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A lifelong process that allows you to become more aware and understanding of cultural differences. 

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The framework for Cultural Competence includes multiple different things, including cultural awareness, cultural knowledge, and cultural skills. Understanding and respecting other cultures is beneficial because it allows you to grow and develop as an individual. Self-assessment is a great way to improve cultural competence. 

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The framework for Cultural Competence includes multiple different things, including cultural awareness, cultural knowledge, and cultural skills. Understanding and respecting other cultures is beneficial because it allows you to grow and develop as an individual. Self-assessment is a great way to improve cultural competence. 

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https://www.youtube.com/watch?v=tsWbODQiDWs

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Implicit Bias is a persons unconscious attitude and stereotypes while cultural competence is the ability to interact with others who have a cultural difference. Understanding the importance between the two, is beneficial in a classroom in order to build and create a safe space for children to learn and build successful relationships. This is how students grow into their beliefs and understandings of life and education.

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Implicit Bias is a persons unconscious attitude and stereotypes while cultural competence is the ability to interact with others who have a cultural difference. Understanding the importance between the two, is beneficial in a classroom in order to build and create a safe space for children to learn and build successful relationships. This is how students grow into their beliefs and understandings of life and education.

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Implicit Bias | Cultural Competence | Wild Iris Medical Education

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Define cultural competency. Learn about stereotypes and strategies to reduce implicit bias in patient care regarding race, gender, sexual orientation, etc.

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This can influence a teachers perceptions, interactions, and expectations. It's important for teachers to process and understand their implicit bias in order to benefit their classroom and students. 

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This can influence a teachers perceptions, interactions, and expectations. It's important for teachers to process and understand their implicit bias in order to benefit their classroom and students. 

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Bias can negatively impact students, people, relationships, etc. There are so many factors that go into implicit bias and cultural competence. Stereotypes, personal experiences, cultural context, and societies stereotypes can all impact this. Identifying and processing these thoughts and concerns are important.

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Bias can negatively impact students, people, relationships, etc. There are so many factors that go into implicit bias and cultural competence. Stereotypes, personal experiences, cultural context, and societies stereotypes can all impact this. Identifying and processing these thoughts and concerns are important.

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3 kinds of bias that shape your worldview | J. Marshall Shepherd

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Assessing bias: the importance of considering confounding

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It is common to come across a study that reports that treatment A “provided significantly better pain relief” than treatment B.

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Impact of Various Factors represents differences in social circumstances, environmental conditions, economic policies, and so much more that can have negative or positive impacts.

https://www.youtube.com/watch?v=LcNvkhS4UYg

https://pmc.ncbi.nlm.nih.gov/articles/PMC3503514/

https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2021.802439/full

https://www.youtube.com/watch?v=QnzkWc4b4mY

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Frontiers | The Impact of Cognitive Biases on Professionals’ Decision-Making: A Review of Four Occupational Areas

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The author reviewed the research on the impact of cognitive biases on professionals’ decision-making in four occupational areas (management, finance, medicin…

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The Kirwan Institute for the Study of Race and Ethnicity

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Implicit Bias | Cultural Competence | Wild Iris Medical Education

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Define cultural competency. Learn about stereotypes and strategies to reduce implicit bias in patient care regarding race, gender, sexual orientation, etc.

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Six Interventions to Tackle Unconscious or Implicit Bias

The following six interventions are representative of the evolving body of knowledge on ways to address implicit bias. These interventions have been adapted for health care practitioners and settings.

1. Acknowledge and accept the existence of implicit bias, its manifestations, and its impact

For many people, issues associated with culture, race, ethnicity, privilege, social class, prejudice, bias, stereotyping, discrimination, homophobia, institutional racism, and oppression are emotionally charged and difficult to both face and admit. ⁵ Those committed to careers in health care and public health are in it for the greater good and may not view themselves as harboring any ill intent, conscious or unconscious, toward populations and individuals to whom they provide care and related services. Yet countless studies indicate that bias on the part of health care providers contributes to health and health care disparities by impacting clinical decision-making, treatment options, the quality of the patient-provider relationship, effectiveness of communication, and the overall care provided to diverse patient populations. Moreover, there is substantial evidence that health care practitioners often doubt the existence of health care disparities or deny that such disparities exist in their own practice settings. ⁶⁻¹²

Implicit bias contributes to health and health care disparities among racial, ethnic, and other cultural groups.

Many people are unsettled by discovering biases that they never knew existed. Yet the experts note that becoming aware of and unsettled by one's unconscious biases is the first step to addressing them. 13,14 The following are other steps that are beneficial to health care practitioners in the early stages of discovery and acceptance of implicit bias within themselves and the health care profession.

Action Step. Accept that we all have implicit biases, and that bias is a normal part of human functioning, even among health care practitioners.

Action Step. Acknowledge that unconscious bias can have a direct impact on a physician's ability to fulfill the Hippocratic Oath (first to do no harm) or similarly the code of ethics for nurses, nurse practitioners, and physician assistants.

Action Step. Acknowledge and accept that biases can negatively impact the day-to-day interactions, including compromised medical decision-making, that health care practitioners have with their patients,

Action Step. Minimize feelings associated with guilt and blame as because they only serve to slow and/or interfere with efforts to address unconscious bias. Instead, health care practitioners should focus energy on intentional actions to recognize and combat their biases on a consistent basis.

Action Step. Accept that there are solutions to address the complexities of implicit bias. As noted in the following section, an array of interventions can successfully be employed in practice settings.

