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Running head: CULTURAL COMPETENCE 1

Cultural Competence and the African American Community:

A Meta-Analysis of the Implementation of Cultural Competency

Training Programs in the United States

A Research Paper

Presented to

The Faculty of the Adler Graduate School

____________________

In Partial Fulfillment of the Requirements for

the Degree of Master of Arts in

Adlerian Counseling and Psychotherapy

____________________

By:

Nina D. Mattson

November 2012

CULTURAL COMPETENCE 2

Abstract

In the United States today many mental health practitioners recognize the cultural disparities

among their clientele. They have acknowledged the need for cultural competency training in

order to obtain the skills needed to provide more proficient mental health services to the minority

clients for whom they do have the opportunity to provide services. In response to this need, a

number of state and federal initiatives have been created in order to address these disparities and

conduct research that will allow members of this profession to gain insight into the unmet needs

of minorities, in particular African Americans. Despite the need for mental health services

among the African American populations in our country, a large number of mental health clinics,

practices and academic institutions have done little to implement programs designed to help

increase the cultural competence of mental health practitioners. The purpose of this meta-

analysis is to examine the available research which addresses the reasons behind the low

numbers of African Americans’ utilization of mental health services, the disparities among

mental health care being received by African Americans, a review of successful cultural

competency programs, and of the current trend of cultural competency training program

implementation in the United States.


Acknowledgements

Theodore Mattson: My Bronze Star recipient; Thank you for your service! Without your

sacrifice none of this would have been possible. Thank you also for believing in me and

making it possible for be to obtain my dream.

Theodore Mattson II & Tristan Mattson: Thank you for your patience and support over the past

two years. I appreciate your willingness to take on extra responsibilities around the house

in order to allow me the time I needed to complete my homework assignments. I am

amazed by your creativity and ability to adapt to my ever changing schedule. Thank you

for sacrificing some of your “mommy and me” time to allow me to fulfill my dream.

Frank & Marie Caples: I thank you for believing in me and raising me to believe that I can

accomplish whatever I set my mind to. Both of your strengths and resilience have been an

inspiration to me and will continue to be the driving force behind all my successes in life.

Dr. Marina Bluvshtein: Your encouragement, passionate instruction, patience and strong tutelage

helped me to obtain success and for that I will be forever grateful. You have been a

blessing to not only myself, but many Adler students seeking a little something more than

scholastic support. Your wealth of knowledge has been a valuable asset to me and I thank

you for sharing it with me.

Adler Graduate School’s faculty and staff: I would like to thank the numerous faculty members

at Adler Graduate School who have given me guidance and support over the past two

years. Without your encouragement my success would not have been possible. I

appreciate all of your patience, guidance and hard work in order to help me succeed.


Table of Contents

Abstract…………………………………………………………………………………....Page 2

Acknowledgements……………………………………………………………………….Page 3

Table of Contents………………………………………………………………………...

What is Cultural Competence and Why is it Important?...............……………………Page 5

Mental Health Needs of African Americans……………………………………………Page 7

Necessity for Cultural Competence Training ………………………………………….Page 11

Methods & Techniques…………………………………………………………………. Page 16

Conclusion………………………………………………………………………………...Page 30

References……………………………………………………………………………….. Page 33

Resource List……………………………………………………………………………. Page 35


Cultural Competence and the African American Community: A Meta-Analysis of the

Implementation of Cultural Competency Training Programs in the United States

According to the United States Department of Health and Human Services Office of

Minority Health the definition of Cultural Competence, which was adapted by an earlier

definition from Cross (1989), is as follows:

Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies

that come together in a system, agency, or among professionals that enables effective

work in cross-cultural situations. 'Culture' refers to integrated patterns of human behavior

that include the language, thoughts, communications, actions, customs, beliefs, values,

and institutions of racial, ethnic, religious, or social groups. 'Competence' implies having

the capacity to function effectively as an individual and an organization within the

context of the cultural beliefs, behaviors, and needs presented by consumers and their

communities. (HSOMH, 2001, p. 28)

Furthermore, Cross, Bazron, Dennis, and Isaacs (1989) have defined five components that serve

as a guideline in order help describe cultural competence for professional helpers as was

published in the HSOMH manual: “Valuing diversity, having the capacity for cultural self-

assessment, being conscious of the dynamics inherent when cultures interact, having

institutionalized cultural knowledge, and having developed adaptations of service delivery

reflecting an understanding of cultural diversity” (HSOMH, 2001, p. 5).

In the United States today, Cultural Competence is a growing topic among mental health

professionals. Both practice based and evidence based research support a need for change among

current educational training programs. According to Cunningham of the Department of

Psychiatry and Behavioral Sciences at the Medical University of South Carolina, in Charleston,


S.C., as quoted in an article published on the Models for Change website (2011): “One argument

for utilizing more culturally competent care is the low retention rate of some ethnic groups; for a

variety of reasons, many drop out of programs prematurely and as a result, they don’t receive a

full dosage of treatment” (para.7).

