Essay Grade

BEST PRACTICES
Using the Cultural Formulation Interview to Build
Culturally Sensitive Services
Esperanza Díaz, M.D., Luis M. Añez, Psy.D., Michelle Silva, Psy.D., Manuel Paris, Psy.D., Larry Davidson, Ph.D.
As part of the development of DSM-5, the Cultural Formulation Interview (CFI) was administered to 30 monolingual
Spanish-speaking adults at one site of a 2012 feasibility
study of the CFI. The authors identified salient themes in
data collected through use of the CFI, with a focus on
interventions that could lead to more culturally responsive
mental health services. Findings suggest that establishing
trust and focusing on the restoration of social ties while
Cultural sensitivity increases the probability of a therapeutic
relationship by enhancing trust and improving communication between clinicians and patients (1). Culturally responsive services effectively address health care disparities
and increase providers’ knowledge of diverse cultures. Introducing culturally responsive care increases service utilization and reduces premature termination (2,3). However,
few examples exist that illustrate culturally responsive care
in routine practice beyond its positive effect on help seeking
and service utilization.
The revision of the Outline for Cultural Formulation from
the DSM-IV resulted in the Cultural Formulation Interview
(CFI) to elicit information about perceived cultural influences of care with a set of 16 questions included in the
DSM-5 (4). This personalized interview facilitates individualized assessments by clinicians instead of their relying on
preconceived or stereotypic notions about race-ethnicity or
country of origin (5). The CFI captures the patient’s voice
systematically and documents what is “at stake” for the
person (6). The CFI field trial provided an opportunity to
observe this innovative way to elicit information and to
clarify cultural versus idiosyncratic details. The CFI has a
unique role, even in mental health services that are focused
on racial-ethnic minority groups. In this column, we describe CFI-elicited information in one of the trial sites and
discuss potential ways for the CFI to improve care.
CFI Field Trial
From February to September 2012, we recruited 30 participants for a CFI feasibility study that included an audiorecorded interview. The participants were monolingual
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attending to the impact of stigma and patients’ pressing
psychosocial needs are elements of culturally responsive
services for Hispanic persons. Routine use of the CFI can
help clinicians identify unique needs and preferences
by understanding an individual within his or her cultural
context.
Psychiatric Services 2017; 68:112–114; doi: 10.1176/appi.ps.201600440
Spanish-speaking adults ages 18–70 from several Latin
American countries and were receiving outpatient services
at the Hispanic Clinic of the Connecticut Mental Health
Center, which serves individuals regardless of legal status
and ability to pay. We obtained institutional review board
approval and informed consent. Inclusion criteria were a
stable DSM-IV disorder and the ability to understand the
purpose, requirements, and voluntary nature of the study.
Data Analyses
After reading audio-recorded interview transcripts in Spanish
without any preconceived categories, we identified salient
themes, organized them into initial domains, and created
codes. We compared and revised codes and themes until
reaching agreement (7). Ultimately, the codes were condensed into categories, with three overarching themes:
reasons for seeking treatment, understanding the problem
and how to name it, and how the problem was resolved. Examples of codes were religion, somatic complaints, interpersonal issues, coping style, psychosocial needs, substance use,
loss, and services. Some themes are described below and are
illustrated with participant quotes.
Themes Elicited by the CFI
Disruption of relationships was a major theme. When participants could not get along with important people in their
lives, such as family members or fellow churchgoers, they
sought mental health care. “We do not treat each other like
family anymore.” “He cheated on me, he traumatized me.”
“I have problems with my children.” Interpersonal harmony
Psychiatric Services 68:2, February 2017
BEST PRACTICES
was crucial for participants, and disruption of relationships
was a powerful motivation to seek help.
The loss of trust—“confianza”—was a serious problem for
some participants, requiring professional attention. “Confianza”
is a Hispanic value related to feeling at ease about revealing
personal experiences to others. “I do not trust.” “I could not
work, I felt nervous thinking that other people were talking
about me.” “I felt judged by people around me, especially
from church.” Restoration of trust was critical. Participants appreciated the benefits of talking with a therapist,
and the issue of trust also emerged in this context. As
participants gained trust in the therapeutic relationship,
they reestablished social ties. In turn, restored relationships aided in healing.
Similarly, traumatic experiences emerged as a major
source of stress, forcing some participants to seek help.
