Cultural competency is one of those words that may seem like a bit of a buzz word, but is actually very important to being an effective counsellor. The National Center for Cultural Competence cites the definition given in Cross et al. (1989), which is that “Cultural competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency or among professionals and enable that system, agency or those professions to work effectively in cross-cultural situations.”
Having an awareness of different cultures and how they influence the counselling process helps you ensure that your work takes into account the unique values, beliefs and circumstances of individuals and do not impress your values on them.
For instance, if a Vietnamese student tells you that his family wishes him to study medicine, and he does not want to do so, you may advise him to assert his individuality and tell him otherwise. Unfortunately, in a collectivist society like Vietnam this would be considered an extreme social violation and could lead to the father never speaking to him again.
The APA has developed a set of guidelines for multicultural competence, while Ivey, Ivey & Zalaquett (2007) in their book Intentional Interviewing & Counselling explain the RESPECTFUL Model as a set of multicultural dimensions that can help you identify areas where you are similar or different than your client for the purpose of assessing potential cultural barriers.
Assessing Cultural Competency
The National Center for Cultural Competence has produced a variety of assessment tools, including ones for organizations to build their competence, and a number of individual cultural competence assessment tools depending on the area you work in (including family service, youth, and primary care.)
- Economic/Class Background
- Sexual Identity
- Personal Style and Education
- Ethnic/Racial Identity
- Chronological/Lifespan Challenges
- Family Background
- Unique Physical Characteristics
- Location of Residence and Language Differences
In order to develop your cultural competency, it is important to not only be aware how you differ from your clients in the above dimensions, but also allowing your client to take the lead and explain to you the impact their culture has on their unique experiences.
Etic and Emic Multicultural Counselling
Daya (2011) reviews the two opposing schools of thought in multicultural counselling, that it should focus on elements unique to specific cultures (emic) or universal to all cultures (etic). The etic approach focuses on the basic counselling relationship and the specific techniques that the counsellor uses, while those who believe in the emic approach stress the importance of knowing the specific beliefs and values that the client brings into the counselling session.
Cultural Competence Interventions
Sue et. al. (2009) explored a variety of interventions for cultural competence. With African Americans, he noted a study that used “spirituality, harmony, collective responsibility, oral tradition, holistic approach, experiences with prejudice and discrimination, racial socialization, and interpersonal/communal orientation” to work with African American clients, while story telling was found to be helpful for those of a Latino background.
With individuals of an Asian background, Iwamasa (n.d.) recommends challenging myths such as asians being a “model minority” or always academically or financially successfully, and recognizing cultural specific mental health issues like hwa-byung and taijin kyofyusho.
Cross, T., Bazron, B., Dennis, K., & Isaacs, M., (1989). Towards A Culturally Competent System of Care, Volume I. Washington, DC: Georgetown University Child Development Center, CASSP Technical Assistance Center.
Daya, R. (2011) Changing the Face of Multicultural Counselling with Principles of Change. Canadian Journal of Counselling. 35(1). 49-62.
Ivey, A.E., Ivey, M.B. & Zalaquett, C.P. (2007) Intentional Interviewing & Counselling: Facilitating Client Development in a Multicultural Society. Brooks/Cole: Belmont, Ca.
Iwamasa, G.Y. (n.d.) “Recommendations for the Treatment of Asian-American/Pacific Islander Populations”. American Psychological Association. Accessed electronically on Jun 4 2016 from http://www.apa.org/pi/oema/resources/ethnicity-health/asian-american/psychological-treatment.aspx
Sue, S. Zane, N. Hall, G.C., Berger, L.K. (2009) Annual Review in Psychology. 60: 525–548. doi:10.1146/annurev.psych.60.110707.163651
Introduction to Crisis Case Handling
Crisis case handling is considered quite a bit different from long-term counselling or therapy. While the steps might seem to be very similar e.g. (assessment, intervention, and evaluation) the short-term nature of crisis intervention and the goals are quite different. Crisis intervention aims to restore pre-crisis functioning while therapy’s goal is to work towards an even better way of coping.
