The second useful paradigm for cultural competence is presented by a number of authors in the field of multicultural counseling and psychotherapy (Arredondo et al., 1996; Pedersen, 1988; Sue, Arredondo, & McDavis, 1992; Sue et al., 1982), often referred to as "Pedersen's Model of Training." This approach identifies three domains in cultural competence: awareness, knowledge, and skills. These three domains or dimensions can be conceptualized as developmental levels with trainees progressing from one stage to another. They can also be operationalized into specific goals and objectives for a multicultural training curriculum (Arredondo et al., 1996; Sue et al., 1992). We will examine their applications here.
The first stage or domain is awareness, which is also called the beliefs and attitudes dimension. Here, students and trainees develop awareness of their own cultural heritage and values, as well as their negative emotional reactions, preconceived notions, biases, and stereotypes about other ethnic groups. They also learn to respect their clients' beliefs, values, and culturally based helping practices (Arredondo et al., 1996; Sue et al., 1992).
In our experience, most of the students in graduate programs have some ideas about cultural beliefs and values, especially about biases, stereotypes, and discriminatory practices in the United States. What they often need here is to approach these issues explicitly and subjectively to examine how their culture is affecting their perceptions of other cultures, as well as the extent to which they are aware of the values, beliefs, and practices of other ethnic groups. This applies to students of all ethnic groups, majority as well as minorities. Thus, in a multicultural course, one needs to address issues on the awareness level before moving on to the knowledge stage.
One useful activity for the development of awareness is to have students examine themselves via the cultural competence continuum (Cross et al., 1989) discussed in the previous section. This can be done privately and anonymously so that an individual will not feel embarrassed or defensive in exploring and identifying one's position on the scale. We have been impressed by the number of students who frankly admitted that this exercise was instrumental in helping them realize their positions on the negative levels of the scale. They found the continuum very helpful in identifying their blind spots and helping them set new goals for their cultural competency development. Another useful exercise is to have students research and discuss their families and cultures of origin (Hong & Ham, 1994). Besides awareness of one's own cultural heritage, the class discussions can also help students become aware of the differences in values, beliefs, and practices of diverse cultures.
The second stage or dimension is knowledge. Here, students and trainees acquire specific knowledge of their own cultures, as well as the cultures and life experiences of their clientele, including community issues concerning specific ethnic minority groups. They develop knowledge about cross-cultural communication, as well as cultural issues in assessment, clinical intervention, and the institutional barriers to mental health services (Arredondo et al., 1996; Sue et al., 1992).
Typically, the syllabus of a multicultural course at the graduate level is focused on the awareness and knowledge levels and covers issues concerning the major ethnic minority groups in the United States, namely, African Americans, Hispanic Americans, Native Americans, and Asian/Pacific Islander Americans, sometimes including the ethnic minority groups within the White population. Given the amount of information, there is usually insufficient class time to discuss all the topics in one semester or quarter. As a result, many issues are often left as literature research and reading assignments. This is not a preferable way to approach this domain, as class discussions have an important role in clarifying issues and exposing students to first-hand information provided by students of diverse ethnic backgrounds. In order to prepare mental health professionals to practice effectively in the culturally diverse United States of the new millennium, we want to encourage training programs to extend their multicultural course to at least two semesters and maybe more. This would allow sufficient class time to address all the essential topics concerning the different minority groups, using the integrated etic-emic approach discussed earlier. This extension is justifiable in light of the new demographics.
In addition to reading the literature, direct exposure to minority cultures and communities is also a crucial part of training on the knowledge level. This can be done by organizing visits to community agencies, especially mental health clinics. Students can also be assigned to visit and observe specific ethnic communities or neighborhoods, relating their observations to reading assignments (Hong & Ham, 1994). Guest lectures by individuals from different ethnic backgrounds and films depicting life experiences of ethnic minorities can be also used as supplements or alternatives. These alternatives may be necessary for training programs located in geographical areas where one or more of the major minority groups do not have community agencies for students to visit.
The third stage or dimension is skills. Here, students and trainees develop specific clinical skills for assessment, counseling, and psychotherapy with clients from minority cultures. Students find appropriate resources for consultation and referrals for their clients. They also learn to provide intervention at the institutional level (Arredondo et al., 1996; Sue et al., 1992).
Although the awareness and knowledge domains can be covered in the context of a multicultural course, competence at the skills level can be addressed later in a practicum or internship. To be proficient at this level, students need to integrate information from multicultural courses with their other clinical courses, which, ideally, have also covered specific subject matters in a multicultural context. At this stage, the students are ready for "hands-on" experience. Community agencies are ideal placement sites, as students will have the opportunity to acquire clinical experience while having further exposure to the community (Hong & Ham, 1994). For students and trainees who have difficulty working in certain community agencies due to language barriers, placement in mainstream institutions, such as public schools and college counseling centers, can be an alternative. However, we do encourage students, regardless of their ethnicities, to develop the language skills required for serving the client population they are to work with, as this is one of the competencies at the skills level (Arredondo et al., 1996; Sue et al., 1992).
At the skills level, reflective thinking is a crucial component of the training experience. This is a process that requires deliberate and focused attention on one's thoughts, words, and behaviors as well as their effects in the clinical setting. A number of activities can help students develop skills in reflective thinking, including journal writing, group discussions, case studies, and coaching. Coaching is different from supervision in that the student is guided, but not evaluated. As such, the student is more likely to take risks in sharing sensitive thoughts about a case and one's personal reactions. Students with reflective skills are more likely to develop the cognitive complexity to gain knowledge through investigating different assumptions stemming from different cultural experiences (King & Shuford, 1996). In training students at the skills level, it is important for faculty to recognize that reflectivity is not a spontaneous process. Consequently, instructions and opportunities for students to reflect should be clearly designated as activities in training programs.
In addition to reflective thinking, many practical skills have been identified to be crucial for multicultural mental health services. The following are some of the major ones discussed in the literature (Arredondo et al., 1996; Pedersen, 1988; Sue et al., 1982; Sue et al., 1992):
1. Cross-cultural communication skills, both verbal and nonverbal, including language, idioms, etiquette, customs, and the like
2. Skills in assessment, including recognition of culture-bound syndromes and cultural variations of diagnostic categories in the DSM, and for professionals who provide psychological testing, skills in the selection, administration, and interpretation of tests for a client of a given ethnicity
3. Skills in identifying and integrating specific cultural issues in both diagnostic and treatment formulation
4. Skills in identifying and consulting with traditional helpers in the client's ethnic community
5. Skills in applying emic approaches in assessment and treatment
6. Skills in advocating for a specific client or a client population and for interventions on the institutional level to ensure the availability of services as well as to eliminate societal or institutional conditions that are detrimental to the mental health of a specific cultural/ethnic group
7. Skills in accessing the literature, prevalence data, and other clinical information on specific racial/ethnic groups living within a given community
8. Reflective skills in monitoring one's performance and effectiveness within specific cultural contexts.
Again, these skills are best learned when there is a balance of real-life experience from fieldwork or internships, and solid theoretical background from course instructions.
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