There may be a multitude of reason why ethic minorities in the United States are not

utilizing mental health services at a higher rate; however, research strongly suggests that it is

primarily due to the lack of cultural competence of mental health practitioners. In a study

published byTummala–Narra, P., Singer, R., Li, Z. et al. (2012) and federally funded by the

Mental Health Services Act, which measure the self-perception of the level of cultural

competence among licensed practitioners, evidence based research revealed higher levels of

cultural competence correlate with higher levels of cultural competency training. The

participants in the study were comprised of 64. 3% Caucasian, 8.7% African American, 10.7%

Latino, 4.1 % Asian, 2.6% Asian Indian, 4.6 % Jewish, 1 % Middle Eastern & 4.1 % were

biracial. The results showed that of 196 participants, those who perceived a higher level of

competence and those who actually did have a higher level of competence when working with

ethnic minorities correlated with the amount of cultural competency training received among the

participants prior to participating in the study. The results indicated that with training, more

practitioners can become culturally competent when working with ethnic minorities. However,

despite the growing number of cultural competence initiatives available to mental health

practitioners, there still remains a lack of implementation of cultural competence training

programs across the United States.


Mental Health Needs of African Americans

Cultural competency is a necessity for mental health professionals because understanding

one’s clients is crucial to our ability to provide effective mental health treatment. Trust is a

crucial element when building a counseling relationship with clients, without it our services

become ineffective. Without a better understanding of our clients, it would be difficult to create

client-therapist trust. Furthermore, for a Caucasian therapist, becoming truly open minded may

be difficult, especially when we here in the United States are all governed by the laws, norms

and beliefs of Western Europeans. When your own familial traits replicate those of your nation,

it become conceivable that your personal values are applicable to all, and it may be difficult to

avoid placing judgment on others whose values differ from your personal structure of beliefs.

More African Americans need to obtain the credentials necessary in order to become mental

health professionals. Furthermore, mental health professionals in general need to educate

themselves about the community in order to acquire the ability necessary to help African

American clients accomplish significant therapeutic change. Research provided by the Surgeon

General’s report found that; (Empirical data provided by the 2001 U.S. Surgeon General

Supplemental Report produced the following relevant information about the African American

community):

African-American physicians are five times more likely than white physicians to treat

African-American patients. African-American patients who see African-American

physicians rate their physicians’ styles of interaction as more participatory. African

Americans seeking help for a mental health problem would have trouble finding African

American mental health professionals. (U.S. Surgeon General, August 2001)

The following statistics were also provided (U.S. Surgeon General, August, 2001);


Nearly 1 in 4 African Americans is uninsured, compared to 16% of the U.S.

population. Rates of employer-based health coverage are just over 50% for

employed African Americans, compared to over 70% for employed non-Hispanic

whites. Medicaid covers nearly 21% of African Americans.

Overall, only one-third of Americans with a mental illness or a mental health

problem get care. Yet, the percentage of African Americans receiving needed care

is only half that of non-Hispanic whites. One study reported that nearly 60% of

older, African-American adults were not receiving needed services.

African Americans are more likely to use emergency services or to seek treatment

from a primary care provider than from a mental health specialist. Moreover, they

may be more likely to use alternative therapies than are whites.

With the information provided about the African American community and their view and

utilization of mental health services we as practitioners may begin to acknowledge the differing

life experiences of our clients and gain a better understanding of how to embrace the culture of

others without imposing our own beliefs and values on their style of living.

In 1996, Mental Health America (MHA) conducted a national survey which examined

clinical depression within the African American community and illustrates the variety of African

American mental health needs. The study found that this community has a different view of the

necessity of mental counseling due to viewing depression for example as “the blues” and not a

clinical diagnosis. According to this study sixty three percent of African Americans view

depression as a “personal weakness”, which is significantly higher than the survey average of

fifty four percent. The study also found;


Only 31 percent of African Americans believed that depression was a ‘health problem’,

African Americans were more likely to believe that depression was ‘normal’ than the

overall survey average, 56 percent believed that depression was a normal part of aging,

45 percent believed it was normal for a mother to feel depressed for at least two weeks

after giving birth. (Mental Health America, 2012,Para. 9-11)

The study goes on to show that:

40 percent believed it was normal for a husband or wife to feel depressed for more than a

year after the death of a spouse, Barriers to the treatment of depression cited by African

Americans included: Denial (40 percent), Embarrassment/shame (38 percent), Don’t

want/refuse help (31 percent), Lack money/insurance (29 percent), Fear (17 percent),

Lack knowledge of treatment/problem (17 percent), Hopeless (12 percent) African

Americans were less likely to, take an antidepressant for treatment of depression; only 34

percent would take one if it were prescribed by a doctor. (MHA, Para. 12)

The findings of the MHA are significant because they are indicative of the low numbers of

African American clients enlisting our services as mental health professionals. The study does

not indicate that there is a lack of mental health issues in this community. Now that studies such

as this one and those aforementioned in this analysis have shown by conducting evidence based

research that there exists a need for mental health services in this community, the indication

does, however, support the notion that there may be a lack of implementation of cultural

competency training within the mental health community among other issues.

Based on the findings of MHA, it is apparent that the majority of participants appeared to

have both cultural and socio-economic reasons for not seeking mental health counseling. It is

apparent that the cultural views of depression held by African Americans would not lead them to


seeking mental health treatment. This indicates that besides cultural competency training,

community education about mental illness, in particular depression is needed in this community.

The African American Health Institute of San Bernadino California initiated a community

education program in order to educate African American about mental health disorders, however,

this writer feels this type of initiative would better serve this community if also implemented on

a national scale. In order to prepare for an influx of new clients from this community, therapists

need to be prepared by gaining more knowledge about cultural views of mental illness among

this and other minority groups.

There are also some limitations to this study as it is fully support by government funding

and the results are based solely on participants living in the state of California. Also, when

reviewing the results of this study it was not clear why African Americans were being over

diagnosed and under treated and whether or not the disparities between the levels of health care

coverage of Caucasians versus African Americans had been taken into consideration.