Traumatic experiences sometimes caused strong and
alarming emotional reactions. “I have raw memories. I hear
my partner’s voice.” For Hispanics, auditory hallucinations
can be trauma related without meeting criteria for a psychotic disorder (8). “I cannot find myself. I feel lost.” “The
memories made me nervous.” “My mind is gone.” “I want to
stop remembering sad things. I want to stop thinking bad
thoughts.” These experiences reveal both the trauma and the
resilience of participants. Despite their symptoms, participants were able to cross borders to start a new life. “I was a
victim of domestic violence.” “Many things came from my
childhood. My parents hit me.” These comments reveal the
long wait of many participants to address past traumas and
their hope for recovery with the help of a culturally sensitive
provider.
Through the CFI questions, many participants presented
the problem as a consequence of their actions. “This is a
punishment.” “I was called to preach and did not follow.”
“I did not live a life according to God.” “I abandoned my
children.” “This is because I did not obey my mother.” “This
is a test. If God allowed it, there must be a reason.” Resolutions were facilitated when the treatment valued their
religious beliefs. Participants’ perceptions that they were not
in good standing as church members was also a compelling
reason to seek help. When their concerns were addressed,
they often perceived a restored relationship with God and
reconnected with their church.
Losses had a great impact on participants’ lives, causing a
sense of helplessness. “When my brother died, the sadness
overcame me. I could not go back to his funeral. I could not
say good-bye.” “The depression arrived when my father
died.” Some immigrants are able to return to their countries
of origin. The experiences described here are those of immigrants who could not easily go back. “When I get this urge
to see my dead daughter, I cannot stop crying.” “I left my
children. I cannot eat. I just want to cry and cry thinking how
could I eat when my children might be hungry.” Losses
through immigration had profound effects. Nostalgia and
guilt for being far away from the family were common. Inability to go back can make it difficult for an immigrant to
Psychiatric Services 68:2, February 2017
accept and adapt to the new culture. Ambivalence about
leaving one’s country is part of any acculturation process.
“Sometimes I feel sad without the family and speculate that
perhaps none of this would have happened if I had not left.”
Psychotherapy can address the losses (for example, family,
language, and food), and mourning these losses can help an
immigrant go through a third separation-individuation process to help the person become established in the new country
with a new identity, while respecting the old one (9).
Addressing the stigma related to mental illness was also
an important component for participants. “Now, I can speak
about my problems without shame.” “I do not feel ashamed
to say what I have.” Patients who initially expressed grave
concern about their social networks’ perception of them but
who were able to change their perspective reported feeling
tremendous relief. As they participated with others who had
similar difficulties, the stigma associated with mental health
care decreased (10).
Psychosocial needs also drove participants to seek services.
“I lost my papers and my wallet, all is gone.” “I am homeless.
Waiting for a place is too much stress.” “My finances are bad.
I do not have money.” “I do not come out from the hole.”
Resolution of their psychosocial needs was part of their
recovery. Participants identified obtaining employment
and providing for their families as the most satisfactory
treatment outcome. Participants appreciated attention to
their psychosocial needs as care was facilitated and bureaucratic barriers were overcome.
Advantages of Using the CFI
Traditionally, mental health services for minority groups
have not been organized to increase trust, address stigma,
mend relationships with church and family, and address
psychosocial needs. The data elicited through the CFI support framing the core treatment functions to include these
issues and enhance the cultural responsiveness of care
(11,12). These findings suggest that trust should be considered as a key facilitator of treatment engagement. Moreover,
clinicians should explore patients’ social ties, perceived as
broken, to address their restoration during the treatment.
Restored trust and restored social ties then become treatment outcomes.
The CFI facilitated listening to patients’ perceptions to
consider evidence not traditionally sought in administrative program evaluations. The CFI uncovered their subjective experience and provided reasons to trust. Outcomes
could then be measured not only in terms of symptom reduction or improved functioning but also in improved
ability to pursue culturally relevant goals and effects on the
larger social circle.
Culturally sensitive care for Hispanics includes bilingual
and bicultural staff; Hispanic values such as trust, familism,
and personalism; an understanding of immigration stressors;
attention to psychosocial stressors; shared decision making;
and other components (13,14). Although some of these
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BEST PRACTICES
characteristics were revealed in our data, others were new
and were described with a personal perspective. The wish to
repair disrupted relationships was an urgent reason to seek
help, as was the wish to restore social ties. Both can introduce a new approach to setting treatment goals. The wish
to restore trust as a motivator of treatment was surprising.
