Assignment: Diversity Challenges and Reflections
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
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.
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216 The Family Journal: Counseling and Therapy for Couples and Families 19(2)
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