Addressing Cultural Complexities in Practice: Assessment, Diagnosis, and Therapy [3 ed.] 9781433821448, 1433821443

Table of contents :
Contents
Acknowledgments
I Becoming a Culturally
Responsive Therapist
1 The New Reality: Diversity and Complexity
2
Essential Therapist Knowledge and Qualities
3 Doing Your Own Cultural Self-Assessment
II Making Meaningful
Connections
4
Let’s Talk: Finding the Right Words
5
Understanding Clients’ Identities and Contexts
6
Creating a Positive Therapeutic Alliance
III
Sorting Things Out
7
Conducting a Culturally Responsive Assessment
8
Using Standardized Tests in a Culturally Responsive Way
9 Making a Culturally Responsive Diagnosis
IV
Beyond the Treatment Manuals
10 Culturally Responsive Therapy: An Integrative Approach
11
Indigenous, Traditional, and Other Diverse Interventions
12
Pulling It All Together: A Complex Case Example
13
Conclusion: Looking to the Future
References
Index
About the Author

Citation preview

Addressing Cultural

Complexities in Practice Third Edition

Addressing Cultural

Complexities in Practice Third Edition

Assessment, Diagnosis, and Therapy

Pamela A. Hays, PhD

American Psychological Association • Washington, DC

Copyright © 2016 by the American Psychological Association. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, including, but not limited to, the process of scanning and digitization, or stored in a database or retrieval system, without the prior written permission of the publisher. Published by American Psychological Association 750 First Street, NE Washington, DC 20002 www.apa.org To order APA Order Department P.O. Box 92984 Washington, DC 20090-2984 Tel: (800) 374-2721; Direct: (202) 336-5510 Fax: (202) 336-5502; TDD/TTY: (202) 336-6123 Online: www.apa.org/pubs/books E-mail: [email protected] In the U.K., Europe, Africa, and the Middle East, copies may be ordered from American Psychological Association 3 Henrietta Street Covent Garden, London WC2E 8LU England Typeset in Meridien by Circle Graphics, Inc., Columbia, MD Printer: Bang Printing, Brainerd, MN Cover Designer: Mercury Publishing Services, Inc., Rockville, MD The opinions and statements published are the responsibility of the authors, and such opinions and statements do not necessarily represent the policies of the American Psychological Association. Library of Congress Cataloging-in-Publication Data Names: Hays, Pamela A. Title: Addressing cultural complexities in practice : assessment, diagnosis, and therapy / Pamela A. Hays. Description: Third Edition. | Washington, DC : American Psychological Association, 2016. | Revised edition of the author’s Addressing cultural complexities in practice, 2008. | Includes bibliographical references and index. Identifiers: LCCN 2015025462| ISBN 9781433821448 | ISBN 1433821443 Subjects: LCSH: Cross-cultural counseling. | Psychotherapy. Classification: LCC BF636.7.C76 H39 2016 | DDC 158.3--dc23 LC record available at http://lccn.loc.gov/2015025462 British Library Cataloguing-in-Publication Data A CIP record is available from the British Library. Printed in the United States of America Third Edition http://dx.doi.org/10.1037/14801-000

Contents

a c k n o w l e d g m e n t s   vii

I Becoming a Culturally Responsive Therapist 

1

  1.   The New Reality: Diversity and Complexity  3   2.   Essential Therapist Knowledge and Qualities  19   3.   Doing Your Own Cultural Self-Assessment  39

II Making Meaningful Connections 

61

  4.   Let’s Talk: Finding the Right Words  63   5.   Understanding Clients’ Identities and Contexts  79   6.   Creating a Positive Therapeutic Alliance  101

III Sorting Things Out 

125

  7.   Conducting a Culturally Responsive Assessment  127   8.  Using Standardized Tests in a Culturally Responsive Way  161   9.   Making a Culturally Responsive Diagnosis  195

IV Beyond the Treatment Manuals 

225

10.  Culturally Responsive Therapy: An Integrative Approach  227 11.  Indigenous, Traditional, and Other Diverse Interventions  257 12.   Pulling It All Together: A Complex Case Example  283 13.   Conclusion: Looking to the Future  299 v

vi

contents

references  index 

305

347

about the author 

355

Acknowledgments

T

he first person I must thank is Margery Ginsberg, who pulled the word ADDRESSING out of the earlier and easily forgettable acronym I had been using. Next, I thank Peg LeVine for her suggestion of the capital letter I, specifically in reference to Indigenous people. With each new edition of this book, the list of people I want to thank grows longer, so in addition to those named in previous editions, I would like to add the friends and colleagues who gave me suggestions specifically for this edition, namely, Maryam Bassir, Karen Ferguson, Deborah Gideon, Tedd Judd, and Skip Shewell. I am also deeply grateful to my husband, Bob McCard, for his loving support.

vii

Becoming a Culturally Responsive Therapist

I

The New Reality Diversity and Complexity

I

1

n her work at a community mental health center, a recently graduated, young European American woman named Sarah1 received a referral from the Office of Children’s Services (OCS) for a severely abused, biracial 4-year-old named Maya. Following removal from her biological parents, Maya was brought to the initial appointment by her new foster mom, Carmen, an assertive, self-described Latina/African American Jehovah’s Witness. Carmen agreed to meet with Sarah because OCS required it. During sessions that alternated between individual and family meetings, Carmen interacted defensively with Sarah but was warm and caring with Maya. After 6 weeks, Maya appeared very comfortable with her foster mom, and many of her posttraumatic stress disorder symptoms had improved. However, in a subsequent meeting alone with Sarah, Maya asked her if she believed in Jesus. Sarah said that she wasn’t a Christian but that she believed in

1 All cases are composites with pseudonyms and do not represent a specific individual.

http://dx.doi.org/10.1037/14801-001 Addressing Cultural Complexities in Practice: Assessment, Diagnosis, and Therapy, Third Edition, by P. A. Hays Copyright © 2016 by the American Psychological Association. All rights reserved.

3

4

B ecom i n g a C u l t u r ally Respo n s i v e The r ap i s t

God—a response that clearly distressed Maya, who brought up the topic again in their next individual session, adding that she was afraid Sarah would die and go to the “bad place.” Sarah began to worry that Carmen might be sharing religious beliefs that were reactivating Maya’s fears. She also wondered whether Carmen knew that Sarah was gay and, if so, whether this might be a factor, along with their cultural, age, and religious differences, in Carmen’s defensiveness toward her. Considering Carmen’s disinterest in Sarah’s help, Maya’s overall improvement while in Carmen’s care, and the severe shortage of caring foster homes, Sarah was unsure whether she should address her concerns with Carmen, with OCS, or with both or neither. When I began teaching a multicultural counseling class at Antioch University in Seattle in 1989, the field of multicultural counseling was just beginning, and like most new fields, its focus was relatively narrow. Relevant textbooks focused primarily on the ethnicity and race of the client, with little attention to the therapist’s identity or to the interaction of ethnicity and race with the client’s (or therapist’s) religion, class, age, disability, gender, sexual orientation, or nationality. There were some population-specific fields regarding women, older adults, and people who identified as gay or as having a disability, but the available books and articles in these fields also conceptualized identity in unidimensional terms. Feminist therapy initially focused on women (presumably White, Christian or secular, nondisabled, and middle class); the lesbian, gay, and bisexual literature on lesbian, gay, and bisexual people (presumably White, Christian or secular, nondisabled, and middle class); geropsychology on older men (presumably White, Christian or secular, nondisabled, and middle class); and so on. A field known as transcultural psychiatry overlapped with one called cross-cultural psychology, both of which focused on work with populations outside North America and Europe but were conducted primarily by European and U.S. (White) researchers. Since 1989, the world’s awareness of and approach to diversity have changed significantly. Increasing numbers of people have been displaced both within and across national borders because of war, poverty, and violence. Environmental degradation and extreme climate changes have magnified the impact of natural disasters on human communities. With economic globalization and technology accelerating the pace of change, social connections have increased dramatically across borders, with a wide range of effects including a growing number of people who marry across cultural groups and who identify as multiracial and multicultural and changing attitudes toward minority groups such as lesbian, gay, and transgender people and people who have disabilities. And around the world, as Indigenous people become increasingly empowered and unified, the value of Indigenous traditions is being increasingly acknowledged.

The New Reality

In the face of such changes, therapists are now expected to work effectively with people of diverse ages, ethnic cultures, religions, disabilities, gender identities, sexual orientations, nationalities, and classes. At the same time, the effects of violence, abuse, trauma, chemical dependency, disability, chronic physical and mental illness—that is, poverty-correlated problems—are now commonly encountered in clinical practice, even in many wealthier countries. Counselors and clinicians are expected to “fix” the mental health problems stemming from these persistent social causes even as economic pressures have resulted in higher caseloads, less supervision, and fewer mental health resources. Cases as complex as Maya’s are now commonplace. Recognizing the need for clear guidance on what works, an American Psychological Association (APA) task force took on the project of determining what constitutes practical, research-based, and highly relevant psychotherapy practice. The result was their definition of evidence-based practice in psychology (EBPP) as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (APA Presidential Task Force on EBPP, 2006). This definition does not prioritize any one theoretical orientation but rather tends to support a more integrative approach. In addition, by emphasizing “best available research,” the definition acknowledges the reality that for many minority groups, controlled studies of psychotherapy effectiveness do not exist. The definition also gives equal weight to clinical expertise, with an emphasis on using one’s expertise to adapt therapy to the particular individual and their cultural context.

Developing Multicultural Competence At a national psychology conference in the United States several years ago, I started a conversation with a young European American psychologist who had recently joined the faculty of a prestigious university. In response to my questions about the diversity of the psychology department, she told me that it consisted of 36 full-time members, one of whom was a person of color. She stressed that they’d made significant progress in the hiring of women, but all of the women were White except the one person of color, and none were tenured. I asked her opinion about why this was the case, and she replied, “Well, I think the core faculty put their priority on developing a high-quality research program rather than on hiring for diversity.” This psychologist’s statement reflects the commonly held belief that quality and diversity involve competing agendas. However, I would argue,

5

6

B ecom i n g a C u l t u r ally Respo n s i v e The r ap i s t

as many others have, that the exact opposite is true. A high-quality program by definition includes faculty of diverse perspectives who bring ideas that move a department beyond those of the mainstream. It consists of diverse teachers and supervisors who serve as role models for a culturally diverse student body and clinical faculty who have firsthand knowledge of the cultures of the clients being seen by their students. It includes faculty who speak more than one language, read the psychological literature of more than one culture, and are connected to minority groups whom they consider and consult in their development of research projects. Given the relatively monocultural origins of the field, this is a tall order. However, significant strides have been made. Throughout the fields of psychology, counseling, mental health, and social work, professional organizations have made a clear commitment to increasing the multicultural competence of their members; in North America, this effort has included the APA (2000a, 2000b), the American Counseling Association (Roysircar, Arredondo, Fuertes, Ponterotto, & Toporek, 2003), and the National Association of Social Workers (2007). As researchers, teachers, supervisors, and practitioners in these professions become more diverse, they are experiencing and demonstrating the advantages of a diverse learning environment. And the idea that diversity can be addressed in one multicultural counseling course has been replaced by the view that cross-cultural information, experiences, and questions must be integrated throughout the training curriculum, including practica and internships (Magyar-Moe et al., 2005).

Addressing Both Diversity and Complexity When I teach multicultural awareness workshops, I start by asking participants to do the following: “Take a minute to share with a partner everything you feel comfortable sharing about yourself that explains who you are and your identity, including past and current cultural influences on you.” If you’re reading this by yourself, try doing this in the box before reading further.

List all of the cultural influences you can think of that explain or describe your identity:

_____________________ ____________________ _____________________ ____________________ _____________________ ____________________ _____________________ ____________________

The New Reality

Once people have finished sharing, I ask how many mentioned ethnicity or race in their self-description; depending on the makeup of the group, a varying number of people raise their hand. I then ask how many mentioned religion, and a different number raise their hand. I also ask about age and generational influences, disability, sexual orientation, social class, nationality, language, and gender. Then I ask if anyone thought of influences I did not mention, and participants often add being from a particular geographic region, growing up in the military, working in the business world, and others. This exercise illustrates how, when we think of culture, so many different influences come into play. All of these influences shape who we are, but as I found when I began teaching, the dilemma is how, whom, and what to focus on. For the purposes of psychological practice, I have chosen to focus on the influences and related minority groups that the major helping professions target for special attention because these influences and groups have been neglected in the field and dominant culture. These influences can be organized in an easy-toremember acronym that spells the word ADDRESSING (see Table 1.1). As you read through the list of ADDRESSING influences and dominant and minority groups, you will recognize that for many of the influences, the groups listed as minority groups are minorities only in the United States (e.g., people of Asian heritage are not a minority in China or, for that matter, in the world). So think of this list as only an example: If you are practicing in a different region or country, the dominant and minority groups will be specific to that particular context.