2. Assume individual responsibility to address implicit bias

Given the weight of the evidence on the correlation between implicit bias and health care disparities, systems, organizations, and practices should take action to address this pervasive problem. It is incumbent upon each health care professional to assume individual responsibility to better understand and address his or her own biases.

Practical Solutions for Stepping Up

Write a list of your beliefs that may lead to biased thoughts and behaviors toward others.

Ask one or more colleagues, with whom you have a relationship of trust, to share their views about what they see as biased beliefs or behaviors that you demonstrate.

Reflect on whether and how your beliefs negatively impact relationships with patients and their families.

Make a personal and professional commitment to combat those biases that compromise the care you deliver to patients and their families.

Participate in CME and other professional development/learning forums about implicit bias and approaches to address these biases in health and mental health care.

Advocate for the inclusion of content/sessions that focus on implicit bias in health care in professional meetings, conferences, and symposia with which you are affiliated.

3. Engage in self-reflection and self-assessment

Self-reflection is an integral component of the adult learning experience and a practice of many health professionals. Research emphasizes the importance of active reflection in deepening learning from experience. ¹⁵ The literature in experiential learning acknowledges that the capacity to engage in self-assessment is considered integral to the learning experience in general and essential to personal and professional growth and development in particular. Kolb and Kolb ¹⁶ state that "Learning is best facilitated by a process that draws out beliefs and ideas about a topic so that they can be examined, tested, and integrated with new, more refined ideas."

Self-assessment is also described in the literature as an essential element of culturally competent care for health care practitioners and organizations. ¹⁷⁻²³ Those who engage in the process of self-assessment report personal and professional benefits. There is a range of tools for practitioners to assess cultural and linguistic competence, although fewer are available that specifically focus on bias.

How can I learn about my unconscious or implicit biases?

There are a number of self-assessment tools and instruments designed to help you learn about unconscious or implicit bias. One such tool is the Implicit Association Test (IAT), developed by a team of leading cognitive scientists and rigorously researched.

While the IAT was developed to research unconscious bias, it is now available to those interested in learning about themselves.

Are you ready to take a go at the IAT?

Please open the IAT (this link will open in a separate tab/window).

Instructions

Once on the site, click the button that says Demonstration and choose at least two tests, one of which should relate to race, skin tone, or ethnicity.

What do I do if I have questions about my experience with the IAT?

After taking the test, people often have questions about the results or the process. The site has an excellent FAQs (Frequently Asked Questions) section.

Click here to visit the Project Implicit Web site: https://implicit.harvard.edu/implicit/

How does the IAT work?

You will be asked to look at pictures of people or at words and press a key on your keyboard to indicate a particular concept associated with that picture. As explained on the Project Implicit Web site:

"The IAT asks you to pair two concepts (e.g., young and good, or elderly and good).The more closely associated the two concepts are, the easier it is to respond to them as a single unit. So, if young and good are strongly associated, it should be easier to respond faster when you are asked to give the same response (i.e. the 'E' or 'I' key) to these two. If elderly and good are not so strongly associated, it should be harder to respond fast when they are paired. This gives a measure of how strongly associated the two types of concepts are. The more associated, the more rapidly you should be able to respond." 24

I really am not sure about taking a test that points out my biases.

Taking the IAT can be a little unsettling. Remember: It measures unconscious bias and even those who are fair minded and detest prejudice at a conscious level, often turn out to have some unconscious biases based on race, age, gender, and other demographic factors.

Suzanne Bronheim, PhD, Senior Policy Associate at the National Center for Cultural Competence shares her experience taking the IAT.

Am I predisposed to show preference for people like myself?

We might expect to show preference for those who are more like us. However, we actually may have absorbed attitudes, beliefs, images, and stereotypes from the society at large that rest within our unconscious and impact our actions. For example, even those over 60 years of age have been found to show a preference for "young." Data collected from IAT website consistently reveal approximately even numbers of Black respondents showing a pro-White bias as show a pro-Black bias. 24,25

Vivian Jackson, PhD, Senior Policy Associate at the National Center for Cultural Competence shares her experience as an African American taking the IAT on race.

4. Make good use of the neuroscience to combat "hard wiring"

There is a strong body of evidence that describes the neurological mechanisms of unconscious or implicit bias. This literature also provides insight into how to use the neuroscience to create solutions to circumvent our hard wiring and combat unconscious bias. While there are many solutions to implicit bias, some are more practical and accessible than others. The following interventions were designed to address implicit racial bias, with an emphasis on positive or negative biases for both White and African American populations.

These following interventions are not limited to racial groups. They are applicable across groups defined by ethnicity, gender, age, limited language proficiency, socioeconomic status, and other demographic factors for which data are collected by your practice or health care organization. These solutions are suggested because they can easily be used and they can be included in physicians' and other health care practitioners' day-to-day practices.

* Note on PDFs: This PDF is set by default to open in a new tab or window in your browser. However, your browser may be set up to download the file or to open it in the same window as this page. Please make sure you know how to return to this course.

5. Collect and use data effectively and perform self-monitoring

The literature cites the use of data as an effective means to address both conscious and unconscious biases. The previous intervention that focused on using the neuroscience offered a number of strategies that required using data to discover disparities in diagnosis, treatment, and the provision of care. David Newhouse, MD, MPH, is the Chief of Diversity and Performance Improvement, Kaiser Permanente in Northern California. He provides a remarkable personal narrative of his experience with biases, his own and those of his patients, how he used data to address bias in his practice, and launched a national program that has reached more than 5,000 physicians in the Kaiser system.

Listen to Dr. Newhouse's story: Listen to MP3 audio | PowerPoint Movie with Audio
( Note: this PowerPoint file should download to your computer. Once it has downloaded, you will need to open the file and click on Slide Show.)