Despite its limitations, its results are nonetheless important as they provide useful

implication regarding the issues faced by African Americans across the country as indicated by

U.S. Surgeon General’s report on mental health in the United States.

Overall, the MHA study indicates that no matter what the causes, there is a need to bridge

the gap between mental health professionals and African Americans with mental illness.

Responding to this need are numerous cultural competency programs which are being funded

both privately and publicly through government funding initiatives among state and local

agencies. These agencies are available to not only mental health professionals but many other

service oriented agencies in the health field and beyond.


Numerous cultural competency training programs have been put in place in order to help

provide the tools mental health professionals need in order to learn how to become more

culturally sensitive when working with minority clients, however, despite the breadth of these

training programs, they are not being implemented, as there remains large numbers of mental

health professionals who do not consider themselves culturally competent without the

appropriate training, as indicated in the aforementioned study conducted by Tummala–Narra, P.,

Singer, R., Li, Z. et al.

Necessity for Cultural Competence Training

In order to further investigate cultural competence implementation deficiencies in the

United States, this writer has chosen to review evidence based research and practice based

studies focused on the topic of cultural competence and mental health practitioners in addition to

mental health issues and the African American Community. This writer will also discuss cultural

competence program models currently available in the United States, as well as several methods

and techniques that may be utilized when working with African American clients.

The purpose of becoming a culturally competent mental health professional is to learn

how to better serve our underserved populations in a therapeutic setting, in particular, the African

American community. Cultural competence training is important because a number of studies

have found that there are significant cultural differences between Caucasians and ethnic

minorities due to different styles of life as well as different cultural perceptions regarding mental

health. Research conducted by the Surgeon General examines cultural differences among African

Americans and found that there are discrepancies among the services being provided and how

they are being utilized by this community. Because the majority of mental health practitioners

are Caucasian in the United States according to the 2000 U.S. Census Report conducted by the


U.S. Surgeon General, the discrepancy may in be indicative of a lack of cultural competence on

the part of the practitioners which may lead to a significant number of misdiagnosis and

placements of treatments being provided as well as services. When reviewing several evidence

based articles and several practice based articles on this topic it became apparent that there is a

significant need for mental health services within this community, however this writer was

unable to discern whether or not it was due to actual diagnosable mental disorders or the

misdiagnosis of mental disorder. According to the California Department of Mental Health:

There are pertinent differences between African Americans and Whites in the U.S. (in

scientific reports Whites are still considered the reference population because they are

the majority population). African Americans are 30% more likely to be diagnosed with

serious psychological distress than Whites, and in 2007, were 50% more likely to report

symptoms of depressive episodes. However, Whites are more than twice as likely to

receive antidepressants prescription treatments as are African Americans. (CDMH, 2009

p. 5)

In order to encourage African American clients to seek mental health services and avoid

misdiagnosis among the African American clients that do seek mental health services,

psychological organizations need to set the standard by requiring professionals in this field to

become properly trained by implementing cultural competency training in our colleges,

universities mental health clinics and through the offering of Continuing Education Units

(CEU’s). In 2012 Yeung published an article which was based on a report on African Americans

commissioned by the state of California, Annelle Primm, the American Psychiatric

Association’s deputy medical director and director of its Office of Minority and National Affairs

stated:


Due to lack of cultural understanding, some clinicians may misdiagnose African

American patients. For instance, it is well documented in the literature that African

Americans have been over diagnosed with schizophrenia and underdiagnosed with

illnesses like major depression and bipolar disorder. Expressing 'healthy paranoia,'

regarded as a survival skill among African Americans, may prompt an uninformed

clinician unfamiliar with African American culture to consider this as a symptom of

schizophrenia or psychosis. (Yeung, 2012, Para. 4)

Although there is a need for more mental health practitioners to become culturally

competent and an abundance of cultural competency training programs available, there still

remains a lack of cultural competence training program implementation across the United States,

there. This is important because if African Americans’ perception of mental health symptoms

vary from those of Caucasian, our profession will need more culturally competent practitioners

who have the ability to recognize and address these differences in order to avoid misdiagnosis

and clients’ under reporting of symptoms. Furthermore, the reason for misdiagnosis of African

Americans may also be attributed to under reporting of symptom. For example, one study

showed that African Americans are less likely to report symptoms of depressive episodes may be

attributed to their culturally shaped views of depression and the utilization of mental health

services in general (MHA, 1996).

Notable Cultural Competence Training Programs

In support of this research that this writer has found indicates that training our future

counselors to become competent when working with ethnic minorities is beneficial not only to

the clients but also serves as a vehicle which promotes positive social change. In response to the

need for cultural competency training among professional helpers in the United States, several


non-profit organizations such a Mental Health America (formerly known as The National Mental

Health Association), the National Center for Cultural Competence (NCCC) of the Center for

Child and Human Development at Georgetown University and centers such as the Nathan Kline

Institute (NKI) Center for Excellence in Culturally Competent Mental Health, along with several

organizations who offer to provide funding in support positive social change such as the John D.

and Catherine T. MacArthur Foundation and several federal government agencies across the

United States.

