Cultural Competency
Cross Cultural Issues and
Trauma
Definition of a traumatic event
A traumatic event is any event or
events, which overwhelms our core
capacity to cope.
 It results in an experience of personal
threat to our safety and/or the integrity
of our identity.
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Complex Trauma
Multiple and/or chronic exposure to
developmentally adverse interpersonal
victimization
 physical, sexual and emotional abuse
and neglect
 domestic and community violence
 War
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What Constitutes Cultural Diversity?
Is Vermont Diverse?
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Diversity
Racial
 Ethnic
 Religious
 Immigrant/refugee status
 Sexual orientation
 Living in rural areas
 Disabled youth
 Socio-economic status
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Vermont Diversity
Demographics
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95.3% of Vermont population is Caucasian
 11% of Burlington population is non-white
 30% of public school children in Burlington
are non-white
 28
languages are spoken
Socio-Economic Factors
Income/poverty
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11.1% of Vermont population lives below
poverty
13% nationally
Caucasian: 13%
 Black : 27.4%
 Hispanic: 26%
 Under 18 : 22%
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US Census, 2010
Cultural Competency
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Organizations and personnel have values and
principles and demonstrate behaviors, attitudes,
policies that enable them to work effectively cross
culturally.
Have the capacity to:
Value diversity
 Conduct self-assessment
 Manage the dynamics of difference
 Acquire and institutionalize cultural knowledge
 Adapt to diversity and the cultural contexts of the
communities they serve
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Linguistic Competency
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Capacity of an organization and its personnel to
communicate effectively to persons from diverse
populations including:
Limited English proficiency
Low literacy skills
 Individuals with disabilities
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Organizational , Cultural, and Linguistic Competence, NCTSN
Linguistically Competent Trauma
Informed Services
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Bilingual/bicultural staff
Cross culture communication approaches
Cultural Brokers
Interpreter services
Sign language services
Print materials in applicable languages
In alternate formats (i.e. Braille, audio)
 Easy to read, picture and symbol formats
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Rates of Exposure Relative to Diverse
Backgrounds
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African American adolescents six times more likely
to be murdered than white adolescents.
Victimization is higher for people from lower
socio-economic backgrounds and urban
communities
90% of elementary school children in New
Orleans witnessed severe violence
Chicago survey found that 75% of 10-19 yr olds
had witnessed a shooting or stabbing
(Raia, J.A., Ph.D, Clinical Quarterly, Nat'l Ctr for PTSD, Fall, 1999)
Rates of Exposure Relative to
Diverse Backgrounds
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Racial incidents can be traumatic and have been
linked to PTSD among people of color
Communities of color can have higher rates of
PTSD than the general population
LGBTQ individuals experience victimization
and PTSD at higher rates than the general
population
(source: Leading Change: A plan for SAMHSA’s Roles and Actions)
Trauma and Homelessness
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An estimated 1 -1.6 million youth are homeless
(National Alliance to End Homelessness, 2006)
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Racial and Ethnic Minorities are
overrepresented among homeless youth
3-10% are LGBQI2-S
Sexual abuse victims 17- 35%
Physical abuse victims 40-60% (Robertson & Toro, 1999;
Jenks, 1994).
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Up to 43 percent of homeless adolescent males
and 39 percent of adolescent females report
being assaulted with a weapon while living on
the streets (Whitbeck & Simons, 1990)
Homeless Youth
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Runaway and homeless youth with previous
histories of both physical and sexual abuse have
the most severe psychological conditions
Homeless youth with previous histories of abuse
are greatest risk for revictimization (Ryan, Kilmer, et al.,
2000).
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75 percent of homeless youth use marijuana or
other drugs (Kipke, O’Connor, Palmer, & MacKenzie, 1995; Green, Ennett,
& Ringwalt, 1997)
Service Considerations
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Ensure that agency policies and procedures are not
retraumatizing
Universal trauma screening as part of the intake
process
Unconditional assistance. Provide access to
lowbarrier services, such as a meal or a hot shower,
while they are developing trust.
Consider behavior in the context of their life
experiences including their traumatic histories.
Remain available while still setting limits.
Prioritize youths’ immediate needs.
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Determine the youths’ strengths and talents
Allow homeless youth to make their own choices
whenever possible, including about treatment.
Assess cognitive abilities in order to use appropriate and
understandable language.
Assess psychosocial needs and refer them to
complementary services to augment treatment.
Offer referrals only to youth friendly agencies.
Tailor interactions and treatment plans to individual
needs.
