Clients From Diverse Backgrounds Essay

As the 2000 census makes clear, the United States is a diverse multicultural society. Minority groups make up roughly one-third of the Nation's population, up from one-quarter in 1990. Minority groups are the fastest growing segment of the U.S. population (U.S. Census Bureau 2001). Foreign-born people now constitute more than 11 percent of the population—an alltime high (Schmidley 2003).

This chapter provides the consensus panel's recommendations on how to improve the cultural competence of treatment programs by

Learning About Cultural Competence in Organizations

Administration's Attitude Toward Cultural Competence

Cultural competence starts with the program's administration. The more flexible and adaptable the program's organizational structure is, the more it will be able to incorporate the kind of changes cultural competence calls for. Rigidly hierarchical organizations are resistant to change and are hampered particularly when minority viewpoints need to be included (Administration for Children and Families 1994).

Cultural competence requires that people at all levels of the program learn to value diversity. The administration can demonstrate the seriousness of its commitment to cultural competence by investing human and financial resources in the effort and providing incentives for cultural competence training just as it would for other forms of continuing education. A culture of learning, where self-assessment and staff development are regular program activities, lends itself to cultural competence.

Becoming culturally competent means expanding the perceptions and the worldview of all staff members. The reassessment can result in fundamental changes for both individual staff members and program policy and structure. When staff members are asked to undergo serious self-examination and change, there may be resistance and varying degrees of success. Administrators should anticipate staff objections and reassure staff members that no one is being singled out for being insensitive—everyone can strive to be more culturally competent.

Defining Diversity

The consensus panel recommends that administrators define diversity broadly. Programs often assume that diversity applies only to specific ethnic and racial groups. But cultural diversity includes many groups of clients and many important factors that affect treatment—a client's gender, age, sexual preference, spiritual beliefs, socioeconomic status, physical and mental capacities, and geographic location. Program staff members should be aware of the many dimensions of diversity and how these factors can be used to motivate and assist clients in treatment—or how they can be barriers to engagement, treatment, and recovery.

The glossary in exhibit 4-1 defines common terms in the context of cultural competence.

Exhibit 4-1. Glossary of Cultural Competence Terms

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Cultural diversity. Differences in race, ethnicity, nationality, religion, gender, sexual identity, socioeconomic status, physical ability, language, beliefs, behavior patterns, or customs among various groups within a community, organization, or nation.
Culture. Social norms and responses that condition the behavior of a group of people, that answer life's basic questions about the origin and nature of things, and that solve life's basic problems of human survival and development.
Discrimination. The act of treating a person, issue, or behavior unjustly or inequitably as a result of prejudices; a showing of partiality or prejudice in treatment; specific actions or policies directed against the welfare of minority groups.
Ethnicity. The beliefs, values, customs, or practices of a specific group (e.g., its characteristics, language, common history, and national origin). Every race has a variety of ethnic groups.
Ethnocentrism. The attitude that the beliefs, customs, or practices of one's own ethnic group, nation, or culture are superior; an excessive or inappropriate concern for racial matters.
Multiculturalism. Being comfortable with many standards and customs; the ability to adapt behavior and judgments to a variety of interpersonal settings.
Prejudice. Preconceived judgments, opinions, or assumptions formed without knowledge or examination of facts about individuals, groups of people, behaviors, or issues. These judgments or opinions usually are unfavorable and are marked by suspicion, fear, or hatred.
Race. The categorizing of major groups of people based solely on physical features that distinguish certain groups from others.

Background Resources

An administrator may want to explore materials and resources on cultural competence and organizational change. Information on how to support staff members in changing attitudes and behaviors is available in Thomas (1999). (See appendix 4-A for articles, books, and Web sites on educating staff and preparing programs for cultural competence.)

Federal agencies and academic centers offer information to assist administrators in determining the steps to take in planning, implementing, and evaluating culturally competent service delivery systems. One resource is the National Center for Cultural Competence at Georgetown University's Child Development Center ( The Health Resources and Services Administration (2001) also offers materials.

Research on treatment

Little research exists on practical ways for programs to deliver culturally competent substance abuse treatment to specific populations. Beutler and colleagues (1997) found that matching clients with counselors of the same race improved engagement and retention for some clients but for others it had no effect. Some ethnic groups (e.g., Asians) place such a strong emphasis on community that it is often easier for them to discuss problems with a counselor who is outside their group.

Further complicating the picture, clients' engagement with counselors and retention in programs also can be improved if such race-blind attributes as socioeconomic class, acculturation, and education are used to match clients with counselors (Chinman et al. 2000). Increased retention does not translate necessarily into increased client engagement in the treatment process (Chinman et al. 2000). In the mental health field, evidence that matching clients with counselors based on race improves treatment outcomes is inconclusive (Chinman et al. 2000). Administrators should not overlook the potential benefits of treating diverse clients together, where they can learn from one another across, instead of within, racial and cultural boundaries.

The Center for Substance Abuse Treatment's (CSAT's) forthcoming TIP Improving Cultural Competence in Substance Abuse Treatment(CSAT forthcoming b) provides both the latest research and expert advice from practitioners on clinical issues and treatment of diverse populations. Administrators also should consult TIP 29, Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities (CSAT 1998d), and Health Promotion and Substance Abuse Prevention Among American Indian and Alaska Native Communities: Issues in Cultural Competence (Center for Substance Abuse Prevention 2001). Cultural Issues in Substance Abuse Treatment (CSAT 1999a) contains population-specific discussions of treatment for Hispanics, African-Americans, Asian and Pacific Islanders, and American Indians and Alaska Natives, along with general guidelines on cultural competence.

