Posted: September 19th, 2022

Assignment: Diversity Challenges and Reflections

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Walden University
COUN 6726/COUN 6726S: Couples a

nd

Family Counseling

Photo Credit: [moodboard]/[moodboard / Getty Images Plus]/Getty Images

Week 3: Diversity and Cultural Challenges
Differences in cultural and societal norms, and family member beliefs about what those differences
mean, can have a significant impact on the family system. The family members and subgroups of the
system may each have their own beliefs and preconceived notions based on their cultural
backgrounds.

It is important for couples and family counselors to develop skills in recognizing and understanding
the impact of different cultures and beliefs on the family system. The IAMFC Code of Ethics includes a
section that addresses diversity and multiculturalism, as does the Code of Ethics of the American
Counseling Association.

This week, you will analyze how diversity can affect couples and families. You will reflect on a time
when you and your family were touched by diversity, and you will consider how the issue involved
might have been handled in a counseling session.

Learning Objectives
Students will:

Analyze the impact of diversity issues on families
Analyze cultural sensitivity in future professional practice

Learning Resources
Required Readings

Canfield, B. (2021). Diversity and intercultural work in family counseling. In D. Capuzzi & M. D.
Stauffer (Eds.). Foundations of couples, marriage, and family counseling (2 ed., pp. 47-59).
Wiley & Sons.

nd

Journal: Diversity Challenges and Reflections
Couples and family counseling often involves understanding and integrating diverse influences on the
system’s presenting issues, as well as ongoing wellness and development of the system. Counselors
must be aware not only of these influences, but also the manner in which they may impact the system
members—differing degrees, perceptions, and meaning. In addition, the intersection of multiple
diversity issues can create another layer of challenges for couples and families.

Familiarizing yourself with multicultural standards of practice is a first step in developing cultural
competencies, as is exploring your own thoughts and beliefs regarding diversity. For this Assignment,
you consider a point in your life when your family was touched by diversity, discuss how it affected
your family, and how such an issue might be handled in a counseling session.

To Prepare:

Review the Learning Resources and consider the many challenges diverse populations bring to
counseling sessions.
Reflect on a time when diversity touched your family.

Assignment:

In your Journal, identify a time where diversity touched your family. Based on this time, answer the
following questions:

What impact did this time have on your family?

Sperry, L. (2010). Culture, personality, health, and family dynamics: Cultural competence in the
selection of culturally sensitive treatments. The Family Journal, 18(3), 316–320.
doi:10.1177/1066480710372129

Sperry, L. (2011). Culturally, clinically, and ethically competent practice with individuals and
families dealing with medical conditions. The Family Journal, 19(2), 212–216.
doi:10.1177/1066480711400560

Shannon, P. J. (2014). Refugees’ advice to physicians: How to ask about mental health. Family
Practice, 31(4), 462–466. doi:10.1093/fampra/cmu017

https://go.openathens.net/redirector/waldenu.edu?url=https://doi.org/10.1177/1066480710372129

https://go.openathens.net/redirector/waldenu.edu?url=https://doi.org/10.1177/1066480711400560

https://go.openathens.net/redirector/waldenu.edu?url=https://academic.oup.com/fampra/article/31/4/462/710377

Hypothetically, if you addressed the issue in a family counseling session, what do you think the
counselor should know and explore with your family to fully address the issue?
How will you be sensitive to the impact diversity has on families and couples in your own
professional practice?
Your journal should be 2-3 pages in APA format excluding the title page. Please note this is a
personal journal and APA references are not required.

By Day 7

Submit your Journal.

Note: The focus of Journal assignments is reflection and self-awareness. Submissions do not
need to include resources. Journal assignments should, however, adhere to graduate-level
writing and be free from writing errors.

Submission and Grading Information

Grading Criteria

Submit Your Assignment by Day 7

Week in Review
This week, you considered multicultural issues in counseling and reflected on a time when you and
your family were touched by diversity.

Next week, you will delve further into systems concepts and models by discussing the genogram and
how it can be used as a visual tool for understanding the family system.

To access your rubric:

Week 3 Journal

Rubric

To submit your Journal:

Week 3 Journal

javascript:ActivateLink(‘WK03.JOURNAL.RUBRIC’,true)

javascript:ActivateLink(‘WK03.JOURNAL’,true)

To go to the next week:

Week 4

https://content.waldenu.edu/wa/ms-coun/ms-coun-2022/coun-6726-220228-211227-d3qi3veq/week-04.html

Couples, Families, & Health

Culturally, Clinically, and Ethically
Competent Practice With Individuals and
Families Dealing With Medical Conditions

Len Sperry1

Abstract
Professionals are increasingly expected to provide services that are clinically, ethically, and culturally competent. Counselors and
other professionals working with individuals and families in counseling as well as consultation contexts, where medical concerns
are a focus, would do well to consider the implications of clinical, ethical, and cultural competence in their work. The article
describes clinical, ethical, and cultural competence—and their components—and illustrates them with case material.

Keywords
clinical sensitivity, clinical competence, ethical sensitivity and competence, cultural sensitivity and competence, family dynamics,
family consultation, medical conditions

Competence is an increasingly common term in professional

parlance these days, irrespective of whether the profession is

law, medicine, management, psychology, or counseling.

Competence is increasingly discussed in the clinical sphere, the

ethical sphere, and particularly, the cultural sphere. Professionals

are increasingly expected to provide services that are clinically,

ethically, and culturally competent. Whether the professional

counselor provides individual, couples, or family, or provides

consultation to individuals, couples, or families, competent

practice is expected. This is particularly indicated when medical

conditions are the focus of counseling or consultation. Accord-

ingly, counselors would do well to consider the implications

of clinical, ethical, and cultural competence in their work.

This article describes these areas of competence—and their

components—and illustrates them with case material. It should

be noted that this article focuses on overall competence and not

specific competencies. For example, developing an effective

case conceptualization or establishing an effective therapeutic

relationship are both specific competencies reflecting overall

clinical competence.

This article begins with descriptions and definitions of clinical,

ethical, and cultural competence, as well as their requisite compo-

nents. Next, it discusses the interrelatedness of the three. Then, a

case example is provided that illustrates clinical, ethical, and cul-

tural competence in counseling and consulting with individuals

and families, particularly when a medical condition is present.

Cultural, Ethical, and Clinical Competence:
Descriptions and Definitions

This section briefly describes and defines clinical, ethical, and

cultural competence. In the process, it distinguishes the

components of each competence: knowledge, awareness, and

sensitivity. A case example illustrates clinical, ethical, and

cultural competence.

Cultural Competence

The components of cultural competence include cultural

knowledge, cultural awareness, and cultural sensitivity.

Briefly, cultural knowledge is acquaintance with facts about

ethnicity, social class, acculturation, religion, gender, and age

(Sue & Sue, 2003). Cultural awareness builds on cultural

knowledge plus the capacity to recognize a cultural problem

or issue in a specific client situation. Cultural sensitivity is an

extension of cultural awareness and involves the capacity to

anticipate likely consequences of a particular cultural problem

or issue and to respond empathically (Sperry, 2010b). Cultural

competence is essentially an extension of cultural sensitivity

(Goh, 2005). It is the capacity to translate the counselor’s

cultural sensitivity into action that results in an effective

therapeutic relationship and treatment process which result in

positive treatment outcomes (Paniagua, 2005). In short, it is the

capacity to provide appropriate and effective action in a given

situation.