Principles of Therapy
- Diagnosis: Goal of determining DSM-V diagnostic categories
- Treatment: Exploring the underlying causes of discomfort and behaviour to make long-term changes
- Plan: A comprehensive, personalized approach to accomplish long-term goals
- Methods: Therapy techniques focusing on a mix of short-term, medium-term and long-term goals
- Evaluation: Observation of client’s functioning over several months or even years
Principles of Crisis Intervention
- Diagnosis: Triage to determine immediate risk level
- Treatment: Restoring pre-crisis functioning
- Plan: Focused on restoring immediate short-term issues
- Methods: Time-limited brief crisis and trauma interventions
- Evaluation: Observation of how client’s current function compares to pre-crisis in hours or days
Assessment in Therapy
Many modalities of therapy begin with an assessment stage, where data is collected to give the clinician a deep understanding of the client. This helps in the long-term when the therapist can see a change on specific assessment tools (like the Beck Depression Inventory), or can see the client’s life “come together” and the desired changes occurring.
Assessment in Crisis Intervention
Contrary to therapy, in crisis intervention, the purpose of assessment is focused more on understanding the client’s concerns so that immediate steps can be taken to recover. Extensive paperwork or assessment tools are unlikely to be filled out, with most of the data collected verbally and visually.
Intervention in Therapy
Interventions in therapy include long-term therapies like Cognitive Behavioural Therapy that look at a person’s history of actions, beliefs and cognitions and explores them over a period weeks or months to identify maladaptive thoughts and systematically work to change these.
Intervention in Crisis Intervention
In crisis intervention, the intervention is focused on immediate short-term crisis resolution by providing stabilization, venting, referrals, and in inpatient environments medication. The whole focus of the encounter may be limited to a one hour phone call or a maximum of 72 hour psychiatric stay, so everything proceeds at a much more rapid pace.
Evaluation in Therapy
In therapy, evaluation is the process of determining whether there is a change in the client and whether therapy has “worked.” This is closely associated with the concept of termination, deciding when to end therapy. With psychodynamic therapies, some clients would be in therapy for years. Nowadays, 16-24 sessions (often once a week) is considered a long treatment time.
By observing changes in the client’s behaviours and beliefs over time the therapist will begin to see improvements in their behaviour.
Evaluation in Crisis Intervention
In crisis intervention, evaluation occurs over minutes, hours, or potentially days as you observe whether the client is returning to pre-crisis equilibrium. The goal is not for the client to “get better” but simply to retain enough control over their life that they’re able to function independently.
Crisis case handling is an important skill for crisis workers and therapists alike to learn, because all may experience clients in crises throughout their careers.
Introduction to Classification
Oftentimes when performing research or intelligence analysis, the first step is to classify the available data. Classification provides a number of benefits that make later analysis easier. For one, they allow you to infer other qualities based on all items in a class sharing similar properties.
For instance, knowing that mammals have fur and all mammals give birth birth to live young (as opposed to laying eggs), you can infer that if you see a creature identified as a mammal you can predict these properties about the creature.
Another benefit to classification is that it allows you to see relationships among classes that you may not have been aware of before. The classic Periodic Table is a good example of this: elements along the right-hand side of the periodic table (so-called Noble Gases) all hold similar properties, while other columns ordered together also appear to have similar properties. It is not simply that the elements were organized this way after they were found to match, but in fact “holes” in the periodic table indicated where elements must exist but haven’t been discovered yet.
This brings us to the next benefit of classification, the ability to uncover missing information. Although this is sometimes exploited in military and diplomatic circles (for instance, SEAL Team Six is actually the 4th SEAL team – the number was incremented in order to mislead enemies about how many SEAL Teams there are), this is still a very useful technicque for discovering what you don’t know.
Finally, classification allows you to focus on the properties of group items rather than of individual ones, which can make analyzing large amounts of information much easier than it otherwise would be. We’re sometimes overwhelmed by information and these preliminary steps can help us drill down. This is also accomplished through coding, below.
Statistical coding is the form of classification that is perhaps most familiar to researchers. Coding is the task of taking data and assigning it to categories. This allows us to turn normally qualitative data into quantitative or numerical data. If you look at the example of Gender, assigning Male a value of “0” and Female a value of “1” is a form of coding that allows you to perform statistical analysis.