Performing Cultural Competence Assessment

Agency self-assessment is valuable in planning for culturally competent service delivery. To capture all useful information relating to a program's cultural competence, the self-assessment must survey the community, the clients, and the program itself. This assessment has two key goals: to determine how culturally competent the program's services are and to provide information for a long-term improvement plan. Assessment focuses on the following questions:

  • What is the composition of the local population? Are all those who need care being served in the program?

  • What is the level of satisfaction with the program among clients from minority groups?

  • How prepared and competent is the program to meet the treatment needs of the diverse groups in the community?

Community Assessment

An administrator needs to identify the culturally, linguistically, racially, and ethnically diverse groups in the program's locale. Appendix 4-B provides a matrix that can be used to determine the demographics of a local area, using 2000 census data. These data can be accessed at The information is useful for assessing

  • The percentage of minority and ethnic individuals residing in the catchment area

  • The extent to which individuals from various ethnic groups are accessing services

  • The underrepresented groups that may need targeted outreach

The census data also allow a program administrator to compare community demographics with those of the program staff. Does the staff reflect the makeup of the community? Does the board of directors include individuals who represent local population groups? Does the program have caseworkers, outreach workers, or other personnel who have links to all groups in the community?

Cultural competence has different emphases depending on the makeup of the local community. Each program establishes what cultural competence means with respect to the clients it serves. People from the community and members of the board and the staff who represent diverse groups can provide useful information about the program's level of cultural competence and needed services.

Assessment by Clients

Important information about a program's level of cultural competence can be supplied only by the clients it serves. How satisfied are clients with the services they receive? Surveys help determine the accessibility and sensitivity of the program and are an effective method of program assessment. It is recommended that a program survey clients at the time of discharge (or dropout) from the program. Programs then can analyze by gender, race, ethnicity, religion, and physical ability the feedback received from clients about services.

Program Self-Assessment

Self-assessment of the treatment program's cultural competence should include the following areas:

  • Administration policies

  • Physical facility

  • Staff diversity

  • Staff training

  • Screening and assessment methods and tools

  • Program design

To be effective, cultural competence self-assessment should be undertaken in a supportive environment; involve the entire program, including board members and volunteers; include a formal review in which all who were involved in the assessment learn the results; and culminate with the decision to take specific actions (Gonzalez Castro and Garfinkle 2003; McPhatter and Ganaway 2003).

The results of an agency self-assessment should be used to develop a long-term plan that includes measurable goals and objectives and may indicate changes to be made in the mission statement, policies, administration, staffing patterns, service delivery practices and approaches, and outreach and professional development activities.

Several assessment tools are listed in appendix 4-A.

Implementing Changes Based on Cultural Competence Assessment

Most programs can benefit from administrative-level changes that can be accomplished quickly. These changes can be made in program mission, program policy, board membership, community input, staff diversity, and facility appearance. The more attention the administration pays to diversity, the more positive and supportive all staff members will be about expanding their cultural competence.

Mission statement.The program should ensure that its mission statement incorporates cultural competence as a core value. The cultural competence committee should be involved in developing or modifying the statement.

Program policy.The program policy should endorse explicitly and respect the cultural diversity of program clients, staff members, and the community. Respect should be reflected in the development and enhancement of the program's philosophy, outreach activities, staffing, and client services.

Support for cultural competence should be included in staffing policies. Some suggestions follow:

  • The ability to work sensitively with people from other cultures can be a criterion for evaluating staff performance.

  • Program policy can encourage staff members to pursue continuing education in cultural competence, focused on groups served by the program.

A diverse board of directors.As a result of the agency assessment, an administrator may want to add board members from groups not represented. A diverse board is extremely important and can help provide a broader perspective. Having board members from diverse groups helps establish the program's credibility with members of those groups.

Input from diverse groups.An administrator can identify knowledgeable persons from the community and involve them in the program. Their advice can help develop new interventions and services that affirm and reflect the values of the various cultures in the community.

Diverse staff and management.The administrator needs to make clear, through policy and action, the value of recruiting staff members from diverse groups. Hiring ethnic or minority staff members to work in management, policymaking, and clinical positions is important for programs that serve diverse populations.

Facility appearance.The decor of a treatment facility can make an inclusive or exclusive statement. The program's walls should reflect cultural openness, with posters and pictures showing people representative of the client population. Clients feel welcome when they see pictures of people like themselves. (See appendix 4-A for Web sites that have appropriate posters.)

Developing a Long-Term, Ongoing Cultural Competence Process

To move toward cultural competence, programs need a long-term, ongoing commitment to change, including staff selection and training.

Steps To Take

Based on results of the cultural competence assessment, an administrator might take the following steps:

  • Obtain new screening and assessment instruments. Identify and acquire screening and assessment materials for the diverse groups in the client population (e.g., translated or orally administered materials). Both foreign-born clients who are learning English and those with cognitive impairments may benefit from oral screening methods. Train staff to use these materials and methods.

  • Open a dialog with staff. Convene brown-bag lunches to engage staff members in discussions and activities that offer an opportunity to explore attitudes, beliefs, and values related to cultural diversity and cultural competence.

  • Explore staff development needs. Ask staff members what resources would help them serve culturally, linguistically, racially, and ethnically diverse groups. Use this information to develop ongoing staff training programs.

