Effective Coping: The Role Of Diversity In Health Care

As health care professionals, in order to most effectively work with our clients of increasingly diverse backgrounds, we must commit to move towards an “educational mission that embraces educating to end oppression and for social justice” (Wallace, 2000a, p. 1087). In order to move in this direction, we must appreciate the impact of our own actions on our clients. Wallace (2000b) aptly points out that, as professionals, we may “actually engage in invisible, covert forms of violence” should we inadvertently project “negative and low expectations on clients” or talk to them in a way that implies they are inferior and that we are superior (p. 131). While unintentional, these behaviors carry consequences that can be harmful to our clients and

as Wallace (2000b) points out results in the oppression of others.
As health care professionals, our goals focus around helping others, not oppressing them.

Therefore, in order to improve our effectiveness we must confront our own adaptive affective, behavioral, and cognitive coping responses to diversity and multicultural populations. As noted by Wallace (2005), adaptive affective coping refers to the concept of identifying and focusing on the positive attributes and strengths of a client, while “having positive expectations about this clients ability to change” and sustain the change behaviors over time (p. 144). A critical component of interactions is empathy, which is defined as an emotional state reached by using one’s own potential to feel in order to appreciate a client’s inner emotional experience, and it likely is the most significant factor related to the success of treatment. In addition to displaying empathy, it is important that counselors demonstrate respect, which is an affective state experienced as a consequence of “acknowledgement of another’s experience as valid, real, and worthy of recognition” (p. 147). Once respect is established, it opens the possibility for acceptance. Acceptance is defined as an affective state that results from appreciating a person’s current situation, “what’s going on with the person, and the nature of the person’s experience” (p.148). An important aspect of acceptance is remaining free from negative judgment, criticism, and disapproval of the person’s emotions and behaviors, values,

cultural traditions, and cognitive approaches, even when the counselor does not share the same beliefs.
Maladaptive behavioral coping in response to diversity may be evidenced by such things as interrupting clients when they are speaking, implying their thoughts are not as valuable as those of the clinician (Wallace, 2005). In essence this behavior on the part of the clinician is “consistent with disrespecting, devaluing, or discriminating against a client” (p. 143). An adaptive behavioral response would involve the clinician recognizing the temptation to jump in, refraining, and instead respecting the client by engaging in active listening. This would include aspects of motivational interviewing such as maintaining eye contact, nodding of the head, “asking questions and making appropriate supportive verbal comments” (p. 150).
Maladaptive cognitive coping response may be characterized as those that lead to a “common conditioned affective responses of disdain” (Wallace, 2005, p.143.) On the other hand, adaptive cognitive coping works to actively disturb the bias at the heart of the stigma. For instance, as previously addressed, Latino children have a high rate of obesity and a maladaptive response by the clinician may be expecting or accepting that her Latino pediatric clients will gain weight disproportionately faster than their peers. The act of expecting something negative based on data unduly establishes lower expectations for the client. An adaptive cognitive coping response on the other hand would look to appreciate the strengths the client is demonstrating. For instance, the clinician may comment that their client is working really hard, and if they continue, the “chances of success are excellent” (Wallace, 2005, p. 144). With respect to the pediatric Latino patient, the clinician can re-train herself to focus on the food and exercise related behaviors the family is accomplishing and provide positive, affirming feedback on the value of those efforts.
To conclude the discussion on adaptive affective, behavioral, and cognitive coping responses to diversity and stress the value, Clark and colleagues (1999) illustrate a conceptual model to guide studies that explore the psychological and physiologic impact of perceived racism. They specifically hypothesize that even the perception of racism appreciated by individuals resulting from environmental stimulus can create an “exaggerated psychological and physiological stress response” (p. 806).
To further expand on improving the experience and outcomes of culturally diverse populations, there must be a focus on culturally and linguistically appropriate care as it pertains to health and health care.

The concept of culturally and linguistically appropriate services may be defined broadly as those that are “respectful of and responsive to the cultural and linguistic needs of all individuals” (USDHSS, 2013, p. 9). In an attempt to minimize racial and ethnic healthcare disparities, the Office of Minority Health at the U.S Department of Health and Human Services (USDHHS) revised or enhanced The National Standards for Culturally and Linguistically Appropriate Services (CLAS). The executive summary of the USDHHS notes that “lack of culturally and linguistically appropriate services” is one of the most modifiable factors contributing to health inequities (USDHSS, 2013, p. 8). The original standards were developed in 2000 and were more recently updated to take into consideration the increasing diversity in the U.S., to account for developments in the fields of cultural and linguistic competence, and assure pertinence in light of policy changes that occurred over that

decade.
The reality is, that despite great intentions since the original standards, “racial and ethnic disparities in health and health care remain a significant public health issue” (USDHSS, p. 9). As an example, lack of cultural and linguistic competence within the mental health arena has a significant impact on both access and quality of care (Sanchez, Ybarra, Chapa, & Martinez, 2016). Sanchez and colleagues (2016) also note that the lack of availability of mental health professionals is “amongst the most pressing health care issues facing the nation” (p.14). With respect to medical care, Latinos that have limited English proficiency and are often challenged by lack of information transfer between the client and professional, inaccurate transfers of information pertaining to symptoms, medication regimens, or lack of treatment (Ortega, Rodrigues, Bustamante, 2015). The consequence of these language barriers “can affect the quality of care” or result in “delays in receiving treatment” ultimately contributing to less than optimal health outcomes (p.5)
Along similar lines to linguistically appropriate care, cultural competency in health care, as defined by Betancourt and colleagues (2003) is “understanding the importance of social and cultural influences on patients’ health beliefs and behaviors” and formulating interventions that take the above into account in such a way that establishes the delivery of quality care to diverse individuals (p. 297). An important aspect is consideration for how sociocultural barriers including organizational, structural, or clinical barriers interface within the health delivery system and ultimately impact individuals’ experiences and outcomes. An example of an organizational barrier within this context is the lack of minority representation within “our nation’s health care leadership and workforce”, which can minimize the “acceptability of health care for minority racial/ethnic groups” (p.295). As noted by Betancourt and colleagues (2003), minorities represent less than 2% of senior leadership positions within health care management. This gap in leadership representation inherently places institutions at risk for having “policies, procedures, and delivery systems inappropriately designed” to meet the diverse needs of minority groups (p. 296). Additionally, while the demand for culturally and linguistically competent health care professionals is increasing, there is a growing shortage of Latino physicians to meet the demand (Daar, Alvarez-Estrada, & Alpert, 2017). Of note, “Spanish-speaking providers have been shown to improve control of chronic diseases” and are also shown to instill improved patient engagement in their therapies (Velasco-Mondragon et al., 2016, p. 20).