Use of trauma-exposure therapies is discouraged due to
high incidence of have comorbid substance abuse
disorders and lack adequate support and basic safety
(Thompson, McManus, & Voss, 2006).
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Attend to co-occurring disorders and other
mental health problems that need to be
addressed.
Ask about current sleeping arrangements at each
treatment session and pace interventions
accordingly. Willingness to open up to a mental
health provider is often directly correlated to how
safe they feel when leaving the service provider’s
office.
Engaging and retaining these youth in treatment
is challenging, even for the most skilled clinicians.
Use a harm reduction model
Childhood Trauma World-Wide
■ In the past decade > 2 million children
killed in war.
■ 6 million were wounded
■ One million orphaned
■ More than 300,000 youth serve as child
soldiers.
■ Female soldiers often sold in to sexual
slavery
(United Nations High Commissioner for Refugees)
Refugee Youth
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Refugee
A person who is outside his/her country of
nationality or habitual residence
 Has a well founded fear of persecution because
of his/her race, religion, nationality,
membership in a particular social group or
political opinion
 Is unable or unwilling to avail himself/herself of
the protection of that county or to return there
for fear of persecution
 Half of worlds 20 million refugees are children
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Refugee Youth
■ Between 1998 – 2001 more than 1.3 mil.
refugees admitted to the U.S.
■Approximately 40% were under 18
■ In 2003 more than 10,000 refugees under the
age of 18 arrived in the U.S.
■ By 2004 number rose to 15,000 (US Department of State Bureau of
Population, Refugees and Migration).
■By 2008 numbers fell back to approximately
10,000 (BRYCS - Bridging Refugee Youth and Children's Services)
Refugee Youth
■ Between 1998 – 2001 more than 1.3 mil.
refugees admitted to the U.S.
■ In 2003 more than 10,000 refugees under the
age of 18 arrived in the U.S.
■ By 2004 number rose to 15,000 (US Department of State
Bureau of Population, Refugees and Migration).
Phases of Refugee Experience
■ Preflight
Onset of political violence/war
Social upheaval, increased chaos
Limited access to school
Flight
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Uncertainty
Children may be born during this phase
Displacement
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Separation from caregivers
Resulting increase in vulnerability to victimization
 Increase in mental health issues
 Decreased positive outcomes
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Basic needs uncertain
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Unaccompanied minors:
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INS (ICE) may detain unaccompanied minors in INS
detention centers or juvenile detention ctrs.
Resettlement
■ New belief systems
■Refugees escaping war and persecution are at
higher risk of mental health problems
■May encounter Western MH systems for the first
time
■ Families may be disrupted
New family roles
■Children as culture brokers
 Faster language acquisition
 Faster assimilation
Traumatic Bereavement
Refugee children may have lost family and
friends in violent acts resulting in traumatic
reactions.
■ Unable to go through grieving process
■ Re-Experiencing
■ Wish for revenge
■ Preoccupation with the experience
Traumatic Reaction
Exposure to Trauma
Avoidance/Numbing
Avoiding triggers of
trauma
Detached from others
Unable to form
relationships
Re-Experiencing
Triggers from daily
events
Dwelling on
unbidden thoughts,
memories, sights
Hyperarousal
Nervousness
Hypervigilence
Exaggerated
startle reaction
Insomnia
Refugee Children and PTSD
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As many as 75% of refugee children meet
criteria for PTSD (Allwood et al., 2002).
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Additionally refugee children experience
acculturative stress (Berry, 1994: Birman et al., 2002).
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Few receive services
Need for culturally competent approaches
constitute a barrier to care.
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Culture and Trauma: LGBTQ Youth
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33% of LGB students reported attempting suicide in
the previous year vs. 8% of heterosexual peers
reported attempting suicide.
84% of LGBTQ students were called names or had
their safety threatened due to their sexual orientation
45% of LGBTQ youth of color experienced verbal
harassment and/or physical assault
39% of LGB students and 55 percent of transgender
students were shoved or pushed.
LGBTQ Youth and Trauma
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64% of LGBTQ students feel unsafe at school.
29% missed one or more days of school because
they felt in danger.
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25-40% of homeless youth may identify as
LGBTQ. Parents or caregivers may force them
out of their homes after discovering their child’s
sexual orientation.
LGBTQ Youth & Trauma
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LGBTQ youth experience and are exposed to trauma
in many ways:
Physical and emotional assaults for “coming out,” or
fear of being found out on a daily basis.
Engaging in at-risk behaviors as a way to cope with
confusion about their sexual identity.