Let's explore Dr. Newhouse's work

Let us now find out more about Dave's personal journey of addressing unconscious bias through a systematic approach to collect and analyze data. And how he used those data to effect change in the practices of his own practice and many physicians in the Kaiser Permanente system.

Click here to learn about what he did and how you can use it to address bias in your practice: Solutions for a Changing World: Moving from Study to Action (PDF)* by David Newhouse, MD, MPH, The Permanente Medical Group, Fremont California.

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Practice self-monitoring and mindfulness

As an ongoing approach to increasing awareness of implicit bias, the literature also suggests applying the concept of mindfulness to one's own thoughts and reactions. ²⁵ Bishop, Lau, and colleagues (2004) offer a two-component model of mindfulness. ²⁶ The first component involves the self-regulation of attention so that it is maintained on immediate experience, thereby allowing for increased recognition of mental events in the present moment.The second component involves adopting a particular orientation toward one's experiences in the present moment, an orientation that is characterized by curiosity, openness, and acceptance.Both components are essential, since the literature emphasizes that stigmatizing bias rather than acknowledging its existence is counterproductive. ²⁷

In the following video clip, Suzanne Bronheim, PhD, Senior Policy Associate at the National Center for Cultural Competence provides an example of using mindfulness to explore one's implicit bias and how such biases impact perceptions and judgments.

6. Incorporate cultural and linguistic competence in your practice

A definitive body of evidence describes culturally and linguistically competent approaches to health care delivery as having proven efficacy in addressing disparities in health care and health outcomes for some racial and ethnic groups and populations. ²⁸⁻⁴⁰ Cultural competence and linguistic competence are considered essential for providing quality care to diverse populations in the United States, its territories, and tribal communities. Both cultural competence and linguistic competence are widely recognized by accreditation agencies, quality care organizations, state professional licensing boards, professional medical societies, researchers, educators, and policy makers as core elements of health care. 41,42 Yet significant challenges remain to embrace and incorporate cultural and linguistic competence in the policies and practices of U.S. health care systems and organizations.

While there is conclusive evidence that cultural competence and linguistic competence can help reduce health and health care disparities, can they be useful in efforts to combat implicit bias? To answer this question, let us first define cultural competence, examine the five elements of cultural competence for practitioners, and delineate how these elements can preempt, mitigate, and serve as "protective factors" against implicit bias. We will then examine linguistic competence.

The mechanisms by which implicit bias impacts the clinician-physician interaction (i.e., viewing patients as similar, dissimilar, or the "other"), and the clinician's decision-making processes (i.e., impair executive functioning) elucidate how cultural and linguistic competence can mediate the effects of such biases.

Elena Ríos, M.D., M.S.P.H., President & CEO, National Hispanic Medical Association describes the importance of cultural competence.

Defining cultural competence and its mediating effect on implicit or unconscious bias

Five essential elements or practices of cultural competence at the individual level involve the capacity to: (1) acknowledge cultural differences, (2) understand one's own culture, (3) engage in self-assessment, (4) acquire cultural knowledge and skills, and (5) view behavior within a cultural context. Each of these elements can have a preemptive or mitigating effect on implicit bias.

Cultural Competence-Individual/Practitioner

Cultural competence requires practitioners to: (1) acknowledge and respond to cultural differences; (2) reflect on and understand their own culture and the culture of medicine; (3) engage in self-assessment; (4) acquire cultural knowledge and skills; and (5) and adapt practice to the cultural contexts of individuals, families, and communities. ⁴³

First and foremost, implicit bias cannot be addressed if it is not brought into conscious awareness and acknowledged. ²⁵ Yet there is evidence that many physicians do not fully accept that health and health care disparities exist, or they attribute such disparities to system factors such as insurance coverage or patient variables rather than differential care provided. 6,7,9 Physicians can employ the following culturally competent practices: acquiring cultural knowledge of the health and health care disparities of diverse racial and ethnic populations and engaging in self-assessment to determine the extent to which such disparities exist within their health care setting or practice as well to gauge personal biases using tests such as the IAT.

Cultural Competence-Organization/System

Cultural competence requires that organizations have a clearly defined congruent set of values and principles, and demonstrate behaviors, attitudes, policies, structures and practices that enable them to work cross-culturally. Cultural competence is a developmental process that occurs over time. Organizations and their personnel are at various stages along the cultural competence continuum. ⁴³

Evidence suggests that implicit bias can have a negative impact on patient-physician interactions. While physicians can modify their verbal behavior to be in line with their conscious beliefs that they do not harbor negative biases, non-verbal behavior betrays implicit bias to patients and has an adverse effect on communication and the quality of interpersonal interactions. ⁴⁴ The culturally competent practice of acquiring cultural knowledge and skills, particularly those focused on cross-cultural communication, increases physicians' capacity to be conscious of not only their own non-verbal behaviors but also those of their patients.

In the fast-paced and often stressful clinical environment, implicit bias manifests as stereotyping and simplified approaches to care, resulting in differences in treatment plans offered and thus diminished patient-centered care. 45,46 Culturally competent practices of acknowledging cultural differences and viewing behavior within a cultural context can serve as a buffer against implicit bias as it facilitates highly specific knowledge about patients' values, health beliefs and practices, and the social, cultural, and environmental contexts in which they live that impact health and well-being. The culturally competent practice of understanding your own culture, including the culture of medicine, enables physicians to overcome the implicit bias of judging those perceived as similar and dissimilar. Physicians who are conscious of their own world view are well poised to see the similarities they share with their patients and show more empathy, including understanding patients' needs. Moreover, this practice enables physicians to advocate with and on behalf of populations they serve to address societal inequities, and it helps to diminish the sense of "them" and "us" that contributes to lack of empathy.