1 Department of Counselor Education, Florida Atlantic University, Boca Raton,

FL, USA

Corresponding Author:

Len Sperry, Department of Counselor Education, Florida Atlantic University,

777 Glades Rd., Boca Raton, FL 33431, USA

Email: lsperry@fau.edu

The Family Journal: Counseling and
Therapy for Couples and Families
19(2) 212-216
ª The Author(s) 2011

Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1066480711400560
http://tfj.sagepub.com

http://crossmark.crossref.org/dialog/?doi=10.1177%2F1066480711400560&domain=pdf&date_stamp=2011-02-23

Ethical Competence

The components of ethical competency include ethical

knowledge, ethical awareness, and ethical sensitivity. Briefly,

ethical knowledge is acquaintance with ethical principles,

codes, and guidelines. Ethical awareness builds on ethical

knowledge and the capacity to recognize an ethical consider-

ation or issue in a specific client situation (Sperry, 2007). Ethical

sensitivity is an extension of ethical awareness and involves the

capacity to anticipate likely consequences of a particular ethical

consideration and to respond empathically (Sperry, 2010b).

Ethical competence is essentially an extension of ethical sensi-

tivity. As such, it involves the capacity to provide appropriate

and effective action in a given situation.

As with clinical competence, the ethical competent profes-

sional can anticipate possible scenarios and consequences, and

respond both empathically and in a clinically competent

manner (Rest, 1994). Unfortunately, survey data suggests that

a sizeable percentage of trainees and experienced mental health

professionals fail to exhibit ethical sensitivity, much less high

levels of it (Fleck-Hendersen, 1995). By extrapolation, it could

be concluded that ethical competence is similarly deficient in

these individuals.

Clinical Competence

The components of clinical competence include clinical

knowledge, clinical awareness, and clinical sensitivity. Briefly,

clinical knowledge is acquaintance with the clinical facts of a

medical, psychological, or a relational condition as well as gen-

eral diagnostic and treatment considerations. Clinical aware-

ness builds on clinical knowledge and involves the capacity

to recognize a clinical problem or issue in a specific client

situation. Clinical sensitivity is an extension of clinical aware-

ness and involves the capacity to anticipate likely consequences

of the clinical condition in a specific situation and to respond

empathically. Clinical competence is essentially an extension

of clinical sensitivity. As such, it involves the capacity to pro-

vide appropriate and effective action in a given situation.

Effective professional practice, including counseling prac-

tice, involves much more than clinical knowledge and clinical

awareness; it requires clinical sensitivity and clinical competence.

While clinical knowledge is theory-based and categorized by

clinical signs and symptoms, clinical sensitivity and competence

involves a response to both the signs and symptoms as well as

the human vulnerability manifest in the client experiencing those

signs and symptoms (Nortvedt, 2001).

Consider the following situation. An elderly Asian female

patient had undergone thoracic surgery the day before and had

complained of considerable pain that evening. Upon entering

the patient’s room the next morning, the surgeon is instantly

struck by the uneasiness expressed in the patient’s face and

body. She looks exhausted and uncomfortable with facial

grimaces, but says nothing. Yet, she attempts, with consider-

able difficulty, to bow her head in recognition of the surgeon’s

social status. Before saying anything and before querying her

or doing a brief physical exam, the surgeon is immediately

worried about the patient’s status, particularly the likelihood

of a progressing pneumothorax, that is, a collapsing lung.

Facial expressions spoke volumes. The patient’s expression

of distress and discomfort immediately signals several clinically

relevant questions about the previous surgery and the focus of

the subsequent physical exam that will follow. Empathically,

he responds to the patient’s distress and cultural demeanor by

soft speech and gentle touch of her hand in anticipation that he

might have to quickly reverse the pneumothorax.

In this example, clinical sensitivity is sensitivity regarding

the patient, her illness, and her culture. This sensitivity reflects

clinical knowledge and awareness of the patient’s condition as

well as cultural factors. The clinician’s knowledge about the

patient’s illness and subsequent therapeutic interventions

will be significantly influenced by the realities of a patient’s

condition and situation and the surgeon’s clinical compe-

tence. This is because the patient’s vulnerability, including

her pain, suffering and discomfort, are value-laden. It has

been said that ‘‘sensitivity to the moral realities of a patient’s

clinical condition might reveal important and medically

significant changes in the patient’s clinical condition’’

(Nortvedt, 2001, p. 26).

Table 1 summarizes this discussion with brief definitions of

clinical, ethical, and cultural competence.

Table 1. Clinical, Ethical, and Cultural Competency: Components and Definitions

Components Definitions

Clinical knowledge
Clinical awareness
Clinical sensitivity
Clinical competence

Acquaintance with clinical facts of a condition
Clinical knowledge (þ) recognize it in a specific client situation
Clinical awareness (þ) anticipate consequences and respond appropriately
Clinical sensitivity (þ) take appropriate and effective clinical action

Ethical knowledge
Ethical awareness
Ethical sensitivity
Ethical competence

Acquaintance with ethical principles, codes, and guidelines
Ethical knowledge (þ) recognize it in a specific client situation
Ethical awareness (þ) anticipate consequences and respond appropriately
Ethical sensitivity (þ) take appropriate and effective ethical action

Cultural knowledge
Cultural awareness
Cultural sensitivity
Cultural competence

Acquaintance with facts about ethnicity, acculturation, social class, etc.
Cultural knowledge (þ) recognize it in a specific client situation
Cultural awareness (þ) anticipate consequences and respond appropriately
Cultural sensitivity (þ) take appropriate and effective action

Sperry 213

The Interrelatedness of Clinical, Ethical,
and Cultural Competence

Most research and publications on clinical competence, ethical

competence, and cultural competence considers these three as

separate entities. This section suggests that they are, in fact,

interrelated.

Clinical competence and expertise or mastery is a recent and

important area of counseling practice as well as counseling

research (Jennings, Goh, Skovholt, Hanson, & Banerjee-

Stevens, 2003; Skovholt & Jennings, 2005). Achieving clinical

competency has been described as a process which involves

mastery in the three related domains—cognitive, emotional,

and relational—which are vital to the success or failure of

therapists and counselors (Jennings, Hanson, Skovholt, & Grier,

2005).

Training culturally competent counselors is essential for

effective counseling practice (Sue & Sue, 2003). This senti-

ment is reflected in the recently promulgated standards of the

Council for the Accreditation of Counseling and Related

Educational Programs (CACREP, 2009). A key requirement

is that CACREP accredited programs provide students with

training and knowledge in working with culturally diverse cli-

ents. There is increasing recognition that developing clinical

competency or expertise should occur in the context of striving

for cultural competence. While both clinical and cultural com-

petency have too often been investigated rather independently

of each other, they have been shown to be closely interrelated

(Goh, 2005). An interesting description of the closeness of their

interrelatedness is: ‘‘The presence of multicultural competence

is synonymous with general counseling competence’’ (italics

added, Coleman, 1998, p. 153).