ADDRESSING Influences A stands for Age and generational influences and includes not just chronological age, but also generational roles that are important in a person’s culture. For example, the role of eldest son in many cultures carries specific responsibilities, just as being a parent, grandparent, or auntie brings with it culturally based meanings and purpose. Age and generational influences also include experiences specific to age cohorts, particularly experiences that occurred during the cohort’s childhood and early adulthood (i.e., the formative years). For example, for many elders, the Great Depression, World War II, and racial segregation were generation-related influences that profoundly affected their lives. For baby boomers, important early influences were post-World War II economic prosperity, the civil rights movement, the women’s movement, Vietnam War protests, and the widespread use of drugs. For people in their 20s, economic pressures, college debt, technology and social media, and environmental degradation are common influences—

7

8

B e c o m i n g a C u l t u r a l ly R e s p o n s i v e T h e r a p i s t

TA B L E 1 . 1 ADDRESSING Cultural Influences Cultural influence

Dominant group

Nondominant or minority group

Age and generational influences Developmental or other Disabilitya

Young and middle-aged adults Nondisabled people

Children, older adults

Religion and spiritual orientation Ethnic and racial identity

Christian and secular

Socioeconomic status

Upper and middle class

Sexual orientation

Heterosexuals

Indigenous heritage

European Americans

National origin

U.S.-born Americans

Gender

Men

European Americans

People with cognitive, intellectual, sensory, physical, and psychiatric disabilities Muslims, Jews, Hindus, Buddhists, and other religions Asian, South Asian, Latino, Pacific Islander, African, Arab, African American, Middle Eastern, and multiracial people People of lower status by occupation, education, income, or inner city or rural habitat People who identify as gay, lesbian, or bisexual American Indians, Inuit, Alaska Natives, Métis, Native Hawaiians, _ New Zealand Maori, Aboriginal Australians Immigrants, refugees, and inter­ national students Women and people who identify as transgender

Note.    Adapted from Addressing Cultural Complexities in Practice, Second Edition: Assessment, Diagnosis, and Therapy (p. 18), by P. A. Hays, 2008, Washington, DC: American Psychological Association. Copyright 2008 by the American Psychological Association. a With the increased use of the term intellectual disability, the term developmental disability is being used less often, particularly within the Disability community; however, it is included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM–5) and the International Classification of Diseases, Tenth Edition, Clinical Modification (ICD–10–CM; see Chapter 4).

all of these also affect older people, but people in their 20s have never lived without them. Obviously, age and generational influences vary across ethnic and other cultural groups, just as dominant and minority groups vary in different countries and contexts. In North America, the minority groups associated with age and generational influences are children and older adults, because elders and children do not have the same privileges that young and middle-aged adults have. However, in some countries, elder status carries a great deal of privilege and power. I will provide examples of contextual specifics of these definitions in Chapter 2. The next letters, DD, stand for Developmental or other Disability. The broad category of disability includes disability that may occur at any

The New Reality

time during a person’s lifetime, for example, as a result of illness, accident, or stroke. Developmental disabilities are specifically those that affect a person’s development from birth or childhood, such as fetal alcohol spectrum disorder or Down syndrome. (Note that the term intellectual disability has replaced the pejorative term mental retardation; more on this in Chapter 4.) Related minority groups include people who have cognitive, intellectual, sensory, physical, and psychiatric disabilities. Some individuals with disabilities identify as members of a Disability culture (signified by a capital D). However, many individuals who have disabilities do not consider themselves members of a culture, particularly people who acquire a disability later in life (e.g., an older woman whose cognitive functioning is impaired following a stroke). Similarly, many people who identify as members of Deaf culture do not identify as disabled because they have no impairments when in the Deaf culture; it is the hearing world’s inability to sign that is the problem. The distinction between people who grow up with a disability and those whose disability is acquired later in life has important implications for therapeutic work. Many people who grow up with a disability learn coping skills that enable them to function well in the dominant non­ disabled world; when these individuals come to counseling, it is often for a problem that is unrelated to the disability. In contrast, individuals who become impaired later in life (e.g., following an accident or physical illness) often come to therapy for help with learning how to cope and live with the disability. The next letter, R, stands for Religion and spiritual orientation. In North America, the largest religious minority groups are Muslim, Jewish, Hindu, and Buddhist, and there are many smaller groups (e.g., Baha’i, Shinto, Confucian, Zoroastrian). Although some members of particular Christian religions (e.g., Mormon, Seventh-Day Adventist, Jehovah’s Witness, and fundamentalist Christian) think of themselves as minority groups, they are still Christian groups and as such have privileges that non-Christian groups do not have. Similarly, some individuals with atheistic beliefs consider themselves part of a minority group; however, atheists still benefit from privileges related to the dominant secular culture. E stands for Ethnic and racial identity. In the United States, the largest groupings of ethnic and racial minority cultures are Asian, South Asian, Pacific Islander, Latino, and African American. Also included are people who identify as biracial or multiracial and people of Middle Eastern heritage who are experiencing racism and other oppressive attitudes and behaviors from the dominant culture. Within each of these large cultural groupings, there are many specific groups. For example, South Asian includes people whose heritage originates in Pakistan, India, Bangladesh, Afghanistan, Nepal, Sri Lanka, Bhutan, and the Maldives (and, depending on the definition, some additional countries such as Tibet). Here again, the definition of these cultures as minority groups is specific to

9

10

B ecom i n g a C u l t u r ally Respo n s i v e The r ap i s t

the United States; what constitutes a minority group depends on the country and its dominant culture. S stands for Socioeconomic status, which is usually defined by education, occupation, and income. Related minority groups include people who have lower status because of limited formal education and the occupations and lower income that usually go along with less education. The focus is on people who are living in poverty, often in rural and inner-city areas. The second S stands for Sexual orientation, and the related minority groups include people who identify as lesbian, gay, and bisexual. In the United States, sexual minority groups often use an acronym that includes additional groups, such as LGBTQIA (lesbian, gay, bisexual, transgender, queer, intersex, ally or asexual), but because some of these groups are related more to gender, I group them under the influence of gender identity (see discussion of G that follows). The I stands for Indigenous heritage, and related minority groups are people of Indigenous, Aboriginal, and Native heritage. These terms are similar in meaning but are used differently in different countries and contexts (more on this in Chapter 4 on finding the right words). Within the cultural grouping of Indigenous people, there are many smaller and specific cultures. For example, I work with members of the Kenaitze Tribe, which is the local Indigenous culture where I live in Alaska. Members of the Kenaitze Tribe belong to the larger culture of Dena’ina people, who belong to the larger Athabascan culture, which is one of many Alaska Native cultures. The ADDRESSING acronym lists Indigenous heritage as a separate influence from ethnic and racial identity because many Indigenous people identify as part of a worldwide culture of Indigenous people who have concerns and issues separate from those of ethnic and racial minority groups (e.g., land, water, and fishing rights related to subsistence and cultural traditions) and who, in some cases, constitute sovereign nations. The N stands for National origin, and related minority groups including immigrants, refugees, and international students. Language is often a strong cultural influence related to national origin, but it may also be related to the ADDRESSING domains of ethnic and racial identity, Indigenous heritage, and disability (e.g., sign language). Finally, G stands for Gender identity, and minority groups include women and people of transgender, transsexual, intersex, gender questioning, androgyne, and other gender-nonconforming identities. I’ll talk more about the complexities of gender identity in Chapter 4 on language and terminology. As mentioned earlier, the ADDRESSING acronym summarizes nine key cultural influences that shape the beliefs and behaviors of dominant and minority group members. It calls attention to the overlapping,

The New Reality

multidimensional nature of identity (also referred to as intersectionality; Ecklund, 2012). The acronym serves as a reminder of minority groups related to each of the nine influences, and it can be used to highlight the within-culture diversity of any given culture (whether minority or dominant). In addition, the ADDRESSING acronym is the foundation for what I call the ADDRESSING framework.

The ADDRESSING Framework The ADDRESSING framework is a practitioner-oriented approach to ther­ apy that conceptualizes multicultural work in two broad categories. The first category of personal work involves introspection, self-exploration, and understanding of cultural influences on one’s own belief system and worldview. The second category of interpersonal work focuses on learning from and about other cultures, which usually involves interaction with people. The importance of both the personal and interpersonal aspects of learning has been emphasized throughout the multicultural literature (Arredondo & Perez, 2006).

PERSONAL WORK The ADDRESSING approach begins with an emphasis on understanding the effects of diverse cultural influences on your own beliefs, thinking, behavior, and worldview. These effects stem from age-related generational experiences, experience or inexperience with disability, religious or spiritual upbringing, ethnic and racial identity, and so on (i.e., the ADDRESSING influences). In particular, recognizing the areas in which you are a member of a dominant group can help you become more aware of the ways in which such identities limit your knowledge and experience regarding minority members who differ from you. For example, as a result of her membership in a sexual minority group, a middle-class European American lesbian therapist may hold an exceptional awareness of the sexist and heterosexist biases against lesbian, gay, bisexual, and transgender clients and the challenges these clients face. However, this awareness and expertise do not automatically translate into greater awareness of the issues faced by people of color, people who have disabilities, or people living in poverty. The privileges this therapist holds in relation to her ethnicity, education, mental and physical abilities, and professional status are likely to separate her from people who do not hold such privileges. And if

11

12

B ecom i n g a C u l t u r ally Respo n s i v e The r ap i s t

her friends and family are similar with regard to ethnicity, religion, and social class, she will not have easy access to information that would help her understand, for example, a client of African American Muslim heritage. In contrast, an African American Muslim therapist working with the same client would be more likely to know relevant cultural information or would have easier access to it. Because of the way privilege separates dominant-culture members from knowledge about minority groups, this European American therapist would need to put extra effort into finding and learning the knowledge and skills to understand this client and work effectively with him.

INTERPERSONAL WORK Although we human beings like to think of ourselves as complex, we often regard others as one dimensional, relying on their visible characteristics as the explanation for everything they say, believe, and do. The more we recognize the complexity of human experience and identity, the more able we are to understand and build a positive therapeutic alliance. And by calling attention to multiple identities and contexts, the ADDRESSING framework helps therapists avoid inaccurate generalizations on the basis of characteristics such as the person’s physical appearance, name, or language. For example, by using the ADDRESSING acronym as a reminder of influences that may not be immediately apparent, a therapist attempting to understand an older man of East Indian heritage could begin to think about a more relevant and broader range of questions and hypotheses, such as the following: ❚❚

❚❚

❚❚

❚❚

What are the issues related to Age and generational influences on this man, given his status as a second-generation immigrant? Might he have a Developmental or other Disability that is not apparent, for example, a learning disability, difficulty hearing, or chronic back pain? Could he have had experience with a temporary disability in the past, or might he be a caregiver for a child or parent with a disability? Does he have an identity related to his Religion or spirituality? Was he brought up in a particular religion? (Hindu, or possibly Muslim or Sikh, would be reasonable hypotheses, but at this point, one is simply hypothesizing.) Is he a member of a religious minority that was forcibly ejected from his country of birth or his parents’ residence? (Many Indian people immigrated to African countries but then were forced to leave because of political changes and racism in the host country.) Does he identify himself as having an Ethnic or racial identity? Is he often mistaken for another identity (e.g., Pakistani or Arab)? How does his physical appearance (e.g., skin color) relate to his

The New Reality

❚❚

❚❚

❚❚

❚❚

❚❚

ethnic or racial identity and experiences within his own ethnic group and in the dominant culture? (For examples, see Inman, Tummala-Narra, Kaduvettoor-Davidson, Alvarez, & Yeh, 2015). What was his Socioeconomic status (SES) growing up, and what is it now—within his own ethnic community, and in relation to the dominant culture? How might his within-culture status be affected by factors not commonly associated with SES in the dominant culture—for example, his family name, geographic origins, or marital status? What is his Sexual orientation, not assuming heterosexuality simply because he is or has been married? How would he perceive a question about his sexual orientation? Might Indigenous heritage be part of his ethnic identity, for example, related to his premigration geographic, family, or community origin? What is his National origin? Was he born in his country of residence? What is his national identity (e.g., Indian, the nation of his residence, both, or neither)? What is his primary language— Hindi, English, Bengali, or some other language? Finally, considering his cultural heritage and identity as a whole, what important influences related to Gender has he experienced— for example, gender roles, expectations, and accepted types of relationships in his culture?