Practical examples of how each of the five elements of cultural competence can mitigate implicit or unconscious bias are provided in a crosswalk.
Click here for crosswalk (PDF)*
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The following six interventions are representative of the evolving body of knowledge on ways to address implicit bias. These interventions have been adapted for health care practitioners and settings. 1.

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American College of Emergency Physicians

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Aisha Liferidge, MD, MPH: Diversity, Implicit Bias, and Cultural Competence

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Arkansas Open Educational Resources (OER)

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Abstract

Objectives: The need to address cultural and ethnic diversity issues in medical education as a means to improve the quality of care for all has been widely emphasised. Cultural competence has been suggested as an instrument with which to deal with diversity issues. However, the implementation of culturally competent curricula appears to be difficult. We believe the development of curricula would profit from a framework that provides a practical translation of abstract educational objectives and that is related to competencies underlying the medical curriculum in general. This paper proposes such a framework.

Methods: The framework illustrates the following cultural competencies: knowledge of epidemiology and the differential effects of treatment in various ethnic groups; awareness of how culture shapes individual behaviour and thinking; awareness of the social context in which specific ethnic groups live; awareness of one's own prejudices and tendency to stereotype; ability to transfer information in a way the patient can understand and to use external help (e.g. interpreters) when needed, and ability to adapt to new situations flexibly and creatively.

Discussion: The framework indicates important aspects in taking care of an ethnically diverse patient population. It shows that there are more dimensions to delivering high-quality care than merely the cultural. Most cultural competencies emphasise a specific aspect of a generic competency that is of extra importance when dealing with patients from different ethnic groups. We hope our framework contributes to the further development of cultural competency in medical curricula.

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attitude of health personnel / ethnology

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Cultural competence: a conceptual framework for teaching and learning - PubMed

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The framework indicates important aspects in taking care of an ethnically diverse patient population. It shows that there are more dimensions to delivering high-quality care than merely the cultural. Most cultural competencies emphasise a specific aspect of a generic competency that is of extra impo ...

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Hoshi was born and grew up in Japan. He has been living in the United States for nearly 20 years, going to graduate school and working as a systems analyst, while his family has remained in Japan. Hoshi entered a residential treatment center for alcohol dependence where the treatment program expected every client to notify his or her family members about being in treatment. This had proven to be a positive step for many other clients and their families in this treatment program, where the belief was that contact with family helped clients become honest about their substance abuse, reconnect with possibly estranged relatives, and take responsibility for the decision to seek treatment.

He was reluctant, but staff members persuaded Hoshi to comply with program expectations. He wrote to his family, describing his current life and explaining his need for treatment. It was not until weeks later, after he had been discharged from residential treatment and was participating in the program's continuing care program, that he received a reply. Staff members were shocked to learn that Hoshi's parents had disowned him because he had "shamed" the family by disclosing the details of his life to the program staff, publicly admitting that he had a drinking problem.

As Hoshi's story demonstrates, a well-meaning but culturally inappropriate intervention can be counterproductive to recovery. The program applied a "one size fits all" model without being sensitive to the possibility that such an approach might harm the client. Fortunately, Hoshi eventually reconciled with his family, and the program administration and staff began to develop initiatives to improve their cultural awareness and competence.

Counselors and other behavioral health service providers who are equipped with a general understanding of how culture affects their own worldviews as well as those of their clients will be able to work more effectively with clients who have substance use and mental disorders. Even when culture is not a conscious consideration in providing interventions and services, it is a dynamic force that often influences client responses to treatment and subsequent outcomes. Although outcome research is limited, culturally responsive behavioral health counseling results in greater counselor credibility, better client satisfaction, more client self-disclosure, and greater willingness among clients to continue with counseling ( Goode et al. 2006; Lie et al. 2011; Ponterotto et al. 2000). This Treatment Improvement Protocol (TIP) examines the significance of culture in substance abuse patterns, mental health, treatment-seeking behaviors, assessment and counseling processes, program development, and organizational practices in behavioral health services.

Purpose and Objectives of the TIP

This TIP is intended to help counselors and behavioral health organizations make progress toward cultural competence. Gaining cultural competence, like any important counseling skill, is an ongoing process that is never completed; such skills cannot be taught in any single book or training session. Nevertheless, this TIP provides a framework to help practitioners and administrators integrate cultural factors into their evaluation and treatment of clients with behavioral health disorders. It also seeks to motivate professionals and organizations to examine and broaden their cultural awareness, embrace diversity, and develop a heightened respect for people of all cultural groups. This TIP places significant importance on the role of program management and organizational commitment in the development of cultural competence. Organizational support allows counselors, case managers, and administrators to begin to integrate culturally congruent and responsive services more consistently across the continuum of care-including outreach and early intervention, assessment, treatment planning and intervention, and recovery services.

The key objectives of this TIP are helping readers understand:

Why it is important for behavioral health organizations and counselors who provide prevention and treatment services to consider culture.

The role culture plays in the treatment process, both generally and with reference to specific cultural groups.

Core Assumptions

The consensus panel developed assumptions that serve as the fundamental platform of this TIP. Assumptions were derived from clinical and administrative experiences, available empirical evidence, conceptual writings, and program and treatment service models.

Assumption 1: The focus of cultural competence, in practice, has historically been on individual providers. However, counselors will not be able to sustain culturally responsive treatment without the organization's commitment to support and allocate resources to promote these practices. Organizations that value diversity and reflect cultural competence through congruent policies and procedures are more likely to be successful in the ever-changing landscape of communities, treatment services, and individual client needs.