Just as clinical competency is too often considered as

separate from cultural competency, clinical and cultural

competency are too often separated from ethical competency.

But viewed from a larger perspective, culturally competent

counseling can and should occur in the context of ethically

competent practice (Arredondo, 2004). As noted earlier, basic

to ethical competence is the principle that the counselor’s

primary responsibility is to respect diversity and promote the

client’s welfare. This principle serves as a superordinate criter-

ion for all decisions involving cultural and clinical matters.

In short, clinical, cultural, and ethical competence are closely

interrelated and highly effective practice requires that they be

demonstrated simultaneously (Sperry, 2010a).

In short, clinical, ethical, and cultural competencies are

intimately interrelated. Accordingly, competency in one area

without competence in the other two can be problematic.

While clinical competence is a necessary condition for effec-

tive professional practice, it is seldom a sufficient condition.

That is because ethical and cultural competencies are also

necessary conditions. The following example illustrates this

interrelatedness.

An emergency room physician concludes that a blood

transfusion is needed to stabilize a 16-year-old patient injured

in a motorcycle accident who is becoming ‘‘shocky’’ because

of blood loss. The patient, who had been oriented to person,

place, and time, is now drifting in and out of consciousness.

In talking with the patient’s family, the physician learns that

both the patient and family are Christian Scientists. While he

had originally considered seeking the family’s written consent

for a blood transfusion, he anticipates that the family might

object to a blood transfusion on religious grounds. While a

blood transfusion is the gold standard for treatment of shock

caused by blood loss, and the likelihood that it is incompatible

with the patient’s cultural (i.e., religious) beliefs, he proceeds

tentatively. Instead of attempting to ‘‘force’’ the transfusion

which would reflect cultural and ethical incompetence, he tells

the family that while a blood transfusion is the treatment of

choice, there is another option. The family opts for the alterna-

tive treatment strategy which is the administration of a volume

expander (i.e., a blood substitute). This clinical action was

effective and was well received by the family since it was

culturally responsive. In addition to demonstrating cultural

competence, the physician’s clinical action also reflected

clinical and ethical competence.

Implications for Counseling and Consulting
With Individuals and Families

That clinical competence, ethical competence, and cultural

competence are interrelated has implications and applications

in counseling practice, particularly for counseling and consult-

ing with individuals and families, particularly when working

with individuals and families experiencing a medical condition.

Case Example

The following illustration is based on a case example appearing

in a previous issue of The Family Journal (Sperry, 2010c).

A brief summary of the case is followed by a commentary on

the clinical, cultural, and ethical competence demonstrated

by the counselor who consulted on the case.

Juanita H. is a 54-year-old married, first generation Mexican

American female diagnosed with metastatic breast cancer.

Following a mastectomy and removal of lymph nodes, she was

to begin radiation and chemotherapy but this was delayed for

nearly 4 months because of poor wound healing. She had

become increasingly depressed after the surgery, and her hus-

band, who had faithfully accompanied Juanita to all her medi-

cal appointment before her surgery was no longer coming.

Tearfully, Juanita recounted that they had fought almost con-

stantly since the surgery and that ‘‘Jose won’t even touch me

anymore.’’ Juanita’s physician was stymied by his patient’s

worsening condition and could not explain her poor postopera-

tive course of infections and slow wound healing. He also was

not able to appreciate cultural factors nor the marital difficul-

ties. Frustrated, he decided to seek consultation from Serafina

Garcia, PhD, who is licensed as both a mental health counselor

and as a marital and family therapist. She had considerable

experience working with clients wherein cultural factors and

marital issues exacerbated their medical conditions.

214 The Family Journal: Counseling and Therapy for Couples and Families 19(2)

In their initial consultation, Dr Garcia identified Juanita’s

level of acculturation as low, and that her belief that she could

not afford medical treatment was not accurate which presum-

ably delayed the onset of medical treatment allowing the

fast-growing cancer to metastasize. Rather, her illness percep-

tions were operative and ‘‘interfered’’ with effective treatment

outcomes. These illness perceptions included: ‘‘having breast

cancer means you are being punished by God’’ and ‘‘you are

no longer a woman if you lose a breast.’’ She also found that

Juanita had experienced a low level of depression throughout

most of her adult life, but was exacerbated soon after Juanita’s

discovery of the small breast lump.

After the evaluation, Dr Garcia discussed treatment recom-

mendations with Juanita’s physician. She indicated that Juanita

was clinically depressed but was probably not easily identified

by other health professionals accustomed to prototypic DSM-

IV presentations. Instead, Juanita’s experienced primarily

somatic symptoms not uncommon in immigrants from Mexico.

This untreated depression together with untreated marital

conflict most likely accounted for the rapid proliferation of the

cancer and the retarded wound healing. Accordingly, immedi-

ate evaluation for possible antidepressant treatment was

recommended. Also recommended was individual and couples

counseling because marital discord can also retard wound

healing. Dr Garcia offered to provide this treatment to address

depressive and relational issues, both of which appeared to be

culturally influenced.

Case Commentary

Dr Garcia’s consultation resulted in a biopsychosociocultural

formulation that was considerably broader and more clinically

useful than the physician’s biomedical formulation that was

excluded essential cultural and couple and family dynamics.

Without such a comprehensive formulation, it is unlikely that

another counselor–consultant would have achieved the same

degree of clinical, cultural, and ethical sensitivity and compe-

tence as Dr Garcia. In short, this case suggests that a comprehen-

sive case formulation is a prerequisite for a high degree of

clinical, cultural, and ethical sensitivity and competence.

Dr Garcia’s clinical competence is evident in her sensitive

clinical evaluation of Juanita’s medical–psychological status,

illness perceptions, underlying depression, couple and family

dynamics, and the influence of factors interfering with wound

healing. It was not simply clinical knowledge or awareness that

facilitated this expanded diagnostic and clinical formulation.

Rather, it was also Dr Garcia capacity to identify likely conse-

quences and respond with sufficient empathy to achieve an

effective therapeutic alliance so that Juanita could more fully

collaborate in the evaluation.

Dr Garcia was also able to demonstrate cultural competence

by quickly identifying Juanita’s level of acculturation, the cul-

tural presentation of Juanita’s depression, and the cultural

dynamics reflected in her illness perceptions, family dynamics,

and marital discord. In addition, Dr Garcia was able to offer a

culturally sensitive treatment plan and provide culturally

sensitive counseling that was tailored to Juanita’s personal

needs, and cultural and family circumstances.

Furthermore, Dr Garcia was able to demonstrate ethical sen-

sitivity in both respecting Juanita’s ethnicity, acculturation, and

social class but also by promoting her welfare (Principle A.1.a

of the ACA Ethics Code). By providing a consultation—and

also counseling— that was both clinically sensitive and compe-

tent and culturally sensitive and competent, as well as ethically

sensitive, Dr Garcia demonstrated ethical competence.