  • Revise the budget. Allocate funds to support staff in attending conferences, seminars, and workshops on cultural competence and treatment issues relevant to the program.

  • Investigate funding opportunities. Explore resources that are available to provide special services needed by potential clients. Many Federal grant programs are designed to fund services for underrepresented and underserved populations.

  • Remove barriers. Address any special barriers to treatment for diverse groups identified in the assessment phase. For example, foreign-born clients may need vocational help, translation services, or English-as-a-second-language classes.

  • Inform staff and clients of resources on diversity and substance use disorders. Provide information about the resources that are available to support clients from diverse groups.

Appendix 4-A contains population-specific information that can help staff better understand and treat clients from diverse backgrounds.

Staff Selection and Training

The program's openness to differences in background among clients and staff members should be communicated clearly both to potential clients and to referral sources in the surrounding community. The more diverse the staff is with respect to age, gender, physical ability, race, religion, and ethnicity, the more able the program will be to treat all types of clients. A program needs to make special efforts to hire culturally competent staff.

Selecting a diverse staff

Programs need to recruit staff members whose backgrounds are similar to those of the clients being treated. Unfortunately, the substance abuse treatment field has a shortage of trained counselors from diverse backgrounds. Administrators report that bicultural and bilingual counselors are hard to recruit. A recent survey done by CSAT showed serious disproportion between the demographic backgrounds of clients and those of treatment staffs (Mulvey et al. 2003). In this survey of 3,276 randomly selected facility directors, clinical supervisors, and counselors, only 6 percent of treatment providers were Hispanic and only 11 percent were African-American. Yet the survey showed that Hispanics made up 14 percent and African-Americans 25 percent of the treatment population.

The study concludes that “treatment professionals are generally not from the same ethnic and racial backgrounds as the clients they serve. This situation presents a tremendous challenge for the field” (Mulvey et al. 2003, p. 56). The following planning approach may be helpful in increasing the number of counselors from different backgrounds:

  • Target specific ethnic and cultural groups served by the program, and assess the barriers to finding and hiring clinical staff with the same backgrounds. In areas where these groups constitute a small percentage of the population, hiring qualified counselors from the same backgrounds may be difficult.

  • Tap into State and national recruiting sources, such as the Single State Agency and job search and recruitment Web sites.

  • Establish a file of recruitment resources, and seek their help.

  • Develop a plan to encourage potential counselors to enter the treatment field through internships. Look at providing incentives for promising candidates, including training.

  • Recruit diverse candidates from local colleges; consider granting fellowships to assist advanced students in completing their degrees.

Interviewing and hiring culturally competent staff

Cultural competence is not merely a set of skills; it is also a desire to use those skills to understand others. Programs will move more easily toward cultural competence if they hire individuals who have a genuine interest in cultural diversity. The process of hiring culturally competent staff need not differ much from hiring good counselors. The same qualities are common to each: empathy, use of individualized treatment approaches, willingness to look beyond assumptions, and ability to establish trust.

In interviews, applicants should be asked to discuss what diversity means to them. Administrators should rate more highly applicants who speak of diversity in terms that go beyond race to include religion, physical ability, sexual preference, age, and gender. Applicants also should be asked to speak in detail about their experiences working with diverse colleagues and clients. Administrators also may arrange for prospective counselors to run a group session to see how they interact with diverse clients.

Training staff

All counselors have cultural blind spots. It is important for counselors to acknowledge their beliefs and assumptions, even if they are misguided or based on stereotypes. Learning about the nuances of other cultures, particularly as they affect treatment, is not intuitive. Counselors should be willing to learn from their clients. Counselors should be trained to ask questions to learn what substance abuse and addiction mean in the client's culture. Staff members should not make assumptions about clients based on their physical ability, gender, ethnicity, or religion but approach and treat each client as an individual.

Training can be undertaken by the program itself, can focus on the particular groups being treated in the program, and can be done inexpensively. Knowledgeable people representing the diverse groups in the community can be invited to meet with staff and discuss issues affecting treatment. Training of staff members needs to focus on

  • Self-assessment of cultural biases and attitudes

  • Sources of cross-cultural misunderstanding

  • Sources of social or psychological conflict for bicultural clients

  • Strategies for clinical cultural assessment of individual clients

  • Guidelines for clinical encounters

Appendix 4-A lists tools for cultural competence training and evaluation, including Web links to trainers and consultants.

Undertaking Program Planning

A core set of administrative and structural principles is important for every program providing treatment to diverse groups. Treatment planning and goal setting should be sensitive to the individual client's recovery goals. The client's values and cultural traditions should be accepted and respected in establishing expectations and making the treatment plan. Program staff members should be sensitive to cultural, ethnic, and regional variations in family structures and in the way that clients define their families.

Criteria for Types of Programming

What type of programming will be provided for clients from minority groups in the community? A program can decide to serve diverse clients

  • Within a nonspecialized treatment program, providing one-on-one counseling as needed

  • Within a nonspecialized treatment program, adding specialized group meetings or tracks

  • In a specialized treatment program designed for members of a particular group

Programs should consider whether they can address diverse clients' needs within a nonspecialized treatment program or whether it would be preferable to set up a specialized program serving only these clients. If people are ill at ease outside their own culture, they generally are more comfortable and trusting with others who are like them. Specialized treatment programs consisting of clients from a particular group, such as immigrants from a particular country or women, offer the chance to design program strategies for individuals who share a common background and common concerns.