Assumption 2: An understanding of race, ethnicity, and culture (including one's own) is necessary to appreciate the diversity of human dynamics and to treat all clients effectively. Before counselors begin to probe the cultures, races, and ethnicities of their clients and use this information to improve client treatment, the consensus panel recommends first that counselors examine and understand their own cultural histories, racial and ethnic heritages, and cultural values and beliefs. This applies to all practitioners regardless of race, ethnicity, or cultural identity. Beyond that, clinicians should clearly identify the influences of their own cultural experiences on the counseling relationship. In other words, each counselor must understand, embrace, and, if warranted, reexamine and adjust his or her own worldview to practice in a culturally competent manner. So too, all support staff, clinicians, administrators, and policymakers-including those not from the mainstream culture-must become educated and convinced of the importance of cultural competence in the delivery of effective behavioral health services.

Assumption 3: Incorporating cultural competence into treatment improves therapeutic decision-making and offers alternate ways to define and plan a treatment program that is firmly directed toward progress and recovery-as defined by both the counselor and client. Using culturally responsive practices is essential and provides many benefits for organizations, staff, communities, and clients.

Assumption 4: Consideration of culture is important at all levels of operation-individual, programmatic, and organizational-across behavioral health treatment settings. It is also important in all activities and at every treatment phase: outreach, initial contact, screening, assessment, placement, treatment, continuing care and recovery services, research, and education. Because organizations and systems have their own internal cultures, it is vital that treatment facilities, training and educational programs on substance-related and mental disorders and treatment processes, and licensing agencies and accrediting bodies incorporate culturally responsive practices into their curricula, standards, criteria, and requirements.

Assumption 5: Achieving cultural competence in an organization requires the participation of racially and ethnically diverse groups and underserved populations in the development and implementation of culturally responsive practices, program structure and design, treatment strategies and approaches, and staff professional development. Culturally congruent interventions cannot be successfully applied when generated outside a community or without community participation. Clients, potential clients, their families, and their communities should be invited to participate in the development of a cultural competence plan (an organization's plan to improve cultural competence and to provide culturally responsive services) and, subsequently, the design of culturally relevant treatment services and organizational policies and procedures.

Assumption 6: Public advocacy of culturally responsive practices can increase trust among the community, agency, and staff. The community is thus empowered with a voice in organizational operations. Advocacy can further function as a secondary form of public education and awareness as well as outreach. High collective participation allows treatment to be viewed as of and for the community.

What Is Cultural Competence?

In 1989, Cross et al. provided one of the more universally accepted definitions of cultural competence in clinical practice: "A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enable the system, agency, or professionals to work effectively in cross-cultural situations" (p. 13).

Since then, others have interpreted this definition in terms of a particular field or attempted to refine, expand, or elaborate on earlier conceptions of cultural competence. At the root of this concept is the idea that cultural competence is demonstrated through practical means-that is, the ability to provide effective services. Bazron and Scallet (1998) defined culturally responsive services as those that are "responsive to the unique cultural needs of bicultural/bilingual and culturally distinct populations" (p. 2). The Office of Minority Health ( OMH 2000) merged several existing definitions to conclude that:

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. (p. 28)

Numerous evolving definitions and models of cultural competence reflect an increasingly complex and multidimensional view of how race, ethnicity, and culture shape individuals-their beliefs, values, behaviors, and ways of being (see Bhui et al. 2007 for a systemic review of cultural competence models in mental health). In this TIP, Sue's (2001) multidimensional model of cultural competence guides its overall organization and the specific content of each chapter. The model was adapted to fit the unique topic areas addressed by this TIP ( Exhibit 1-1) and to target essential elements of cultural competence in providing behavioral health services across three main dimensions, as shown in the cube. (Note: Each subsequent chapter displays a version of this cube shaded to emphasize the focus of that chapter.)

Why Is Cultural Competence Important?

The Affordable Care Act, along with growing recognition of racial and ethnic health disparities and implementation of national initiatives to reduce them ( HHS 2011b), necessitates enhanced culturally responsive services and cultural competence among providers. Most behavioral health studies have found disparities in access, utilization, and quality in behavioral health services among diverse ethnic and racial groups in the United States ( Alegria et al. 2008b; Alegria et al. 2011; HHS 2011b; Le Cook and Alegria 2011; Satre et al. 2010). The lack of cultural knowledge among providers, culturally responsive environments, and diversity in the workforce contribute to disparities in healthcare. Even limited cultural competence is a significant barrier that can translate to ineffective provider-consumer communication, delays in appropriate treatment and level of care, misdiagnosis, lower rates of consumer compliance with treatment, and poorer outcome ( Barr 2008; Carpenter-Song et al. 2011; Dixon et al. 2011). Increasing the cultural competence of the healthcare workforce and across healthcare settings is crucial to increasing behavioral health equity.

Additionally, adopting and integrating culturally responsive policies and practices into behavioral health services provides many benefits not only for the client, but also for the organization and its staff. Foremost, it increases the likelihood of sustainability. Cultural competence supports the viability of services by bringing to the forefront the value of diversity, flexibility, and responsiveness in organizations and among practitioners. Beyond the necessity of adopting culturally responsive practices to meet funding, state licensing, and/or national accreditation requirements, cultural competence essential in organizational risk management (the process of making and implementing decisions that will optimize therapeutic outcomes and minimize adverse effects upon clients and, ultimately, the organization). For instance, implementing culturally responsive services is likely to increase access to care and improve assessment, treatment planning, and placement. So too, it is likely to enhance effective communication between clients and treatment providers, thus decreasing risks associated with misunderstanding the clients' presenting problems or the needs of clients with regard to appropriate referrals for evaluation or treatment.

