Journal of Social Work Values & Ethics

The value of cultural competence, as displayed by social work practitioners, is widely recognized. Yet little is known about the effectiveness of various methods for developing this capacity in human service workers. This case study illustrates the impact of cultural consultation, a strategy aimed at enhancing the culturally-specific knowledge of providers. The authors argue that such strategies promote practice that reflects the values, ideals, and ethical standards of the social work profession.

Kathleen Cox, Nancy Sullivan, Jennifer Reiman, and Cher Vang

EMQ Children & Family Services

The Journal of Social Work Values and Ethics, Volume 6, Number 1 (2009)

Copyright © 2009, White Hat Communications

This text may be freely shared among individuals, but it may not be republished in any medium without express written consent from the authors and advance notification of White Hat Communications. 

Abstract

The value of cultural competence, as displayed by social work practitioners, is widely recognized. Yet little is known about the effectiveness of various methods for developing this capacity in human service workers. This case study illustrates the impact of cultural consultation, a strategy aimed at enhancing the culturally-specific knowledge of providers. The authors argue that such strategies promote practice that reflects the values, ideals, and ethical standards of the social work profession.

Key Words: Cultural Competence, Consultation, Hmong-American Families

1. Introduction

The National Association of Social Workers’ Code of Ethics (NASW, 2006) is replete with references to the importance of cultural competence on the part of practitioners serving diverse client populations. Social workers are admonished to “treat each person in a caring and respectful fashion, mindful of individual differences and cultural and ethnic diversity” (p. 4). They are further advised to “understand culture and its function in human behavior” and to “demonstrate competence in the provision of services that are sensitive to clients’ cultures and to differences among people and cultural groups” (p. 9).  Moreover, the expectation is made clear that they obtain education in order to acquire a knowledge base relative to the particular culture of the individuals, families, and communities that they serve (Ethical Standard 1.05).

The social work literature also highlights the importance of cultural competency in the delivery of human services to diverse populations. More specifically, it draws attention to inadequacies in service provision to ethnic-minority populations. For instance, a disproportionately high rate of unmet mental health needs for racial and ethnic minorities relative to non-Hispanic white Americans is clearly documented (U.S. Department of Health and Human Services, 2001). Recommendations offered toward the elimination of such disparities include the provision of mental health services that are tailored to culturally diverse populations and delivered by practitioners who respect the beliefs, norms, and values of the minority clients that they serve (President’s New Freedom Commission on Mental Health, 2003)   

Another emphasis in the literature is on providing a conceptual understanding of cultural competency and general guidelines for its development. Stanley Sue suggests that in order to attain a high level of cultural competence, providers should avoid drawing premature conclusions about the status of their culturally different clients and instead develop creative ways to test their clinical hypotheses. Practitioners are encouraged to avoid stereotypes, appreciate the importance of culture, and acquire culture-specific expertise (Sue, 1998). Authors Lynch & Hanson (1993) define cross-cultural competence as “the ability to think, feel, and act in ways that acknowledge, respect, and build upon ethnic, socio-cultural, and linguistic diversity” (p. 50). Like Sue, they assert that the development of this capacity includes learning culture-specific information about clients from varying cultural groups (Lynch & Hanson, 2004).

One strategy designed to enhance the cross-cultural competence of social work practitioners, cultural consultation, has received recent attention by authors. It involves the use of an ethnospecific cultural expert who offers services that supplement those provided by the primary worker. The consultant (typically a psychiatrist, psychologist, or social worker) performs an assessment of the client system and follow-up consultation to the primary provider in an effort to assist the latter in understanding the cultural meaning of the client’s symptoms and the social context of their distress. Such services have been found to be successful in unearthing cultural misunderstandings, incomplete assessments, incorrect diagnoses, and the use of treatments inappropriate to the client’s belief system (Kirmayer, Groleau, Guzder, Blake & Jarvis, 2003).

What follows is a case study that demonstrates the value in using cultural consultation as an adjunct to social work services provided to ethnically diverse clients and their families. More specifically, it portrays the process through which workers providing behaviorally-oriented social work services to a Hmong-American youth recognized the need for assistance in order to serve their client in a manner that was culturally competent and, thus, ethically sound. This case also reveals how practitioners changed course following the use of cultural consultation – a shift in strategy that resulted in dramatic improvement in the youth’s behavior and her family’s responsiveness to services. Based on this case review, recommendations are offered to social workers who aspire to meet the highest ethical standards of their profession by understanding and appreciating the cultural values of clients served.