However, because treatment resources are limited, administrators may face difficult choices about integrating diverse clients into general programs. Some questions to answer include

  • Is the potential volume of clients sufficient to support a specialized program?

  • Is financial support available for these clients?

  • Will treatment goals of the specialized services fit into the program?

  • Are counselors available who are sensitive to the group?

  • Will there be access to training regarding the special needs of this population?

  • Are links and referrals to other service providers possible for this target population?

When the answers to these questions do not support the development of a separate specialized program, administrators may want to consider enhancing their program's general outpatient treatment services with special groups and tracks.

Administrative Support for Counselors

When clients from diverse groups are to be treated in a general program, the counselor who works with them should be experienced and supportive. Such clients may need additional time in individual counseling, as well as the counselor's help to integrate them into the treatment group.

Clients from diverse groups may need ongoing, long-term social support. The available peer support groups in the community may not serve some of these clients adequately. Programs should identify and maintain a list of local mutual-help groups. If appropriate support groups cannot be identified for a particular group (e.g., Hispanic clients who abuse alcohol), the treatment program should consider sponsoring a specialized alumni support group. Bonding with a long-term support group can be a significant factor in recovery.

Specialized Treatment Programs

If a specialized program is deemed necessary, administrators should be aware that the program must follow mandatory State requirements and meet the same licensure regulations as other treatment programs. These requirements need not hamper treatment of minority clients. Directors of ethnocentric treatment programs note that, although State and accreditation requirements are the same for all programs, culturally sensitive treatment can deploy the required program elements to serve culturally diverse clients.

Identified special client populations

Clients for whom specialized programs are highly recommended include

  • Foreign-born clients. The special language needs of some immigrant groups may be met best through specialized programming. Bilingual counselors need to be available when treating clients who speak a language other than English. Specialized programs for recent immigrants also may require focusing on U.S. laws that pertain to substance abuse and on available social support systems. For clients with limited English-language skills, important documents (e.g., confidentiality, grievance, and complaint forms) need to be translated or explained.

  • Clients benefiting from an ethnocentric approach. Individuals from minority groups may have problems with identity, self-esteem, and cultural alienation. Ethnocentric programs that build on the individual's strengths and ethnic roots can be empowering. Treatment programs developed for Native Americans and Alaska Natives—using both Western and traditional healing methods—represent an example of the enhanced effectiveness that ethnocentric programs can achieve.

  • Clients who are disabled, including those from the Deaf community.

Components of specialized programs

Specialized programs for a particular group should include

  • Staff members, supervisors, and administrators representing backgrounds similar to those of the clients. Although it is important that program staff members reflect the diversity of the client population, it should not be assumed that counseling staff members will be competent simply because they share the clients' ethnicity or culture. For example, middle-class African-American counselors may not share the life experiences of African-American clients who live in inner-city poverty. Native-American programs may find that their Western-trained Native counselors need training and support before they can treat clients effectively using Native healing ceremonies and traditions.

  • Staff training and supervision. Cultural training is important for counselors in an ethnocentric program. Programs serving foreign-born clients need to employ staff members who are multilingual and multicultural. It is important to be aware that a counselor from the same culture as the client may still need cultural sensitivity training. Culture changes within a country over time. A counselor whose family immigrated during his or her childhood may not be attuned to the culture of the recent immigrant. Also, the level of acculturation can change drastically between immigrants and their children born in this country.

  • Unbiased assessment tools. Program staff should be sensitive to issues of cultural bias in assessment procedures. To ensure appropriate test interpretation, programs should use standardized and program-based instruments that have norms for the ethnic or cultural groups that are being treated.

  • Special programming components. Treatment programs that serve a particular group should be culturally relevant for the particular group in content, delivery of services, and philosophy. Before designing a specialized program, administrators should seek help and advice from other providers who have developed programs for the same population. Focus groups comprising recovering members of a specific minority population, drawn from program alumni, also can be valuable.

Clients With Disabilities

Clients who are deaf

One-half of one percent of the American population is deaf, but people who are deaf are underrepresented among the population that seeks treatment (McCrone 1994). It is important for administrators to be aware of potential barriers to treatment, some of which come from within the close-knit Deaf community. Because people who are deaf socialize primarily with one another, a fear exists that personal information shared in treatment will become public via the Deaf community's communication grapevine. The Deaf community's desire to present a positive image also may deter some members from admitting to substance use problems (Guthmann and Blozis 2001).

Individuals who are deaf are reluctant to enter treatment if they think they will encounter barriers to communication. For this reason, most people who are deaf and seeking treatment for a substance use disorder prefer to be in a program with other people who are deaf (CSAT 1998d). Because having a separate group often is not feasible, most programs treat individuals who are deaf with hearing clients.

Deafness is defined as a disability by the Americans with Disabilities Act (ADA) of 1990; clinics are required to provide accommodations to individuals who are deaf and seek treatment. In most cases, the accommodation will consist of hiring an individual fluent in American Sign Language (ASL) to interpret during sessions. Family members of the individual who is deaf should not be used as interpreters. Administrators should not assume that all individuals who are deaf are proficient in ASL; some use other manual languages. Written materials might be difficult to understand for some individuals who are deaf; the average adult who is deaf reads at the fourth grade level (Crone et al. 2003).

Recovery can be particularly difficult for individuals who are deaf. Because there may be few people who are deaf in the area, people who are deaf and in recovery who want to sever ties with substance-using friends may have to turn their backs on nearly everyone they know. Also, support groups that include ASL interpreters are rare (Guthmann and Blozis 2001). Programs should maintain a list of resources that can be accessed by individuals who are deaf and in recovery (Guthmann and Sandberg 1998). The Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals offers resources and training for treating this population. Its Web site ( includes articles on assessment and treatment, as well as information for ordering manuals for individuals in recovery and videotapes of mutual-help programs interpreted in ASL.