Organizational investment in improving cultural competence and increasing culturally responsive services will likely increase use and cost effectiveness because services are more appropriately matched to clients from the beginning. A key principle in culturally responsive practices is engagement of the community, clients, and staff. As organizations establish community involvement in the ongoing implementation of culturally responsive services, the community will be more aware of available treatment services and thus will become more likely to use them as its involvement with and trust for the organization grows. Likewise, clients and staff are more apt to be empowered and invested if they are involved in the ongoing development and delivery of culturally responsive services. Client and staff satisfaction can increase if organizations provide culturally congruent treatment services and clinical supervision.

Culturally responsive practice reinforces the counselor's need for self-exploration of cultural identity and awareness and the importance of acquiring knowledge and skills to meet clients' specific cultural needs. Cultural competence requires an understanding of the client's worldview and the interactions between that worldview and the cultural identities of the counselor and the client in the therapeutic process. Culturally responsive practice reminds counselors that a client's worldview shapes his or her perspectives, beliefs, and behaviors surrounding substance use and dependence, illness and health, seeking help, treatment engagement, counseling expectations, communication, and so on. Cultural competence includes addressing the client individually rather than applying general treatment approaches based on assumptions and biases. It also can counteract a potentially omnipotent stance on the part of counselors that they know what clients need more than the clients themselves do. Cultural competence highlights the need for counselors to take time to build a relationship with each of their clients, to understand their clients, and to assess for and access services that will meet each client's individual needs.

How Is Cultural Competence Achieved?

Cultural groups are diverse and continuously evolving, defying precise definitions. Cultural competence is not acquired merely by learning a given set of facts about specific populations, changing an organization's mission statement, or attending a training on cultural competence. Becoming culturally competent is a developmental process that begins with awareness and commitment and evolves into skill building and culturally responsive behavior within organizations and among providers.

Cultural competence is the ability to recognize the importance of race, ethnicity, and culture in the provision of behavioral health services. Specifically, it is awareness and acknowledgment that people from other cultural groups do not necessarily share the same beliefs and practices or perceive, interpret, or encounter similar experiences in the same way. Thus, cultural competence is more than speaking another language or being able to recognize the basic features of a cultural group. Cultural competence means recognizing that each of us, by virtue of our culture, has at least some ethnocentric views that are provided by that culture and shaped by our individual interpretation of it. Cultural competence is rooted in respect, validation, and openness toward someone whose social and cultural background is different from one's own ( Center for Substance Abuse Treatment [CSAT] 1999b).

Nonetheless, cultural competence literature highlights how difficult it is to appreciate cultural differences and to address these differences effectively, because many people tend to see things solely from their own culture-bound perspectives. For counselors, specific cognitions, attitudes, and behaviors characterize the path to culturally competent counseling and culturally responsive services. Exhibit 1-2 depicts the continuum of thoughts and behaviors that lead to cultural competence in the provision of treatment. The "stages" are not necessarily linear, and not all people begin with a negative impression of other cultural groups-they may simply fail to recognize differences and diverse ways of being. For most people, the process of becoming culturally competent is complex, with movement back and forth along the continuum and with feelings and thoughts from more than one stage sometimes existing concurrently.

What Is Culture?

Culture is defined by a community or society. It structures the way people view the world. It involves the particular set of beliefs, norms, and values concerning the nature of relationships, the way people live their lives, and the way people organize their environments. Culture is a complex and rich concept. Understanding it requires a willingness to examine and grasp its many elements and to comprehend how they come together. Castro (1998) identified the elements generally agreed to constitute a culture as:

A common heritage and history that is passed from one generation to the next.

Shared values, beliefs, customs, behaviors, traditions, institutions, arts, folklore, and lifestyle.

Similar relationship and socialization patterns.

A common pattern or style of communication or language.

Geographic location of residence (e.g., country; community; urban, suburban, or rural location).

Patterns of dress and diet.

However, culture is not a definable entity to which people belong or do not belong. Within a nation, race, or community, people belong to multiple cultural groups, each with its own set of cultural norms (i.e., spoken or unspoken rules or standards that indicate whether a certain behavior, attitude, or belief is appropriate or inappropriate).

The word " culture" can be applied to describe the ways of life of groups formed on the bases of age, profession, socioeconomic status, disability, sexual orientation, geographic location, membership in self-help support groups, and so forth. In this TIP, with the exception of the drug culture, the focus is on cultural groups that are shaped by a dynamic interplay among specific factors that shape a person's identity, including race, ethnicity, religion, socioeconomic status, and others.

What Is Race?

Race is often thought to be based on genetic traits (e.g., skin color), but there is no reliable means of identifying race based on genetic information ( HHS 2001). Indeed, 85 percent of human genetic diversity is found within any "racial" group ( Barbujani et al. 1997). Thus, what we perceive as diverse races (based largely on selective physical characteristics, such as skin color) are much more genetically similar than they are different. Moreover, physical characteristics ascribed to a particular racial group can also appear in people who are not in that group. Asians, for example, often have an epicanthic eye fold, but this characteristic is also shared by the Kung San bushmen, an African nomadic Tribe ( HHS 2001).