Coding is often used to group responses together. If asking someone what their first emotion is after a sudden loss or grief, you may have to translate disparate responses like, “I was overwhelmed”, “I didn’t know what to do”, and “I felt numb” into simple categories (“Overwhelmed”, “Confused/Shocked”, “Numb”) and later into numerical values (1, 2, 3.)
Make sure to store the results of your coding in a “codebook” so that later you can remember what variable was turned into what coding.
There are a few advantages of statistical coding. For one, it allows you to perform statistical analyses not possible on qualitative data and allows you to perform “blind” analyses without us knowing which variable corresponds to which value.
The Crisis Triage Rating Scale (CTRS; Bengelsdorf, et. al. 1984) is a telephone triage tool that can be used for determining whether an individual in crisis requires psychiatric assessment. Turner & Turner (1991) determined that a cut-off score of 9 or lower necessitated admission. This was confirmed in a follow up study by Adeosun et. al. (2013)
The CTRS has three subscales:
- Support System
- Ability to Cooperate
Each category is rated from 1-3, so the entire scale is scored from 3-15 (with a lower score representing less functioning.) This copy of the CTRS from the Human Services and Justice Coordinating Committee lists the response guidelines:
||Urgency of Response
||Immediate response recommended
||A. Dangerousness _____
||See within 2 hours
||B. Support System _____
||See within 12 hours
||C. Ability to Cooperate _____
||See within 48 hours
||Total Score: _______
||See within 2 weeks
Community Use and Validation of the CTRS
The CTRS has been used in community organizations that have mobile crisis teams, for the purpose of assessing whether callers require inpatient admission to a hospital. This can help guide the often murky process of crisis assessment.
Bonynge & Thurber (2008) determined that the CTRS was accurate in determining the difference between inpatient and outpatient treatment but that with all the tools tested (the Crisis Triage Rating Scale, the Triage Assessment Form and the Suicide Assessment Checklist), the determination of exactly what inpatient treatment (Hospitalization in a psychiatric or substance abuse settings, partial hospitalization or crisis beds) is most effective.
Limitations of the Crisis Triage Rating Scale
Molina-Lopz et. al. (2016) note that the CTRS “requires knowledge of each patient’s social and family support system at the time of assessment, which can be especially difficult to gauge in aggressive, agitated, suspicious, isolated or non-cooperative patients” which is a reasonable criticism of the Support System subscale of the tool.
The criteria used for the Dangerousness subscale is also interesting, for each rating there are 3-4 criteria given. Because of the difficulty in evaluating these (e.g. “Expresses suicidal/homicidal ideas with ambivalence, or made only ineffectual gestures. Questionable impulse control”) the reliability of the CTRS may be suspect.
The CTRS can be downloaded from the Human Services and Justice Coordinating Committee here.
Adeosun, I., Adegbohun, A., Jeje, O., & Omoniyi, O. (2013). 1364 – Predictive validity of the crisis triage rating scale in the disposition of patients attending a nigerian psychiatric emergency unit. European Psychiatry, 281. doi:10.1016/S0924-9338(13)76409-5
Bengelsdorf, H., Levy, L., Emerson, R., & Barile, F. (1984). A crisis triage rating scale: Brief dispositional assessment of patients at risk for hospitalization. Journal Of Nervous And Mental Disease, 172(7), 424-430.
Bonynge & Thurber (2008). Development of Clinical Ratings for Crisis Assessment In Community Mental Health. Brief Treatment and Crisis Intervention. 8(4):304-312; doi:10.1093/brief-treatment/mhn017
Molina-López, A., Cruz-Islas, J. B., Palma-Cortés, M., Guizar-Sánchez, D. P., Garfias-Rau, C. Y., Ontiveros-Uribe, M. P., & Fresán-Orellana, A. (2016). Validity and reliability of a novel Color-Risk Psychiatric Triage in a psychiatric emergency department.BMC Psychiatry, 161-11. doi:10.1186/s12888-016-0727-7
Turner, P.M., Turner, T.J. (1991). Validation of the crisis triage rating scale for psychiatric emergencies. Canadian Journal of Psychiatry. 36(9):651-4
Coping strategies are the things, internally and externally that we do to help ourselves work through crises. Internal coping strategies are the things that we do for ourselves, that don’t require anyone and else and may involve activities, attitudes, and beliefs that help us be resilient. External coping strategies involve others, and can include people in our immediate environment and professionals that we may bring into our circle of coping (such as a therapist.)