The ADDRESSING acronym does not provide the answers to these questions; rather, it is a tool for developing hypotheses and questions. In some cases, it may be appropriate to ask a question directly. However, in many cases such questions will be perceived as irrelevant or offensive, with a resulting diminishment of the therapist’s credibility. The way I use the acronym is to facilitate my consideration of questions and hypotheses that I might otherwise overlook. Once I know how a client identifies, I can then seek out the culture-specific information that will help me better understand the client. Regarding this point about gathering cultural information, I have heard some therapists say that it is best to let the client educate you about their culture, but I think this point needs clarification. As a therapist, I believe it is my responsibility to learn as much as I can about the broad cultural influences related to the client’s identity. This broad cultural information can then help me understand the client’s individual experience within that culture. The broader cultural information serves as a sort of template that helps me generate hypotheses and questions that are closer to the client’s reality, increasing my efficiency and decreasing the likelihood of offensive questions. I will talk more about the use of the ADDRESSING acronym to facilitate hypothesis generation and culturally responsive assessment in Chapters 5 and 7.

13

14

B ecom i n g a C u l t u r ally Respo n s i v e The r ap i s t

What’s New in This Edition? Since publication of the previous edition, a number of significant developments have occurred in clinical and counseling psychology, including the growing integration of behavioral health with medical practice. Along with society’s increasing diversity (ethnic minority cultures now make up over one-third of the U.S. population), the move toward integrated care has raised awareness of the need for evidence-based practices that work with a greater diversity of clients and patients. The American Psychiatric Association (2013) recently published the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–5), and the 10th edition of the International Classification of Diseases (ICD–10; World Health Organization, 1992) is being adopted in the United States as the 11th edition nears completion. The field of positive psychology has contributed to a new perspective on health aimed at building well-being (i.e., beyond simply eliminating symptoms). And broader social changes affecting professional practice include continuing poverty-related problems, increased social awareness of diversity, and changing expectations regarding therapists and psychological services. To address these changes, in the third edition of this volume I have included ❚❚

❚❚

❚❚

❚❚

❚❚

❚❚

❚❚

a new chapter on continually changing multicultural terminology and language, including offensive terms and preferable alternatives; up-to-date information on the DSM–5, ICD–10, and upcoming ICD–11; new sections on poverty, children, transgender people, and traumainformed care; new information on intellectual and neuropsychological assessment across cultures; a chapter on the integrative approach to psychotherapy, with a focus on culturally responsive cognitive–behavioral therapy; research from the new field of positive psychology, including mindfulness practices; and practice exercises at the end of each chapter that can be used individually or as class assignments.

Organization With the intention of conveying cultural information in the way therapists typically experience it, this edition continues to be organized according to the flow of clinical work (rather than the one-chapter-per-

The New Reality

group organization of most multicultural texts). This more integrated approach allows for consideration of the specifics and complexities of psychotherapy practice. The book begins with suggestions for facilitating therapists’ personal process of becoming more culturally aware and knowledgeable, followed by information on building a positive alliance, conducting assessments, testing, making diagnoses, and providing psychotherapy. Throughout these sections, I use case examples of people who hold complex identities. For example, the case of an older African American woman does not focus solely on her ethnic and racial identity; it also considers disability, gender, generational experiences, religion, and socioeconomic status. In addition, I include cases in which therapists have diverse identities, too. Recognizing the heavy emphasis on U.S. ethnic minorities within the multicultural counseling literature, I include information on and case examples of cultures and minority groups not commonly found in U.S. texts (e.g., Indonesian, Tunisian Arab, French Canadian, Mauritanian, Filipino, Haitian, East Indian, Costa Rican, Korean, and Greek cultures). To increase awareness of U.S.-centric assumptions, some of these cases are set in Canada. Cases involving international identities are also included, although setting cases in a variety of national contexts proved difficult because what constitutes a minority culture in one country is often a dominant culture in another. One of the biggest challenges in multicultural competence training is providing information that translates academic learning into actual therapeutic practice (Sehgal et al., 2011). To help with this process, I’ve included practice exercises at the end of each chapter that provide an opportunity to take this learning beyond book reading. In Part I, Becoming a Culturally Responsive Therapist, Chapters 2 and 3 describe specific steps and exercises for facilitating your own cultural self-assessment. Chapter 2 focuses on the exploration of personal experiences, values, and biases. Strategies are described for developing compassion and critical thinking skills and for preventing defensive interactions with clients. Chapter 3 provides an extended case example of the self-assessment process with a particular therapist who discusses the complexity of his identity, including generational experiences, ethnicity, sexual orientation, and the other ADDRESSING influences. This chapter provides exercises for understanding your own cultural identity and the role of privilege in the context of your work. Consistent with the premise that you are engaged in and committed to the self-assessment process, in Part II, Making Meaningful Connections, Chapter 4 addresses language, with a focus on terms that unintentionally convey bias along with an explanation of preferable alternatives. Chapter 5 explains how to use the ADDRESSING framework to facilitate greater understanding of clients’ identities through the formulation of

15

16

B ecom i n g a C u l t u r ally Respo n s i v e The r ap i s t

hypotheses and questions that are closer to clients’ experiences. Chapter 6 outlines considerations in establishing rapport and demonstrating respect with people of diverse identities. In Part III, Sorting Things Out, Chapter 7 provides specific suggestions for conducting culturally responsive assessments, including guidelines for working with interpreters. Chapter 8 focuses on standardized testing in mental status, intellectual, neuropsychological, and personality assessments. Chapter 9 addresses cross-cultural issues in the diagnostic process using the new DSM–5, along with information regarding the ICD–10–CM (World Health Organization, 1992a) and the upcoming ICD–11. Part IV, Beyond the Treatment Manuals, focuses on the use of diverse approaches to psychotherapy, with an integrative orientation to culturally responsive work. Chapter 10 illustrates the application of this orientation in the form of culturally responsive cognitive behavior therapy. Chapter 11 provides examples of Indigenous, traditional, and other approaches to healing, including expressive modalities (e.g., art and play therapies) and family, couple, and group approaches. Finally, Chapter 12 pulls together suggestions from the preceding chapters in the case example of an older African American woman and her family who see a young African American male psychologist.

Your Journey The year I began teaching multicultural psychology, Stephen R. López (López et al., 1989) published a study with a group of graduate students that chronicled the students’ development of awareness, knowledge, and skills during a multicultural training course. The subsequent analysis of their writings showed four stages in the development of multi­ cultural competence. In the first stage, the students had little awareness of cultural influences and believed themselves to be bias free. In the second stage, as they learned about the influence of culture, they began to see their own biases, but their attempts to understand clients were often characterized by stereotypical explanations. In the third stage, the students experienced mounting confusion, frustration, and defensiveness as they recognized their limited knowledge and skills and perceived the consideration of cultural influences to be more of a burden than a help. However, by the fourth stage, the students were able to use cultural information flexibly, adapting it to clients’ particular needs and preferences, and they were aware of their biases but also more accepting of their limitations and the need for lifelong learning. These stages did not always occur in linear fashion; an individual could have a high level of competence with members of one group and very little with another and move in and out of different stages not necessarily in this order.

The New Reality

As you read this book, possibly along with a related course or internship, and learn more about whatever cultures are new to you, I hope that you will keep these stages in mind. If you find yourself thinking that you have no biases regarding a group with which you have little experience, dig a little deeper, because as the next chapter explains, we all have biases. If you begin to feel frustrated or confused because of the complexity of applying your learning with real people, be gentle with yourself and remember that this is a normal part of the process. Keep in mind that the development of multicultural competence is a lifelong process with unlimited domains for new learning. It is my hope that this book conveys to you how exciting, life enriching, and positive this process can be.

Practice: Starting From Where You Are Choose a minority or dominant cultural group that you belong to, and think about your multicultural competence with members of this group. Write a paragraph describing how your multicultural competence with this group fits or doesn’t fit one of the stages described by López et al. (1989). Then choose a minority group with which you have little or no experience, and write a paragraph describing how your multicultural competence with this group fits or doesn’t fit one of the stages. (Note: Save your writing, because at the end of this book I will ask you to look back at it.)

Key Ideas

  1. Evidence-based practice in psychology (EBPP) is defined by the American Psychological Association (APA) as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.”   2. The APA definition of EBPP supports an integrative approach to psychotherapy, acknowledges the reality that controlled studies of psychotherapy effectiveness with many minority groups do not exist, and emphasizes the importance of clinical expertise in adapting therapy to the particular individual and his or her cultural context.  3. The ADDRESSING acronym stands for Age and generational influences, Developmental or other Disability, Religion and spirituality, Ethnic and racial identity, Socioeconomic status, Sexual orientation, Indigenous heritage, National origin, and Gender.

17

18

B ecom i n g a C u l t u r ally Respo n s i v e The r ap i s t

  4. The ADDRESSING acronym is a tool for developing hypotheses and questions about cultural influences that therapists may be inclined to overlook; some of these questions may be appropriate to ask clients directly, and some may not.   5. The ADDRESSING framework makes use of the ADDRESSING acronym through two categories of work: (a) the personal work of introspection, self-exploration, and understanding the cultural influences on one’s own belief system and worldview; and (b) the interpersonal work of learning from, about, and with diverse people.   6. Recognizing the areas in which you are a member of a dominant group can help you become more aware of the ways in which privilege limits your knowledge and experience regarding minority members who differ from you.  7. Age and generational influences include not just chronological age but also generational roles that are important in a person’s culture and experiences specific to age cohorts.   8. Many people who grow up with a disability learn coping skills that enable them to function well in the dominant nondisabled world, and when these individuals come to counseling, it is often for a problem that is unrelated to the disability.   9. The definition of a group as a minority group is contextual; that is, it depends on the context and its dominant cultures. 10. The idea that diversity can be addressed in one multicultural counseling course has been replaced by the view that multicultural learning is lifelong and that cross-cultural information, experiences, and questions must be integrated throughout the training curriculum, including practica and internships.

Essential Therapist Knowledge and Qualities

O

2

ne day, a young Iñupiaq1 therapist told me his supervisor (a middle-aged White woman) asked him to develop a set of policies and procedures for a new program. He said that during a feedback meeting to discuss the document, the supervisor focused solely on what needed to be changed, with no comments on anything positive about the document. The therapist agreed to make the changes, but afterward he told me how frustrated he felt because the supervisor did not say anything positive about the outline, which took him hours to develop. He added that he later overheard the supervisor telling someone what a great relationship they had and how well they worked together. This example illustrates the vastly different perceptions that minority and dominant-culture members often report regarding the same event. Because privilege insulates the dominant culture from minority perspectives that might

1 One of many Alaska Native cultures, originating in the most northern part of Alaska.

http://dx.doi.org/10.1037/14801-002 Addressing Cultural Complexities in Practice: Assessment, Diagnosis, and Therapy, Third Edition, by P. A. Hays Copyright © 2016 by the American Psychological Association. All rights reserved.

19

20

B e co m in g a C u l t u r a l ly R e s pon s i v e T h e r api s t

challenge the dominant view, it’s easy for dominant-culture members to remain unaware of these alternative views. And because the dominant culture is so dominant, its members may begin to believe that their view is the right one. If you belong to a dominant group, your views have more power, and this power can negatively affect your work because it limits your understanding of clients who do not have the same power. It is not enough to simply be open minded. Truly understanding and connecting with people who have minority perspectives that differ from yours requires knowledge regarding individual and social biases and power structures. I consider this knowledge to be essential for multi­ cultural work.