White Americans constitute the largest racial group in the United States. In the 2010 Census, 72 percent of the United States population consisted of non-Hispanic Whites, a classification that has been used by the Census Bureau and others to refer to non-Hispanic people of European, North African, or Middle Eastern descent ( Humes et al. 2011). The U.S. Census Bureau predicts, however, that White Americans will be outnumbered by persons of color sometime between the years 2030 and 2050. The primary reasons for the decreasing proportion of White Americans are immigration patterns and lower birth rates among Whites relative to Americans of other racial backgrounds ( Sue and Sue 2003b).

Whites are often referred to collectively as Caucasians, although technically, the term refers to a subgroup of White people from the Caucasus region of Eastern Europe and West Asia. To complicate matters, some Caucasian people-notably some Asian Indians-are typically counted as Asian ( U.S. Census Bureau 2001a). Many subgroups of White Americans (of European, Middle Eastern, or North African descent) have had very different experiences when immigrating to the United States.

African Americans, or Blacks, are the second largest racial group in the United States, making up about 13 percent of the United States population in 2010 ( Humes et al. 2011). Although most African Americans trace their roots to Africans brought to the Americas as slaves centuries ago, an increasing number are new immigrants from Africa and the Caribbean. The terms African American and Black are used synonymously at times in literature and research, but some recent immigrants do not consider themselves to be African Americans, assuming that the designation only applies to people of African descent born in the United States. The racial designation Black, however, encompasses a multitude of cultural and ethnic variations and identities (e.g., African Caribbean, African Bermudian, West African, etc.). The history and experience of African Americans has varied considerably in different parts of the United States, and the experience of Black people in this country varies even more when the culture and history of more recent immigrants is considered. Today, African American culture embodies elements of Caribbean, Latin American, European, and African cultural groups. Noting this diversity, Brisbane (1998) observed that "these cultures are so unique that practices of some African Americans may not be understood by other African Americans...there is no one culture to which all African Americans...belong" (p. 2).

The racial category of Asian is defined by the U.S. Census Bureau (2001a) as people "having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam" (p. A-3). In the 2010 census, Asian Americans accounted for 4.8 percent of the total United States population, or 5.6 percent when biracial or multiracial Asians were included ( Hoeffel et al. 2012). For those who identified with only one Asian group, 23 percent of Asian Americans were Chinese; 19 percent, Asian Indian; 17 percent, Filipino; 11 percent, Vietnamese; 10 percent, Korean; and 5 percent, Japanese. Asian Americans comprised about 43 ethnic subgroups, speaking more than 100 languages and dialects ( HHS 2001). The tremendous cultural differences among these groups make generalizations difficult.

Until recently, Asian Americans were often grouped with Pacific Islanders (collectively called Asians and Pacific Islanders, or APIs) for data collection and analysis. Beginning with the 2000 Census, however, the Federal Government recognized Pacific Islanders as a distinct racial group. As a result, this TIP does not combine Asians with Pacific Islanders. Nonetheless, remnants of the old classification system are evident in research based on the API grouping. Where possible, the TIP uses data solely for Asians; however, in some cases, the only research available is for the combined API grouping.

Native American is a term that describes both American Indians and Alaska Natives. Racially, Native Americans are related to Asian peoples (notably, those from Siberia in Russia), but they are considered a distinct racial category by the U.S. Census Bureau, which further stipulates that people categorized in this fashion have to have a "Tribal affiliation or community attachment" ( U.S. Census Bureau 2001a, p. A-3). There are 566 federally recognized American Indian or Alaska Native Tribal entities ( U.S. Department of the Interior, Indian Affairs 2013a), but there are numerous other Tribes recognized only by States and still others that go unrecognized by any government agency. These Tribes, despite sharing a racial background, represent a widely diverse group of cultures with diverse languages, religions, histories, beliefs, and practices.

What Is Ethnicity?

The term ethnicity is sometimes used interchangeably with " race," although it is important to draw distinctions between the two. According to Yang (2000), ethnicity refers to the social identity and mutual sense of belonging that defines a group of people through common historical or family origins, beliefs, and standards of behavior (i.e., culture). In some cases, ethnicity also refers to identification with a clan or group whose identity can be based on race as well as culture. Some Latinos, for example, self-identify in terms of both their ethnicity (e.g., their Cuban heritage) and their race (e.g., whether they are dark or light skinned).

Because Latinos can belong to a number of races, the Census Bureau defines them as an ethnic group rather than a race. In 2010, Latinos comprised 16 percent of the United States population ( Ennis et al. 2011). They are the fastest growing ethnic group in the United States; between 2000 and 2010, the number of Latinos in the country increased 43 percent, a rate nearly four times higher than that for the total population ( Ennis et al. 2011). By 2050, Latinos are expected to make up 29 percent of the total population ( Passel and Cohn 2008). Nearly 60 percent of Latino Americans were born in the United States, but Latinos also account for more than half of the nation's foreign-born population ( Larsen 2004; Ramirez and de la Cruz 2003). Foreign-born Latinos include legal immigrants, some of whom have succeeded in becoming naturalized American citizens, as well as undocumented or illegal immigrants to the United States. Approximately three-quarters (74 percent) of the Nation's unauthorized immigrant population are Hispanics, mostly from Mexico ( Passel and Cohn 2008).