Professional Requirements for Cultural Competence Training

Many colleges and university graduate level programs often require students to take a

multicultural counseling courses, many professional counselors are encouraged to become more

culturally sensitive, however, studies as recent as 2009 show that the percentage of African

American enlisting mental health services remains lower than those of other cultural groups. The

number who reported having a mental illness is also quite low. According to a report about the

African American population in the United States:

Any mental illness among adults aged 18 or older is defined as currently or at any time in

the past year having had a diagnosable mental, behavioral, or emotional disorder

(excluding developmental and substance use disorders) of sufficient duration to meet

diagnostic criteria specified within the DSM-IV, regardless of their level of functional

impairment (APA, 1994). In 2009, about 17% of Asian, Native Hawaiian/Other Pacific

Islander, Hispanic, and African American groups reported having any mental illness.

Whites and American Indians/Alaska Natives were a little higher at 21%. The highest

prevalence (32.7%) of any group who reported having any mental illness was among

persons of two or more ethnicities. (Woods, 2009, Para. 6.2)


There may be many reasons that ethnic minorities are reporting mental illness at a lower rate that

Caucasian Americans, however as further research indicates this reason is largely due to a lack of

cultural competence among mental health professionals, the majority of which in the U.S. are

largely Caucasian. According to the MHA’s report on African American Communities and

Mental Health based largely on the 2000 US census report; “In 1998, only 2 percent of

psychiatrists, 2 percent of psychologists and 4 percent of social workers said they were African

Americans”. Low numbers of African American mental health professionals at that time may be

another reason why African Americans may not consider enlisting mental health service as a

viable option. Part of seeking this type of service is to gain insight into one’s personal mental

health issues. When doing this it is important that one feels that their personal norms, beliefs and

values will be understood, rather than discounted or being judged by someone who may not

understand their and their community’s value system and beliefs. This may indicate yet another

reason for the low number of African Americans who are willing to enlist the services of mental

health professionals in the United States.

According to Sue part of the issue may be that many practitioners are choosing not to

seek cultural competence training due to their belief that treating everyone the same is sufficient

for working with this community, when in fact this is not sufficient. According to Sue (p. 122,

2009):

Mental health professionals who enter the field usually have a strong desire to help

clients regardless of race, creed, gender, and so on. They operate under the dictum of

‘liberating clients from their distress and doing no harm’ whenever possible. Because

helping professionals view themselves as just, fair, and non-discriminating, they find it

difficult to believe that they commit microagressions and may be unhelpful and even


oppressive. The fact that therapists possess unconscious biases and prejudices is

problematic, especially when they sincerely believe they are capable of preventing these

attitudes from entering the session. (Sue, 2009, p. 122):

Furthermore, by not acknowledging the client’s culturally unique qualities and

differences, the therapist may be sending the message to the client that their cultural experiences

are unimportant and not worth acknowledging (Sue, 2009).

Methods and Techniques

In order to understand the culture of others we must first accept the belief that there are

many different ways to conduct ourselves in society and whether or not we agree with them, we

need to learn to embrace and accept them. This is not to say that we cannot hold clients

accountable for their actions because we still must uphold the basic laws that govern our country.

For example, if a male Pakistani client tells you that last week he punished his wife for being

insolent and he hit her several times with a cane so that she would learn from her mistakes, and

then he tells you that it was the right thing to do because in his culture that is how such insolence

is handled. The laws of our country do not allow one person to physically assault another. The

correct response would be to explain to the client that you are a mandated reporter and what that

means, and then refer the client to your informed consent agreement, followed by explaining that

as a mandated reporter you must report the abuse, as no allowance for cultural differences can

supersede the current laws that govern our country.

According to Sue:

Many social scientists (Boyd-Franklin, 2003; Duran, 2006; Guthrie, 1997; Halleck, 1971)

believe that psychology and therapy may be viewed as encompassing the use of social


power, and that therapy is a handmaiden of the status quo. The therapist may be seen as a

societal agent transmitting and functioning under Western values. (Sue, 2007, p. 141)

As mental health practitioners, we must also be aware of inadvertently exposing our

clients to our own biases through microagressions such as microassaults and microinsults which

Sue et al (2007) defines as; “brief and commonplace daily verbal or behavioral indignities,

whether intentional or unintentional, that communicate hostile, derogatory, or negative racial

slights and insults that potentially have harmful or unpleasant psychological impacts on the

target person or group.”. Once aware of your own cultural beliefs, you will begin to recognize

the existence of other cultural norms, beliefs and values. Therefore, as a mental health

practitioner who will be working with a wide variety of clientele from a variety of cultures,

gaining a better understanding of one’s own cultural beliefs is a crucial component to becoming

an effective and culturally competent practitioner. According to Sue: “In almost all human

service programs, counselors, therapists and social workers are familiar with the phrase: “know

thyself”. Programs stress the importance of not allowing our own biases, values or hang-ups to

interfere with our ability to work with clients” (Sue, 2007, p. 44). In the above quote Sue points

out the significance for a practitioner to have a good understanding of their own culture and this

writer supports the idea of self evaluation of one’s own culture as it seems to be a good way to

gain knowledge of our limitations and gives us the opportunity to expand our cultural

understanding of others.

Based on the research of Sue acknowledging the differences between a client and

therapist is acceptable. It is advisable for therapist to ask questions, to be unafraid to take the role

of the student, allowing the client to take the role as the teacher. It is not offensive to seek

knowledge about a cultural difference between yourself and the client. One aspect of becoming


culturally competent begins with becoming aware of how others communicate. According to Sue

(2007), who examined therapeutic interventions addressing the highly contextualized manner in

which various ethnic minorities prefer to communicate and which approaches are most

compatible with their style of communication is vital to becoming culturally competent. Sue

advised practitioners; “many minority clients prefer an active/directive approach to an inactive

nondirective one in treatment.” Therefore other Western approaches such as Person Centered

Therapy and Rogerian Psychotherapy, are incompatible with therapeutic approaches that are

recommended for use with African American populations.