Essential Knowledge Elaine, a European American therapist in her early 30s, received a call from a local physician who wished to obtain counseling for his patient, Mrs. Sok, a Cambodian (Khmer) woman in her 50s who had been crying, sleeping poorly, and losing weight since learning 3 weeks earlier that her apartment building was scheduled to be demolished. The physician gave Elaine the name and phone number of Mrs. Sok’s case manager, who would bring Mrs. Sok to the mental health center. Elaine called the case manager and made arrangements for an initial assessment session to be attended by Mrs. Sok, Elaine, and an interpreter named Han. During this initial meeting, Mrs. Sok spoke in a soft voice and made little eye contact with Elaine. Mrs. Sok could not provide her age, the date, or the name of the building in which they were meeting. The interpreter, Han, explained that Mrs. Sok had never learned to read or write in her own language and that she did not keep track of dates by the “Western” calendar. Elaine quickly realized that it would be meaningless to ask the other mental status questions she would normally ask in an assessment of this sort (e.g., to spell a word backward, recall three objects, or draw geometric designs). Instead, she chose to focus on obtaining more information about Mrs. Sok’s medical and social histories. With Han interpreting her questions, Elaine learned that Mrs. Sok had been widowed when her husband was killed in the war in Cambodia and that three of her four children at the time also died or were killed. During the years she lived in a refugee camp in Thailand, Mrs. Sok had two more children by a man whose whereabouts she no longer knew. Subsequently, Mrs. Sok and her two youngest children (now young adults) immigrated to the United States, where they had been living in

Essential Therapist Knowledge and Qualities

an apartment building next door to two other Cambodian families. The family managed to live on public assistance and the money her children earned from jobs in a restaurant. As Elaine obtained this information, she began to notice that Mrs. Sok’s responses in Khmer were much shorter than Han’s subsequent interpretations in English. Elaine asked Han if she was adding information, and Han said yes, she was adding information that she thought would help Elaine understand Mrs. Sok’s answers. When Elaine asked Han in a firm tone to interpret exactly what was said with no additions or deletions and explained that this would allow her to gain a more accurate assessment of Mrs. Sok, Han agreed but appeared uncomfortable. Although Mrs. Sok showed little emotional response to questions about her history, she became tearful when Elaine asked about the impending loss of her apartment. She said that her friends were there and that she didn’t know where else she would go. Elaine made an empathic comment in response but did not ask any additional questions about the housing situation. Instead, she focused on obtaining more information about Mrs. Sok’s experiences during the war. As their time was ending, Elaine told Mrs. Sok that she believed she could be of help and wanted her to return the next week. She added that she would like Mrs. Sok to also see a psychiatrist, who might recommend some medicine to help her sleep. Mrs. Sok nodded her head in agreement. At this point, the session had already taken 2 hours and another client was waiting outside, so Elaine scheduled their second meeting, and they all said goodbye. The next week, Mrs. Sok did not appear for the appointment, and when Elaine telephoned the case manager to find out why, the case manager told her that Mrs. Sok did not want to return. This case describes a situation that is not at all unusual in mental health practice. A compassionate and well-meaning therapist tries to understand a new client’s needs and explain how she might be of help. At the same time, the new client is assessing the trustworthiness and competence of a relative stranger (the therapist) to determine whether the benefits of counseling will outweigh the time, effort, and embarrassment involved. For one or more reasons, the client decides that therapy will not be helpful and so does not return. From Mrs. Sok’s perspective, Elaine seemed young to be in her position of authority and not especially sensitive to those around her; Elaine’s pressing questions about Mrs. Sok’s past and Han’s apparent discomfort at something Elaine said (the request to interpret verbatim—an impossible task) made Mrs. Sok feel cautious about trusting Elaine. Mrs. Sok had had no prior experience with a counselor or psychotherapist, and when her physician and case manager had told her that “counseling can help you,” she assumed that such help would address her most pressing problem, namely, the destruction of her home.

21

22

B e co m in g a C u l t u r a l ly R e s pon s i v e T h e r api s t

Although Elaine was at least minimally aware that Mrs. Sok’s and Han’s Cambodian heritage influenced how they perceived and presented Mrs. Sok’s needs, she did not think carefully about how these influences were relevant to the assessment. Had Elaine systematically considered the role of culture in Mrs. Sok’s situation, she might have recognized her own lack of experience and knowledge regarding Cambodian culture, refugees, and older Cambodian women. This realization could have led her to treat Han less as an assistant and more as a peer in the recognition that Han’s knowledge of Cambodian people was as extensive as Elaine’s knowledge of the mental health field. She might then have seen the need to consult with Han before and after the assessment, an action that would have helped her gain the trust and respect of Han and thus, indirectly, of Mrs. Sok. (See Bradford & Munoz, 1993, regarding the importance of preand postassessment meetings with interpreters; Struwe, 1994, regarding clinical interviewing with refugees; and Criddle, 1992, for accounts of Khmer people’s resettlement experiences.) Additionally, Elaine could have facilitated rapport if she had systematically considered the ways in which her own personal and professional experiences might be influencing her conceptualization of Mrs. Sok’s situation. For example, Elaine’s theoretical orientation and training led her to assume that Mrs. Sok’s current symptoms were attributable to past trauma. As a result, she focused on eliciting information about Mrs. Sok’s war-related experiences, despite the fact that Mrs. Sok was asking for help with something else. If Elaine had recognized the legitimacy of Mrs. Sok’s conceptualization, she might then have focused on what Mrs. Sok considered central—that is, the threatened loss of her home— and Mrs. Sok might have felt more understood. In turn, if Mrs. Sok had felt understood, she would have been more likely to return. With further assessment, it might have become apparent that past trauma indeed was contributing to Mrs. Sok’s distress, and in this case Elaine would understandably have wanted to consider it. But because Elaine did not establish rapport and trust first, Mrs. Sok did not return, and the therapist lost the opportunity to help her in this and any other way.

Understanding Bias One way to think about the mistakes Elaine made is in terms of bias, however positive her intentions were. Although Elaine could have conceptualized Mrs. Sok’s case in a variety of ways, her experiences and training biased her toward a particular view that then inclined her to take certain actions and not others. Although Elaine would have been

Essential Therapist Knowledge and Qualities

open to considering these biases if someone had pointed them out, she did not see them on her own. Largely because she thought of bias in dichotomous terms (i.e., that one is either biased or not), the possibility that she might be biased did not occur to her. A more helpful way to think about bias is simply as a tendency to think, act, or feel in a particular way. In some cases, these tendencies may guide individuals toward more accurate hypotheses and a quicker understanding of someone. In other situations, they may lead individuals to embarrassingly wrong assumptions. For example, I once visited a small Unitarian discussion group in a rural area. The circle was talkative and cheery with the exception of one man. Dressed in a plaid shirt, jeans, and hiking boots, he appeared to be European American and had a long, untrimmed beard. His facial expression was somber, and he didn’t say a word as he listened intently. I interpreted his affect and silence as hostility and his untrimmed beard (in the context of the larger conservative rural community) as connected to some extremist White militant group. During the coffee hour afterward, I avoided eye contact with him. As I was driving home with a friend, I asked her about this man. She said, “Oh, he’s an interesting guy. He’s a biologist and a professional musician. He gets up at 4:00 every morning to practice his music before he goes to work. He’s also a Quaker, so he doesn’t say much in the service, but when he does, it’s always interesting.” Ouch. It is clear that my biases did not facilitate helpful hypotheses about this man. On the contrary, they sent me in the opposite direction— toward inaccurate assumptions that then led me to behave in a way that reinforced these assumptions. By avoiding eye contact with him, I was denying myself the opportunity to learn anything from him that might have contradicted my misunderstanding. At the individual level, biases emerge in tandem with two other cognitive processes, those of categorization and generalization. Categorizing information and then generalizing this data to new situations are universal processes that help us organize the vast amounts of information we encounter on a daily basis (Tropp & Mallett, 2011). Usually, these cognitive processes facilitate learning and social interactions, but they can also contribute to the formation of inaccurate assumptions, as in my example. When these assumptions become rigid, they become stereotypes—that is, knowledge, beliefs, and expectations associated with a particular group— that in turn feed prejudice or prejudgment—that is, “positive or negative evaluations of social groups and their members” (Sherman, Stroessner, Conrey, & Azam, 2005, p. 607). To avoid making inaccurate assumptions about their clients, therapists may decide that the best approach is to assume nothing about a client’s culture and allow the client to share whatever he or she believes is important. Although such an approach is well motivated, it contains

23

24

B e co m in g a C u l t u r a l ly R e s pon s i v e T h e r api s t

a problematic assumption—namely, that therapists are able to assume nothing about their clients if they choose. The idea that one can “turn off” preconceptions about groups of people is appealing. However, given the subtle and pervasive nature of assumptions, such control is extremely difficult, if not impossible. What is more likely to occur when one attempts to ignore the presence of assumptions is decreased awareness that one is making them (Pedersen, 1987). It may be helpful to think of a lack of experience with a particular group as creating a hole or vacuum inside of yourself (Hays, 2007). As with any vacuum, there is a tendency for all surrounding material to be sucked in. When it comes to minority groups, this material often consists of dominant cultural messages that cause people to assume that differences are deficits, sometimes so subtly that they do not perceive the assumption. People then use this information to make generalizations and draw conclusions about individual members of a group despite a lack of direct experience. It is humbling to recognize that we all carry around our own little vacuum packs of ignorance. Our challenge as therapists and human beings is to recognize these vacuum packs and commit ourselves to opening them up and replacing inaccurate information with real experience and direct learning. In an initial assessment, if a therapist has already established rapport and trust, clients will often give the therapist the benefit of the doubt and overlook or forgive inaccurate assumptions. However, in most initial assessments, therapists do not yet have the benefit of a solid working relationship with the client. Upon meeting an individual or family for the first time, therapists must establish rapport and trust in a relatively short period or risk losing the opportunity to help. Knowledge of a client’s culture can facilitate this early work, because it enables the therapist to formulate hypotheses and ask questions that more closely connect to the client’s real experience. The deeper and broader a therapist’s knowledge of and experience with a client’s culture, the more accurate and relevant these hypotheses and questions will be (S. Sue, 1998). In turn, well-informed hypotheses and questions often increase clients’ trust and confidence in the therapist.

Examining Social Bias and Power The case example of Mrs. Sok illustrates bias at the level of cognitive structures that predispose all human beings to the development of prejudice and stereotypes. However, we cannot fully understand bias at the

Essential Therapist Knowledge and Qualities

individual level without knowledge of sociocultural influences (S. O. Gaines & Reed, 1995). Perhaps the concept most central to an understanding of the influence of sociocultural biases on individuals is that of power (Kivel, 2002). Because high-status groups hold more power, they can exert more control over their own situations and the situations of lower status groups (Lott, 2002). One way in which powerful groups exert control is through stereotypes (Fiske, 1993). Stereotypes can be described in terms of two key functions: descriptive and prescriptive. Descriptive stereotypes define how most people in a particular group behave, what they prefer, and where their competence lies. Descriptive stereotypes exert control because they create a starting point for people’s expectations. That is, the stereotyped person must choose to either stay within the boundaries of these expectations or go outside of them; in either case, the stereotype places a burden on the person being judged and on his or her interactions with others (Fiske, 1993). Adding to the effect of descriptive stereotypes, prescriptive stereotypes define how certain groups should think, feel, and behave (Fiske, 1993, p. 623). For example, prescriptive stereotypes shape the dominant culture’s expectations regarding people with disabilities. People with disabilities are frequently expected to make daily adjustments to the nondisabled world without complaint and to work hard to “overcome” or “transcend” their disability despite inaccessible physical environments and social barriers caused by others’ fears and hostilities. Moreover, they are expected to do all of this cheerfully (Olkin, 2002). Many stereotypes are overt or explicit, meaning that people are aware they hold them; for example, many White people consciously believe the stereotype of African Americans as exceptionally athletic. However, studies have shown that people also hold implicit bias and stereotypes without any conscious awareness (Greenwald & Banaji, 1995). Furthermore, these unconscious biases and stereotypes can influence people to behave in discriminatory ways (Kirwan Institute, 2014). And implicit biases and stereotypes are particularly difficult to change because if one doesn’t perceive that one is biased, then one sees nothing to change. (To take a test of your own implicit biases, see http://implicit. harvard.edu/implicit/.) Stereotypes, prejudice, and bias, when combined with power, form systems of privilege known as the “-isms” (e.g., racism, sexism, classism, heterosexism, ageism, ableism, colonialism; Hays, 2013). Society socializes less privileged members of these systems to be acutely aware of the lines separating those who have privilege from those who do not. Unprivileged people need to pay more attention to differences and rules, because the outcomes of their lives are more dependent on those who hold power (Fiske, 1993).

