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Cultural Humility
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Additional Cultural Competence/Humility Models and Tools
Staff Access
Services for Specific Populations
Culture, Language & Religious Issues
Cultural Competence vs. Cultural Humility
The Cultural Formulation – APA Practice Guideline
The cultural formulation also includes specific consideration of cultural elements influencing the relationship between the individual and the clinician. In this regard, it is important for clinicians to cultivate an attitude of "cultural humility" in knowing their limits of knowledge and skills rather than reinforcing potentially damaging stereotypes and overgeneralizations.
– From: "Cultural Formulation: From the APA Practice Guideline for the Psychiatric Evaluation of Adults", 2nd Edition, Focus 4:11, Winter 2006, http://focus.psychiatryonline.org/cgi/content/full/4/1/11
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Cultural Competence and the risk of Stereotyping
Very often, when we first begin to learn about different culture groups, the tendency is to take the facts we learn and apply them to everyone who is a member of the group. We do this without evaluating the extent to which the individual members adhere to the dominant values and beliefs. For example, a service provider may have read that in Mexican families, the man is the decision maker and that women in the family will not make service decisions by themselves. Based on this information, the service provider will not spend the time discussing service decisions with a Mexican woman without her husband or father present. This is a form of stereotyping. In some Mexican families, the man may be the primary decision-maker, but in other families of Mexican origin, women assume autonomy in making decisions that affect them personally.
One way to avoid stereotyping is to look at new knowledge about an ethnic group as a generalization, which is a beginning point, knowledge that indicates common trends for beliefs and behaviors that are shared by a group. Generalization, as a beginning point, acknowledges that additional information is needed to determine whether the information known about the group applies to a particular individual within the group (emphasis added).
-Adapted from: Culture Brokering: Providing Culturally Competent Rehabilitation Services to Foreign–Born Persons Mary Ann Jezewski, Ph.D. and Paula Sotnik Copyright © 2001, http://cirrie.buffalo.edu/monographs/cb.php.
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"Cultural Humility" – Tervalon & Murray-Garcia, 1998
Cultural humility is best defined not by a discrete endpoint but as a commitment and active engagement in a lifelong process that individuals enter into on an ongoing basis with patients, communities, colleagues, and with themselves…a process that requires humility in how physicians bring into check the power imbalances that exist in the dynamics of physician-patient communication by using patient-focused interviewing and care.
–From: "Definitions of Cultural Competence", National Center for Cultural Competence, Georgetown University, http://www.nccccurricula.info/culturalcompetence.html
Cultural humility is proposed as a more suitable goal in multicultural medical education. Cultural humility incorporates a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the patient-physician dynamic, and to developing mutually beneficial and nonpaternalistic clinical and advocacy partnerships with communities (emphasis added) on behalf of individuals and defined populations.
-Tervalon, M. and Murray-Garcia, J. (1998). Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved. 9(2), 117-125. http://info.kp.org/communitybenefit/pdfs/Cultural_Humility_article.pdf
Are You Practicing Cultural Humility? – The Key to Success in Cultural Competence
The starting point for such an approach is not an examination of the client’s belief system, but rather having health care/service providers give careful consideration to their assumptions and beliefs that are embedded in their own understandings and goals of their encounter with the client. Training for cultural competency, with its emphasis on promoting understanding of the client with her/his ‘own culture’, has often neglected consideration of the providers' worldview....
Providers are encouraged to develop a respectful partnership with each client through client-focused interviewing, exploring similarities and differences between her/his own and each client's priorities, goals, and capacities....
Effectively exploring cultural issues in the client/provider encounter should begin with recognition that "cultural difference" refers to a relationship between two perspectives. It involves self-awareness and an awareness and acceptance of the other person and any differences in the contrasting cultures. Culturally competent providers develop skills for exploring the existence and importance of differences in the basic assumptions, expectations, and goals they and their clients bring to any interaction.
– From: "Are You Practicing Cultural Humility? – The Key to Success in Cultural Competence", California Health Advocates. http://www.cahealthadvocates.org/news/disparities/2007/are-you.html
"Cultural Humility" Defining Cultural Competence: A Practical Framework for Addressing Racial/Ethnic Disparities in Health and Health Care – Betancourt et al
The methods for cross-cultural education have varied, and range from the “categorical” or “multicultural” approach, in which specific information about certain cultures is taught to providers, to a more “crosscultural” approach, which focuses on the key process issues of caring for patients from diverse backgrounds (e.g., communication issues). Traditionally, training in cross-cultural medicine has focused on a categorical approach, describing the relevant attitudes, values, beliefs, and behaviors of certain cultural groups. For example, training in methods of caring for the “Asian” patient or the “Hispanic” patient would present a list of common health beliefs, behaviors, and key “do’s and don’t’s” for providers. With the huge array of cultures in the U.S. and the many powerful influences such as acculturation and socioeconomic status leading to intra-group variability, it is difficult to learn a set of “facts” about any particular group and hope to be effective in caring for them. Furthermore, these approaches may contribute to stereotyping (emphasis added). Still, there may be certain helpful, culturally specific information that can be effectively taught while avoiding stereotypes. This includes particular folk illnesses among certain populations; ethnopharmacology; disease incidence, prevalence, and outcomes among distinct populations; the impact of the Tuskegee Syphilis Study and segregation as the cause of mistrust among African Americans; the effect of war and torture on certain refugee populations and how this shapes their interaction with the health care system; and the common cultural and spiritual practices that might interfere with prescribed therapies, to name a few.
