About Cultural Competency in Nevada (342)Page 10 of 18

9. Cultural Competency in Veteran Services, Mental Health Services, and for Older Adults

For many healthcare providers, practicing culturally competent care can be challenging for certain groups of people, especially if a provider has limited personal experience with the difficulties faced by these groups. For members of the military and veterans, military culture is often little understood by the general population. This can be true also for people with mental health issues and for older adults.

9.1 Military and Veteran Cultural Competency

[Unless otherwise noted the information in section is from Isserman and Martin, 2022].

Military members, veterans, and their families belong to a unique American subculture. Military culture, which is acquired through training and experiences that are integrated into the service members’ mind, body, and spirit, is comprised of implicit values and beliefs shared through time-honored rituals, customs, and organizational traditions.

While there is great diversity among the various sectors of the armed forces, there are implicit cultural values and beliefs shared across all components and service branches. For example, the concept of service before self, is a core military value that stresses integrity and requires service members to place their duty responsibilities before their own personal interests and desires. These values are ingrained early in military training and remain with military members and their families even after transitioning from military service to veteran status.

Numerous studies have identified the need for health professionals to acquire what is referred to as “military/veteran cultural competence” to effectively engage with this population. This allows clinicians to understand the importance of recognizing how a client’s life experiences and relationships have been impacted by military service and veteran status.

Military cultural competence includes developing an understanding of the basics of military life and language and the impact of military lifestyles and duties on behavioral and physical health, combat-related exposures, and family separations. Understanding workplace challenges confronting the armed forces—issues like sexual violence, addiction, and suicide are also important.

Service members, veterans, and their family members expect providers to have a basic cultural appreciation, understanding, and interest in their military-related experiences. This includes listening to their experiences, even when these stories may be horrific or painful. It is critical that healthcare providers not let their own personal biases interfere with an understanding of a client’s unique military duty or military life experiences.

Healthcare providers can break down military cultural barriers by initiating discussions about specific problems related to trauma, military sexual trauma, intimate partner violence, PTSD, and behavioral health issues. Be aware that a client may be affected by conditions such as moral injury, challenges faced during deployment, and military grief for children.

Key points about military/veteran cultural competence:

  1. Screen clients for military or veteran status.
  2. Become knowledgeable about military culture.
  3. Understand the cultural stigma clients face in reaching out to therapists for counseling.
  4. Understand any preconceptions you may hold about the military.
  5. Learn about the values and factors that impact a military client’s behavioral and relational difficulties.

Test Your Knowledge

You have a client who was injured in the Afghanistan conflict who was referred to you for counseling. You haven’t had any other clients who fought in the war and aren’t sure whether to ask your client about her experience or not. What should you do?

Answer: Ask her about her military service and praise her for reaching out for help. Remember that many veterans are reluctant to seek mental health care and may feel ashamed or stigmatized.

9.2 People with Mental Health Issues

Although culture is a fluid concept, it is a central part of how we understand mental health. Culture influences what gets defined as a problem, how the problem is understood, and which solutions to the problem are acceptable. It has many layers, which interact with class, religion, language, nationality, and gender, each of which influences how an individual engages with and experiences mental health services (Salla et al., 2023).

Culture provides standards for normality and abnormality, and the definitions of what constitutes a mental disorder are socially and culturally negotiated. Culture determines the variations of normalcy in behaviors; while some cultures are tolerant of high levels of deviant behaviors, other cultures insist on conformity (Ogundare, 2020).

Cultural differences can affect the rates of diagnosis of certain mental disorders. For example, diagnosis of attention deficit hyperactivity disorder diagnosis varies widely across countries. These variations reflect the influence of culture on the tolerability of certain behaviors in children, and the perception and acceptance of the diagnosis (Ogundare, 2020).

Current diagnostic classifications of mental illness rely mostly on western worldviews of what constitutes abnormal behaviors and assume a universalist view of mental illness. In reality, however, there are many cultural variations in the phenomenology of mental illness and psychopathology. These variations affect the reliability and validity of the diagnostic instruments that are used to diagnosis mental illness (Ogundare, 2020).