In 2001, Sue developed a Multidimensional Model of Cultural Competence (MDCC)

which was designed for practitioners to use when working with minority clients. According to

Sue:

This was an attempt to integrate three important features associated with effective

multicultural counseling: (1) the need to consider specific cultural group’s worldviews

associated with race, gender, sexual orientation, and so on; (2) components of cultural

competence (awareness, knowledge, and skills); and (3) foci of cultural competence.”

Sue found that by using this model, practitioners may gain a clearer understanding of

how to become more culturally competent by learning the various contexts in which they

can relate with their minority clients. (Sue, 2007, p. 48)

Further support for the need to develop mental health instruments that are culturally

inclusive is found in the 2010 study conducted by Chao, Olson, Spaventa & Smith who

developed and tested the Multiculturally Sensitive Mental Health Scale (MSMHS) in an

empirical study. Significant data from their study revealed;


When we examined African Americans’ and Whites’ scores on the three subscales of the

MSMHS—Well Being, Depression and Anxiety—together with the

Racism/Discrimination subscale, we noted that racist experiences are related to well-

being, depression, and anxiety for African Americans, but not for Caucasian Whites.

Scholars and counselors alike may need to understand the components of mental health

by taking into account people’s cultural experiences. (MSMHS, 2010, p.9)

Their findings were significant and relevant to the need for cultural competency training among

mental health professionals working cross culturally with clients, in particular African

Americans.

The Effects of Racism and Oppression

Cultural competency should begin at intake but asking questions that directly address the

cultural dynamics of their lifestyle being presented while meeting with our clients and assessing

the level of perceived racism. According to Chao, Olson, Spaventa, & Smith:

Discrimination due to race is a culture-related stressor, thus the level of racism is a

critical variable in understanding the mental health of African Americans and other ethnic

minority groups (Constantine & Sue, 2006; Utsey, Chae, Brown, & Kelly, 2002).

Unfortunately, most current mental health measures are extrapolated from Whites’

perceptions of mental distress (Sue & Sue, 2008) and fail to include assessment of mental

health stressors due to discrimination or perceived racism. Culturally sensitive

assessment of mental health should include measuring perceived racism. The 2008 Sue

study developed the Multiculturally Sensitive Mental Health Scale (MSMHS) to respond

to the need to assess African Americans’ mental health, including perceptions of racism.

(Chao, Olson, Spaventa, & Smith, 2010, p. 10)


Their research is further support by Sue who also feels oppression is a factor that affects

the lives of minority populations, including African Americans. Sue states; “Rather than educate

or heal, rather than offer enlightenment and freedom, and rather than allow for equal access and

opportunities, historical and current practices have restricted, stereotyped, damaged, and

oppressed the culturally different in our society.” (Sue, 2007, p. 85) Acknowledgement and

assessment of the factors of racism and also oppression and how it affects our African American

clients is a crucial component of gaining insight into the cultural perspective of members of this

community.

Perceptions and depictions of African American culture among influential leaders, such as

the media and social scientists in our society here in the United States, are particularly damaging

and have long-lasting effects that lead to assumptions based on these malformed perceptions.

Therefore, this writer believes that the effects of oppression should be taken into consideration

when assessing African Americans for mental health issues. Being treated negatively by a majority

of your kinsmen because of the color of your skin, or your ethnicity would likely have lasting

psychological effects. In support of this theory a recent study conducted by conducted by

Mohanesh, Ibriahim, Templin, et al. states:

The results replicated the first study results as collective identity trauma has a negative

appraisal of collective trauma discrimination have the highest Beta coefficients on

predicting PTSD and CTD compared to other traumas. Further we found the same results

for predicting anxiety, depression and self annihilation. These findings, while partially

confirm the validity of some of the assumptions of the new taxonomy of traumas; pose

clinical challenges in the assessment and treatment of health and mental health clients,

especially minorities, as most assessment and treatment approaches tend to ignore such


trauma. Our interventions should be trauma informed, especially with a focus on

collective identity traumas effects, especially when dealing with minority populations.

(Mohanesh, Ibriahim, Templin, et al., 2006, p. 17)

According to Sue: “White social science” has tended to reinforce a negative view of African

Americans among the public by concentrating on unstable Black families instead of on the many

stable ones.” (Sue, 2007, p.71). Racial discrimination helps to perpetuate negative views of

African Americans and therefore is another factor that should be taken into consideration when

working with the African American populations. As members of a collectivist culture that are

also community focused, a negative social perception would logically have negative effects on

members of this community. According to the report by Chao, R.C.L., et al:

The omnipresence of racial discrimination over generations and in many areas of life has

been found to have significant adverse impacts on the quality of life for African

Americans. Depression, anxiety, tension, anger about racism (Harrell, 2000), and lower

life satisfaction and self-esteem (Constantine & Sue, 2006) are common problems in

psychotherapy (Landrine & Klonoff, 1996). Despite abundant studies on the relationship

between racism and mental health (e.g., Constantine & Sue, 2006), no scale today

includes an appraisal of the experience of racism as an origin of mental distress among

African Americans. Thus, we have four reasons for creating a culturally sensitive

instrument to assess the specific mental health problems of African Americans. (Chao,

R.C.L., et al., 2010, p. 2)

This writer felt that in order to fully examine all aspects of one’s clients, the

incorporation of the Multiculturally Sensitive Mental Health Scale (MSMHS) in the intake

process would be a helpful tool for use with African American clients. It would also be important


to incorporate cultural sensitivity training for mental health support staff who receives clients at

intake. Greeting an already hesitant client at a mental health clinic is an important task, as the

client will view their entire experience as a whole, including how they perceive both the support

staff and the therapist.

