Keywords

The origins of cultural competence as a construct are unclear. We have evidence as far back as 1927 of discussions regarding race and culture in psychology. Klineberg’s (1927, 1934) pioneering work in intelligence testing debunked myths of racial superiority using scientific data and Kenneth and Mamie Clark’s foundational experiments (Clark & Clark, 1939) were used to support school desegregation in the USA in 1954. In the 1950s, Madeleine Leininger began developing a theory of cultural care diversity and universality (Leininger, 1988). In 1967, Gordon Paul (1967) famously asked “What treatment, by whom, is most effective for this individual with that specific problem, and under which set of circumstances,” (p. 111) albeit outside of a discussion of culture, this question remains deeply relevant to psychotherapists advancing cultural competence today. In the 1970s, various conferences in psychology (Vail, Austin, Dulles conferences) professionals discussed the need for integrating multiculturalism into training (Gamst, Liang, & Der-Karabetian, 2011; Sue et al., 1982). The term itself increased in prominence in the scholarly literature in the 1990s (Saha, Beach, & Cooper, 2008).

In the decades following, there has been much support for the concept of cultural competence (Gallardo, Parham, Trimble, & Yeh, 2012) especially related to health care delivery across applied professions (e.g., nursing, social work, psychology, medicine; Kohli, Huber, & Faul, 2010; Leininger, 1988; Loftin, Hartin, Branson, & Reyes, 2013; National Association of Social Workers, 2015). Among academics and practitioners in cultural competence, there is agreement that cultural considerations in treatment ought to transform practice rather than be an added consideration in practice (Gallardo et al., 2012; Leininger, 1988).

Professionals across helping professions appear to enthusiastically favor an approach to service provision, scholarship, and teaching that considers culture and context. How to define cultural competence and practice in accordance to guidelines for the advancement of cultural competence, however, appears to be a work in progress. In this chapter, we will focus on definitions of cultural competence and associated constructs in the context of helping professions. There is much work in other fields (e.g., education; McAllister & Irvine, 2000; National Education Association, 2017), however that work is beyond the scope of our discussion. We provide a table with definitions advanced across helping professions. We also report on efforts to train students and providers to improve cultural competence.

Definitions of Cultural Competence

Literature on cultural competence exists in multiple fields such as nursing, mental health, medicine, education, and social work (to name a few) with definitions and terminology varying from discipline to discipline. For example, social work was one of the first fields to examine the idea of “cultural awareness” as an important factor in service provision (Green, 1982). One of the earliest mentions of cultural competence as a framework for informing patient care in nursing is “cultural care theory,” which is a holistic method of acknowledging cultural lifeways while providing patient services (Leininger, 1988). Leininger recognized that interactions between providers and patients were a process with multiple moving parts which required a certain sense of linkage to help unify exchanges.

In the field of mental health, cultural competence is generally conceptualized as a tripartite model composed of self-awareness, knowledge, and skills (Sue, Arredondo, & McDavis, 1992). Self-awareness refers to both attitudes that a person holds about cultural groups other than their own and awareness of themselves as cultural beings. Knowledge refers to specific knowledge about other cultural groups (e.g., language, traditions, beliefs). Skills refer to specific interpersonal and intervention abilities. This definition is one of the most frequently cited models in the literature (Bernhard et al., 2015), especially within psychology. Cultural competence is also frequently defined as a set of congruent behaviors that extend well beyond tolerance to allow professionals to work effectively in cross-cultural settings (Cross, Bazron, Dennis, & Isaacs, 1989; Roberts et al., 1990). While Sue et al.’s (1992) definition focuses on individual’s abilities, Cross et al. (1989) focus on a “system of care” that includes individual as well as programs, agencies, and institutions.

Table 2.1 illustrates the evolution of definitions of cultural competence over time. While this table is not exhaustive, it is representative across helping professions. Existing definitions constitute a wide range from “the process of working with patients from a different cultural background than one’s own” (Hadwiger, 1999, p. 47) to a more nuanced set of guidelines based on an ecological approach to cultural competence that reflect “current trends in the literature that consider contextual factors and intersectionality among and between reference group identities, including culture, language, gender, race, ethnicity, ability status, sexual orientation, age, gender identity, socioeconomic status, religion, spirituality, immigration status, education, and employment, among other variables” (American Psychological Association, 2002, 2017).