2.    The Case of Mai

Mai Khang* was a 15-year-old Hmong-American girl who presented with frequent and serious suicidal gestures and episodes of aggression. Upon referral to a social work team that provides intensive, in-home, behaviorally-oriented services, it was reported that she drank small amounts of toxic chemicals (e.g., bleach, nail polish remover, laundry detergent) 2-3 times per day and assaulted her mother or father roughly 1-2 times per day. Mai frequently ran away from home and “hooked up with undesirable strangers.”  It was also noted that she had, on occasion, threatened to kill her parents with an axe. The mental health therapist who referred her for behavioral intervention had given her a diagnosis of major depressive disorder with psychotic features, in large part as a result of her reported visual and auditory hallucinations and suicidal ideations.

The behavioral specialists began, with the assistance of a Hmong-speaking interpreter, to attempt engagement with Mai’s monolingual Hmong-speaking mother and father. The initial focus of services was on specifying the girl’s high-risk behaviors and on developing a preliminary safety plan. The workers subsequently conducted a functional behavior assessment that defined the frequency and nature of the child’s target behaviors, as well as their antecedents and consequences. Through this process, it was observed that Mai’s aggressive and self-injurious behaviors were usually triggered by: rejection by a “boyfriend,” limit setting by her parents (particularly with regard to phone use), or boredom (her access to age-appropriate activities was limited because of her parents’ unwillingness to transport). The typical consequence of her acting-out behaviors was determined to be increased access to the people, places, and attention she desired. Thus, these dangerous behaviors were thought to express an underlying need for connection and belonging with others.

Consistent with this assessment, the behavior specialists initiated strategies aimed at increasing Mai’s access to recreational and peer-based activities in the community (e.g., Boys’ and Girls’ Club programs, youth group at Hmong Community Center). A safety plan was also developed to decrease her access to toxic solutions and “undesirable” strangers. With the assistance of the Hmong interpreter, her parents were encouraged to closely monitor her whereabouts at times when she was likely to sneak out of the home (late at night), limit her access to the phone, and utilize a behavior chart for tracking non-aggressive behavior. In addition, a system of positive reinforcement was set up in which Mai’s parents were asked to reward her with stickers and other tokens when she behaved in a safe and responsible manner.

None of the above named interventions proved successful. Mai refused to attend peer-related activities in the community. Her parents did not follow through with the behavior management systems recommended, despite their reported willingness to do so. They continued to assert that Mai was of age to be married and cared for by a husband who would deal with her need for structure. Eventually, the service providers concluded that they were stuck. Not having a full understanding of the values and practices of the Hmong culture, they were operating in the dark and making little headway toward managing the risk involved with Mai’s behavior.   

These workers sought out the assistance of a cultural consultant who contracted with the County Department of Mental Health to provide input to mental health providers regarding culturally-specific issues that can impact a Hmong client or family’s progress in treatment. Upon referral by the county department, the Hmong psychiatric consultant contacted the service providers on this case to gain basic information regarding the need for his services. Next, this consultant conducted several meetings at the provider’s office, the first of which was held with the child recipient of services. He subsequently met with Mai’s mother and sister-in-law and elicited information regarding their perspectives of her behavioral challenges. Finally, he debriefed with the primary providers, at which time he shared his findings and offered recommendations.

As a result of this experience with consultation, the primary social workers learned a great deal about faulty assumptions they had made that contributed to poor progress on the part of the child and family. Those were as follows:

1. Mai’s language of choice was English.  It was apparent to the consultant that, while Mai is bilingual (Hmong and English), she much preferred speaking in Hmong. When communicating in English, she often had had difficulty grasping certain concepts that were being relayed by the English-speaker.

2.  Mai’s parents understood her target behaviors to be dysfunctional and wanted them to stop. One of the most striking insights that emerged out of the cultural consultation process concerned the parents’ interpretation of Mai’s symptoms and behaviors. It was revealed that they understood her high-risk behavior to be an indication of her call into shamanism, a form of healing that originated over 10,000 years ago. The primary providers learned that, according to Hmong tradition, the call to shamanism occurs through the visitation of spirits. Typically, a young person is summoned to this vocation during a psychic or spiritual crisis that accompanies a physical illness. By overcoming the disease, the youth reportedly acquires the ability to heal others with compassion. In the Hmong community, the shaman is revered and thought to serve as a bridge between the material and spiritual worlds (The Split Horn, n.d.).

Mai’s parents reported that an elder shaman had once confirmed that she had, in fact, been called into this profession. Because they respected her emerging role as a shaman, Mr. and Mrs. Khang did not wish to curtail her risky behaviors entirely; they merely wanted to keep her alive and free from serious harm. Mai, on the other hand, was not convinced that she was a shaman and appeared anxious when the topic was raised. Once the primary providers demonstrated their ability to discuss shamanism with her in a non-judgmental manner, her discomfort with this subject began to dissipate.