Other considerations at intake include addressing basic information about the style of life

of the client such as familial roles, socioeconomic status, employment, educational level and

goals, spiritual beliefs (affiliation, sect, denomination etc.) community roles and relationships

and ethnic identity. This report illustrates how the direct approach appeals to the collectivist

cultural beliefs of African Americans. The best way to find out information about your clients is

to ask them. When building a relationship with your African American clients, don’t make

assumptions, ask questions. Using a Genogram is a helpful tool that can be used in the first or

second session with a client to help mental health practitioners gain a better understand of the

clients family constellation and familial patterns that influence the client, which are indicators of

cultural influences in any client’s life.

Therapeutic Techniques

According to Sue (2007) African Americans tend to seek therapy in order to get the

answers to their problems from a collectivist perspective. Many therapists are trained to work

from a model that limits giving too much feedback, instead leading the clients to find answers for

themselves. To some extent this practitioner finds this to be a useful approach which encourages

more introspection among my clients. However, when working with African American clients,

this writer is more engaged and often relies on Cognitive Behavior Techniques (CBT) that seems

to be effective. Research by Sue supports more direct approaches when working with this

population. Sue states;


Therapists are expected to avoid giving advice or suggestions and disclosing their

thoughts and feelings—not only because they may unduly influence their clients and

arrest their individual development, but also because they may become emotionally

involved, lose their objectivity, and blur the boundaries of the helping relationship (Pack-

Brown & Williams, 2003). Parham (1997) states, however, that a fundamental African

principle is that human beings realize themselves only in moral relations to others

(collectivity, not individuality): “Consequently, application of an African-centered

worldview will cause one to question the need for objectivity absent emotions, the need

for distance rather than connectedness, and the need for dichotomous relations rather than

multiple roles. (Sue, 2007, p. 81)

Research conducted by Tummala–Narra, P., Singer, R., Li, Z. et al., which was referred to

earlier, found that practitioners using CBT methods with ethnic minorities were more successful

that other more popular theoretical based methods. According to Tummala–Narra, P., Singer, R.,

Li, Z. et al.:

A core competency of psychodynamic practice involves attending to unconscious

processes, and particularly the interpretation of unconscious conflict and related defenses

thought to serve both adaptive and pathological functions for an individual (McWilliams,

1999; Sarnat, 2010). A core competency of cognitive–behavioral practice is a focus on

the here and now, conscious thoughts, and behavioral change (Hays, 2009; Newman,

2010). The interactions between clients and therapists likely reflect these theoretical

distinctions, as cognitive–behavioral therapists may be trained to adopt a more directive

and self-disclosing position while psychodynamic therapists may be trained to adopt a


more nondirective and neutral position. (Tummala–Narra, P., Singer, R., Li, Z. et al.,

2012, p.172)

The authors of this study suggest that CBT methods may be more useful when working with

minority clients due it being a directive method, which Sue (2009) also suggests is more

compatible with the cultural communication styles of ethnic minorities.

When working with African Americans, a lifestyle assessment would help map out their

journey and help the clinician understand more about their life experiences, beliefs and

misconceptions that may be contributing to purpose of the behavior that led them to seek mental

health treatment. Collecting information about clients, their families and communities that can be

used to help serve our clients in a way that is sensitive to their cultural needs in order to better

understand their styles of life.

In this writer’s review of evidence-based research as well as variety of other resources,

various culturally sensitive techniques have been developed that are designed to work well with

African American clients and their families, in order to improve the percentage of African

Americans who seek mental health treatment and those who complete treatment. Some Adlerian

techniques which may be helpful when collecting cultural information about your clients include

the Lifestyle Assessments, which helps mental health professionals gain a better understanding

of their client’s familial relationships, life experiences and beliefs. Examining a client’s early

recollections and dreams in order to better understand their expression of their style of life, and

ultimately your client’s private logic, may also be a beneficial tool when working with this

community.

Sharing positive stories about their experiences induces a level of comfort between

client and therapist which includes some self-disclosure but is less objective and more conducive


to building a relationship with your clients which is taught by Adlerians to be the first of four

basic principles when working with clients in a therapeutic setting. Eliciting negative stories and

life experiences from your clients will expose mistaken beliefs that can be used to better

understand various facets of the clients’ lifestyles that affect their current modes of operation in

life. Using the concept of moving clients from a ‘felt minus to a perceived plus’ can benefit all

clients, and in particular African American clients discouraged due to their life circumstances, as

well as from racism and oppression faced by all African Americans in the United States as

members of the minority population. According to Ansbacher & Ansbacher (1956): “There is

one basic dynamic force behind all human activity, a striving from a felt minus situation towards

a plus situation, from a feeling of inferiority towards superiority, perfection, totality.”