Other clients with disabilities

Individuals who are disabled have higher rates of substance use disorders than the general population (Moore and Li 1998). The higher rates can be attributed to increased risk factors, such as chronic pain, a feeling of entitlement to drugs, and access to prescription drugs. Administrators should know that the presence of a physical or mental disability may conceal signs of substance use (Li and Ford 1998).

ADA guarantees equal access to treatment for clients with disabilities. If the building that houses the program does not permit equal access to people with disabilities, administrators should consider making the necessary changes. Physical barriers include not just stairs, but narrow hallways, conventional doorknobs that prevent access to people with limited manual dexterity, deep pile carpet that interferes with wheelchairs or crutches, and water fountains and telephones that are located too high on walls (CSAT 1998d). People who use wheelchairs or crutches may need help arranging transportation to and from the treatment facility. While there, they may require extra time to get from place to place.

Administrators should be aware of local programs and services that are equipped to help individuals with disabilities. TIP 29, Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities (CSAT 1998d), contains information about screening and treating this population; chapter 5 of TIP 29 focuses on administrative tasks, appendix B lists resources, and appendix D discusses the implications of ADA.

Designing Ongoing Outreach Efforts

Community involvement and outreach are critical parts of any long-term, cultural competence plan. Providers need to think about how they can recruit clients from cultures not adequately reached by the program. Programs should reach out to minority individuals who are in need of treatment but may be reluctant to seek it.

Programs will benefit greatly from drawing on the cultural experience and expertise of diverse members of the community. Administrators should involve the diverse groups in developing program goals, designing networking, and ensuring client entry and retention.

The following steps can be taken:

  • Network with appropriate organizations. Contact organizations concerned with the culturally diverse groups the program serves. Solicit their involvement and input in the design and implementation of service delivery initiatives with these groups.

  • Work to identify and remove barriers to treatment for diverse groups. Address clients' need for transportation services, limited free time to participate in treatment, and the need for childcare services.

Although there is widespread agreement that understanding of and sensitivity to the increasingly diverse cultural groups in the United States are positive developments, it is unclear how these developments should affect treatment. McFadden (1996) observes that “simply knowing about a culture is not sufficient. The counselor must use this new information obtained through experience and incorporate it into the counseling process” (p. 234). Studies conducted to date on the implementation of culturally specific elements in substance abuse treatment have been inconclusive.

The consensus panel believes that cultural competence is a worthwhile goal for programs and recommends that it involve the entire program—from the board of directors to the part-time staff members, from the mission statement to outreach efforts. When administrators commit program resources to train and support staff members in their efforts to improve their cultural competence, the program as a whole benefits.

Appendix 4-A. Cultural Competence Resources

Background Information on Diversity and Cultural Competence

  • The Substance Abuse and Mental Health Services Administration's (SAMHSA's) National Clearinghouse for Alcohol and Drug Information (NCADI) (—The NCADI Web site provides access to publications on specific populations. Click on Audience to access information on African-Americans, American Indians, Alaska Natives, Asians and Pacific Islanders, disabled individuals, Hispanic and Latino populations, and lesbian, gay, and bisexual individuals.

  • Hawaii AIDS Education and Training Center (—This Web site provides links to resources on clients who are homeless, have disabilities, or are members of minority groups. The information and links provided discuss more than just HIV/AIDS and health care.

  • “Effective Therapies for Minorities: Meeting the Needs of Racially and Culturally Different Clients in Substance-Abuse Treatment” (Beatty September/October 2000;—This journal article includes basic steps that programs can take to move toward cultural competence.

  • Cultural Competence in Substance Abuse Treatment, Policy Planning, and Program Development (—This annotated bibliography of resources has sections on African-Americans, Asian and Pacific Islanders, Native Americans, and Latinos, compiled by the Addiction Technology Transfer Center of New England, at Brown University's Center for Alcohol and Addiction Studies.

  • The Provider's Guide to Quality and Culture (—This Web site provides descriptions of attributes and beliefs of many cultural groups, with links and references, as well as information on cultural diversity and self-assessment tools.

  • Cultural Competence Standards in Managed Mental Health Services: Four Underserved/Underrepresented Racial/Ethnic Groups (Center for Mental Health Services 1997;—This book discusses guiding principles for cultural competence in the context of treatment for African-Americans, Asians and Pacific Islanders, Hispanic populations, Native Americans, Alaska Natives, and Native Hawaiians.

  • “Develop Your ‘Ethnocultural Competence’ and Improve the Quality of Your Practice” (Straussner November/December 2002;—This journal article provides a good introduction to ethnicity and culture and how both affect treatment.

  • Cultural Diversity in Health and Illness (Spector 2003)—This book includes chapters on traditional views of health in African-American, Hispanic, American Indian, and Asian and Pacific Islander communities and appendixes that list population-specific resources.

Preparing for Cultural Competence Assessment

  • Managing Multiculturalism in Substance Abuse Services (Gordon 1994)—This book focuses on developing a multicultural framework for treatment, program evaluation, and leadership. It includes tools to evaluate the needs of the community and the effectiveness of cultural competence training.