25

26

B e co m in g a C u l t u r a l ly R e s pon s i v e T h e r api s t

In contrast, society does not socialize powerful groups to perceive the rules and barriers separating them from the unprivileged because those with power do not need to do so; oppressed groups have little impact on their daily lives. For example, There are many things that an African American child can do that will get him or her characterized as “acting Black” or “acting White,” but there is very little that a European American child can do that will prompt such labeling. . . . Living in a Whitedominated society, the average African American child is made aware implicitly and explicitly of these categorizations on a daily basis . . . [whereas] the average European American child rarely is made aware of anything having to do with these categories. (S. O. Gaines & Reed, 1995, p. 98)

In the United States, systems of privilege and oppression are intimately tied to capitalism. Sexism and racism support the view of women and people of color as “a surplus labor force” that “can be pushed in and out of employment in keeping with current needs of the economy (depression, expansion, wartime, or a period of union-busting)” (Blood, Tuttle, & Lakey, 1995, p. 156). Corporate capitalism also pressures men, who, if they are too demanding, can be easily replaced by women or people of color who cost less. Gender and racial stereotypes—often aided by the media, educational institutions, and the legal system—reinforce the belief that this arrangement is fair and natural (Blood et al., 1995). Members of dominant groups often find it painful to acknowledge the existence of systems of privilege, because the idea goes against fundamental Western beliefs in meritocracy (e.g., “If you work hard enough, you’ll succeed”) and democracy (e.g., “Majority rule is fair”; Robinson, 1999). It is easier for people to believe that instances of prejudice and discrimination are primarily the fault of individual “bad apples.” From his perspective as a European American man, Croteau (1999) explained, To me, racist attitudes and behaviors were solely about the moral or psychological failures or shortcomings of individual White people. Although I probably would not have explained it in a way that sounded this judgmental, it really came down to my seeing racism as what “bad” White people do to people of color. I desperately wanted to be a “good” White person. In retrospect, I realize that this exclusively individualistic and highly judgmental perspective on racism left my fragile ego on the line with every interpersonal interaction I had across racial lines. . . . Seeing racism solely through the lens of individualism was an unforgiving perspective that failed to take into account the reality of socially learned racism. (p. 30)

As Croteau (1999) suggested, systems of privilege harm those who hold privilege as well as those who do not (Locke & Kiselica, 1999). Systems of privilege can separate whole domains of information, knowl-

Essential Therapist Knowledge and Qualities

edge, and skills from the members of dominant groups who might also benefit. For instance, traditional healing practices, many of which do not involve the side effects of European American medications and medical practices, were seen as inferior by the dominant medical establishment until 1978, when the World Health Organization and UNICEF officially recognized traditional practitioners (Jilek, 1994). As a result, European American physicians (and the dominant culture) have been slow to accept such practices (e.g., acupuncture), which continue to be less available to patients in U.S. health care settings. In therapy, this separation of minority-culture knowledge works against the dominant-culture therapist’s understanding of and connection with clients of minority groups. Consider the example of a male cisgender (i.e., one whose social and biological identities are the same) therapist who has a traditional masculine identity and no experience with people who identify as transgender or gender nonconforming. Because this therapist is likely to have the dominant culture’s same limited knowledge and negative bias, he will be limited in his ability to understand the types of daily situations experienced by such a client. To increase his understanding, he would need to work extra hard to obtain the knowledge held by a gender-nonconforming therapist. At the level of personal growth and development, privilege can lead to the internalization of feelings of superiority. Privilege (e.g., in the form of money or powerful social connections) may also prevent a person from developing the coping abilities that less-privileged individuals develop to survive (McIntosh, 1998). A series of studies at the University of California, Berkeley, even found that privilege promoted unethical behavior (Piff, Stancato, Côté, Mendoza-Denton, & Keltner, 2012).

Essential Qualities of Culturally Responsive Therapists Looking for wisdom about how life can best be lived, H. Smith (1991) studied the world’s major religions, including Hinduism, Buddhism, Confucianism, Taoism, Islam, Judaism, Christianity, and Aboriginal Australian spirituality. He concluded that all of these traditions agree on three elements involved in wisdom: humility, charity, and veracity. It seems to me that these characteristics are equally important in becoming a culturally responsive therapist. Humility reminds me that my way of looking at things is not always the best and helps me avoid judging differences as inferior. Compassion (my word for charity) keeps me open and able to appreciate people who challenge my beliefs and values. And critical thinking (which I equate with veracity) requires me

27

28

B e co m in g a C u l t u r a l ly R e s pon s i v e T h e r api s t

to question my assumptions and look for explanations that go beyond what appears to me to be self-evident—to let go of illusions about what I want things to be or how I want to see myself. In addition to these three elements, I add a fourth, courage, because reaching across cultural divides can be painful. Although, in the context of therapy, courage rarely involves the physical threat faced by people who have fought for civil rights, it still takes courage to keep trying. In the face of fear or in the midst of pain from our own or others’ mistakes, the coming to critical consciousness involved in cross-cultural work is, as bell hooks (1998) wrote, “a difficult, ‘trying’ process, one that demands that we give up set ways of thinking and being, that we shift our paradigms, that we open ourselves to the unknown, the unfamiliar” (p. 584). Although it may never be possible to completely escape the influence of societal biases, it is possible to gain an awareness and knowledge base that can help you recognize the influence of these biases on yourself and your work. Such awareness and knowledge increase the likelihood that your decisions, beliefs, and behaviors will be conscious and well informed. Let’s consider further these qualities that facilitate this work.

STAYING HUMBLE WHILE THINKING CRITICALLY I was talking with coworkers in the Native counseling center where I worked when the conversation turned to our workloads. In response to others’ complaints, I said, “I’m so booked out, I have workshops scheduled into next year!” An older Yup’ik woman with whom I had a good relationship smiled and said, “Pam, do you have your death scheduled too?” I laughed along with everyone else, but it was a humbling moment—one that made me think about the ridiculousness of such busyness and the implication that it’s something to boast about. Over the course of my professional life, I have asked various people what they believe is the most important quality or characteristic for someone doing cross-cultural work. The most common response I’ve received is that the person needs to be humble. The word humble comes from humility, which is related to the word humus, meaning earth, and a humble person is often described as down to earth. A humbling experience is one that causes us to think more deeply and thus become a better person (in contrast to a humiliating experience, which is destructive to one’s dignity). When people are humble, they recognize that other viewpoints, beliefs, behaviors, and traditions may be just as valid as their own. In my experience, people who are humble often have a good sense of humor, too. It may seem that the idea of critical thinking is opposed to that of humility because the term critical is often equated with negativity

Essential Therapist Knowledge and Qualities

or confrontation. But thinking critically about our core beliefs and assumptions and the privileges we take for granted invariably leads to a recognition of the legitimacy of other views and of the unfairness of systems that privilege some people’s views and not others’ (Gallardo, 2014). Used in this way, critical thinking facilitates humility, particularly when we use it on ourselves. For example, I consider myself a feminist, and although I recognize some of the objections to its applications (e.g., the early focus on White middle-class women to the exclusion of people of color), I still subscribe to the philosophy. Among my values is the belief that women are better off if they can support themselves financially; for me, this has something to do with personal empowerment and a desire for egalitarian relationships. When I was in my mid-20s, I spent several months interviewing Arab women living in three different environments in North Africa: (a) the cosmopolitan capital city of Tunis, (b) a midsized village that was conservative and traditional in its values and mores, and (c) an impoverished Bedouin community that had gone from a nomadic existence to a settled agricultural life in the previous generation. As part of this research, I wanted to learn how Tunisian women’s lives had changed since the country gained independence in 1956 and enacted laws aimed at improving the status of women. I expected to find some form of economic independence to be associated with greater satisfaction and freedoms, at least for middle-class women. What I found was a bit more complicated (Hays & Zouari, 1995). Nearly all of the middle-class urban women were employed outside the home. They cited mixed reasons for this, namely, that they liked working outside, but that they also needed to bring in extra money because of the higher cost of living in the city. The Bedouin women were poor and had always worked outside the home, in the fields alongside their husbands. Theirs was extremely hard work—bending over for long periods in the hot sun, often with a baby tied to their back. Not surprisingly, this kind of work did not lead the Bedouin women to feel greater satisfaction with their lives; rather, they expressed the most frustration. It was the middle-class women in the village who surprised me by their disinterest in outside employment or a personal income. Granted, occupational opportunities were limited, but among those women who did have some personal income, whether from inheritance or sewing, the money was considered theirs. One woman summarized a common attitude: “I already do all the work at home [as one job]. Why would I want two?” She added that she liked having time in the afternoon to do embroidery and visit with her sisters, her mother, and her friends. She was astonished at how hard I chose to work; I think she even thought I was a little nutty. My learning from her and the other women

29

30

B e co m in g a C u l t u r a l ly R e s pon s i v e T h e r api s t

Think about this: When was the last time you felt humbled by an experience of your own or of someone you met or heard about? Did it lead you to think more deeply about yourself or others?

I spent time with led me to think more critically about my beliefs about women’s roles, men’s roles, personal empowerment, and relationships. Seeing women who were satisfied with lifestyles that contradicted some of my most firmly held beliefs was humbling, to say the least. In this way, humility and critical thinking operate in a reciprocal relationship. Humility opens you to new forms of learning and diverse sources of knowledge, whereas critical thinking about your knowledge, sources of information, and ways of learning, along with constant testing of alternative hypotheses, helps you stay humble and open (López et al., 1989). Sound clinical judgments require both humility and critical thinking. Because a willingness to question oneself is communicated in nonverbal ways, both have the added benefit of facilitating rapport. Consider the example of a European American male therapist working with a single woman of Mexican American heritage and her three children, ages 6, 8, and 12. Following her divorce, the client, who had a 2-year college degree, received no child support and had to move to a low-income apartment and find a job that would support her family. She came to counseling to obtain help in dealing with her 6-year-old son’s bedwetting, so the therapist began working with her to help her son. However, after a couple of sessions, the therapist began having concerns about the 12-year-old daughter, whom he thought of as a “parentified” child (i.e., in the role of the mother’s confidante and partner in raising the two younger children). Because the daughter had no academic or behavioral problems, the therapist decided to consult with a Latina therapist before sharing these concerns with the mother. Through the consultation, he began to realize how his own cultural heritage was influencing his views of what constitutes healthy child rearing. He began to see the possibility that in this family’s case, the child’s role might not be pathological. Although his concerns did not disappear completely, he began seeing the family in a more accepting way, an attitude that manifested itself in behaviors that were respectful of the mother and all that she was doing for her children. (See Falicov, 2014, and Santiago-Rivera, Arredondo, & Gallardo-Cooper, 2002, for more on child rearing in Mexican American and Latino families.) Therapists can ask themselves a number of questions to prevent premature judgments, including the following: ❚❚ ❚❚ ❚❚

❚❚

How did I come to this understanding? How do I know that this is true? Are there alternative explanations or opinions that might be equally valid in this situation? How might my view of the client’s situation be influenced by my age or generational experiences, my ethnic background, my socioeconomic status, and so forth (i.e., the ADDRESSING influences)?

Essential Therapist Knowledge and Qualities

❚❚

❚❚

Might there be some information that lends validity to the view with which I disagree? Might there be a positive, culturally related purpose for the behavior, belief, or emotion that I perceive as dysfunctional or unhealthy?

These sorts of questions will not prevent you from making clinical judgments but rather will slow the process down by encouraging you to consider the client’s context. In addition, asking these questions will increase the likelihood that your hypotheses are closer to the client’s real experience. And the closer your hypotheses are to the client’s real experience, the fewer questions you’ll have to ask, and the less likely you are to ask something irrelevant or offensive. Returning to my learning from the Tunisian women, although I still hold my feminist beliefs, I now realize that my values are directly related to my identity, my opportunities, and my context. Trying to think critically about my beliefs and why I believe what I believe helps me be more open to people who hold values that I might see as contrary to mine. The more open I am, the more compassionate and understanding I can be toward others, which in turn helps me to be a better therapist.

OVERCOMING OBSTACLES TO COMPASSION The concept of compassion is not unique to Buddhism, but it is so clearly described that I find it helpful to use Buddhist concepts when thinking about it (Chodron, 2000; His Holiness the Dalai Lama, 2003; Hanh, 1992). The centrality of compassion in becoming a healthier and happier human being (and thus therapist) was explained by the Dalai Lama, the Buddhist spiritual leader of Tibet: If you maintain a feeling of compassion, loving kindness, then something automatically opens your inner door. Through that, you can communicate much more easily with other people. And that feeling of warmth creates a kind of openness. . . . Then there’s less need to hide things, and as a result, feelings of fear, self-doubt, and insecurity are automatically dispelled. Also, it creates a feeling of trust from other people. . . . Anger, violence, and aggression may certainly rise, but I think it’s on a secondary or more superficial level; in a sense, they arise when we’re frustrated in our efforts to achieve love and affection. (His Holiness the Dalai Lama & Cutler, 1999, pp. 40, 54–55)

Patanjali, a 2nd-century B.C. scholar and author of part of the Yoga Sutras, posited five obstacles to growth that can also be seen as obstacles to compassion: fear, ignorance, aversion to pain, desire, and egoism (Frager & Fadiman, 1998, p. 501). To understand how these obstacles can interfere with a therapist’s effectiveness, consider the examples in the following paragraphs.

31

32

B e co m in g a C u l t u r a l ly R e s pon s i v e T h e r api s t

Fear and Ignorance A young White female therapist experienced an initial fear of an African American male client despite a lack of positive or negative experience with African American men. Her fear led her to pull into herself, away from the client’s experience, thus impeding her ability to engage with and respond compassionately to the man. Fear is often related to a lack of experience and knowledge. As the metaphor of the vacuum pack suggests, as long as this hole of inexperience and knowledge is unfilled by direct personal learning, it is vulnerable to being filled by dominant cultural assumptions that further increase the fear and negative belief about a particular group.