As members of a racially oppressed group living in a country where social inequality is

prevalent, this concept seems to be fitting for motivational and goal-directed work with clients of

this group. Understanding goal directedness of clients and how oppression and racism may have

affected them and is important in defining treatment goals for your client. According to

Ansbacher & Ansbacher (1956):

The finalistic point of view is an absolute necessity [for our understanding]. In the first

place, we can never regard a person other than as a self-consistent being and thus as a

goal-directed and purposeful whole; in the second place, life itself and purposeful

movements require of him the continuous adherence to a self-consistent goal. Thus the

teleology of human psychological life arises from immanent necessities, but is in its

uniqueness a creation of the individual. (Ansbacher & Ansbacher, 1956, p. 177):


Understanding the communal life of your clients how their three life tasks of love, work and life

intersect with each other and how they are intertwined within their community is essential. In

support of this idea, Ansbacher & Ansbacher wrote:

The continuous striving for security urges toward the overcoming of the present reality in

favor of a better one. This goal of perfection must bear within it the goal of an ideal

community, because all that we value in life, all that endures and continues to endure, is

eternally the product of social interest. (Ansbacher & Ansbacher, 1956, p. 107)

Although Adlerian therapy seems compatible with treating clients of all walks of life, when

assessing a client’s direction of striving using the concept of ‘useless and useful sides of life’

with African American clients, or any clients, one must be careful not to make the assessment

based on one’s own personal concepts of which behaviors are useless and which are useful, as

your concept of useless and useful may be shaped by your own cultural beliefs, norms and

values, and therefore may be subject to personal bias. Imposing one’s own personal bias on a

client may have a negative effect on the relationship with the client, as they may feel judged or

misunderstood.

Other concepts that take cultural components of the African American culture into

consideration include the use of spirituality beliefs of the African American community.

According to Hines & Boyd-Franklin (1996) as cited by Sue and Sue in Counseling the

Culturally Diverse:

Highly emotional religious services conducted during slavery were a great importance in

dealing with oppression. Often signals as to the time and place of an escape were given

then. Spirituals contained hidden messages and a language of resistance (e.g. “Wade in

the Water” and “Steal Away”). Spirituals (e.g. “Nobody Knows the Trouble I’ve Seen”)


and the ecstatic celebrations of Christ’s gift of salvation provided Black slaves with

outlets for expressing pain, humiliation, and anger. (Sue & Sue, 2007, p. 227)

Educating one’s self on the history of a client’s culture as well as their community norms,

beliefs, and values may help improve the cultural competency of mental health practitioners

when working with minority clients. Hines & Boyd-Franklin reveal historically relevant coping

and survival skills used by early African Americans that are still relevant today as many African

Americans turn to spirituality for strength and guidance when faced with adversity. Although the

use of spirituals had mixed meanings during the times of slavery, they are still used as a tool to

survive the effects of adverse life experiences such as racism and oppression (Sue & Sue, 2007).

As members of a minority group, turning to each other (collectivism) or spiritual

guidance for support versus finding support from members of the majority group, who largely

make up the psychological services field, would be less likely. Therefore, dispelling the belief

held by some African American clients that mental health professionals and support staff will

shame and judge their lifestyles can be overcome by training mental health professionals to

become more aware of the cultural beliefs of their clients in order to better empathize and

overcome the cultural divide between the two cultures. By offering training to all employees

who have client contact, agencies and practitioners, as well as their support staff, will become

more culturally competent, which will attract more ethnic minorities such as African Americans

to seek support from the mental health community.

Understanding the importance of educating one’s self about other cultures, and

conducting a self assessment of your personal beliefs is crucial when working with all clients,

and in particular, ethnic minorities. One self assessment tool that this writer found to be useful is


the NAMI Star Center’s National Research and Training Center’s Cultural Competency Tool Kit

of which will be discussed in fuller detail.

When treating African American clients we can all learn to become culturally competent

mental health professionals by learning more about the culture of our clients. Therefore, it is

crucial to begin collecting culture specific information about our clients immediately. Collecting

information about clients, their families & communities that can be used to help serve our clients

in a way that is sensitive to their cultural needs in order to better understand their styles of life.

Based on evidence-based research, various culturally sensitive techniques can be developed that

are designed to work well will African American clients and their families in order to improve

percentage of African Americans who seek mental health treatment and those who complete

treatment. According to Lindsay:

In presenting an overview and framework for measuring racial identity, Budew and

Smith (1991) examined models of methods for measuring racial identity and for

providing theoretical groundwork that stimulated development of other research

instruments in this area. They provided an overview of the measures of racial identity that

have evolved, and proposed a framework for conceptualizing the measures' differences

and appropriate usage. They argued that, "First ... at least implicitly ... researchers should

not employ a strategy of using only one measure of racial identity over all others. Such a

strategy denies the multidimensionality of racial identity. ‘Their framework’ organizes

the existing measures into the following categories: (1) developmental approaches; (2)

Afrocentric approaches; (3) group-based approaches; and (4) measures of racial

stereotyping." With developmental approaches, "the individual is initially in a state


characterized by confusion of self-worth, degradation of Blackness, and a related need to

be accepted as something other than one's true self. (Lindsay, 1998, p. 48)

Lindsay seems to suggest that when working with members of the African American

community it is important to assess each individual client according to their level of cultural

awareness and self-acceptance. Using this framework, a practitioner is able to choose from a

variety of approaches as all clients will not respond in the same way due to the variances, such as

socio-economic status and style of life, of racial identity among members of this group.

To attend cultural events can actively expand your knowledge base of others, such as

Minnesota’s longstanding Festival of Nations event held every spring in Saint Paul, is one way to

actively expand your knowledge base of others. This event features food, artwork and

information booths representing more than 50 different nations. As a child, this writer had the

pleasure of helping her family run the African American food, artwork and information booths

from the late 1980’s through middle 1990’s. Being able to field many culture-based questions

and interact with patrons taught this writer about others as well as more about her own culture.