A newer approach focuses on the process of communication and trains providers to be aware of certain cross-cutting cultural and social issues and health beliefs that are present in all cultures. The focus is on the individual patient as teacher and on developing important attitudes and skills for providers (emphasis added). For example, curricula of this type have focused on identifying and negotiating different styles of communication, decision-making preferences, roles of family, sexual and gender issues, and issues of mistrust, prejudice, and racism, among others. Ultimately, some balance of cross-cultural knowledge and communication skills seems to be the best approach to cultural competence education and training.
– From: "Cultural Humility" Defining Cultural Competence: A Practical Framework for Addressing Racial/Ethnic Disparities in Health and Health Care
Authors: Joseph R. Betancourt, MD,MPH, Alexander R. Green, MD, J. Emilio Carrillo, MD,MPH, Owusu Ananeh-Firempong II, Public Health Reports / July–August 2003 / Volume 118 pp. 293- 302 At: http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1497553&blobtype=pdf retrieved 1/09.
Additional Cultural Competence/Humility Models and Tools
- Cultural destructiveness- attitudes, policies and practices are exhibited that can be destructive to a culture.
- Cultural incapacity- biased, authoritarian system that lacks capacity to facilitate growth in culturally diverse groups
- Culture blindness- "we're all human" approach is used where it is thought that culture, ethnicity and race make no difference in how services are provided
- Cultural pre–competence- cultural sensitivity wherein there is a decision made and attempts are made to deliver services in a manner respectful of cultural diversity
- Cultural competence- an acceptance of and respect for cultural norms, patterns, beliefs, differences, and self assessment regarding cultural competence
- Cultural proficiency- motivation toward adding to the knowledge base of culturally competent service provision, and developing a culturally therapeutic approach
- Listen with sympathy and understanding to the patient's perception of the problem
- Explain your perceptions of the problem
- Acknowledge and discuss the differences and similarities
- Recommend treatment
- Negotiate agreement
- What do you call your problem? What name does it have?
- What do you think caused your problem?
- Why do you think it started when it did?
- What does your sickness do to you? How does it work?
- How severe is it? Will it have a short or long course?
- What do you fear most about your disorder?
- What are the chief problems that your sickness has caused for you?
- What kind of treatment do you think you should receive?
- What are the most important results you hope to receive from the treatment?
- Consider all clients as individuals first, as members of minority status, and then as members of a specific ethnic group
- Never assume that a person's ethnic identity tells you anything about his or her cultural values or patterns of behavior
- Treat all "facts" you have ever heard or read about cultural values and traits as hypotheses, to be tested anew with each client. Turn facts into questions
- Remember that all minority group people in this society are bicultural, at least. The percentage may be 90-10 in either direction, but they still have had the task of integrating two value systems that are often in conflict. The conflicts involved in being bicultural may override any specific cultural content
- Some aspects of a client's cultural history, values, and lifestyle are relevant to your work with the client. Others may be simply interesting to you as a professional. Do not prejudge what areas are relevant.
- Identify strengths in the client's cultural orientation which can be built upon. Assist the client in identifying areas that create social or psychological conflict related to bi-culturalism and seek to reduce dissonance in those areas
- Know your own attitudes about cultural pluralism, and whether you tend to promote assimilation into the dominant society values or stress the maintenance of traditional cultural beliefs and practices
- Engage your client actively in the process of learning what cultural content should be considered
- Keep in mind that there are no substitutes for good clinical skills, empathy, caring, and a sense of humor.
1. Continuum from Cultural Incompetence to Cultural Competence
Rorie and colleagues (1996) provide a useful framework describing a continuum from incompetence to competence.
It should be noted that each time a service provider encounters a consumer from an ethnic group that the provider is not familiar with, the provider may have to move through all or part of the competence continuum. Developing competency takes time with each new culture encounter.
L-E-A-R-N Model of Cross Cultural Encounter Guidelines for Health Practitioners
Negotiation is perhaps the key concept of the proposed LEARN model. It is necessary to understand a patient's perceptions and to communicate the provider's perspective so that a treatment plan can be developed and negotiated. There may be a variety of options from the biomedical, psychosocial or cultural approaches that could be appropriately applied. The final treatment plan should be an amalgamation resulting from a unique partnership in decision making between provider and patient. A patient can truly be involved in the instrumentation of recovery if the therapeutic process fits within the cultural framework of healing and health.
– Berlin EA. & Fowkes WC, Jr.: A teaching framework for cross-cultural health care--Application in family practice, In Cross-cultural Medicine. West J. Med. 1983, 12: 139, 93~98 http://www.diversityrx.org/HTML/MOCPT2.htm or complete article at: http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1011028&blobtype=pdf
3. Kleinman's Tool to Elicit Health Beliefs in Clinical Encounters
Source: Dr. Arthur Kleinman, Patients and Healers in the Context of Culture. The Regents of the University of California. 1981. http://www.diversityrx.org/HTML/MOCPT3.htm
4. Strategies for Clinical Cultural Assessment and Interactions for Social Workers
The following strategies for cultural assessment are offered as guidelines for social workers, and they may apply to other transcultural interactions.
Source: Nancy Brown Miller, "Social Work Services to Urban Indians", Cultural Awareness in the Human Services, James Green, ed. Prentice-Hall, 1982, p.182. http://www.diversityrx.org/HTML/MOCPT4.htm