Aversion to Pain Aversion to pain may also lead a therapist to avoid certain topics, shut down, or emotionally distance himself or herself when a painful topic such as cultural differences arises. For example, a nondisabled European American male therapist was repeatedly hurt by others’ assumptions that he was lacking in compassion for people of minority identities. As he attempted to understand the meaning of a female client’s disability from the client’s perspective, he said something (he wasn’t sure what) that seemed to make her angry. As he then reactively pulled into his own pain and anger, the client sensed the disconnection and moved further into her own anger. On the basis of their work with families of people who have disabilities, Hulnick and Hulnick (1989) suggested the following: We have observed many times that there is a sequence that always seems to be present at times of emotional upset. It goes like this. Whenever anger is present and we look beneath the anger, we always find hurt. Anger turns out to largely be a reaction occurring when we feel hurt. And when we look beneath the hurt, we always find caring. We are only hurt when something or someone we care about has been, in some way, desecrated or violated. . . . This sequence gives us the key for effectively handling these types of situations. It is this. Give a client full permission to express his or her deepest pain. In fact, assist clients by actively encouraging them in expressing it. (p. 168)

Desire and Egoism The fourth and fifth obstacles of desire and egoism can play out in the therapist’s attachment to a particular theoretical orientation or outcome. From a Buddhist perspective, attachment to one viewpoint, conceptualization, or idea often leads to unnecessary suffering (Rao, 1988). In the therapeutic setting, allowing one’s theoretical orientation to take precedence over a client’s concerns may result in an inaccurate assessment or an intervention that is inappropriate or ineffective.

Essential Therapist Knowledge and Qualities

For example, in working with a client who has anxiety about an impending move, a present-oriented, cognitive–behavioral therapist might overlook the importance of the family’s multigenerational migration history. Alternatively, in response to a client’s depression in dealing with coworkers’ racist comments, a psychodynamically oriented therapist might overemphasize the client’s early upbringing in exploring feelings about the situation and fail to address the need for immediate practical changes in the client’s environment (e.g., talking to a supervisor, filing a grievance, requesting a transfer).

MINIMIZING DEFENSIVENESS Fear, ignorance, aversion to pain, and attachment contribute to defensiveness—the cognitive and emotional rigidity that occurs when one feels threatened or attacked. As C. B. Williams (1999) noted, it is a frequent reaction among counselors when talking about racial issues across racial groups (and, I would add, across the other ADDRESSING identities as well). In the therapeutic setting, feelings of defensiveness may lead therapists to focus on the justification of their own ideas or perspective—a shift in one’s primary concern that is easily perceived by clients, who may then engage in self-protective behaviors such as emotionally distancing themselves from the therapist. In turn, therapists’ defensive behaviors may include tense body posture, raised voice, patronizing voice tone, recitation of one’s credentials, loud sighing, and so on. It is probably impossible to eliminate defensive feelings. It may also be undesirable, because emotions often serve as cues that something is amiss. However, it is possible and usually desirable to refrain from engaging in defensive behaviors, particularly if these behaviors interfere with one’s acceptance of and concern for another person. My friend Bob was principal of a high school in a Siberian Yup’ik village in Alaska. One day, a European American male teacher (all of the teachers were European American) came in to see him. The teacher was furious because he said that he had corrected one of his students, and the boy had laughed at him. The teacher considered the boy’s behavior to be a sign of disrespect. So Bob suggested that he bring the boy in, which the teacher did, and as the teacher repeated his complaint in a loud, angry voice, the boy began laughing again. Bob told the teacher to leave. When they were alone, Bob asked the boy what had happened, and the boy dissolved into tears. The boy hadn’t meant to laugh, but like all the students there, he spoke English as a second language and didn’t understand what the teacher had wanted him to do. His laughter was out of embarrassment at the teacher’s angry focus on him. Unfortunately, the teacher was too stuck in his own defensiveness to stop the downward spiral of their interactions

33

34

B e co m in g a C u l t u r a l ly R e s pon s i v e T h e r api s t

(i.e., the more the teacher shouted, the more the boy laughed). If Bob had accepted the teacher’s (dominant cultural) view of the problem, he would have missed the opportunity for seeing what was really happening. But by staying open and looking for alternative explanations, Bob opened the way for a deeper understanding of the boy.

MAINTAINING A MINDFUL APPROACH One way to build humility and sustain openness (and in turn prevent defensiveness) is to become nonjudgmentally aware of your experience in the moment, a process known as mindfulness. The Vietnamese monk Thich Nhat Hanh (1992) described the importance of mindfulness in resolving defensive feelings: The word samyojana refers to internal formations, fetters, or knots. When someone says something unkind to us, for example, if we do not understand why he said it and we become irritated, a knot will be tied in us. The lack of understanding is the basis for every internal knot. If we practice mindfulness, we can learn the skill of recognizing a knot the moment it is tied in us and finding ways to untie it. Internal formations need our full attention as soon as they form, while they are still loosely tied, so that the work of untying them will be easy. If we do not untie our knots when they form, they will grow tighter and stronger. (p. 48)

Think about this: What are your defensive behaviors? If you don’t know, ask your partner, your closest friend, or your teenager.

We often experience these “knots” as physical sensations (e.g., chest tightness, stomach butterflies, adrenaline rush) associated with emotions of anger, fear, pain, or jealousy. These sensations can serve as cues that you are focusing more on yourself than on your client. Identifying the precipitants of these sensations and feelings can help you predict in advance your inclination to behave in an unhelpful way. Then your increased awareness can help you take action that helps you “stay with” your client instead of being pulled into defensive behavior. For instance, in a session with an older client, a young therapist began to experience tension in his forehead and upper back. He used these sensations as cues to recognize that he felt some fear about working with a client who was much older than he was. In recognizing this fear, he was then able to refrain from behaviors that he would normally unconsciously engage in when he felt afraid and inadequate. Rather than describing his qualifications in such a way that the client perceived him as bragging (i.e., a form of focusing on oneself that pushes the other person away), the therapist openly discussed with the client how his younger age might limit his understanding of the client’s situation. Because the latter behavior made the therapist vulnerable and thus communicated his humanness, it facilitated a sense of connection between the two.

Essential Therapist Knowledge and Qualities

When confronted with feelings of discomfort or defensiveness, a helpful first step is to take a deep breath, exhale slowly, then focus for a few seconds on your breath. This emphasis on breathing as a way of grounding oneself is found in Yogic and Buddhist meditation practice as well as in their behavioral descendent, relaxation training. With this focus, it is then more possible to ask yourself about the need for you and the client to agree. That is, must this client conceptualize his or her problem, situation, or options in the same way that you do? It may also be constructive to ask yourself if there are alternative opinions that may be as valid or useful as your own. Might there be some information or experiences that would allow you to appreciate these different perspectives? How might you go about getting information or experiences that could lead to a broader vision and understanding of the client and his or her situation? Note that these questions parallel those offered earlier for thinking critically while staying humble. To summarize, we can never eliminate defensive feelings. However, we can decrease defensive behaviors by following these steps: 1. Be mindful of the physical sensations that accompany feelings of defensiveness, fear, and pain. If possible, identify the precipitants of these sensations and feelings to help you predict defensive feelings and behaviors before they occur. 2. Use these physical sensations as cues to what you are feeling. When you feel defensive sensations and emotions arise, take a deep breath, exhale slowly, and then focus for a few seconds on your breath. 3. Refrain from defensive behaviors (e.g., talking too much, emphasizing your own accomplishments, emotional distancing or withdrawal). 4. Question the need for clients’ views to match your own. Are there equally valid alternative opinions? 5. Recognize your need for additional information and experiences. If appropriate, discuss the limitations of your knowledge and experience with the client.

KEEPING A SENSE OF HUMOR A few years ago, I was asked to see Mr. Smith, a married man in his 70s, for questions about depression and cognitive difficulties. As I approached his hospital room, I could hear what sounded like an argument between him and his physician: Physician: Now, George, you’re gonna have to start listening to what I’m telling you. If you don’t do this, you’re going to have bigger problems. Are you listening to me?

35

36

B e co m in g a C u l t u r a l ly R e s pon s i v e T h e r api s t

Mr. Smith: Oh, why don’t you just go find somebody else to pester? Cringing a little inside, I knocked on the open door, then walked in and introduced myself. Mr. Smith was in a wheelchair and hooked up to an IV. He was hunched over (whether he had osteoporosis or depression or was just angrily facing the floor, I couldn’t tell). The physician gave me a warm smile and said, “Well, George, I guess you’re the lucky one who gets to stay here and talk with Dr. Hays, so I’ll just be heading out.” Mr. Smith grumbled something; I couldn’t see his face. Just then, the physician turned away to sign his chart note. In that moment, Mr. Smith raised his head, looked right at me, winked, and put his head back down. I immediately relaxed and let go of the negative expectations and defensive feelings I’d been building since approaching the door. Humor provides an opportunity to step out of one’s cognitive set, even if only for a few moments (Mahrer & Gervaise, 1994). This shift can help you see a new perspective and appreciate people who hold beliefs with which you disagree (Lemma, 2000). It can also help clients do the same, assuming that the humor is not hurtful. Years ago, I read somewhere that sharing a healthy laugh with someone can be as powerful a way to feel connected as sharing one’s pain, and this certainly seems true to me.

Conclusion To understand and connect with people of diverse minority identities, it is essential that therapists have knowledge of how individual and societal biases form and of the impact of systems of privilege and oppression on minority and dominant groups. Humility, compassion, critical thinking, and courage are all important for using this knowledge effectively in the therapeutic setting. But these qualities, skills, and knowledge do not ensure culturally responsive practice. There is still the need to be aware of one’s own personal knowledge gaps, biases, and areas for further growth. This topic is explored in the next chapter.

Practice: Preventing Defensiveness During the next week, watch for your own defensive reaction and the situation or person that elicits the defensive feelings in you. Then try using one or more of the five steps listed in this chapter to avoid engaging in defensive behaviors and stay respectfully connected to the other person.

Essential Therapist Knowledge and Qualities

Key Ideas

  1. Bias is best thought of as a tendency to think, act, or feel in a particular way, sometimes guiding one toward more accurate hypotheses, but sometimes not.   2. When bias is reinforced by powerful groups and social structures, the results are systems of privilege and oppression (e.g., racism, sexism, classism, heterosexism, ableism, ageism, colonialism).  3. Unprivileged members of these systems are socialized to be acutely aware of the lines separating those who have privilege from those who do not, because the outcomes of their lives are more dependent on those who hold power.   4. Privileged members are socialized to be less aware of the lines and differences related to privilege.   5. Members of dominant groups often find it painful to acknowledge the existence of privilege systems because the idea goes against fundamental Western beliefs in meritocracy (e.g., “If you work hard enough, you’ll succeed”).   6. Privilege separates dominant-culture therapists from information and experiences that could help them understand and connect with minority-culture clients.   7. Humility, compassion, critical thinking, and courage facilitate therapists’ work across lines of privilege and oppression.   8. The obstacles of fear, ignorance, aversion to pain, and attachment can contribute to defensiveness.   9. Although defensive feelings can be helpful as cues that something needs attention, defensive behaviors are a problem when they create emotional distance between the therapist and client. 10. Steps to minimize defensive behaviors include being mindfully aware of the physical sensations that accompany defensive emotions, focusing on one’s breath in the moment, and questioning the need for a client to see things in the same way you do.

37

Doing Your Own Cultural Self-Assessment

S

3

ue was a newly hired clinician at a rural American Indian counseling center. Although she had several years of experience working in urban clinics with Latino and African American people, she had never worked with a Native organization or in a rural community. Sue liked her new work and the people, but over time she became frustrated with the slowness of change. After a few months, she complained to an Indian coworker that she couldn’t understand why it took so long to decide on a solution and implement it. The coworker explained that in contrast to many non-Native organizations in which decisions are made by an individual director, their center placed a high value on consensus and giving everyone who might be affected a chance to speak, share concerns, and contribute to the solution. The goal was to have everyone on board with the change whenever possible—a process that took longer on the front end but, once the decision was made, involved less time taken up by employee distress, resignations, and new hires.

http://dx.doi.org/10.1037/14801-003 Addressing Cultural Complexities in Practice: Assessment, Diagnosis, and Therapy, Third Edition, by P. A. Hays Copyright © 2016 by the American Psychological Association. All rights reserved.

39

40

B e c o m in g a C u lt u r ally R e sp o nsi v e T h e r apist

Before this job, Sue had never worked in a setting that prioritized consensus over speed, and because she was a member of the dominant culture herself, there was nothing in her personal experience that challenged this value priority. So not only was she frustrated by the clinic’s different approach, but she also had a negative bias toward it—that is, she assumed that her (the dominant culture’s) approach was better. But after talking with her coworker, she could see the prioritization of different values as culturally based and began to appreciate the respect embedded in this slower approach. In general, our privileged areas are those in which we hold the least awareness, because privilege tends to cut those with privilege off from direct knowledge of and experience with minority perspectives. The challenge for us as therapists is to recognize our particular areas of privilege and commit to the extra work that is required to fill our knowledge gaps. Toward this goal, there are a number of practical steps you can take to increase your self-awareness and knowledge, including, but not limited to ❚❚ ❚❚

❚❚ ❚❚

investigating your cultural heritage and how it influences you; paying attention to the influence of privilege on your understanding of cultural issues, and hence on your work with clients; educating yourself through diverse sources of information; and developing relationships with diverse people.