Concluding Comment

While counseling theory and research typically considers clin-

ical competence, ethical competence, and cultural competence

as separate entities, counseling practice suggests that the three

are intimately related. While there is increasing awareness of

the importance of the theoretical and practical value of these

domains of competence, obstacles persist in more fully imple-

menting this awareness in counseling practice. A main obstacle

is a lack of consensus on terminology with regard to distinc-

tions and definitions. This article offers consistency in the

definitions of clinical, ethical, and cultural competence and

their components: knowledge, awareness, and sensitivity.

These definitions and distinctions have been set forth in hopes

of fostering dialogue which is an essential prerequisite for

achieving consensus on these distinctions and definitions.

Declaration of Conflicting Interests

The author declared no potential conflicts of interests with respect to

the authorship and/or publication of this article.

Financial Disclosure/Funding

The author received no financial support for the research and/or

authorship of this article.

References

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Coleman, H. (1998). General and multicultural counseling compe-

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Council for the Accreditation of Counseling and Related Educational

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Fleck-Hendersen, A. (1995). Ethical sensitivity: A theoretical and

empirical study. Dissertation Abstracts International, 56, 2862B.

Goh, M. (2005). Cultural competence and master therapists: An inextric-

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Sperry 215

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216 The Family Journal: Counseling and Therapy for Couples and Families 19(2)

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Couples, Families, & Health

Culture, Personality, Health, and
Family Dynamics: Cultural Competence
in the Selection of Culturally Sensitive
Treatments

Len Sperry1

Abstract
Cultural sensitivity and cultural competence in the selection of culturally sensitive treatments is a requisite for effective counseling
practice in working with diverse clients and their families, particularly when clients present with health issues or medical
problems. Described here is a strategy for selecting culturally sensitive treatments (cultural interventions, culturally sensitive
interventions, or culturally sensitive therapy) based on a comprehensive assessment of cultural factors, personality dynamics,
family dynamics, and health or medical conditions. A case example is provided that illustrates this strategy.

Keywords
acculturation, cultural sensitivity, cultural competency, cultural interventions, culturally sensitive interventions, culturally sensitive
therapy

Although most clinicians report that cultural sensitivity and

culturally sensitive treatments are important in providing cultu-

rally competent care to clients, couples, and families, very few

clinicians report that they actually provide culturally sensitive

treatment (Hansen et al., 2006). Arguably, there are various

reasons for this, but a likely explanation is that few clinicians

have had adequate training and experience with culturally sen-

sitive treatment. Such training would include assessment of

such factors as cultural identity, level of acculturation, family

dynamics, and ‘‘explanatory models,’’ indications for the use

of various types of culturally sensitive treatment, and a method

of selecting if, when, and how to use such treatments. The value

of such training and experience is particularly evident when cli-

ents present with health issues or medical conditions (Sperry,

2006). This article addresses these factors and provides a clini-

cally useful strategy for selecting such treatments. It begins by

briefly distinguishing cultural intervention, culturally sensitive

therapy, and culturally sensitive intervention. Then, it provides

a strategy—in the form of guidelines—for making such deci-

sions. A case example illustrates the use of this strategy.

From Cultural Sensitivity to Cultural
Competence

Although training programs today seem to be effective in pro-

moting cultural sensitivity, that is, awareness of how cultural

variables may affect the treatment process, they do seem to

be as effective in promoting cultural competency, that is, the

capacity to translate cultural sensitivity into action that results

in effective treatment. This is the consensus among most of the

clinicians and supervisors I have spoken with recently as well

as the conclusion of a recent large-scale survey of practicing

clinicians (Hansen et al., 2006).

Becoming culturally competent involves such essential

skills as the accurate assessment of cultural identity, level of

acculturation, family dynamics, explanatory model, and per-

sonality dynamics as they influence a client’s presenting prob-

lem and the identification and selection of the best ‘‘fit’’ type of

culturally sensitive treatment. Selecting appropriate culturally

sensitive treatment presupposes the clinician has accurately

assessed cultural identity and level of acculturation. Cultural

identity refers to an individual’s self-identification and sense

of belonging to a particular culture or place of origin, while

acculturation is the process and degree to which a client inte-

grates new cultural patterns into his or her original cultural pat-

terns (Paniagua, 2005). Level of acculturation can be

determined based on the client’s language, generation, and

social activities, as these factors are assessed by instruments

such as the Brief Acculturation Scale (Burnam, Hough, Karno,

1 Florida Atlantic University, Boca Raton, FL, USA

Corresponding Author:

Len Sperry, Florida Atlantic University, 659 N.W. 38th Circle, Boca Raton, FL

33431, USA

Email: lsperry@fau.edu

The Family Journal: Counseling and
Therapy for Couples and Families
18(3)

316

320

ª 2010 SAGE Publications
DOI: 10.1177/1066480710372129
http://tfj.sagepub.com

316

Escobar, & Telles, 1987). It also presupposes the clinician can

accurately assess personality and relevant family dynamics.

Because family conflicts and marital discord can arise from dif-

ferent levels of acculturation among family members and

spouses leading to anxiety, depression, and noncompliance

with medical regimens, it is essential that the clinician identify

‘‘discrepancies in levels of acculturation among family mem-

bers and clients’ perceptions of ‘elevated levels of acculturative

stress’’’ (Paniagua, 2005, pp. 170, 171). Eliciting a client’s

explanatory model, that is, the personal explanation of the

cause of his or her problems, symptoms, and impaired function-

ing is essential in working with any client who presents with a

health issue or medical condition, and particularly those with

lower levels of acculturation (Sperry, 2006). Related to expla-

natory model is the concept of ‘‘illness perceptions’’ that are a

client’s belief about his or her illness in terms of its identity or

diagnostic label, its cause, its effects, its time line, and the con-

trol of symptoms and recovery from it (Sperry, 2009). Often,

such client explanations and illness perceptions reflect key cul-

tural values, beliefs, sanctions, and taboos that if not heeded

can interfere with the treatment process and outcomes.

Types of Culturally Sensitive Treatments

Based on a comprehensive assessment of the factors and

dynamics affecting the client’s presenting problem, the clini-

cian may select a conventional or a culturally sensitive treat-

ment. This section briefly describes three types of culturally

sensitive treatment

(Sperry, 2010).

Cultural Intervention

A cultural intervention is a healing method or activity that is

consistent with the client’s belief system regarding healing and

has the potential to effect a specified change. Some examples

are healing circles, prayer or exorcism, and involvement of tra-

ditional healers from that client’s culture. Sometimes, the use

of cultural interventions requires collaboration with or referral

to such a healer or other experts (Paniagua, 2005). Still, a clin-

ician can begin the treatment process by focusing on core cul-

tural value, such as respito and personalismo, in an effort to

increase clinician’s achieved credibility, that is, the cultural cli-

ent’s perception that the clinician is trustworthy and effective.

Culturally Sensitive Therapy

Culturally sensitive therapy is a psychotherapeutic intervention

that directly addresses the cultural characteristics of diverse cli-

ents, that is, beliefs, customs, attitudes, and their socioeco-

nomic and historical context. Because they use traditional

healing methods and pathways, such approaches are appealing

to certain clients. For example, cuento therapy addresses cultu-

rally relevant variables such as familismo and personalismo

through the use of folk tales (cuentos) and is used with Puerto

Rican children. Likewise, Morita therapy that originated in

Japan and is now used throughout the world for a wide range

of disorders ranging from shyness to schizophrenia. These

kinds of therapy appears to particularly effective in clients with

lower levels of acculturation.