3. It is always appropriate to enter Mai’s house for a home visit if a family member answers the front door.  The cultural consultant clarified for the workers that when a cluster of green leaves is found hanging on the front door, it is a signal that spiritual cleansing is taking place within the home.  This ritual, referred to as “caiv,” is performed to protect the family from evil spirits. It was advised that when the team encountered this type of leafy display that they avoid entering the house; otherwise they would disrupt the ritual, resulting in a need for the family to reinitiate the cleansing process.

Based on these new insights, the behavioral specialists re-conceptualized the therapeutic needs of Mai and her family. They redefined the function of her aggressive and self-harmful behavior as expression of her need to resolve identity confusion and attain validation within her family and cultural community.  Consequently, their interventions focused on the following:

1.  The use of written narratives and scrap-booking. These activities were done to assist Mai in ethnic identity formation and goal-setting. Through this process, she identified an interest in pursuing a career as a translator, teacher, or mortician (interestingly, all aspects of the role of shaman).

2.  Joining with the family by recognizing their cultural beliefs and customs. The workers made an increased effort to recognize the family’s beliefs and traditions. They began noticing and asking about pictures in the home that depicted extended family celebrations. In addition, they expressed an interest in learning more about shamanism from Mai and her parents. Consequently, family members welcomed visits by the providers and appeared more open to input and suggestions aimed at managing Mai’s behavior.

3.  Building skills in emotions regulation. Mai was taught how to formulate and utilize coping statements (e.g., “I can find something positive to do when I am bored,” “I can control myself when mad,” and “I don’t need a boyfriend to be happy”). Social skills were also taught and practiced to prepare her for connection to age-appropriate social activities.

Following this shift in strategy on the part of the behavior specialists, Mai made substantial

progress. She learned how to access reading material at the public library and discovered a particularly strong interest in Hmong literature. Most importantly, she evidenced marked improvements in her behavior. While Mai continued to leave the home at times without permission, incidents of self-harm diminished, and she displayed a newfound ability to control her aggression.

When the providers neared completion of services, a Hmong-speaking staff member from their agency interviewed Mai and her parents with the intent to explore the extent to which they observed a change in the nature of service delivery subsequent to the implementation of cultural consultation. The family reported that the cultural consultant encouraged them to use the therapeutic services available – thereby granting implicit permission for them to accept help from members outside their cultural community. Mai and her parents all noted that following the meetings with the cultural consultant, the primary workers appeared more open to their culture and respectful of their customs. Mr. and Mrs. Khang also stated that, over time, the providers began encouraging them to use their cultural practices to help Mai decrease her dangerous behaviors. They recognized these workers for not giving up on them or their daughter and expressed their gratitude and appreciation for services rendered.

3.    Discussion

The case study described above sheds light on the benefits that can result from the use of cultural consultation as an adjunct to social work services provided to individuals and families. In order to attain such benefits, providers must, first, be willing to recognize their limitations with regard to understanding the role of culture as it impacts individual or family functioning. Sadly, practitioners are often reluctant to admit when they are making minimal progress with a client or client system and, thus, in need of assistance from a consultant. Moreover, when provider-client cultural and linguistic differences are at play, the provider may inaccurately assume that the use of an interpreter is adequate in terms of meeting the individual or family needs. The worker may fail to detect his or her their own assessment of problematic behaviors or clinical issues misses the mark when it comes to reflecting clients’ perspective of their own strengths and concerns.

As can be seen in the case example provided above, cultural consultation involves much more than linguistic translation. It offers an explanation of the client’s cultural beliefs, customs, and traditions that may have eluded the provider’s understanding or awareness. In addition, it places individual and family challenges into a rich context that leads the practitioner to previously undiscovered strengths and resources. As was illustrated above, cultural consultation holds potential for illuminating the function that a particular target behavior serves within a family or extended family system.

Another positive impact of this intervention is seen when the consultant is able to legitimize the role of the primary provider in the eyes of the client. By validating services and verifying the provider’s trustworthiness, the consultant can pave the way to an increased level of client involvement in the therapeutic process. In the case of Mai, this benefit is reflected in the comments made by her parents indicating that the consultant encouraged them to utilize the assistance of the behaviorally-oriented social workers. An intervention of this kind on the part of the consultant is invaluable – it serves to advance the client’s willingness to engage with workers of differing cultural backgrounds, particularly if these providers begin to recognize and appreciate the client’s values and customs.

In conclusion, the authors encourage social workers to consider the potential benefits of cultural consultation when conducting cross-cultural practice. Furthermore, they recommend that systems of care serving culturally and linguistically diverse individuals and families assemble a wide array of cultural experts and make their cultural consultation services readily available to human service providers. Such an investment in the provision of cross-culturally competent services is a requisite of service delivery that upholds the core values and ideals of the social work profession.

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          *The client’s name was changed to protect her privacy.