Immigrants’ profound suffering, elicited in the voices of
these patients, underscores the need to prioritize their
mourning and calls attention to the fact that many have
waited a long time to address their past traumatic experiences. In addition, attention to psychosocial needs becomes
a priority for treatment.
Potential uses of information from this field trial are related
to building shared decision-making services and a more sustained focus on building “confianza.” Services for Hispanics
should explore church membership and spirituality and their
role in helping individuals cope and regain social ties. Efforts
to engage local churches to collaborate in providing services
are important, especially because some churches do not endorse the use of traditional mental health services (15).
Aiming for restoration of social ties and supportive social
networks as immediate treatment outcomes and using approaches that will build trust with the local community
should be included in revised program strategies. To formulate a useful care plan, clinicians should consider the
importance of the social networks available to a person.
Reducing stigma related to mental illness was also an important component of patients’ stories. Priorities for revising
services should include interventions to promote stigma
reduction, coping, and grief resolution; to address the multiple difficulties involved in immigration; and to support the
creation of social networks.
Clinical and Policy Implications
When used routinely, the CFI can help clinicians identify
unique needs and preferences by providing a better understanding of an individual within the context of his or her
culture. Use of the CFI domains as part of a routine program
evaluation opens new perspectives about services. The CFI
can help identify what works for a specific group and uncover
new evidence of cultural responsiveness. The descriptions
presented here illuminate important aspects to include in
clinical and system interventions and could be considered
practice-based evidence that offer lessons for development
of culturally sensitive services.
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AUTHOR AND ARTICLE INFORMATION
The authors are with the Department of Psychiatry, Yale University
School of Medicine, New Haven, Connecticut (e-mail: esperanza.diaz@
yale.edu). Marcela Horvitz-Lennon, M.D., M.P.H., is editor of this column.
The study was supported by a grant from the American Psychiatric Association. The authors thank Roberto Lewis-Fernandez, M.D., for helpful
comments on the manuscript.
The authors report no financial relationships with commercial interests.
REFERENCES
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2. Betancourt JR, Green AR, Carrillo JE, et al: Defining cultural
competence: a practical framework for addressing racial/ethnic
disparities in health and health care. Public Health Reports 118:
293–302, 2003
3. Alegría M, Mulvaney-Day N, Woo M, et al: Psychology of Latino
adults: challenges and an agenda for action; in Mental Health
Across Racial Groups. Edited by Chang E, Downey C. New York,
Springer, 2012
4. Cultural Formulation Interview. Arlington, Va, American Psychiatric Publishing, 2013. http://www.psychiatry.org/psychiatrists/
practice/dsm/dsm-5/online-assessment-measures
5. Lewis-Fernandez R, Aggarwal NK, Hinton L, et al: DSM-5 Handbook on the Cultural Formulation Interview. Arlington, Va, American
Psychiatric Publishing, 2015
6. Kleinman A, Benson P: Anthropology in the clinic: the problem of
cultural competence and how to fix it. PLoS Medicine 3:e294, 2006
7. Miles MB, Huberman AM: Analysing data II: qualitative data
analysis; in Qualitative Data Analysis: An Expanded Source Book.
Thousand Oaks, Calif, Sage, 1994
8. Lewis-Fernández R, Horvitz-Lennon M, Blanco C, et al: Significance of endorsement of psychotic symptoms by US Latinos.