Table 2.1 Definitions of cultural competence
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While social workers, nurses, physicians, and counselors may often represent a much needed “front line,” cultural competence may be extended throughout service industries as it also pertains to the work of receptionists, administrative staff, human resources specialists, and CEOs. The notion that organizations must have the ability to incorporate cultural competence “in all aspects of policy making, administration, practice, service delivery and systematically involve consumers, key stakeholders and communities” has become more widely recognized (National Center for Cultural Competence, 1998). Through continued evolution of these concepts, cultural competence has been utilized from a systems perspective with multiple authors acknowledging the need for application of cultural competence in policy making and at multiple tiers of service-oriented organizations (Brach & Fraserirector, 2000). Some definitions of cultural competence have also included recognizing systemic forms of oppression (Schlesinger & Devore, 1995), social justice (Krentzman & Townsend, 2008), and health disparities (Capell, Veenstra, & Dean, 2007).

Emerging Components of Cultural Competence

As the definition of cultural competence has expanded and become more refined, more terms have been developed. For example, authors often emphasize cultural competence as “demonstrated” or an ongoing “lifelong process” where the competent provider acts as a lifelong learner, able to put cultural competence into action while incorporating new skills across multiple settings and situations (Lavizzo-Mourey & Mackenzie, 1996a; Tervalon & Murray-Garcia, 1998). Campinha-Bacote (1999) extended previous views of cultural competence to incorporate “cultural encounters” as a necessary component of building on cultural competence skills. Campinha-Bacote also added “cultural desire” as a means of gauging the investment of the professional in the competence process. In Table 2.2, we lay out some existing and emerging terms in the cultural competence literature.

Table 2.2 Terms in cultural competence literature
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We view the terms in Table 2.2 as emerging components of cultural competence and not as separate entities. For example, cultural adaptation of evidence-based interventions is related to cultural competence but is a distinct construct. Indeed, a recent meta-analysis provides evidence for both in the same manuscript (Soto, Smith, Griner, Domenech Rodríguez, & Bernal, 2018). Cultural adaptation refers to the efforts made to tailor a specific treatment, often a manual, whereas cultural competence refers to the skills of a person. A culturally competent provider may look for a cultural adapted treatment manual to support their intervention efforts.

In reference to the numerous ways in which cultural competence and other terms from the literature intersect, some common themes emerge. For instance, words such as “consideration,” “acknowledgement,” and “engagement” are frequently used across terminologies, denoting that competence regardless of discipline requires both a reflective and active component. Certainly, we cannot learn to be culturally attuned, responsive, or competent without first exploring or considering the histories and modern contexts in which an individual exists. Language and cultural identities are key components of this existence continuum, as are ways of knowing, being, and operating in a given environment (Bernal, Jiménez-Chafey, & Domenech Rodríguez, 2009; Hoskins, 1999). As an added layer of complexity, we live in a multicultural world and cultures interact. Hence the aforementioned components may vary from setting to setting (e.g., differ from the emergency room to a therapy session) or manifest quite differently in the presence of service providers of varying demographic characteristics (e.g., a patient seeing a doctor of similar or dissimilar race, ethnicity, age, sexual identity).

The idea of “considering,” while one of the most frequently used descriptors in cultural competence frameworks, can be troublesome. By way of interpretation, “considering” may run the gamut from mild curiosity to in-depth examination. Likewise, “acknowledgement” is also a multifaceted component that requires personal introspection as to definition. Service providers may define acknowledgement as synonymous with recognition, equate the term with tolerance, or define it as acceptance. “Engagement” is equally ambiguous—Is the engagement process passive or active? Is “engagement” an agreement or a commitment? We would posit that the culturally competent provider is capable of taking a deeper dive into context, of moving beyond simple recognition, and be able to commit to actively becoming a part of the competence process. Reflection and action become mechanisms through which cultural competence is conducted and with them comes a certain awareness on the part of the service provider, which maybe unpleasant or even painful depending on the insights gained. We think this further demonstrates that the terms in Table 2.2 are facets of the same cultural competence paradigm, each having specific utility within their own service frameworks. This is not to discount the importance of these diverging terms. The spirit in which these frameworks operate is the same one personified by true cultural competence wherein providers may hold varied perspectives together to arrive at a more comprehensive understanding. Regardless, a unified definition is certainly lacking despite “increased attention to understanding,” and practitioners and researchers generally agree there is a distinct need for a clearer conceptualization of cultural competence (Boyle & Springer, 2001; Roberts et al., 1990; Worthington, Soth-McNett, & Moreno, 2007).