  • Planning, Implementing and Evaluating Culturally Competent Service Delivery Systems in Primary Health Care Settings: Implications for Policymakers and Administrators (—This checklist from the National Center for Cultural Competency helps organizations implement policies and practices that support cultural competence.

  • “Evaluating Outcomes in a Substance Abuse Training Program for Southeast Asian Human Service Workers” (Amodeo and Robb 1998)—This journal article explores the challenges that cross-cultural substance abuse training programs face.

  • Culture, Race, and Ethnicity in Performance Measurement (Philips et al. 1999)—This is a compilation of resources and readings on providing and evaluating culturally competent mental health care.


  • A Guide to Enhancing the Cultural Competence of Runaway and Homeless Youth Programs (Administration for Children and Families 1994;—This guide presents tools for assessing and enhancing cultural competence in youth-serving organizations. Assessment questionnaires that focus on the community, clients, and the program itself are included in appendix A. The tools and information can be adapted for drug treatment programs.

  • Cultural Competence Self-Assessment Instrument (Child Welfare League of America 1993;—This resource provides tools for assessing cultural competence of policies, programs, and staff and guidelines for strengthening cultural competence.

  • Health Resources and Services Administration. Study on Measuring Cultural Competency in Health Care Delivery Settings: A Review of the Literature (—This report details a comprehensive review of the cultural competence theoretical and methodological literature.


  • Cultural Competency Tool (order forms at—Available from the Society for Social Work Leadership in Health Care for $15 for members and $20 for nonmembers, this instrument assists in evaluating the cultural competence of staff and can be used for performance assessment, evaluation of prediversity and postdiversity efforts, or compliance with Medicaid/Medicare conditions or JCAHO cultural competence standards.

  • Toolkit for Cross-Cultural Communication (—These materials compare patterns of communication across diverse groups and discuss myths that impair cultural competence, including a table of communication norms and values across cultures.

  • Handbook for Developing Multicultural Awareness, 3d edition (Pedersen 2000)—This book employs a three-stage model of multicultural training, focusing on culturally learned assumptions, accurate information, and counseling skills; it also discusses ethical dilemmas and conflict management.

  • Developing Intercultural Awareness: A Cross-Cultural Training Handbook (Kohls and Knight 1994)—This book contains training activities, including preplanned 1- and 2-day workshops.

  • Figuring Foreigners Out: A Practical Guide (Storti 1999)—This workbook focuses on interactions with people from outside the United States. Lessons can be used for group training or self-instruction and are designed to teach new attitudes and behaviors for interacting with people from diverse cultures.

  • Culture and the Clinical Encounter: An Intercultural Sensitizer for the Health Professions (Gropper 1996)—This book presents cross-cultural health care scenarios with possible outcomes from which the reader chooses. Each choice is discussed in a separate answer key. The question-and-answer format makes this a useful training tool.

  • Intercultural Communication Institute (—This organization conducts an annual Summer Institute for Intercultural Communication.

  • The National Center for Cultural Competence (—Web site lists links for trainers.

  • Diversity Training Associates of Portland, OR (800-484-9711, ext. 8250)—This organization provides consultants and trainers.


SAMHSA's NCADI stocks posters and office materials that can be viewed and ordered at

Population-Specific Information

For information and resources that address specific populations, see TIP 47, Substance Abuse: Clinical Issues in Intensive Outpatient Treatment (CSAT 2006b).

Appendix 4-B. Community Diversity Form

Total City Population: ________________

Total County Population: ________________

View in own window

Characteristic Total City % of Total Total County % of Total
Age Distribution15 to 19
20 to 24
25 to 44
45 to 59
60 to 74
75 and Older
Hispanic OriginMexican
Puerto Rican
Not a Citizen
EthnicityAmerican Indian/Alaska Native
Asian or Pacific Islander (API)
Asian Indian
Black or African-American
Learn how to understand cultures and build relationships with people from other cultures.


  • How do you learn about people's cultures?

  • How do you build relationships with people from other cultures?

Relationships are powerful. Our one-to-one connections with each other are the foundation for change. And building relationships with people from different cultures, often many different cultures, is key in building diverse communities that are powerful enough to achieve significant goals.

Whether you want to make sure your children get a good education, bring quality health care into your communities, or promote economic development, there is a good chance you will need to work with people from several different racial, language, ethnic, or economic groups. And in order to work with people from different cultural groups effectively, you will need to build sturdy and caring relationships based on trust, understanding, and shared goals.

Why? Because trusting relationships are the glue that hold people together as they work on a common problem. As people work on challenging problems, they will have to hang in there together when things get hard. They will have to support each other to stay with an effort, even when it feels discouraging. People will have to resist the efforts of those who use divide-and-conquer techniques--pitting one cultural group against another.

Regardless of your racial, ethnic, religious, or socioeconomic group, you will probably need to establish relationships with people whose group you may know very little about.

Each one of us is like a hub of a wheel. Each one of us can build relationships and friendships around ourselves that provide us with the necessary strength to achieve community goals. If each person builds a network of diverse and strong relationships, we can come together and solve problems that we have in common.

In this section, we are going to talk about:

  • Becoming aware of your own culture as a first step in learning about other people's culture.
  • Building relationships with people from many different cultures.

But first let's talk about what culture is. Culture is a complex concept, with many different definitions. But, simply put, "culture" refers to a group or community with which we share common experiences that shape the way we understand the world. It includes groups that we are born into, such as gender, race, national origin, class, or religion. It can also include groups we join or become part of. For example, we can acquire a new culture by moving to a new region, by a change in our economic status, or by becoming disabled. When we think of culture this broadly we realize we all belong to many cultures at once. Do you agree? How might this apply to you?