Journal of Nervous and Mental Disease 197:337–347, 2009
9. Akhtar S: A third individuation: immigration, identity, and the
psychoanalytic process. Journal of the American Psychoanalytic
Association 43:1051–1084, 1995
10. Corrigan P: How stigma interferes with mental health care.
American Psychologist 59:614–625, 2004
11. Kirmayer LJ: Rethinking cultural competence. Transcultural Psychiatry 49:149–164, 2012
12. Miranda J, Bernal G, Lau A, et al: State of the science on psychosocial interventions for ethnic minorities. Annual Review of
Clinical Psychology 1:113–142, 2005
13. Sabogal F, Marin G, Otero-Sabogal R, et al: Hispanic familism and
acculturation: what changes and what doesn’t? Hispanic Journal of
Behavioral Sciences 9:397–412, 1987
14. Curtis LC, Wells SM, Penney DJ, et al: Pushing the envelope:
shared decision making in mental health. Psychiatric Rehabilitation Journal 34:14–22, 2010
15. Williams DR, Griffith EE, Young JL, et al: Structure and provision
of services in Black churches in New Haven, Connecticut. Cultural
Diversity and Ethnic Minority Psychology 5:118–133, 1999
Psychiatric Services 68:2, February 2017
The APA is offering the Cultural Formulation Interview (including the Informant
Version) and the Supplementary Modules to the Core Cultural Formulation
Interview for further research and clinical evaluation. They should be used in
research and clinical settings as potentially useful tools to enhance clinical
understanding and decision-making and not as the sole basis for making a
clinical diagnosis. Additional information can be found in DSM-5 in the Section
III chapter “Cultural Formulation.” The APA requests that clinicians and
researchers provide further data on the usefulness of these cultural formulation
interviews at http://www.dsm5.org/Pages/Feedback-Form.aspx.
Measure: Cultural Formulation Interview (CFI)
Rights granted: This material can be reproduced without permission by
researchers and by clinicians for use with their patients.
Rights holder: American Psychiatric Association
To request permission for any other use beyond what is stipulated above,
contact: http://www.appi.org/CustomerService/Pages/Permissions.aspx
Cultural Formulation Interview (CFI)
Supplementary modules used to expand each CFI subtopic are noted in parentheses.
GUIDE TO INTERVIEWER
INSTRUCTIONS TO THE INTERVIEWER ARE ITALICIZED.
The following questions aim to clarify key aspects of the
presenting clinical problem from the point of view of
the individual and other members of the individual’s
social network (i.e., family, friends, or others involved
in current problem). This includes the problem’s
meaning, potential sources of help, and expectations
for services.
INTRODUCTION FOR THE INDIVIDUAL:
I would like to understand the problems that bring you here so that I can
help you more effectively. I want to know about your experience and
ideas. I will ask some questions about what is going on and how you
are dealing with it. Please remember there are no right or wrong answers.
CULTURAL DEFINITION OF THE PROBLEM
CULTURAL DEFINITION OF THE PROBLEM
(Explanatory Model, Level of Functioning)
Elicit the individual’s view of core problems and key
concerns.
Focus on the individual’s own way of understanding the
problem.
Use the term, expression, or brief description elicited in
question 1 to identify the problem in subsequent
questions (e.g., “your conflict with your son”).
1. What brings you here today?
IF INDIVIDUAL GIVES FEW DETAILS OR ONLY MENTIONS
SYMPTOMS OR A MEDICAL DIAGNOSIS, PROBE:
People often understand their problems in their own way, which may
be similar to or different from how doctors describe the problem. How
would you describe your problem?
Ask how individual frames the problem for members of
the social network.
2. Sometimes people have different ways of describing their problem to
their family, friends, or others in their community. How would you
describe your problem to them?
Focus on the aspects of the problem that matter most to
the individual.
3. What troubles you most about your problem?
CULTURAL PERCEPTIONS OF CAUSE, CONTEXT, AND SUPPORT
CAUSES
(Explanatory Model, Social Network, Older Adults)
This question indicates the meaning of the condition for
the individual, which may be relevant for clinical care.
4. Why do you think this is happening to you? What do you think are the
causes of your [PROBLEM]?
Note that individuals may identify multiple causes, depending on the facet of the problem they are considering.
PROMPT FURTHER IF REQUIRED:
Some people may explain their problem as the result of bad things
that happen in their life, problems with others, a physical illness, a
spiritual reason, or many other causes.
Focus on the views of members of the individual’s social
network. These may be diverse and vary from the individual’s.
5. What do others in your family, your friends, or others in your community think is causing your [PROBLEM]?
Page 1 of 3
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Cultural Formulation Interview (CFI)
STRESSORS AND SUPPORTS
(Social Network, Caregivers, Psychosocial Stressors, Religion and Spirituality, Immigrants and Refugees, Cultural Identity, Older
Adults, Coping and Help Seeking)
Elicit information on the individual’s life context, focusing
on resources, social supports, and resilience. May
also probe other supports (e.g., from co-workers, from
participation in religion or spirituality).
6. Are there any kinds of support that make your [PROBLEM] better,
such as support from family, friends, or others?
Focus on stressful aspects of the individual’s environment. Can also probe, e.g., relationship problems,
difficulties at work or school, or discrimination.
7. Are there any kinds of stresses that make your [PROBLEM] worse,
such as difficulties with money, or family problems?