Competencies and Benchmarks

Cultural competence training has evolved based on the available definitions and conceptualizations. Older publications point to frameworks. For example, Cross et al.’s (1989) continuum for understanding a provider or agency’s location on the cultural competence spectrum that ranges from culturally destructive to culturally proficient. For each of the six levels, Cross provides attitudinal and behavioral descriptors. Sue et al. (1982) provided the first benchmarks for cultural competence from the American Psychological Association’s Division 17 Education and Training Committee for clinicians. Currently, individual and cultural diversity are considered one of the foundational competencies for psychologists and the behavioral anchors for the benchmarks include knowledge of self and others as cultural beings and applies to interactions, assessment, treatment, and consultation (Fouad et al., 2009; Hatcher et al., 2013).

Standards for accreditation for Medical Education include cultural competence and health care disparities based on the tripartite model, including self-awareness, knowledge, and skills (Liaison Committee on Medical Education, 2018). Medical professionals must acknowledge “[t]he manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments” (p. 11) and the standard goes further to include the need to recognize and address health care disparities (Liaison Committee on Medical Education, 2018). Medical educators developed benchmarks for faculty in medical schools (Sorensen et al., 2017) and evaluated them empirically to derive ten critical characteristics of cultural competence needed to effectively train medical students (Hordijk et al., 2019).

In the field of social work, the emphasis on cultural competence is interwoven into many facets of the profession. The Code of Ethics of the National Association of Social Workers begins by stating “[t]he primary mission of the social work profession is to enhance human well-being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty” (National Association of Social Workers, 2017). Principles in the ethics code highlight the importance of diversity and cultural competence is a prominent ethical standard. One of the nine educational accreditation competencies in social work is to “Engage Diversity and Difference in Practice” (Council on Social Work Education, 2015). The professional practice guidelines in social work further expand the reach of cultural competence in that it

also requires advocacy and activism. It is critically important to provide quality services to those who find themselves marginalized; and it is also essential to disrupt the societal processes that marginalize populations. Cultural competence includes action to challenge institutional and structural oppression and the accompanying feelings of privilege and internalized oppression (National Association of Social Workers, 2015, p. 10).

The importance of cultural competence for helping professionals in the field has become more evident with multiple professional organizations adopting and tailoring specific guidelines of cultural competence to facilitate education and training of professionals in response to the increasing diversity of patients, clients, and students (Boyle & Springer, 2001; Frusti, Niesen, & Campion, 2003). Elements of cultural competence can be found throughout the American Counseling Association’s code of ethics (American Counseling Association, 2014) and in many different practice competencies, such as Competencies for Counseling the Multiracial Population (Multi-Racial/Ethnic Counseling Concerns (MRECC) Interest Network of the American Counseling Association Taskforce & Counseling Association Taskforce, 2015), Multicultural and Social Justice Counseling Competencies (The Multicultural Counseling Competencies Revisions Committee, 2015), in addition to competency guidelines for specific populations. Psychology professionals can look to the Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change (American Psychological Association, 2017) as well as guidelines for specific populations, such as Guidelines for Psychological Practice With Transgender and Gender Nonconforming People (American Psychological Association, 2015).

Summary and Recommendations

Rather than seeing the definition of cultural competence as a moving target, we understand that the definitions of both “culture” and “competence” are elusive in nature and, thus, a definition of cultural competence is necessarily a work in progress. As we culled through the literature, we see many terms and we welcome them, and we also know that sometimes narratives are more directed at replacing rather than enriching bodies of scholarship. One of our overarching recommendations is for scholars and practitioners to embrace the complexity of this construct and resist the urge to find a replacement construct with a neat definition but rather incorporate new knowledge and conceptualizations as they arise and celebrate the deeper and broader understanding that results from added concepts.