Culturally Sensitive Intervention

A culturally sensitive intervention is a Western psychothera-

peutic intervention that has been adapted or modified to be

responsive to the cultural characteristics of a particular client.

Largely because of their structured and educational focus,

diverse clients seem to find cognitive behavior therapy (CBT)

interventions acceptable and are the most often modified to be

culturally sensitive (Hays & Iwamasa, 2006). For example,

particularly in culturally diverse clients with lower levels of

acculturation, disputation, and cognitive restructuring of a

maladaptive belief are seldom the CBT intervention of choice,

whereas problem solving, skills training, or cognitive replace-

ment interventions (Sperry, 2010) may be more appropriate.

Strategy for Selecting a Culturally Sensitive
Treatment

Here is a strategy for selecting culturally sensitive treatment

when indicated. This strategy includes seven specific guide-

lines and is particularly valuable when health issues or medical

conditions are present.

1. Elicit or identify the client’s cultural identity, level of

acculturation, explanatory model, that is, belief about the

cause of their illness (e.g., bad luck, spirits, virus or germ,

heredity, early traumatic experiences, chemical imbalance

in brain, etc.) and treatment expectations. In addition, elicit

the client’s personality dynamics, particularly as they

influence the treatment process.

2. Identify family dynamics and the level of acculturation of

family members who have direct influence on the client. In

addition, elicit their explanatory models of the client’s

health or medical problem and their own expectations for

treatment. Then, estimate the difference, if any, between

the client and family members on these parameters, and its

actual or potential effect on the client’s response to

treatment.

3. Develop a cultural formulation framing the client’s pre-

senting problems within the context of the overall family’s

cultural identity, acculturation levels, explanatory models,

treatment expectations, and the interplay of culture and the

client’s personality dynamics.

4. If a client identifies (cultural identity) primarily with the

mainstream culture and has a high level of acculturation

and there is no obvious indication of prejudice, racism,

or related bias, consider conventional interventions as the

primary treatment method. However, the clinician should

be aware that a culturally sensitive treatment may also

be indicated as the treatment process develops.

5. If a client identifies largely with the mainstream culture

and has a high level of acculturation and there is an

Sperry

317

317

indication of prejudice, racism, or related bias, consider

culturally sensitive interventions or cultural interventions

for cultural aspect of the client’s concern. In addition, it

may be useful to utilize conventional interventions for

related noncultural concerns, that is, personality dynamics.

6. If a client identifies largely with their ethnic background

and level of acculturation is low, consider cultural inter-

ventions or culturally sensitive therapy. This may necessi-

tate collaboration with or referral to an expert and/or an

initial discussion of core cultural values.

7. If a client’s cultural identity is mainstream and accultura-

tion level is high, but that of their family is low, such that

the presenting concern is largely a matter cultural discre-

pancy, consider a cultural intervention with the client and

the family. However, if there is an imminent crisis situa-

tion, consider conventional interventions to reduce the cri-

sis. After it is reduced or eliminated, consider introducing

cultural interventions or culturally sensitive therapy

(Sperry, 2010).

Case Illustration: Strategy for Selecting
Culturally Sensitive Treatment

Marques is a 23-year-old single, first generation unmarried

Haitian American male. He presented at mental health clinic

with complaints of sadness and was evaluated by a licensed

mental health counselor who was a middle-aged Caucasian

male. His mood was depressed and he admitted experiencing

increased social isolation, low energy, and hypersomnia, that

is, sleeping 10–12 hr per night. Marques also noted that he was

also having difficulty dealing with a ‘‘tough situation.’’ He pre-

sented as shy and passive while his mood was sad with con-

stricted affect. He is the oldest of three siblings and lives

with his mother and younger sister in a predominantly Haitian

community since migrating from Haiti.

The counselor elicited his explanatory model and health

beliefs. Marques believed that his depression was primarily due

to distress and disappointment about law school, having with-

drawn at the semester break of his first year despite having a

full scholarship. He was tearful in describing his exclusion

from a study group and the complaints of White students that

minorities were admitted only because of affirmative action.

This was particularly troubling to Marques because he had

high

law school admission tests (LSATs) and a 3.9 grade point aver-

age (GPA) in his undergraduate studies. He believed he could

not return to school because of fear of reexperiencing racism.

Marques disclosed that when he was in sixth grade, he was hit

in the head with a rock during a confrontation between White

and Haitian student; and afterward avoided all confrontations.

Accordingly, the counselor was not surprised that he had

refused to confront the law school situation and instead quietly

withdrew. His treatment expectations were to ‘‘get rid of the

sadness’’ and to be less troubled by criticism of others and to

better face ‘‘tough situation.’’ Marques identified himself as a

‘‘middle-class American of Haitian heritage’’ and demon-

strated a high level of acculturation. After securing his written

consent, the clinician interviewed Marques’s mother and his

younger sister. They likewise exhibited high levels of accul-

turation and also believed that Marques’s depression stemmed

from his withdrawal from law school. His mother shook her

head and said that while Haitian men tend to be less dominant

than Haitian women, she ‘‘couldn’t understand why he’s so shy

and passive, especially when wronged by others. He’s been this

way since he was a kid.’’ This description seems consistent

with the dynamics of the avoidant

personality.

To complete this initial evaluation, the counselor arranged

for a routine medical consultation of Marques because it had

been nearly 2 years since he had completed an annual medical

checkup. The results of that evaluation were positive for a diag-

nosis of hypothyroidism. The physician conjectured that

Marques’s thyroid had been underfunctioning for a year or

more and was hopeful this chronic medical condition could

be controlled by Synthroid that he agreed to take as prescribed.

Because low energy and depression are common symptoms of

hypothyroidism, the counselor evaluated Marques’s symptoms

over the next 4 weeks. By then, lab tests indicated that his

thyroid levels were in the normal range. However, while he had

returned to his previous energy level, he continued to experi-

ence sad feelings and was still socially isolated.

In terms of a clinical and cultural formulation, his depres-

sive symptoms and social isolation appeared to be triggered

and exacerbated by his experience with racism leading to his

withdrawal from school. Prominent was his avoidant behavior

that seemed to be exacerbated by both his avoidant personality

as well as cultural beliefs that appeared to be operative in his

response to Caucasian law students.

Figure 1 visually depicts the relative impact of cultural

dynamics, personality dynamics, and medical condition on

Marques, as he presented for counseling. Note that personality

dynamics were rated as high while cultural dynamics were

rated as midrange and as such were considered contributory

to His initial presentation. In contrast, family dynamics was

rated as low and considered noncontributory. His medical con-

dition was contributory but to a lesser extent than culture or

personality.