ROLE OF CULTURAL IDENTITY
(Cultural Identity, Psychosocial Stressors, Religion and Spirituality, Immigrants and Refugees, Older Adults, Children and Adolescents)
Sometimes, aspects of people’s background or identity can make
their [PROBLEM] better or worse. By background or identity, I
mean, for example, the communities you belong to, the languages
you speak, where you or your family are from, your race or ethnic
background, your gender or sexual orientation, or your faith or religion.
Ask the individual to reflect on the most salient elements
of his or her cultural identity. Use this information to
tailor questions 9–10 as needed.
8. For you, what are the most important aspects of your background or
identity?
Elicit aspects of identity that make the problem better or
worse.
Probe as needed (e.g., clinical worsening as a result of
discrimination due to migration status, race/ethnicity,
or sexual orientation).
9. Are there any aspects of your background or identity that make a
difference to your [PROBLEM]?
Probe as needed (e.g., migration-related problems;
conflict across generations or due to gender roles).
10. Are there any aspects of your background or identity that are causing
other concerns or difficulties for you?
CULTURAL FACTORS AFFECTING SELF-COPING AND PAST HELP SEEKING
SELF-COPING
(Coping and Help Seeking, Religion and Spirituality, Older Adults, Caregivers, Psychosocial Stressors)
Clarify self-coping for the problem.
11. Sometimes people have various ways of dealing with problems like
[PROBLEM]. What have you done on your own to cope with your
[PROBLEM]?
Page 2 of 3
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Cultural Formulation Interview (CFI)
PAST HELP SEEKING
(Coping and Help Seeking, Religion and Spirituality, Older Adults, Caregivers, Psychosocial Stressors, Immigrants and Refugees,
Social Network, Clinician-Patient Relationship)
Elicit various sources of help (e.g., medical care, mental
health treatment, support groups, work-based counseling, folk healing, religious or spiritual counseling,
other forms of traditional or alternative healing).
Probe as needed (e.g., “What other sources of help
have you used?”).
Clarify the individual’s experience and regard for previous help.
12. Often, people look for help from many different sources, including
different kinds of doctors, helpers, or healers. In the past, what kinds
of treatment, help, advice, or healing have you sought for your
[PROBLEM]?
PROBE IF DOES NOT DESCRIBE USEFULNESS OF HELP RECEIVED:
What types of help or treatment were most useful? Not useful?
BARRIERS
(Coping and Help Seeking, Religion and Spirituality, Older Adults, Psychosocial Stressors, Immigrants and Refugees, Social Network, Clinician-Patient Relationship)
Clarify the role of social barriers to help seeking, access
to care, and problems engaging in previous treatment.
Probe details as needed (e.g., “What got in the way?”).
13. Has anything prevented you from getting the help you need?
PROBE AS NEEDED:
For example, money, work or family commitments, stigma or discrimination, or lack of services that understand your language or
background?
CULTURAL FACTORS AFFECTING CURRENT HELP SEEKING
PREFERENCES
(Social Network, Caregivers, Religion and Spirituality, Older Adults, Coping and Help Seeking)
Clarify individual’s current perceived needs and expectations of help, broadly defined.
Probe if individual lists only one source of help (e.g.,
“What other kinds of help would be useful to you at this
time?”).
Now let’s talk some more about the help you need.
14. What kinds of help do you think would be most useful to you at this
time for your [PROBLEM]?
Focus on the views of the social network regarding help
seeking.
15. Are there other kinds of help that your family, friends, or other people
have suggested would be helpful for you now?
CLINICIAN-PATIENT RELATIONSHIP
(Clinician-Patient Relationship, Older Adults)
Elicit possible concerns about the clinic or the clinician-patient relationship, including perceived racism,
language barriers, or cultural differences that may
undermine goodwill, communication, or care delivery.
Probe details as needed (e.g., “In what way?”).
Address possible barriers to care or concerns about the
clinic and the clinician-patient relationship raised previously.
Sometimes doctors and patients misunderstand each other because
they come from different backgrounds or have different expectations.
16. Have you been concerned about this and is there anything that we
can do to provide you with the care you need?