The DSM-IV (to some extent) and DSM-V (to a larger extent) have recognized the importance of cultural considerations in the manifestation of illness, diagnosis, and treatment of mental disorders. The DSM-V includes a cultural formulation chapter that aims to help clinicians evaluate cultural aspects of the diagnostic procedure and added a Cultural Formulation Interview to aid the implementation (Ogundare, 2020).

When the social and cultural factors are neglected in the assessment of patients, misdiagnosis and perpetuation of clinical stereotypes based on race, ethnicity, gender, among other factors occur, leading to disparities in mental healthcare. For example, in the U.S., there is a long history of misdiagnosis of schizophrenia and other psychosis-related disorders among Black people, dating as far back as the early 1900s (Ogundare, 2020).

Clinical diagnosis of a mental disorder requires clinicians to fit patient information into existing diagnostic categories, and the weaker the fit between the available information about the patient and the diagnostic criteria, the greater the uncertainty regarding clinical diagnosis. In these situations, clinicians often make clinical judgments based on underlying assumptions about the patient within the context of the general population (Ogundare, 2020).

Failure to consider a patient’s cultural context leads to misinterpretation of the patient’s behaviors and leads to diagnostic inaccuracies. Conversely, cultural sensitivity and knowledge of the cultural context provides a more contextualized perspective, improves diagnostic accuracy, and helps identify a patient’s severity and ongoing vulnerability (Ogundare, 2020).

Healthcare professionals are not immune to making racially biased decisions; ideas related to race and culture overlap. In relation to mental health, barriers to help-seeking are not simply a cultural nuance, they are infused with a fear among racial minorities about the care they will receive because of their identity. Cases of historical mistreatment of racial minorities by the state and by mental health services contribute to cultural beliefs and values about mental health services (Salla et al., 2023).

9.3 Cultural Competency and Older Adults

They are many aspects to cultural competence for older adults. A patient’s culture and background often affect whether and where they seek healthcare, their understanding of medical information, and how they make healthcare decisions. Recognizing the different health issues your older patients are likely to face, as well as the factors that contribute to these differences, will help you provide the most effective care.

Adults from different cultures and traditions have varied attitudes about aging. In some cultures, older adults are customarily respected for their wisdom and experience. Other cultures tend to be more youth-centered, valuing the qualities of youth over those of old age (NIA, 2023 June 27).

For older adults, culturally competent, linguistically appropriate care is essential to meet the needs of what is becoming a larger and more diverse population. The value of cultural competence lies in understanding how cultural variables impact and inform the healthcare experiences of older adults (Chowdhury et al., 2022).

For older adults, many complex and interacting factors underlie disparities in health risk and disease burden. These factors include:

  • unequal access to healthcare services
  • availability of social support
  • neighborhood and workplace environments
  • food availability and accessibility
  • wealth and income gaps
  • racism, sexism, and other forms of discrimination (NIA, 2023 June 27)

Additional factors such a lack of geriatrics specialists, medical insurance issues, ageism, hearing and visual changes, chronic diseases, cognitive changes, limited English proficiency, and health literacy can lead to stigma and misunderstandings that contribute to inaccurate diagnoses, lack of followup care, and poor health outcomes.

9.3.1 Patient-Centered Care

There is increasing recognition of the importance of including patient perspectives on the quality of healthcare delivery, which has traditionally been driven solely by healthcare professionals and policy makers. Person-centered care prioritizes viewing older adults as partners in receiving, planning, and monitoring care. Ensuring patients are involved and central to their care is a key component of high-quality healthcare (Chowdhury et al., 2022).

Because older adults from culturally diverse backgrounds are often miscategorized as a homogenous group despite prominent sociocultural differences, moving away from a “one-size-fits-all” approach is critical. Person-centered care encourages providers to tailor care delivery to the participants’ specific sociocultural backgrounds. As such, person-centered care is a crucial component of cultural competence in healthcare settings, and each informs the other (Chowisdhury et al., 2022).