Work in each of these areas can be facilitated through the use of the ADDRESSING framework.

Investigating Your Own Cultural Heritage To start or deepen your cultural self-assessment, it can be helpful to think about the ways in which the ADDRESSING influences have affected you, whether you are a member of a dominant or minority group (or both) in relation to each influence. Table 3.1 shows how a cultural self-assessment might look using the therapist Olivia as an example. Under Age and generational influences, Olivia wrote, “55 years old; third-generation U.S. American; member of politically active generation of Chicanos and Chicanas in California; first generation affected by post-civil rights academic and employment opportunities in the 1970s.” On the line for Developmental or other Disability, she wrote, “Chronic knee problems since early adulthood, including multiple surgeries; sometimes I use crutches to walk.” She continued through the list, with some overlap

Doing Your Own Cultural Self-Assessment

TA B L E 3 . 1 Cultural Self-Assessment: Example of Olivia Cultural influence

Olivia’s self-assessment

*Age and generational influences

55 years old; third-generation U.S. American; member of politically active generation of Chicanos and Chicanas in California; first generation affected by post-civil rights academic and employment opportunities in the 1970s. No developmental disability, but chronic knee problems since early adulthood, including multiple surgeries; sometimes I use crutches to walk. Mother is a practicing Catholic, father a nonpracticing Presbyterian; my current beliefs are a mixture of Catholic and secular; I do not attend mass. Mother and father both of mixed Mexican (Spanish and Indian) heritage, both born in the United States; my own identity is Chicana; I speak Spanish, but my primary language is English. Parents urban, working, lower-middle-class members of an ethnic minority culture; however, my identity is as a university-educated Chicana; I identify with working-class people, although my occupation and income are middle class. Heterosexual; I have one friend who is lesbian. My maternal grandmother was Indian and immigrated to the United States from Mexico with my grandfather when they were young adults; what I know about this part of my heritage came from her, but she died when I was 10 years old. United States, but deep understanding of the immigration experience from my grandparents. Woman, Chicana, divorced, mother of two children.

Developmental or other Disability *Religion and spiritual orientation Ethnic and racial identity *Socioeconomic status

*Sexual orientation Indigenous heritage

*National origin Gender

* connotes dominant cultural identity.

between categories, providing a general sketch of both minority and dominant cultural influences and identities salient for her.

YOUR CULTURal SELF-ASSESSMENT Take some time to answer the questions in Exercise 3.1, but don’t feel limited by the questions; they’re simply a starting point to get you thinking about the cultural influences on you. If these influences or your identity has changed over time (e.g., if you grew up identifying with a religious community and no longer do), note the earliest ones first, then the later ones. Fill in every category, even those for which you hold a dominant cultural identity, because this, too, is meaningful information (e.g., even if you have never had a disability, consider how your physical and intellectual abilities have affected your life and opportunities). As already noted, some of these influences overlap. For

41

42

B e c o m in g a C u lt u r ally R e sp o nsi v e T h e r apist

EXERCISE 3.1 Your Cultural Self-Assessment Age and generational influences: When you were born, what were the social expectations for a person of your identity? What are they now? Do you identify with a particular generation (e.g., baby boomers, millennials, Generation X or Y, World War II veterans)? How have your values and worldview been shaped by the social movements of or influences on your generation (e.g., the Great Depression, World War II, Vietnam War, women’s movement, Stonewall riots, Americans With Disabilities Act, civil rights movement, social media, economic downturn, university costs, climate change, wars in Iraq and Afghanistan)? What generational roles are core to your identity (e.g., aunt, father, adult child, grandparent)? How have these roles influenced your life? ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Developmental or other Disability: Were you born with a disability, or did you acquire one later in life? If yes, is it a visible or nonvisible disability (e.g., chronic pain, psychiatric illness, or cognitive impairment)? If no, have you been a caregiver or lived with someone who has a disability? How has disability affected your life and opportunities? ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Religion and spiritual orientation: Were you brought up in a religious or spiritual tradition? Do you identify with a religion or have a spiritual practice now? How were your values and goals shaped by your religious or nonreligious upbringing? ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Ethnic and racial identity: What do you consider your ethnic or racial identity? If you were adopted, what are the identities of your biological and adoptive parents? How do other people identify you? Are these the same? Are there ethnic or racial differences within your family? If so, how are these differences perceived, and how have they affected you? ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Socioeconomic status: What social class did you grow up in, and what do you consider to be your socioeconomic status now? When you were in high school, what were the educational and work opportunities available to you? Do you have peer-level relationships with people who differ from you socioeconomically (i.e., defined by educational, income, and occupational levels)? ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

Doing Your Own Cultural Self-Assessment

E X E R C I S E 3 . 1 (Continued) Sexual orientation: Do you identify as gay, lesbian, bisexual, or heterosexual? If you are heterosexual, do you have a family member or friend who is gay? Is your family accepting of a gay member? How has your minority or dominant sexual orientation affected your relationships and educational and work experiences? ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Indigenous heritage: Do you have any Native heritage—for example, Native Hawaiian, First –ori, or Aboriginal Australian? Did Nations, Alaska Native, American Indian, New Zealand Ma you grow up on or near a reservation or Native community? If so, how has this affected you? If not, how has the lack of such experience affected you? Do you belong to a culture that has a multigenerational connection to a particular land, water, or place? ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ National origin: Are you a U.S. citizen, an international student, or an immigrant? Were you born in the United States? Do you (and your parents and grandparents) speak English as a first language? How has your English-language ability affected your life and opportunities? How has your nationality affected your life and opportunities? ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Gender: What were and are the gender-related roles and expectations for you in your family of origin and current family? When you were a teenager, what were the norms, values, and gender roles supported within your family, by your peers, in your culture, and in the dominant culture? How have these expectations affected your choices in life? ________________________________________________________________________________________ ________________________________________________________________________________________ Note.  Adapted from Addressing Cultural Complexities in Practice, Second Edition: Assessment, Diagnosis, and Therapy (p. 44), by P. A. Hays, 2008, Washington, DC: American Psychological Association. Copyright 2008 by the American P­ sychological Association.

example, if you are Jewish, you might note your Jewish heritage under Ethnic and racial identity, or under Religion and spiritual orientation, depending on how you conceptualize these influences on you. The degree to which this exercise is helpful depends on how far you take your exploration. For instance, in the area of Age and generational influences, simply recognizing your chronological age is not particularly informative. However, exploring generational influences, including

43

44

B e c o m in g a C u lt u r ally R e sp o nsi v e T h e r apist

historical and sociocultural contexts and their developmental impact on you at particular ages, is a rich source of information. In addition, exploring the meaning of these diverse influences on you can be facilitated by participation in a group, because hearing the ways in which other people have experienced culture will bring up ideas you may have overlooked.

HOW PRIVILEGE AND CULTURE AFFECT YOUR WORK Taking this exploration a step further, the next exercise will help you recognize the ways in which identity privileges affect your life and work. I’ve found it helpful to emphasize privilege (rather than oppression) because most of us are very aware of the areas in which we feel oppressed but much less aware of the areas in which we hold privilege. And unrecognized privilege is dangerous for therapists because privilege cuts us off from information and experiences that help us understand our clients. Now return to your cultural self-assessment (Exercise 3.1). Look back over each category, and next to the areas in which you hold a dominant cultural identity, put a little star (*). (Look again at Table 3.1 to see the stars next to Olivia’s dominant cultural influences.) For example, if you are between 30 and 60 years old (i.e., a young to middle-aged adult), put a star next to “Age and generational influences.” If you do not have a disability (i.e., if you are a member of the nondisabled majority), put a star next to “Developmental or other Disability.” If you grew up in a secular or Christian home, put a star next to ”Religion and spiritual orientation.“ Continue on down the list, starring “Ethnic and racial identity” if you are of European American heritage, “Socioeconomic status” if you were brought up in a middle- or upper-class family or are currently of middle- or upper-class status, “Sexual orientation” if you are heterosexual, “Indigenous heritage” if you have no Indigenous heritage, “National origin” if you live in the country in which you were born and grew up, and “Gender” if you are a cisgender male. Now look at your ADDRESSING self-description with attention to the stars. Every individual has a different constellation. However, because a majority of therapists in North America hold membership in dominant ethnic, educational, and socioeconomic groups (e.g., the composition of many U.S. mental health disciplines is 90% White; F. F. Duffy et al., 2004), when I do this exercise in the United States people are often surprised by how many stars—that is, how much privilege—they have. This is true even for therapists who hold a minority identity in one area, such as ethnicity, but are privileged in others, such as generational status, educational level, socioeconomic status, sexual orientation, or physical abilities. As you may notice, recognizing the areas in which we hold privilege is not simple. Privilege can change over time—for example, for a person who grew up in poverty but now lives a middle-class lifestyle. Privilege

Doing Your Own Cultural Self-Assessment

also varies depending on context. For example, a middle-class older Chinese man living in British Columbia may experience little privilege in relation to the dominant Anglo majority. However, within the Chinese Canadian community in Vancouver, the same man’s age, gender, and socioeconomic standing may give him significant privilege. In fact, he may be quite powerful in his particular community. Perceiving one’s own privileges can be difficult because, as the saying goes, privilege is like oxygen—you don’t notice it unless it’s not there. This is particularly true among members of dominant groups, because there’s a tendency to become defensive, which blocks recognition of one’s own privilege. For example, I once met a woman who insisted she had no privilege while teaching in a Yup’ik village in Alaska. She said that because she was one of the few White people there, she was the “oppressed one.” But what she didn’t recognize was that despite it being a Native village, everyone in her workplace had to speak her language (English); the curriculum she was teaching was developed by people of her culture; the power structure and values prioritized in the school were those of her culture; the school authorities (principal and superintendent) and legal authorities (state trooper who flew in and regional judge) were members of her culture; and the computer, TV, and radio were dominated by perspectives representing her culture.

The Case of Ned To give you a better idea of how the process of self-exploration and selfquestioning can work, consider the responses to questions by a therapist named Ned.1 People would generally see Ned as a middle-aged, middle-class White man; however, his identity is much more complex when considered via the ADDRESSING framework. His example is a good one for illustrating the point that cultural influences affect all people in complex ways, whatever their identities. Table 3.2 summarizes the ADDRESSING influences in Ned’s life. The following interview provides the background for understanding the meaning of Ned’s self-description in Table 3.2: Interviewer: How have these cultural influences shaped who you are, how you see yourself, and how clients see you? Ned: Well, clearly they’ve all influenced me in a great way. I think the most significant factor in my life would probably be having been . . . adopted; I’m 1 Ned chose to use his real name for this interview to be congruent with his beliefs and his desire to be open about who he is.

45

46

B e c o m in g a C u lt u r ally R e sp o nsi v e T h e r apist

TA B L E 3 . 2 Cultural Self-Assessment: Example of Ned Cultural influence

Ned’s self-assessment

Age and generational influences

Post-World War II baby boomer; I identify with the sense of hopefulness of my generation and a shared history of political and social upheaval in my early adult years (grew up near Berkeley, CA). No current disability, but I once had cataracts on both eyes that hindered my work for 1 year; also, I was the primary caregiver for parents, both of whom had a heart attack or stroke in their 50s. Grew up in a fairly religious Irish Roman Catholic family; currently a “recovered” Catholic with a strong sense of spirituality as well as a belief in reincarnation, Buddhist philosophy, and earth-based spiritualities. One-half Irish, one-quarter French Canadian, one-quarter Seneca Indian; adopted at birth and reared in an Irish American family; as an adult, reconnected to Native heritage through legal search, academic study, professional work, and social relationships. Adopted into a middle-class family that made it into upper middle class; currently upper middle class. Gay, with some bisexual leanings; was married to a woman in my early 20s, had a child with her, then divorced; was married to a male partner 23 years and politically active in the gay community. See Ethnic and racial identity. Born and reared in United States; English is first language. Male; roles as son, brother, father, and partner.