However, it was this experience with the Festival of Nations that taught this writer that seeking

information in the form of a question about another’s culture is simple and effective way to gain

knowledge about another, and a perfectly acceptable way to gain the information being sought.

Building on a common African American belief that getting help means being able to be

allowed to “lay down your burdens” this writer has developed a technique that has been used

with this writer’s clients titled the Burden Board. Each session, the client is invited to come in

and write down their burdens and issues that they are having and then post them on the board.

Along with the therapist the client will spend 10-15 minutes (or longer if necessary) discussing

the burden using “I” statements in order to keep the focus on the behavior on the client. The


client begins with just talking about each burden, enlisting feedback from the clinician if desired.

After discussing each burden with the client, the therapist assists the client in reframing the

events. If the client feels able to process and let go of this burden during this session, the

clinician asks them to remove the burden, crumple and discard it into the waste bin. Following

each burden (time usually allows for only 1 or 2 per session) an early recollection is collected

and later reviewed by the clinician in order to better assess and make connections between the

current behavior of the client and their mistaken beliefs.

In support of the use of spirituality in therapeutic practices with African American clients

the Nathan Kline Institute (NKI) Center for Excellence in Culturally Competent Mental Health

states:

Spirituality is defined as the internalization of positive values, and is distinguished from,

yet may be an outcome of religiosity (Mattis, J. 2000). It encompasses quintessential,

internal and external, consoling and transforming dimensions and is found globally and

culturally prominent (Newlin, K. et al. 2002). Spirituality plays an important role for

African American women. In a study of women in recovery from substance abuse, those

who scored higher on a Spiritual Well-Being Scale had more positive self-concepts, an

active coping style, healthier perceptions of family climate and parenting attitudes

(Brome D et al., 2000). Another study of multi-generational families viewed health

concerns from a spiritual rather than medical perspective affirming strong beliefs in

divine healing, acceptance of health outcomes as an expression of God's sovereignty and

transmitting these beliefs across generations (King, S. et al., 2005, Para. 24).

Interventions which involved culturally compatible components are yet another way in which a

practitioner may connect and empathize with their African American clients and help promote

http://jbp.sagepub.com/content/26/1/101.abstract

http://www.ncbi.nlm.nih.gov/sites/entrez?orig_db=PubMed&db=pubmed&cmd=Search&TransSchema=title&term=Newlin%20K%5Bfirst%20author%5D%20AND%20African%20American%20spirituality%3A%20a%20concept%20analysis

http://jbp.sagepub.com/content/26/4/470.abstract

http://roa.sagepub.com/content/27/4/420.abstract


health self-acceptance by incorporating techniques which normalize components of this culture's

norms, values, practices and beliefs.

Conclusion

It is evident that there exists a need for mental health practitioners to become culturally

competent when working with ethnic minorities in the United States. There are a multitude of

culturally competent training programs and institutes in place which are prepared to aid mental

health practitioners in their acclimation to cultural competent practices when working with the

African American communities. This analysis of the existing research on cultural competence

and mental health treatment among the African American community has revealed a growing

need for an increase in the number of culturally competent mental health practitioners and also a

lack of implementation of culture competence training programs in the United States.

The U.S. Mental Health Act established in 1962, over 50 years ago, conducted research

that revealed a lack of utilization of mental health services among the African American

community although the number of African Americans who utilize mental health services has

increased over the last several decades, this community remains to be one of the least likely

groups to elicit support from mental health professionals, despite studies that illustrate a growing

number of African Americans suffering from untreated mental health issues in the United States.

Until the mental health community implements sufficient cultural competency training

requirements, as are supported by evidence based and practice based research, mental illness

among members of the African American community will remain untreated and underdiagnosed.

According to the NCCC; “Studies have shown that spirituality and religion can play a

role in how an individual adult or child copes with being sick, may influence medical decisions

that are made, and may have an impact on the medical outcome.” As many mental health


practitioners strive to become more holistic in the treatment of their clients, becoming culturally

competent should be considered just one more facet of creating holistic therapeutic treatment

methods. Holism is a biopsychosocial approach to mental health counseling, which invites the

practitioner to consider their clients in mind, body and spirit. And based on what this writer has

learned, culturally competent mental health counseling should takes this approach in order to

incorporate biopsychosocial aspects of the African American client’s of their lives when

assessing their mental health needs.

The NAMI STAR center has created a comprehensive cultural competency training

program, funded by SAMHSA (Substance Abuse and Mental Health Services Administration)

and implemented a number of pilot programs across the United States. After a three month time

period the survey results shows positive improvements in cultural competencies among the

participants. According to the research conducted by the NAMI STAR center of the University

of Illinois at Chicago included in their 2010 Cultural Competence publication:

Only 11 percent of agencies indicated that their mission statement specifically mentioned

cultural and linguistic competence. However, more than 67 percent reported that this

component was included after participating. Another area where improvement was noted

was in the development of culturally relevant policies. Overall, 55 percent of agencies

reported improving their program policies in order to encourage staff and members to

learn more about cultural beliefs and practices within the local community. (NAMI,

2010, p. 4)

This writer finds these results encouraging and hopes that more agencies continue to

answer the call for mental health professionals to become more culturally competent in order to

better serve African Americans and other culturally diverse populations in the United States.


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