Page 3 of 3
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A TreATmenT ImprovemenT proTocol
Improving Cultural
Competence
TIP 59
A TreATmenT ImprovemenT proTocol
Improving Cultural
Competence
TIP 59
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
1 Choke Cherry Road
Rockville, MD 20857
Improving Cultural Competence
Acknowledgments
This publication was produced by The CDM Group, Inc., under the Knowledge Application
Program (KAP) contract numbers 270-99-7072, 270-04-7049, and 270-09-0307 with the
Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of
Health and Human Services (HHS). Andrea Kopstein, Ph.D., M.P.H., Karl D. White, Ed.D.,
and Christina Currier served as the Contracting Officer’s Representatives.
Disclaimer
The views, opinions, and content expressed herein are those of the consensus panel and do not
necessarily reflect the views, opinions, or policies of SAMHSA or HHS. No official support of
or endorsement by SAMHSA or HHS for these opinions or for particular instruments, software,
or resources is intended or should be inferred.
Public Domain Notice
All materials appearing in this volume except those taken directly from copyrighted sources are
in the public domain and may be reproduced or copied without permission from SAMHSA or
the authors. Citation of the source is appreciated. However, this publication may not be
reproduced or distributed for a fee without the specific, written authorization of the Office of
Communications, SAMHSA, HHS.
Electronic Access and Copies of Publication
This publication may be ordered or downloaded from SAMHSA’s Publications Ordering Web
page at http://store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-7264727) (English and Español).
Recommended Citation
Substance Abuse and Mental Health Services Administration. Improving Cultural Competence.
Treatment Improvement Protocol (TIP) Series No. 59. HHS Publication No. (SMA) 14-4849.
Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.
Originating Office
Quality Improvement and Workforce Development Branch, Division of Services Improvement,
Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services
Administration, 1 Choke Cherry Road, Rockville, MD 20857.
HHS Publication No. (SMA) 14-4849
First Printed 2014
ii
Contents
Consensus Panel………………………………………………………………………………………………. vii
KAP Expert Panel and Federal Government Participants ……………………………………………ix
What Is a TIP? …………………………………………………………………………………………………..xi
Foreword ……………………………………………………………………………………………………….. xiii
Executive Summary …………………………………………………………………………………………… xv
Chapter 1—Introduction to Cultural Competence ……………………………………………………. 1
Purpose and Objectives of the TIP………………………………………………………………………………. 2
Core Assumptions……………………………………………………………………………………………………… 4
What Is Cultural Competence? …………………………………………………………………………………… 5
Why Is Cultural Competence Important? …………………………………………………………………… 7
How Is Cultural Competence Achieved? ……………………………………………………………………… 9
What Is Culture? …………………………………………………………………………………………………….. 11
What Is Race? …………………………………………………………………………………………………………. 13
What Is Ethnicity? ………………………………………………………………………………………………….. 15
What Is Cultural Identity? ………………………………………………………………………………………. 16
What Are the Cross-Cutting Factors in Race, Ethnicity, and Culture? ………………………….. 16
As You Proceed ……………………………………………………………………………………………………….. 33
Chapter 2—Core Competencies for Counselors and Other Clinical Staff ………………………35
Core Counselor Competencies ………………………………………………………………………………….. 36
Self-Assessment for Individual Cultural Competence ………………………………………………….. 55
Chapter 3—Culturally Responsive Evaluation and Treatment Planning………………………..57
Step 1: Engage Clients……………………………………………………………………………………………… 59
Step 2: Familiarize Clients and Their Families With Treatment and Evaluation Processes . 59
Step 3: Endorse Collaboration in Interviews, Assessments, and Treatment Planning……….. 60
Step 4: Integrate Culturally Relevant Information and Themes …………………………………….. 61
Step 5: Gather Culturally Relevant Collateral Information ………………………………………….. 64
Step 6: Select Culturally Appropriate Screening and Assessment Tools………………………….. 65
Step 7: Determine Readiness and Motivation for Change ……………………………………………. 69
Step 8: Provide Culturally Responsive Case Management ……………………………………………. 70
Step 9: Integrate Cultural Factors Into Treatment Planning …………………………………………. 71
iii
Improving Cultural Competence
Chapter 4—Pursuing Organizational Cultural Competence ……………………………………….73
Cultural Competence at the Organizational Level ………………………………………………………. 74
Organizational Values ………………………………………………………………………………………………. 76
Governance …………………………………………………………………………………………………………….. 78
Planning …………………………………………………………………………………………………………………. 80
Evaluation and Monitoring ………………………………………………………………………………………. 84
Language Services……………………………………………………………………………………………………. 88
Workforce and Staff Development …………………………………………………………………………….. 90
Organizational Infrastructure ……………………..