To ensure care supports all older adults, healthcare providers need to be responsive to the many diverse characteristics influencing the health and care needs of older people. Five key principles of culturally competent include (Ogrin et al., 2022):

  1. Awareness of unconscious bias and prejudice. Reduced healthcare involvement can occur because of unintentional judgments about older people by healthcare providers.
  2. Promotion of inclusion. Focus on similarities between people rather than differences supports a sense of belonging. Language is critical, such as using “person with dementia,” rather than the derogatory “demented patient.”
  3. Access and equity. Inclusive healthcare requires embedding access and equity in policy and practice. These components have wide-reaching effects for participation of older people in their healthcare. Any deficits in these aspects should be identified by healthcare workers who understand the diverse needs of older people.
  4. Appropriate engagement. Participation supports involvement and sharing of decision-making. Building trust and rapport leads to open and meaningful discussions.
  5. Intersectionality. This involves moving away from viewing people through a single lens, towards understanding the intersection of their various characteristics. For example, the interplay of characteristics, such as an older woman, from a culturally and linguistically diverse background, living in a remote community with few services, will inform this woman’s ability to participate in healthcare in a meaningful way.

9.3.2 Ageism

Ageism is an often underrecognized form of discrimination that includes stereotypes and prejudices directed toward people on the basis of their age. Ageism has serious implications for the health of older people. Age-based discrimination has been associated with poorer physical and mental health, reduced quality of life, and even earlier death (NIA, 2023 June 27).

Effective communication builds satisfying relationships with older patients to best manage their care. It strengthens the patient-provider relationship, leads to improved health outcomes, reduces medical errors, and makes the most of limited interaction time (NIA, 2023 January 25).

Key points (NIA, 2023 January 25):

  1. Speak to the patient as a fellow adult. Having physical, sensory, or cognitive impairments does not lessen the maturity of an adult patient. Establish respect right away by using formal language as a default (such as Mr. or Ms.). Avoid terms, such as “dear,” which could be perceived as disrespectful. Ask patients how they prefer to be addressed.
  2. Make older patients comfortable. Make sure patients have a comfortable seat in the waiting room and, if necessary, help with filling out forms. Check on them often if they have a long wait before being seen. Patients with impaired mobility may need extra help. They may require assistance with climbing on to the exam table or removing clothing or shoes.
  3. Avoid hurrying older patients. Be mindful if you are feeling impatient with an older person’s pace. Some people may have trouble following rapid-fire questioning or torrents of information. Try speaking more slowly to give them time to process what is being asked or said, and don’t interrupt. Once interrupted, a patient is less likely to reveal all of their concerns.
  4. Speak plainly. Use common language and ask if clarification is needed. Check to be sure your patient understands the health issue, what they need to do, and why it is important to act.
  5. Address the patient face-to-face. Don’t talk to patients with your back turned or while typing. Many people with hearing impairment understand better when they can read lips as well as listen. Watching a patient’s body language can also help you know whether they understand what you’re saying.
  6. Write down or print out takeaway points. It can often be difficult for patients of any age to remember everything discussed during an appointment. Older adults with more than one medical condition or health concern benefit from having clear and specific written notes or printed handouts.
  7. Recognize that people from different backgrounds may have different expectations. Be sensitive to cultural differences that can affect communication with your patients. When needed, provide professional translation services and written materials in different languages.

Test Your Knowledge

You have an older, Spanish-speaking client who is concerned about her declining health and has come to you for counseling. She tells you she has been very depressed for more than a year. Your Spanish is less than adequate but you decide it’s good enough for this sweet old woman. Her granddaughter offers to translate but you decline and ask the granddaughter to wait outside. In terms of cultural competency, what have you already done wrong?

Answer Any person with limited English should be offered professional translation services. You have already made several inaccurate assumptions about this woman. You have stereotyped her as a sweet, old woman who probably just needs someone to talk to. You don’t feel the need to completely understand her needs and issues and will very likely be unable to draw her out due to your lack of fluency and lack of understanding of this women’s cultural background.

What Should You Do? Ask if she would like to have a translator or see another counselor with a cultural background similar to hers. Refrain from infantilizing older women as sweet, cute, lonely, and inoffensive. Speak to her as a fellow adult and provide Spanish-language and provide her with educational materials in Spanish.