How do you learn about people's cultures?

Start by becoming aware of your own culture.

It may seem odd that in order to learn about people in other cultures, we start by becoming more aware of our own culture. But we believe this is true. Why?

If you haven't had a chance to understand how your culture has affected you first hand, it's more difficult to understand how it could affect anyone else or why it might be important to them. If you are comfortable talking about your own culture, then you will become better at listening to others talk about theirs. Or, if you understand how discrimination has affected you, then you may be more aware of how it has affected others.

Here are some tips on how to becoming more aware of your own culture:

What is your culture?

Do you have a culture? Do you have more than one? What is your cultural background?

Even if you don't know who your ancestors are, you have a culture. Even if you are a mix of many cultures, you have one. Culture evolves and changes all the time. It came from your ancestors from many generations ago, and it comes from your family and community today.

In addition to the cultural groups we belong to, we also each have groups we identify with, such as being a parent, an athlete, an immigrant, a small business owner, or a wage worker. These kinds of groups, although not exactly the same as a culture, have similarities to cultural groups. For example, being a parent or and an immigrant may be an identity that influences how you view the world and how the world views you. Becoming aware of your different identities can help you understand what it might be like to belong to a cultural group.


Try listing all the cultures and identities you have: (This is just a list of suggestions to get you started. Add as many as you think describe you.)

What is your:

Sexual identity
Marital status
Geographic region

Are you:

A female
A male
From an urban area
From a rural area
A parent
A student

Have you ever been:

In the military
In prison
In the middle class
In the working class

Did this help you think about your identities and cultures? How have these different cultures and identities affected your life?

How do you build relationships with people from other cultures?

There are many ways that people can learn about other people's cultures and build relationships at the same time. Here are some steps you can take. They are first listed, and then elaborated upon one at a time.

  • Make a conscious decision to establish friendships with people from other cultures.
  • Put yourself in situations where you will meet people of other cultures.
  • Examine your biases about people from other cultures.
  • Ask people questions about their cultures, customs, and views.
  • Read about other people's culture's and histories
  • Listen to people tell their stories
  • Notice differences in communication styles and values; don't assume that the majority's way is the right way
  • Risk making mistakes
  • Learn to be an ally.

Make a conscious decision to establish friendships with people from other cultures

Making a decision is the first step. In order to build relationships with people different from yourself, you have to make a concerted effort to do so. There are societal forces that serve to separate us from each other. People from different economic groups, religions, ethnic groups, and races are often isolated from each other in schools, jobs, and neighborhoods. So, if we want things to be different, we need to take active steps to make them different.

You can join a sports team or club, become active in an organization, choose a job, or move to a neighborhood that puts you in contact with people of cultures different than your own. Also, you may want to take a few minutes to notice the diversity that is presently nearby. If you think about the people you see and interact with every day, you may become more aware of the cultural differences that are around you.

Once you have made the decision to make friends with people different from yourself, you can go ahead and make friends with them in much the same way as with anyone else. You may need to take more time, and you may need to be more persistent. You may need to reach out and take the initiative more than you are used to. People who have been mistreated by society may take more time to trust you than people who haven't. Don't let people discourage you. There are good reasons why people have built up defenses, but it is not impossible to overcome them and make a connection. The effort is totally worth it.

Put yourself in situations where you will meet people of other cultures; especially if you haven't had the experience of being a minority, take the risk.

One of the first and most important steps is to show up in places where you will meet people of cultures other than your own. Go to meetings and celebrations of groups whose members you want to get to know. Or hang out in restaurants and other gathering places that different cultural groups go. You may feel embarrassed or shy at first, but your efforts will pay off. People of a cultural group will notice if you take the risk of coming to one of their events. If it is difficult for you to be the only person like yourself attending, you can bring a buddy with you and support each other in making friends.

Examine your biases about people from other cultures.

We all carry misinformation and stereotypes about people in different cultures. Especially, when we are young, we acquire this information in bits and pieces from TV, from listening to people talk, and from the culture at large. We are not bad people because we acquired this; no one requested to be misinformed. But in order to build relationships with people of different cultures, we have to become aware of the misinformation we acquired.

An excellent way to become aware of your own stereotypes is to pick groups that you generalize about and write down your opinions. Once you have, examine the thoughts that came to your mind and where you acquired them.

Another way to become aware of stereotypes is to talk about them with people who have similar cultures to your own. In such settings you can talk about the misinformation you acquired without being offensive to people from a particular group. You can get together with a friend or two and talk about how you acquired stereotypes or fears of other different people. You can answer these kinds of questions:

  • How did your parents feel about different ethnic, racial, or religious groups?
  • What did your parents communicate to you with their actions and words?
  • Were your parents friends with people from many different groups?
  • What did you learn in school about a particular group?
  • Was there a lack of information about some people?
  • Are there some people you shy away from? Why?

Ask people questions about their cultures, customs, and views

People, for the most part, want to be asked questions about their lives and their cultures. Many of us were told that asking questions was nosy; but if we are thoughtful, asking questions can help you learn about people of different cultures and help build relationships. People are usually pleasantly surprised when others show interest in their cultures. If you are sincere and you can listen, people will tell you a lot.

Read about other people's cultures and histories

It helps to read about and learn about people's cultures and histories. If you know something about the reality of someone's life and history, it shows that you care enough to take the time to find out about it. It also gives you background information that will make it easier to ask questions that make sense.