Researchers may feel the most desire to have a working operational definition, especially in consideration of measurement. Existing measures are usually based on different components of cultural competence, including the tripartite components (e.g., Revised Multicultural Awareness, Knowledge, & Skills Survey, Counselor Edition: Kim, Cartwright, Asay, & D’Andrea, 2003; Multicultural Counseling Self-Efficacy Scale, Racial Diversity Form: Sheu & Lent, 2007; Sheu, Rigali-Oiler, & Lent, 2012). The aforementioned scales, as most measures of cultural competence, are practitioner self-report and can serve to facilitate self-awareness and reflection. There are also measures of supervisor ratings of trainees cultural competence (LaFromboise, Coleman, & Hernandez, 1991), trainees’ and supervisors’ perspectives of multicultural competence in supervision (Pope-Davis, Toporek, & Ortega-Villalobos, 2003), student ratings of professional programs’ training and curriculum in regards to multicultural climate (Pope-Davis, Liu, Nevitt, & Toporek, 2000), and client perceptions of helping professionals’ cultural competence (Cornelius, Booker, Arthur, Reeves, & Morgan, 2004). These measures are not a criterion style measure as there is not a cut-off score and thus one possesses cultural competence, but these measures allow for room to grow in cultural competence.

A criticism of cultural competence is that the term somehow communicated that one is to possess said competence. In fact, cultural competence has been operationally defined as a journey, not a destination, from early inceptions (Cross et al., 1989; Sue et al., 1982). When introducing the concept of cultural humility, Tervalon and Murray-Garcia (1998) did not suggest it as a replacement term but rather recommended that cultural humility might be a more realistic achievement for medical trainees receiving cultural competence training given the definition of cultural competence they espoused which was “a commitment and active engagement in a lifelong process that individuals enter into an ongoing basis with patients, communities, colleagues, and themselves”(p. 118). Their working definition was similar to Cross et al. (1989):

Becoming culturally competent is a developmental process for the individual and for the system. It is not something that happens because one reads a book, or attends a workshop, or happens to be a member of a minority group. It is a process born of a commitment to provide quality services to all and a willingness to risk. (p. 21)

Similarly, Resnicow, Baranowski, Ahluwalia, and Braithwaite (1999) clarify that cultural competence is the ability to exercise cultural sensitivity in an interpersonal exchange. The authors provide an important distinction that cultural competence resides in practitioners whereas cultural sensitivity resides in materials and messages. Domenech Rodríguez and Bernal (2012) make a similar distinction between cultural competence which resides in the practitioner, and cultural adaptations, which reside in the treatment manuals.

We do understand the practical concerns that have led to a desire to have an agreed upon definition so that interventions may be developed for trainees or helping professionals, which in turn would allow for their test of effectiveness for both learning of providers and the outcomes of those whom they serve. We do believe the literature shows a great deal of diversity in conceptualizations, and also points fairly clearly to agreement over the use of the tripartite model of cultural competence as a primary conceptualization. For providers that want clear guidance, it would be reasonable to proceed with that model (Sue et al., 1992; Sue, 1998).

In sum, a great deal of thought and consideration has gone into understanding the importance of culture in interpersonal exchanges as they relate to outcomes in psychotherapy and other helping professions. We believe the elusive nature of the construct of cultural competence is perhaps due to the very nature of cultural competence as a complex and multi-faceted one. Rather than consider the construct as elusive or problematic, we believe the work is still in progress. However, practitioners, educators, researchers, administrators, and other stakeholders cannot necessarily wait until a definition is perfectly operationally defined and measurable. We recommend proceeding with caution, while actively pursuing self-awareness, knowledge of cultural others, and specific skills. We are particularly fond of scientific mindedness and dynamic sizing as important guidelines for specific behavior. We would challenge mental health professionals to expand the notion of scientific mindedness and dynamic sizing to include efforts outside of themselves and include consultation with other professionals. The process by which each professional pursues cultural competence, is itself a marker of this so-called elusive trait.