Barriers to finding a safe and trusted relationship as
disclosure may put them at further risk of harm.
The trauma of this "double bind" underscores the
need for confidentiality and safety from a trusted
helper.
Trauma and Deaf Children
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Deaf children are at increased risk for
traumatization. The ongoing communication
barriers that often exist within the family and in
other key settings can cause:
Increased frustration by adults and children;
 Difficulty in teaching deaf children about safety;
 A lack of educational resources such as safety
curricula and sexual abuse/kidnapping prevention
programs
 Assumptions by perpetrators that deaf children are
less able to disclose information about abuse
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Difficulties in teaching/learning skill building and
socialization
Decreased opportunities for incidental learning;
 Decreased opportunities for trusting, open
relationships;
 Less disclosure of abuse to caregivers; and
Less understanding of the parameters of
healthy/safe touching.
Deaf people may also experience
 additional communication barriers
misunderstanding, and fear during the disclosure or
investigation of a traumatic event
Exacerbated feelings of isolation and difference
after a traumatic event.
Service Considerations
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Find a certified interpreter that can commit to
working with the deaf client.
Get details about history of hearing loss and social
emotional development.
Assess history of language use and ability to
communicate in multiple settings.
Ask about educational background and school
settings.
Find out about the availability of culturally relevant
supports.
■Be aware of the oppression, stigmatization, and
isolation that deaf people often face.
■Consult with specialized providers about bringing a
culturally affirming view of deafness into the work
■Find out about the family’s past experiences with
therapy and interpreters.
■Working w/ an interpreter:
■Prepare the interpreter for traumatic content
■ Debrief with the interpreter after each session.
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Arrange physical placement to maximize your direct
eye contact with client.
Look and speak directly to the deaf individual, not
the interpreter.
Work with the interpreter to repeat or rephrase as
necessary to ensure the client’s understanding.
Remember that the interpreter has an ethical
obligation to interpret all that is said in the room.
Interpreter’s own history could affect his/her ability
to interpret accurately; personal issues could lead to a
violation of boundaries or a dual relationship between
the client and interpreter.
Adapting individual child sessions
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Modify relaxation techniques to focus on visual
and tactile aspects.
A trauma narrative may need to be done with a
more visual medium than writing.
The therapist and interpreter together may need
to teach the child and family appropriate signs
and words for what has happened to them.
The therapist may need to put more emphasis
on increasing socialization skills and safety.
Effects of Exposure to Trauma
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Dissociation. Some traumatized children experience a feeling
of detachment or depersonalization, as if they are “observing”
something happening to them that is unreal.
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Behavioral control. Traumatized children can show poor
impulse control, self-destructive behavior, and aggression
towards others.
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Cognition. Traumatized children can have problems focusing
on and completing tasks, or planning for and anticipating
future events. Some exhibit learning difficulties and problems
with language development.
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Self-concept. Traumatized children frequently suffer from
disturbed body image, low self-esteem, shame, and guilt.
Trauma Informed System
Trauma-informed services are not designed
to treat symptoms or syndromes related to
abuse or trauma. Instead, the primary
purpose is to deliver mental health,
addictions, housing supports, vocational or
employment counseling services, etc., in a
manner that acknowledges the role that
violence and victimization play in the lives
of most consumers of mental health and
substance abuse services.
Trauma Informed System
This understanding is used to design service
systems that accommodate the vulnerabilities of
trauma survivors and allow services to be delivered
in a way that will facilitate consumer participation
that is appropriate and helpful to the special needs
of trauma survivors.
Harris, M., & Fallot, R. EDS. (2001) Using trauma Theory to Design Service Systems, Jossey-Bass, San Francisco.
What Works
■ RICH:
 Respect
 Information
 Connection
 Hope
■Empowering and Collaborative Relationships
Risking Connection, Karen Saakvitne
What Works
■
Power
■
Choice
■
Control
Harris, M., & Fallot, R. EDS. (2001) Using trauma Theory to Design Service Systems, Jossey-Bass, San
Francisco.
How Can a Teacher Help?
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Provide a stable, predictable, comforting
environment
Provide clear, consistent rules and
expectations
Signal that you are available to listen
Never pressure a student to tell his/her story
 Provide opportunities for students to tell their
story
 Remember that ‘bad behavior’ may be a traumatic
reaction
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Trauma Informed & Culturally
Competent
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Provide Access to Tutors
Display welcome signs in different
languages
Display photographs/items from different
countries represented in the student body
Have general class discussion about
prejudice and stereotypes