Caplan’s Coping Strategies
Caplan (1964) lists seven strategies for helping individuals to cope:
- Actively exploring reality issues and searching for information
- Freely expressing both positive and negative feelings and tolerating frustration
- Actively invoking help from others
- Breaking problems down into manageable bits and working them through one at a time
- Being aware of fatigue and tendencies toward disorganization; while pacing efforts and maintaining control in as many areas of functioning as possible
- Mastering feelings where possible (accepting them when necessary), being flexible and willing to change
- Trusting in oneself and others and having a basic optimism about the outcome
These are explored in more detail below.
Actively Explore Reality Issues
Exploring reality means ensuring that you actually have a reliable view of your situation. This goes back to the concept of ego strength – if you have an accurate view of the situation you’re in a better position to handle it.
Someone who has to drop out of college may believe that they will be doomed to a life of poverty as a result of doing so. While they might have more difficulty achieving their goals, there are other avenues to continuing their college education or making a good living that will help them avoid poverty. For instance, they can attend a community college on a part-time basis, online, pursue apprenticeship or vocational training, self-study, and so on.
Freely Express Positive and Negative Feelings
It’s important that a person can express both positive and negative feelings in order to cope effectively.
Being unable to express positive feelings may indicate that an individual is having trouble seeing the world accurately (as in above) which is something that counselling can help. On the other hand, someone unable to express negative feelings may be the result of someone bottling up their emotions, which can cause difficulty working through those feelings. This may be related to alexithymia, the inability to express feelings with words.
Actively Invoking Help from Others
We know that having available resources is one of the most important protective factors to prevent suicide. Help-seeking is a very important part of your library of coping strategies. This does not necessarily mean seeing a therapist or a doctor – but also reaching out to those in your immediate environment like friends and family, trusted coworkers or other support systems.
Research has shown that the high rate of male suicide is partially explained by a pattern of help-seeking that is characterized by withdrawing from others and trying to deal with things internally rather than externally.
Break Problems into Manageable Bits
This is a common element in effective problem-solving. Many problems can seem so large as to be overwhelming and therefore un-fixable. Someone who has lost their job may feel like it’s impossible to get another one, especially in a rough economy. Breaking “get a new job” down into a series of manageable steps that can be done over a week can make them easier:
- Monday: Create budget to find minimum salary
- Tuesday: Update resume
- Wednesday: Reach out to job network (if exists)
- Thursday: Begin applying to jobs
- Friday: Create learning plan to identify missing skills for desired jobs
- Saturday and Sunday: Begin putting learning plan into place while continuing applying to jobs
As you can see, there is a lot of tasks here – but if you spend a couple hours a day it seems much more manageable.
Be Aware of Fatigue
Fatigue can set in for both helpers and individuals who are in crisis. This is where self-care becomes important: recognizing your own limits and taking time to recharge ensures that you can continue to be be an effective crisis worker.
By pacing yourself when you realize you don’t have the energy to handle both your own emotional issues and those around you will help prevent compassionate fatigue, which can lead to burnout.
Master Feelings Where Possible
Sometimes we don’t have control over our feelings. Although counselling can help us reframe our beliefs in order to gain new perspective and defuse negative emotions, sometimes it is necessary to simply accept that we feel the way we do and then to control our reactions.
Acceptance and Commitment Therapy (ACT) focuses on the idea that we have to accept our emotions but that we can control our reactions and responses in order to have the best outcomes.
Optimism About the Outcome
By believing in your ability to deal with your situation and having faith or trust in the individuals who are supporting you, it is easier to deal with the demands of your life. This, in combination with the other internal coping strategies listed here will help you cope effective as you perform crisis work.
Caplan, G. (1964) Principles of Preventive Psychiatry. Basic Books: New York, NY