Based on this evaluation, a treatment plan was developed in

which both conventional and culturally sensitive treatments

were included. This mutually agreed up treatment plan

involved four treatment targets. The first was depressive symp-

toms that would be addressed with CBT and continuation of

thyroid medication. The medical consultant doubted that an

antidepressant was indicated but left that option open to recon-

sideration at the judgment of the counselor. The second target

was his avoidant personality style and behaviors that were cul-

turally influenced for which a ‘‘culturally sensitive interven-

tion’’ would be directed at dealing more effectively with

‘‘tough situations’’ such as prejudice and racism. The clinic’s

Haitian male therapist would be involved with this treatment

target as well as the third target in which he would serve as a

co-therapist with Marques’ Caucasian counselor in group

therapy. This third target involved the personality component

of Marques’ avoidant personality style for which conflict

318

The Family Journal: Counseling and Therapy for Couples and Families 18(3)

318

resolution and assertive communication skills training would

be a central part of the group work. The fourth target involved

career exploration including the possibility of reinstatement in

law school. His therapist would consult with and involve the

school’s minority affairs director, who was an African Ameri-

can male.

Case Commentary

As a result of the assessment and cultural formulation, it was

determined that Marques would be best treated with conven-

tional interventions aimed at personality dynamics and a ‘‘cul-

turally sensitive intervention’’ aimed at cultural dynamics.

However, had Marques’ explanatory model of depression and

his treatment expectations been more culture based, and his

personality dynamics less dominant, consideration would have

been given to a ‘‘cultural intervention.’’ Similarly, if there was

a discrepancy on acculturation levels between Marques and his

mother and younger sister and/or interfering family dynamics

were operative, cultural interventions and family interventions

might have played a more prominent role in the treatment plan.

Concluding Note

A case was made for the importance of counselors and other

mental health providers to become more culturally sensitive

and culturally competent with regard to determining the need

for and selection of culturally sensitive treatment when indi-

cated. Using the selection strategy described and illustrated

in this article is quite demanding, particularly when the client

presentation involves chronic medical condition and family

dynamics. Among other things, it requires the acquisition of

a number of skill sets and competencies including the assess-

ment of cultural identity, level of acculturation, explanatory

model and illness perceptions, cultural formulation, as well

as assessment of family dynamics, and medical and psycholo-

gical symptoms. Nevertheless, this strategy has the potential to

increase cultural sensitivity and foster cultural competence in

mental health providers.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interests with respect

to the authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research and/or

authorship of this article.

References

Burnam, M., Hough, R., Karno, M., Escobar, J., & Telles, C. (1987).

Acculturation and lifetime prevalence of psychiatric disorders

among Mexican Americans in Los Angeles. Journal of Health and

Social Behavior, 278, 89-102.

Influence of cultural dynamics

low high

< >

Influence of personality dynamics

low high

< >

Influence of family dynamics

low high

high

< >

Influence of health factors

low

< >

X

X

X

X

Figure 1. Influence of cultural dynamics, personality dynamics, family dynamics, and health factors on presenting problem in the case of
Marques.

Sperry

319

319

Hansen, D., Randazzo, K., Schwartz, A., Marshall, M., Dalis, D.,

Frazier, R., . . . Norvig, G. (2006). Do we practice what we preach?

An exploratory survey of multicultural psychotherapy competen-

cies. Professional Psychology: Research and Practice, 37, 66-74.

Hays, P., & Iwamasa, G. (2006). Culturally responsive

cognitive-behavioral therapy: Assessment, practice, and supervi-

sion. Washington,

DC: American Psychological Association Books.

Paniagua, F. (2005). Assessing and treating cultural diverse clients: A

practical guide. Thousand Oaks, CA: SAGE.

Sperry, L. (2006). Psychological treatment of chronic illness: The

biopsychosocial therapy approach. Washington, DC: American

Psychological Association.

Sperry, L. (2009). Treating chronic medical conditions: Cognitive

behavioral strategies and integrative protocols. Washington,

DC: American Psychological Association Books.

Sperry, L. (2010). Highly effective therapy: Developing essential

clinical competencies in counseling and psychotherapy. New

York, NY: Routledge.

320 The Family Journal: Counseling and Therapy for Couples and Families 18(3)

320

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© The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Refugees’ advice to physicians: how to ask about
mental health
Patricia J Shannona,b,*
aSchool of Social Work, University of Minnesota and bThe Center for Victims of Torture, St. Paul, MN, USA.

*Correspondence to Patricia J Shannon, School of Social Work, University of Minnesota, 1404 Gortner Avenue, St. Paul, MN 55108,
USA; E-mail: pshannon@umn.edu

Received November 27 2013; revised March 23 2014; Accepted March 24 2014.

Abstract

Background. About 45.2 million people were displaced from their homes in 2012 due to persecu-
tion, political conflict, generalized violence and human rights violations. Refugees who endure
violence are at increased risk of developing chronic psychiatric disorders such as posttraumatic
stress disorder and major depression. The primary care visit may be the first opportunity to
detect the devastating psychological effects of trauma. Physicians and refugees have identified
communication barriers that inhibit discussions about mental health.
Objectives. In this study, refugees offer advice to physicians about how to assess the mental
health effects of trauma.
Methods. Ethnocultural methodology informed 13 focus groups with 111 refugees from Burma,
Bhutan, Somali and Ethiopia. Refugees responded to questions concerning how physicians should
ask about mental health in acceptable ways. Focus groups were recorded, transcribed and ana-
lyzed using thematic categorization informed by Spradley’s Developmental Research Sequence.
Results. Refugees recommended that physicians should take the time to make refugees com-
fortable, initiate direct conversations about mental health, inquire about the historical context of
symptoms and provide psychoeducation about mental health and healing.
Conclusions. Physicians may require specialized training to learn how to initiate conversations
about mental health and provide direct education and appropriate mental health referrals in a
brief medical appointment. To assist with making appropriate referrals, physicians may also ben-
efit from education about evidence-based practices for treating symptoms of refugee trauma.

Key words: Culture and disease/cross-cultural health issues, doctor-patient relationship, immigrant health, mental health,
primary care, trauma.

Introduction

There were 45.2 million people displaced from their homes in
2012 due to persecution, political conflict, generalized violence
and human rights violations (1). The largest groups of refugees
resettled to the USA were fleeing political wars and conflicts in
Burma, Bhutan, Iraq and Somalia (2). Refugees presenting in
family practice clinics may be struggling with significant physi-
cal and mental health symptoms of war trauma and torture (3).
The initial primary care visit is often the first opportunity for
physicians to address the devastating effects of such traumatic

experiences. However, several barriers to communication have
been identified by physicians and refugees that may inhibit dis-
cussions about the effects of war trauma and torture (4,5). In
this study, refugees describe culturally acceptable processes for
assessing the mental health effects of trauma.

