The changing demographics of California’s population and the need to understanding the cultural complexity and rich diversity that exist in our state, makes it critical to address cultural competency in all levels of mental health treatment, services, program planning and patients’ rights advocacy. As had been defined earlier in this manual, the major focus of advocacy is the process of representing and promoting the rights and interests of clients in the mental health system to help give "voice" to the client. The question must be asked; how do we effectively provide patients’ rights advocacy services while maintaining a commitment to being culturally competent in representing the clients? First, there must be recognition and awareness that patients’ rights advocacy representation must ensure cultural competency at all levels of client representation. This will require a commitment to an ongoing dialogue to address these issues.

As a beginning point, it must be understood that cultural competency needs to be more fully integrated into this manual and all aspects of training and patients’ rights advocacy service. It is recognized that this has not been done in this revision of the manual but efforts will be made to fully address cultural competency in future revisions. However, in this revision an effort is made to provide preliminary information on the concepts and principles of cultural competency. Developing cultural competency in patients’ rights advocacy efforts should be viewed as a developmental process. It should include more discussion with those providing advocacy services and input from the diverse populations receiving these services. A commitment must be made to address cultural competency in an ongoing way to insure a movement toward the more positive end of the continuum. In an effort to move the Patients’ Rights Advocate towards more effective culturally competent services within it is necessary that we begin with general concepts of cultural competency to develop a framework for future discussion.

It is expected that addressing issues of cultural competency in client representation will introduce many questions that will need to be answered.

A. Cultural Competency Definition:

For the individual: cultural competency is defined as "the state of being capable of functioning effectively in the context of cultural differences."

For an organization: cultural competency "acknowledges and incorporates at all levels the importance of culture, the assessment of cross-cultural relations, vigilance towards the dynamics that results from cultural differences, and expansion of cultural knowledge and the adaptation of services to meet culturally unique needs."

Competence: this word is used because it implies having the capacity to function effectively.

Culture: The integrated pattern of human behavior that includes thought, communication, actions, customs, beliefs, values and institutions of a racial, ethnic, religious or social group. Culture defines the preferred ways for meeting needs.

Cultural competency for the Patients Rights Advocate: It is essential that the advocate, in doing his/her job, is aware of the dynamic that culture plays in competent service representation. In representing and promoting the rights and interest of a client, the advocate must be aware that it is the client’s voice that is being heard and represented and that sensitivity to the cultural context of the client is recognized. This will require an ongoing commitment by patients’ right advocates to be knowledgeable of and promote cultural understanding and self-awareness. It is important that the rights and desires of the client are being represented and not those of the advocates. The challenge is to recognize value difference cross culturally. The Patients’ Rights Advocate must be aware that within a client’s cultural context what is being asked in terms of advocacy representation can and is most likely viewed very differently by individuals from different ethnic and cultural groups. The advocate must be aware that the concept of patients’ advocacy may be an unfamiliar and new concept by some more recent immigrant groups. It may be necessary for the advocate to provide some initial education regarding their role to individuals not familiar with the advocacy concept. The responsibility of the advocate is to be aware of this and create an environment for acceptance of differences, negotiating desired outcome and a sense of inclusion. This requires the advocate to feel comfortable in addressing issues of culture that may not arise initially but is critical for successful representation and eventual resolution of issues. Thus, there must be a commitment at all levels of patients’ rights advocacy to support a process for ongoing training, discussion on cultural competency issues.

Language access plays a critical role in competent patients’ rights advocacy. The current mental health cultural competency plan (DMH Information. Notice # 97-14) specifically requires counties to have interpreters and written material available by identified threshold languages. Patients’ Rights Advocates need to have a plan in place for responding to a client that speaks a language not spoken by the advocate. Thought should be given to identify the current language capacities of Patients’ Rights Advocate. Efforts should be made to increase the number of advocates that have diverse language capacities. Ongoing strategies should be identified to ensure appropriately trained translators, with knowledge in the field of patients’ rights advocacy, be available at minimum in the threshold languages of specific county’s. It is better to have a plan in place rather than wait until the advocate is confronted with a need for a translator in a potential crisis situation. Consideration should be given to whether the existing translators, identified by a county Mental Health Plan or facility, can or should be used by Patients’ Rights Advocate. The issue of understanding the role and function of patients’ rights activities and the ability to provide accurate information is critical. Without appropriate language access the advocate will have difficulty identifying the issues necessary to provide effective patient’s rights advocacy.

It is important to translate advocacy informational materials into different languages. These materials should be identified, prioritized and translated to assist in the exchange of information between the advocate and the client. It is also important to review the level of cultural specific knowledge among Patients’ Rights Advocates.

To value diversity is to see and respect its worth. Patients’ rights advocacy is strengthened when the clients served are from different backgrounds and will make different choices based on culture. What you may value from a patients’ right viewpoint may be very different for the client you are representing. For example, the value of independence or privacy can be viewed in different ways depending upon the cultural of the client. Some may view dependence very negatively. Dependence in some communities of color is viewed positively, as independence and separation from the family is not appropriate.

A patients’ rights advocacy systems must be able to evaluate itself and have a sense of its own culture. As stated previously, the patients’ rights advocacy movement came from the patient/ex-patient actions and institutional reform. Perhaps a question to ask is how much input from an ethnically diverse client population was solicited in establishing the values in the early patients’ rights movement? There must be an understanding that systems are shaped by culture norms and beliefs. Sometimes these beliefs are so imbedded in the system culture that there is little room for diverse world or cultural views. The challenge is to create awareness and space for this process in the patients’ rights advocacy system.

one culture interacts with a person of another both risk coming together with misjudgments and predicted viewpoints based on learned expectations. Patients’ Rights Advocates must be constantly watchful of misinterpretation and misjudgment.

There must be support for incorporating cultural knowledge into the training of Patients’ Rights Advocates. The ability to access cultural information should be available at all levels. Systems need to be established to ensure that knowledge is available and required.

competent services and a dedication to change over time to more effectively address the communities we are responsible to serve. The patients’ rights advocacy approach must be adapted to create a better relationship between the needs of ethnic specific clients and the advocacy which is provided.

In advancing patients rights advocacy towards a more culturally competent program, there are several areas that need to be addressed. It is important for all programs to evaluate their level of cultural competence and develop a plan for improvement. In order to do so, a program must analyze their structure, practice, policy and attitudes.

Cultural competence is a goal toward which patients’ rights advocacy programs must strive in order to move forward. The initial step is recognizing that ongoing efforts must take place in order to advance patients’ rights advocacy towards a more cultural competent program.