The terms "Hispanic" and "Latino" refer to people whose cultural origins are in Spain or Portugal or the countries of the Western Hemisphere whose culture is significantly influenced by Spanish or Portuguese colonization. Regional and political differences exist among various groups as to whether they prefer one term over the other. The literature currently uses both terms interchangeably, as both terms are widely used and refer generally to the same Latin-heritage population of the United States. That said, a distinction can technically be drawn between Hispanic (literally meaning people from Spain or its former colonies) and Latino (which refers to persons whose origins lie in countries ranging from Mexico to Central and South America and the Caribbean, which were colonized by Spain, and including Portugal and its former colonies as well). For that reason, this TIP uses the more inclusive term Latino, except when research specifically indicates the other. The term Latinas is used to refer specifically to women who are a part of this cultural group. Within a racial group (e.g., Asian, White, Black, Native American), there are many diverse ethnicities, and these diverse ethnicities often reflect vast differences in cultural histories. The White Anglo-Saxon Protestant peoples of England and Northern Europe have, for example, many differing cultural attributes and a very different history in the United States than the Mediterranean peoples of Southern Europe (e.g., Italians, Greeks).

What Is Cultural Identity?

Some of the factors that are likely to vary among members of the same culture include socioeconomic status, geographic location, gender, education level, occupational status, sexuality, and political and religious affiliation. For individuals whose families are highly acculturated, some of these characteristics (e.g., geographic location, occupation, religion) can be more important than ethnic culture in defining their sense of identity. The section that follows provides more detailed information on the most important cross-cutting factors involved in the creation of a person's cultural identity.

What Are the Cross-Cutting Factors in Race, Ethnicity, and Culture?

As You Proceed

This chapter has established the foundation and rationale of this TIP; reviewed the core concepts, models, and terminology of cultural competence; and provided an overview of factors that are common among diverse racial, ethnic, and cultural groups. As you proceed, be aware that diversity occurs not only across racially and ethnically diverse groups, but within each group as well-there are cultures within cultures. Clinicians and organizations need to develop skills to create an environment that is responsive to the unique attributes and experiences of each client, as outlined earlier in this chapter in the " What Are the Cross-Cutting Factors in Race, Ethnicity, and Culture? " section. As you read this TIP, remember that many cross-cutting factors influence the counselor-client relationship, the client's presentation and identification of problems, the selection and interpretation of screening and assessment tools, the client's responsiveness to specific clinical services, and the effectiveness of program delivery and organizational structure and planning.

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Hoshi was born and grew up in Japan. He has been living in the United States for nearly 20 years, going to graduate school and working as a systems analyst, while his family has remained in Japan.

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Teacher Bias: The Elephant in the Classroom

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The principle is the same—whether it’s gender or race, student preference or handwriting, any factor that causes a teacher to have higher…

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Last week at Colgate University in central New York, reports of a black male carrying a gun - which in reality was a Colgate student carrying a glue gun for a school project - prompted school officials to put the campus on lockdown. In a message to the university, President Brian W. Casey wrote: "It is important that we understand the role that implicit racial bias had in the initial reporting of and responses to the events of last night."

African Americans have learned to expect bias in their lives from an early age, and very little has been done to counteract the effects associated with implicit biases. If black students experience the effects of implicit bias from the first day they step into a school, how can we expect them to develop healthy or positive attitudes toward authority figures later in life? While we may think of ourselves as unbiased, it is important for educators to recognize and purposefully counteract any effects of implicit bias by beginning with staff and then spreading understanding beyond schools and into the public mindset.

Implicit bias - unconscious attitudes and stereotypes used by the brain to make decision-making more efficient - often alters our actions and decisions in high-stress and split-second situations. When bias relates to preferred foods or colors, very few - if any - negative consequences occur. However, implicit bias often enters our judgments related to other people based on skin color, ethnicity, language, and other traits. In schools, the effects of implicit bias on students of color have been linked directly to excessive discipline, lower teacher expectations, and over-critical grading procedures; and linked indirectly to higher dropout rates, future incarceration, and lower higher education outcomes.

Experiences of implicit bias and related differences in treatment of individuals by race starts at an early age. A study by Yale University faculty found that preschool teachers looking to prevent behavioral problems focused on black male students significantly more than their peers. National data sets show K-12 black students received suspensions and expulsions at rates higher than students of all other races, and they experienced out-of-school-suspensions 3.8 times more often than white students. Resulting differences in discipline exposure by race lead to juvenile incarceration, lower graduation rates, diminishing academic achievement, higher incidences of future poverty, and high costs to taxpayers through assistance programs and extended time in the K-12 school system.

To begin lessening the effects of implicit bias, schools must provide professional development opportunities to make teachers aware of implicit bias and the different ways it might impact students. Data collection and analyses in the form of equity audits provide clear information as to where implicit bias most severely impacts students. Schools need to implement policies that allow for adequate time for teachers to react to and respond to the academic, disciplinary, and social needs of students. Recognition of culture must become an integral part of school climate and be allowed to grow and change based on the population of students served by the school.

Personal bias mitigation can begin with systemic self-examination. The Implicit Associations Test, developed by social psychologists, is a tool that assesses levels of implicit bias in several categories. Although it is difficult, individuals may begin to change their levels of implicit bias by reading stories that go against popular beliefs about people or cultures and experiencing examples of strong and/or successful people of color. Individuals must share awareness of bias with local communities or workplaces and practice making informed decisions and thoughtful reactions when working through situations subject to bias. Every situation will be different, but beginning to identify and address one's own implicit biases is an important first step toward the realization of a more just and equitable society.

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Dr. Beachum is the Bennett Professor of Urban School Leadership at Lehigh University. He is also the program director and an associate professor in the Educational Leadership program in the College of Education. Gina Gullo recently completely her doctorate in Educational Leadership at Lehigh University.

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The negative effects of implicit bias in schools - WHYY

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Last week at Colgate University in central New York, reports of a black male carrying a gun - which in reality was a Colgate student carrying a glue gun for a school project - prompted school officials to put the campus on lockdown. In a message to the university, President Brian W.