Historical estimates indicate that up to 35% of refugees are
torture survivors (6). Recent studies indicate much higher tor-
ture prevalence rates for Iraqis (56%) (7), Somalis (36%) (8),
Oromos (55%) (8) and Karen (30%) (9). Non-tortured refugees

462

Family Practice, 2014, Vol. 31, No. 4, 462–466
doi:10.1093/fampra/cmu017
Advance Access publication 12 May 2014

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Refugees’ advice to physicians 463

are exposed to trauma at even higher rates with whole popula-
tions facing political oppression, forced displacement, war, deten-
tion, forced labour and violence in camps (10). Refugee trauma
survivors may present with physical symptoms of chronic pain,
traumatic brain injury, headaches, abdominal pains, sleep diffi-
culties, burns and injuries to eyes, ears, mouth and feet (3,11,12).
In their meta-analysis of 181 surveys with refugees, Steel et al.
(13) reported prevalence rates of 30.6% for post-traumatic stress
disorder and 30.8% for depression. Untreated mental health dis-
tress can be debilitating and lead to long-term illnesses includ-
ing hypertension, coronary vascular disease, metabolic syndrome
and diabetes mellitus (3,7). It is crucial that family physicians be
aware of refugees in their practices, their exposure to trauma,
and provide assessment of physical and mental health symptoms.

Physicians, refugees and researchers have identified several
barriers to communication about the symptoms of trauma.
Physicians have described feeling uncomfortable asking refugees
about their trauma histories, experiencing greater communica-
tion difficulties when interpreters are needed, and lacking time
and culturally appropriate tools to initiate sensitive conversa-
tions (14,15). Physicians have further identified a reluctance
to discuss mental health with refugees due to system barriers
to obtaining mental health care (15). Refugees have identified
a lack of understanding of mental health conditions, mental
health stigma, a reluctance to initiate conversations about men-
tal health and cultural barriers to accessing mental health care
(4,5). Barriers to receiving care that have been identified through
research include the lack of interpreters in mental health clinics,
cultural differences in understanding mental health, lack of reli-
able transportation and difficulty navigating complex systems
of care (16).

Primary care physicians who work with refugees successfully
have described what is required to help refugees discuss past
trauma and obtain the necessary care to begin healing. Crosby
(3) asserted that refugees should be given an opportunity to tell
their stories in a way that is comfortable and that physicians
need to understand the full trauma story and its cultural and per-
sonal significance to provide an accurate diagnosis. Physicians
who assess torture survivors have also recommended asking
survivors directly about their past experiences of torture (12).

In this study, refugees describe how physicians can ask about the
psychological symptoms of torture and war trauma.

Methods

These data are part of a larger data set gathered to develop cul-
turally grounded mental health screening processes for refugees.
We used ethnocultural methods to conduct 13 focus groups with
111 total participants from four refugee groups between 2009
and 2011 (17). Table 1 reports brief demographic characteris-
tics. Participants were recruited through cultural leaders who
recognized the importance of the study. Following their guid-
ance, the research team conducted interviews with separate
groups for men and women in the Somali and Oromo com-
munities and mixed-gender groups in the Karen and Bhutanese
communities. We conducted separate mixed-gender young adult
groups for participants between 18 and 25, who preferred to be
interviewed separate from their elders.

This study was granted exempt status by the university insti-
tutional review board due to the community-based nature of the
interviews. However, each participant completed an informed
consent and received a $10 gift card. Focus groups lasted 2
hours and participants responded to questions concerning how
they describe their problems, thoughts and feelings related to
war and conflict and what are culturally acceptable ways to
talk about these problems? Focus group interviews were con-
ducted by myself and a faculty co-investigator through trained
interpreters. Both faculty researchers have extensive experience
working with refugee trauma survivors. Interviews were audio-
recorded and transcribed by a member of the research team,
which included two graduate assistants with refugee experience.
We hired trained interpreters from health care organizations and
provided additional training on the goals of the study, interpre-
tation process and follow-up debriefing.

The data analysis procedure was informed by Spradley’s
Developmental Research Sequence as a method for discovering
refugees’ emic perspective on mental health (18). We explored
taxonomies among and within domains, categories, themes
and subthemes. Coding was conducted by a team composed
of two co-investigators and four graduate assistants. Analysis

Table 1. Characteristics of focus group participants

Refugee group Gender Age Years in USA

Male Female Mean Standard deviation Mean Standard deviation

Bhutanese 20 14 37.2 17.3 1 0
Karen 11 12 38.3 14.9 2.17 2.0
Oromo 17 10 45.5 20.6 8.7 4.4
Somali 14 13 45.9 23.4 6.8 5
Total 62 49

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Family Practice, 2014, Vol. 31, No. 4464

began immediately with transcription of the first focus group
and proceeded with ongoing reading of transcripts, developing
a list of codes, coding the data and meeting as a research team
to review and reconcile emerging data. Cultural leaders were
consulted for extensive peer debriefing of emerging domains and
the interpretation of the data. To enhance trustworthiness of the
data, credibility, transferability, dependability and confirmabil-
ity were systematically tracked (19). Data trustworthiness was
established through regular consultation with cultural leaders
throughout the research and analysis process.

Results

Findings reported in this study describe a domain labelled,
‘Recommendations for Assessing Mental Health’. There were
seven categories describing recommendations for how physicians
should ask refugees about the mental health effects of trauma: (i)
make refugees comfortable, (ii) ask about the historical context of
symptoms, (iii) ask direct questions about mental health distress,
(iv) provide psychoeducation, (v) provide trained interpreters, (vi)
interview some family members separately and (vii) use family
as an ally. The first four categories were endorsed by all refugee
groups. The last three were suggested by only a few refugee com-
munities. Figure 1 provides a summary of these key points. Quotes
identify participant number with ‘P’ and group number with ‘G’

Make refugees comfortable

Refugees from all four cultural groups emphasized that physi-
cians should take the time to make refugees feel comfortable.
Doctors need to show refugees that they care. They need time
to ask questions and refugees need time to speak about the pain
they are suffering. Oromo refugees said, ‘Don’t cut us short,
let us speak’ (P1, G1). Providers need to work to build trust.
Oromo youth suggested that providers take time to establish an
ongoing relationship with refugees. Bhutanese refugees stated
that physicians could make refugees comfortable by asking
about their lives back home. Somali refugees stated, ‘Doctors
should be open and friendly and joke with them. If the doctor
is not friendly and he is an uptight person, the refugee will not
feel comfortable to talk to him’ (P3, G4). They complained that
short appointment times, changing interpreters and multiple
providers contributed to lack of trust in physicians.

Ask about the historical context of symptoms

Refugees want physicians to be interested in discussing the
political and historical contexts of their symptoms. Oromo
men stated, ‘Don’t just focus on pain. There are histories that
are causing pain’ (P7, G4), ‘Connect pain to our problems back
home’ (P1, G1) and ‘freedom back home, the political issues is
one of the causes of depression’ (P2, G1). Oromo youth asserted
that it is politically important for physicians to recognize their
identity as Oromos instead of Ethiopians. Somali refugees stated,
‘Instead of saying. how is your mental state, if you could ask
about the historical background and what they went through
and then say how are you feeling right now?’ (P4, G2).

Karen refugees explained their symptoms as being caused
by political conflict including war, traumatic loss, displacement
and violence in camps. They recommend getting political history
from family members in the initial medical screening if necessary
for understanding the symptoms of patients. Bhutanese refugees
asserted that physicians should ask about traumatic histories at
the first appointment. They said, ‘Our people will not lie, they
will tell you the name of the prison they were in and everything.
They will tell you how their children were killed’ (P2, G7).

