping approaches. Next the worker should identify useful and complementary social work interventions that support the cultural ones. It is not an either/or approach; rather, it is a both/and, side-by-side integration of the helping process from both perspectives.
The particular paradigm model of the preceding shift is Fong, Boyd, and Browne's (1999) biculturation of intervention approach. It brings together the client's culture and world view and the adaptation of Western interventions. This model incorporates appropriate ethnic group norms and practices, and supplements them by using Euro-American practices as well. It is analogous to the Asian approach of integrating and blending Eastern and Western medicine where there is a common belief and practice of using Eastern herbal medicine and Western medication and surgery. Fong et al. (1999, p. 105) identify the important values in the ethnic culture that can be used to reinforce therapeutic interventions; chooses a Western intervention whose theoretical framework and values are compatible with the ethnic cultural values of the family client system; analyzes an indigenous intervention familiar to the ethnic client system in order to discern which techniques can be reinforced and integrated with a Western intervention; develops a framework and approach that integrates the values and techniques of the ethnic culture with the Western intervention; and applies the Western intervention, at the same time explaining to a client family how the techniques reinforce cultural values and support indigenous interventions.
In short, culturally competent practice is a healthy and thriving sibling of competency-based and evidence-based social work practice. Culturally competent practice will thrive and grow as social work educators and practitioners thoughtfully reflect on their theoretical knowledge and practical experiences with ethnic and culturally diverse clients.
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