However, you don't have to be an expert on someone's culture to get to know them or to ask questions. People who are, themselves, from a culture are usually the best experts, anyway.

Don't forget to care and show caring

It is easy to forget that the basis of any relationship is caring. Everyone wants to care and be cared about. Caring about people is what makes a relationship real. Don't let your awkwardness around cultural differences get in the way of caring about people.

Listen to people tell their stories

If you get an opportunity to hear someone tell you her life story first hand, you can learn a lot--and build a strong relationship at the same time. Every person has an important story to tell. Each person's story tells something about their culture.

Listening to people's stories, we can get a fuller picture of what people's lives are like--their feelings, their nuances, and the richness of their lives. Listening to people also helps us get through our numbness-- there is a real person before us, not someone who is reduced to stereotypes in the media.

Additionally, listening to members of groups that have been discriminated against can give us a better understanding of what that experience is like. Listening gives us a picture of discrimination that is more real than what we can get from reading an article or listening to the radio.


You can informally ask people in your neighborhood or organization to tell you a part of their life stories as a member of a particular group. You can also incorporate this activity into a workshop or retreat for your group or organization. Have people each take five or ten minutes to talk about one piece of their life stories. If the group is large, you will probably have to divide into small groups, so everyone gets a chance to speak.

Notice differences in communication styles and values; don't assume that the majority's way is the right way.

We all have a tendency to assume that the way that most people do things is the acceptable, normal, or right way. As community workers, we need to learn about cultural differences in values and communication styles, and not assume that the majority way is the right way to think or behave.


You are in a group discussion. Some group members don't speak up, while others dominate, filling all the silences. The more vocal members of the group become exasperated that others don't talk. It also seems that the more vocal people are those that are members of the more mainstream culture, while those who are less vocal are from minority cultures.

How do we understand this? How can this be resolved?

In some cultures, people feel uncomfortable with silence, so they speak to fill the silences. In other cultures, it is customary to wait for a period of silence before speaking. If there aren't any silences, people from those cultures may not ever speak. Also, members of some groups (women, people of low income, some racial and ethnic minorities, and others) don't speak up because they have received messages from society at large that their contribution is not as important as others; they have gotten into the habit of deferring their thinking to the thinking of others.

When some people don't share their thinking, we all lose out. We all need the opinions and voices of those people who have traditionally been discouraged from contributing.

In situations like the one described above, becoming impatient with people for not speaking is usually counter-productive. However, you can structure a meeting to encourage the quieter people to speak. For example, you can:

  • Have people break into pairs before discussing a topic in the larger group.
  • At certain times have each person in the circle make a comment. (People can pass if they want to.)
  • Follow a guideline that everyone speaks once, before anyone speaks twice.
  • Invite the quieter people to lead part of the meeting.
  • Talk about the problem openly in a meeting, and invite the more vocal people to try to speak less often.
  • Between meetings, ask the quieter people what would help them speak, or ask them for their ideas on how a meeting should be run.

A high school basketball team has to practice and play on many afternoons and evenings. One team member is a recent immigrant whose family requires her to attend the birthday parties of all the relatives in her extended family. The coach is angry with the parents for this requirement, because it takes his player away from the team.

How do we understand this? How can this be resolved?

Families have different values, especially when it comes to family closeness, loyalty, and responsibility. In many immigrant and ethnic families, young people are required to put their family's needs first, before the requirements of extra-curricular activities. Young people from immigrant families who grow up in the U.S. often feel torn between the majority culture and the culture of their families; they feel pressure from each cultures to live according to its values, and they feel they have to choose between the two.

As community workers, we need to support and respect minority and immigrant families and their values. It may already be a huge concession on the part of a family to allow a teenager to participate in extracurricular activities at all. We need to make allowances for the cultural differences and try to help young people feel that they can have both worlds--instead of having to reject one set of values for another.

As community builders, it helps to develop relationships with parents. If a young person sees her parents have relationships with people from the mainstream culture, it can help her feel that their family is accepted. It supports the teen in being more connected to her family and her community--and also, both relationships are critical protective factors for drug and alcohol abuse and other dangerous behaviors. In addition, in building relationships with parents, we develop lines of communication, so when conflicts arise, they can be more easily resolved.

Risk making mistakes

As you are building relationships with people who have different cultural backgrounds than your own, you will probably make mistakes at some point. That happens. Don't let making mistakes of making mistakes keep you from going ahead and building relationships.

If you say or do something that is insensitive, you can learn something from it. Ask the affected person what you bothered or offended them, apologize, and then go on in building the relationship. Don't let guilt bog you down.

Learn to be an ally

One of the best ways to help you build relationships with people of different cultures is to demonstrate that you are willing to take a stand against discrimination when it occurs. People will be much more motivated to get to know you if they see that you are willing to take risks on their behalf.

We also have to educate ourselves and keep informed so that we understand the issues that each group faces and we become involved in their struggles--instead of sitting on the sidelines and watching from a distance.

In Summary

Friendship is powerful. It is our connection to each other that gives meaning to our lives. Our caring for each other is often what motivates us to make change. And establishing connections with people from diverse backgrounds can be key in making significant changes in our communities.

As individuals, and in groups, we can change our communities. We can set up neighborhoods and institutions in which people commit themselves to working to form strong relationships and alliances with people of diverse cultures and backgrounds. We can establish networks and coalitions in which people are knowledgeable about each other's struggles, and are willing to lend a hand. Together, we can do it.

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