Ask direct questions about mental health

Refugees uniformly stated that they will not discuss mental health
unless the doctor asks directly. Deference to the physician’s author-
ity was common across all cultural groups. Oromo women asserted
that doctors should ask directly about ‘worrying too much’. They
explained, ‘We’re used to worrying to ourselves. Day and night
we are worrying and there is no place to go to get relief from our
worry and our thinking’ (P7, G9) and ‘We are always thinking
about those who are there. The problem is thinking about, worry-
ing about them’. (P2, G9) Bhutanese stated, ‘If you don’t ask, I’m
not going to answer’ (P6, G7). They explained that if the doctor
leads the question, ‘they will be able to say but spontaneously, it
will be difficult to say’ (P8, G8). They recommended physicians
ask very direct questions, ‘What kind of life did you have in the
refugee camp? Were you beaten? We will definitely tell’ (P1, G7).
They added that the first medical screening appointment is the best
time to ask. Bhutanese youth suggested that physicians ask youth
direct questions about their current fears. They suggested asking,
‘Do you remember any events in the past that have affected you?’
and ‘Do you still have fear from the past?’ (P8, G10).

Karen refugees stated that if they are asked about the impact
of war at a medical screening, they will answer but they tend not
to complain. One Karen man said, ‘If the doctor asks something
about pain, they will answer. But if the doctor doesn’t ask about
sleep, we won’t answer that question. So you need to ask specific
questions’ (P1, G6). Karen youth stated that children should also be
asked direct questions such as ‘What problems did you have living
in the camp?’ (P1, G12). Somali refugees stated that if doctors ask

• Make refugees comfortable
• Initiate direct questions about mental health in

historical context
• Provide psychoeducation
• Use trained interpreters
• Use family as ally
• Interview some children separately

Figure 1. Key advice for interviewing refugees.

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Refugees’ advice to physicians 465

in the middle of the consultation, refugees might be most likely to
tell you about their suffering. Somali’s stated that it is okay to ask
direct questions about mental health or drug and alcohol use; how-
ever, they suggest that doctors gain experience knowing how to ask
mental health questions. It may be most helpful if a mental health
professional works alongside the primary care doctor. Somali
youth stated that it is okay to ask direct questions about mental
health as most Somalis will tell you what is wrong; however, they
emphasized that elders need to be questioned in respectful ways.

Provide psychoeducation about mental health

Karen stated that it is important for physicians to provide edu-
cation about mental health and common effects of war because
Karen will take advice from educated people even more than
their parents or family. Somali youth emphasized the impor-
tance of normalizing symptoms, making Somalis feel comfort-
able to talk and explaining that there is a cure for the problems.
Otherwise, Somalis will not talk. They state that Somalis don’t
know what stress is, so there should be a lot of classes or educa-
tion. One Somali refugee recommended explaining the symp-
toms of trauma before asking the questions,

You have to show them it’s curable otherwise they won’t tell.
There’s no point of them telling you something personal if it
can’t be cured. And I think a way to approach this would be
you saying the symptoms without telling them, ‘ hey you have
this’ and let them tell you ‘ these are the same symptoms I’ve
experienced’. (P10, G11)

Oromo youth stated that it is important to let people know that
it is okay to talk and Bhutanese youth stated that they would
definitely go to talk with a counsellor if the doctor referred them.

Provide trained interpreters

Oromo youth stated that refugees need someone who speaks
the language and understands the culture. They explained that
it takes time to build a relationship and get comfortable with
interpreters and doctors. Interpreters also need to be regular.
One Oromo youth stated, ‘Just because you have an inter-
preter doesn’t mean you are going to tell everything. It should
be someone who you will see regularly instead of going from
clinic to different clinic’ (P8, G13). Oromo discussed their diffi-
culty describing symptoms through interpreters. Sometimes they
don’t use the correct word or even speak the same dialect.

Interview some family members separately

Bhutanese youth stated that doctors should ask parents about
children’s mental health difficulties because they will know
them best; however, teenagers should be interviewed separately.
Karen refugees discussed the existence of domestic violence in

their community and recommended that children be interviewed
separately. They stated that some children will be very afraid to
report domestic violence honestly because they fear either being
beaten at home or that the police will take their parents away.
Educating families is seen as one way to help break this pattern.
Somali youth believe that children will not talk in front of their
parents so they should be interviewed separately.

Use the family as an ally

Bhutanese refugees stated that convincing the family can be
helpful when trying to engage refugees in mental health care.
First they will seek out help through prayer or a Shaman, but if
you can convince the family that mental health care is needed,
the family will convince the patient. Somali refugees stated that
it can be important to have a family member there when inter-
viewing someone with mental health symptoms. Sometimes it
may be better for the family to speak for the patient. Somalis
in general suggested that it may be easier to trust the process if
someone from their own cultural background is there helping to
ask the questions.

Discussion

Refugees offer several concrete tips about how physicians can
inquire about mental health in the context of a primary care
visit. They also express frustration that there is often not enough
time to have meaningful discussions about mental health with
physicians who appear too busy. Refugees requested that phy-
sicians take the time to make them comfortable, initiate con-
versations about mental health and ask direct questions in the
context of their histories, utilize trained interpreters, and pro-
vide psychoeducation about normal responses to trauma as well
as available treatments. Although physicians may be hesitant
to ask refugees about their trauma histories, refugees state that
they are interested to discuss mental health symptoms resulting
from traumatic histories; however, they assert that the physician
needs to ask first. These findings are consistent with previous
research with Liberian refugees who also indicated their willing-
ness to talk about the impact of war to benefit their health (5).
Liberians also stated that physicians need to ask about men-
tal health before they will discuss it. Refugees tend to defer to
authority figures and will not address issues that are not initiated
by the physician. Physicians may require specialized training to
learn how to initiate conversations about trauma and provide
direct education and appropriate mental health referrals in a
brief medical appointment. To assist with making appropriate
referrals, physicians may also benefit from education about evi-
dence-based practices for treating symptoms of refugee trauma.

Because stigma has been cited as a barrier to refugees receiv-
ing mental health services, physicians have a great opportunity

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Family Practice, 2014, Vol. 31, No. 4466

in the primary care visit to provide education that de-stigma-
tizes both the symptoms of war trauma and the mental health
services needed to heal. Refugees may be relieved to know
that symptoms of posttraumatic stress disorder and major
depression are common and treatable responses to trauma.
For torture survivors, recognizing the dehumanizing and vio-
lating nature of torture can be empowering and healing. The
primary care visit may be the first time their stories are told
and believed. Contrary to the popular belief that exploring
traumatic histories may be re-traumatizing, the refugees in
this study asserted that they want the historical causes of their
symptoms acknowledged.

These findings are limited by the focus group nature of the
interviews. It is possible that in-depth interviews would provide
a more complete understanding of what may be helpful to refu-
gees in conversation with physicians. It would also be helpful
to better understand communication challenges from the per-
spective of physicians. Despite these limitations, refugees clearly
indicate that they welcome more direct conversations with phy-
sicians about their histories and symptoms of trauma.

Declaration
Funding: Blue Cross and Blue Shield Foundation of Minnesota.
Ethical approval: Institutional review board of the University of Minnesota.
Conflict of interest: none.

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