*Developmental or other Disability *Religion and spiritual orientation

*Ethnic and racial identity

*Socioeconomic status Sexual orientation

Indigenous heritage *National origin *Gender

* connotes dominant cultural identity.

hesitating, because the word that comes to mind is abandoned, and I do think that’s a significant piece, because the abandonment stuff has been pretty big in my life.  I was adopted by my Irish Catholic family at the age of 10 months. My sister was also adopted, but she was 100% Irish. I’ve known my whole life that I was adopted, but I did not find out more about my background until high school. Then, much later, I did a legal search, not to get in contact with my biological parents, but because I wanted more of a cultural identity, more of a sense of who I was. And that’s how I found out about the French Canadian and Seneca piece.  [As for the meaning of this for me,] it’s a mixed blessing. Because I found it out as an adult, with a fair amount of education behind

Doing Your Own Cultural Self-Assessment

me and an interest already in diversity, the first thing that it did was that it slapped me in the face with my own prejudice. What I felt was a lot of pain because I realized how much I had bought into stereotypes growing up. I lived in a family with a father who was pretty bigoted, my mother less so but still influenced by her culture. I was raised in a pretty privileged, White, uppermiddle-class environment on the East Coast, in the Midwest, in the South, and then in California. I went to junior high and high school in Oakland, California, and that was very diverse; the schools were about 60% students of color. That introduced me to a whole lot more. But I still lived in a White neighborhood.  In finding out more about my ethnic heritage, I had fairly avoidant behaviors, particularly around Native Americans. One, because growing up in the East and Midwest, I didn’t see them; even in California, the Native population was not very visible. Seattle is the first city I’ve lived in where there is a much larger Native population that is urban. I also had a painful awareness of how I had these internalized stereotypes of people who were lazy, who were drunk, who didn’t parent very well. And then having to discover that there was a part of me that fit into that group was really hard, and it still is.  I’ve never felt a part of my family, so to some degree I feel more connected now that I have a sense of my ethnic heritage. But I still feel pretty isolated from a community. Through my adoptive family, I can connect to my Celtic heritage, but there’s still this other half of me. I’m trying to find ways to connect with that in more meaningful ways. I battle with feeling like an outsider because, basically, I am. I have been putting out feelers to the Seneca tribe, which is one of the more decimated groups of the Iroquois Nation. They are primarily in upper New York State, Ontario, and Québec. But they’ve lost their land and don’t really have a place.  I’ve also made some strong connections in the Seattle community. I completed the Native American mental health specialist certification

47

48

B e c o m in g a C u lt u r ally R e sp o nsi v e T h e r apist

and did a lot of work with the Seattle Indian Health Board, which gave me more of a sense of how to work. I have also spent a lot of time in some rural areas of Mexico, particularly with Zapotec Indians. I did observations with their healers, studying with a translator, as part of my dissertation work.  I had these interests even before I knew the details of my heritage. But it was still pretty painful for me to see that despite all of that, there was still part of me that avoided Indian people. I don’t have this problem when I’m someplace else. But in my own home community, I really have to push myself to change that. It’s still a struggle in that I generally want to feel connected, but I also feel like a fraud, because I was not raised with the identity. And clearly the other piece for me is that I look White. Interviewer: How do these influences affect your comfort level in certain groups and your feelings about particular clients? Ned: There’s a double-edged sword. On one hand, they allow me to feel fairly comfortable about being with people I don’t know. I resort back to being the quiet observer at the beginning before I move in. The flip side of it is that I can get so introspective and so conscious about how I can best connect that I get in the way of opportunities that are available. It’s the fraud thing. I would hate for any person or group of people to think that I’m co-opting them or attempting for all the wrong reasons to be a part of them. Interviewer: What is the relationship between your visible identity and your self-identification? Ned: Today, they are much more congruent. But I would say historically, I was really good at having a facade of being personable and present, when internally I experienced myself differently. I did a really good job of acting. But I didn’t feel as confident inside. Interviewer:  How has your self-identification been influenced by your cultural context? Ned: A lot. I think there’s a cultural thing with being an adult adoptee. It comes out in the part of me that realizes the male White privilege I have

Doing Your Own Cultural Self-Assessment

and how uncomfortable I can feel about that sometimes, even though I realize it’s somewhat uncontrollable. And adding to it is the recognition that I had all of that, and then finding out that I’m not really that at some level, or not all of me. I mean, in the purest sense, I’m not this White middle-class straight male. And that’s a whole thing that we haven’t even touched on— the gay aspect. Interviewer: Was there a parallel between the time you began to recognize that you were gay and the time you started to learn about your ethnic identity? Ned: The gay part happened much earlier. I mean, I knew, but I didn’t have a word for it. But I knew that I was attracted to other boys at about age 6 to 8. Certainly, culturally, it was not just my family but also the world around me. I didn’t really get it—that there were gay people—until I was in college. And that says something about the interaction between the social and family system. I mean, I grew up in the Bay Area, and I had no clue until I moved here. And I spent lots of time in San Francisco, and so, like, where was I? I have no idea. I dated women, and I had these full-blown attractions to men. And I was comfortable about it, but I knew I couldn’t talk about it.  I think the hard thing now in my life is that although I feel so much more congruent, I am more aware when I act in opposition to this desire to be authentic. I don’t have to or want to hide parts of myself. There are certainly places and situations where I come up against that—hiding myself—where it feels very clear that I should keep my mouth shut, for safety. However, I am no longer willing to consciously lie. Now, I might find creative ways around it that feel safe. Still, being more conscious means being aware of my discomfort.  But that’s contemporary, and it’s been true for the past 10 to 15 years. Previous to that, it was a real struggle. I mean, my homophobic stuff played itself out in terms of finding ways to avoid having to deal with it. I didn’t want to lie, but I didn’t want to get in trouble either, and I could pass as straight really well. To me, it was

49

50

B e c o m in g a C u lt u r ally R e sp o nsi v e T h e r apist

particularly evident not so much in my own life and how it had an impact on me, but in the sense that I wouldn’t say anything when other people were making jokes or cracks. And now I feel ashamed that I didn’t say something—which I’m no longer willing to do, about anybody. And that’s true in terms of my ethnic relations stuff, too. If I have anything in my life that haunts me now, that’s it—that for a long chunk of time I didn’t stand up and say, “This is not OK.” Interviewer: When clients first meet you, and know nothing about you, do you have an awareness of how they perceive you? Ned: I suspect that they perceive me as this middleaged—oh, I don’t like to say that word—this youthful, middle-aged, White guy and assume that I’m straight. I think that once we’ve chatted for a little while, they have a sense of me that’s deeper. And it’s not so much about whether my exterior has changed, but their sense of my being that’s shifted. Interviewer: How might your areas of privilege affect your work (e.g., your clinical judgments, theoretical preferences, view of clients, beliefs about health care)? Ned: The biggest piece for me, and I try to keep really conscious of this, is the biases that come out of the givens of my life. It’s something that I always have to pay attention to in terms of the expectations I have of people. In other words, when someone is clearly different from me, it’s much easier for me to step out of my biases, because I think I’m more conscious of them. I actually struggle more with people who look like me, or are more like me, because then it’s easier to make assumptions that I shouldn’t make about their experience. On one level, I really do believe that we all have the capacity to do whatever we want to do. And I think that there are tremendous obstacles based on history and all these “isms” we’re talking about.  But underneath that, I still really believe the idea that we can all transcend ourselves in some way, even if it’s just our attitude. So sometimes

Doing Your Own Cultural Self-Assessment

I have to be careful that I’m not leaving things out, like the obstacles; that has happened, and I have to catch myself that I don’t make these assumptions.  The other thing to pay attention to is values with people of particular backgrounds. The biggest place I get caught is between the value of the group versus the value of the individual, to stay conscious of not placing importance on the individual only. I’ve also been in situations where there’s so much value placed on the group that the individual gets lost. It’s not that it’s right or wrong; it’s just priorities. Interviewer:  How about in terms of your theoretical preferences? Ned: I can’t help but assume that because I was raised in this Western culture as a White male, that’s influenced me to some degree. I’ve certainly known that early on, for me, a cognitive–behavioral training program was attractive because it was rational. It was about changing thinking, and that made sense to me—even though that’s not how I operate very well, but I got caught in it, and I was good at it.  I also think that my later attraction to existentialism was influenced by Western culture, which values the individual more than the group. And I think that I was attracted to Zen Buddhism for the same reason. Zen Buddhism is a very rational, individually oriented kind of thing, and I think it’s also larger than that. It’s about the individual within a group context. When I talk to people who were raised in Buddhist cultures, they have a very different slant on it than I do, yet this doesn’t diminish the usefulness of this perspective for me.  I also have a firm belief that both of these theoretical leanings have lots of room to be widened. I think that there are elements of each that address societies and groups and not just the individual. But that has to be conscious, something you do with it, which is most of the work I’m trying to do now. Clearly, I’m still influenced by my experience, which I can’t change.

51

52

B e c o m in g a C u lt u r ally R e sp o nsi v e T h e r apist



 And that’s the other big thing I’ve come to realize: I can’t leave behind my context, so how do I adapt it? I think it’s a trend now to want to throw it out, because it’s “bad,” but I can’t. We see this now in how many Westerners attempt to co-opt Eastern thought without truly understanding the context. In the process, they have once again done this Western dualistic split— Eastern is good, Western is not.  I can change what I think about things, but I can’t change who I am. So I have a hard time with folks out there throwing everything off of their Euro/White, Christian culture and trying to be something they’re not. I think we can learn from lots of other things, but we’re always going to interpret it in a Western way. We can live in another country for years, and there’s still going to be a way in which we perceive things. I think that’s one of the reasons why both Zen Buddhism and existentialism offer me so much, because the one thing they do similarly and really well is that they hold the paradox. To me that’s so essential. It’s not about leaving one behind and moving to another, or either–or. It’s about both–and. Interviewer: Now, at the age of 60, how have your agerelated experiences affected you? Ned: I’m so much more aware of the aging process and the way others perceive who I am. It’s funny, in that we often hear older adults talk about the almost discordant way in which their internal experience of themselves and what they see in the mirror are so different. I intellectually understood that, but it wasn’t until the past several years that I really got it. I don’t feel very different than when I was in my thirties and forties, but I know that others perceive me as “older.” Certainly I have very real moments of being aware of aging (yoga is not quite as easy as it used to be; I have more aches and pains when I am not staying active), but my internal frame of reference for life in general still has me thinking of myself as young.

Doing Your Own Cultural Self-Assessment



 In addition, the loss of my partner of almost 28 years was a significant event in my life. It was so totally unexpected and sudden. He was 4 years younger than I and suddenly, at the age of 52, was diagnosed with cancer. Although initially it was termed “highly treatable,” it got into his brain and nervous system, and things went downhill fast. From diagnosis until death was only a little over 3 months. Although over the past 15 years I’ve also lost both parents, theirs were more expected, and they had lived fuller lifespans. Losing a younger partner is and was so much more a shock to the system. Believe me, going through that major life event 4 years ago completely reshaped my perspective on being in the world.  Although I am immensely grateful for the amazing community support we both had, and the fact that we had the time to do closure and say what was needed, it really made me reevaluate my life and what I wanted to do from that point on. I think it has both grounded me in the reality of time and mortality and truly allowed me to live even more in the present, which is something I have been attempting to practice for many years.  Now I’m not willing to just do what is expected. I’m not willing to waste my life on things that do not provide meaning and value. I’ve been able to disengage from administrative work commitments that no longer provide meaning for me so that I have more time to do work that I love (teaching, mentoring, writing, creating). I’ve even reintegrated my first profession (theater) back into my life—with another former theater professional, I’ve started a theater company focused on theater with a social conscience and have been producing, acting in, and directing plays for the past 4 years. It brings great joy and balance to my life. In addition, it has really allowed me to see how much my previous theater training and experience contributed to my work as a clinician and how much of my clinical training and practice deepens my work as an actor and director.

53

54

B e c o m in g a C u lt u r ally R e sp o nsi v e T h e r apist

Interviewer: Has disability affected you as you’ve aged? Ned: I’ve fortunately not really had to deal with disability at this point in life. Although I do have some small peripheral vision loss as a result of a torn, detached retina and the subsequent surgery several years ago, I have been lucky that the surgery stabilized my vision, and I have had no further problems. As my doctor stated, “You have really healthy eyes; they are just really old.” Oh, boy! Interviewer: How have these experiences helped you be a better therapist? Ned: I definitely know that going through real and potential losses has had a great impact. The very real losses of my parents and my partner and the awareness of the potential to lose one of my senses (sight) both offered me the opportunity to self-reflect and attend to what priorities I had placed on my day-to-day life and to reevaluate and make changes in what was and is important to me. Now, as I work Think about this: with clients and students, I feel I 1. How have cultural influences shaped who have such a different and deeper compassion for suffering in all forms. you are, how you see yourself, and how I feel like it is easier in many ways clients see you? to find the places where they and I 2. How do these influences affect your comfort connect, whether it is similar expelevel in certain groups and feelings about riences or feelings or beliefs. It has particular clients? allowed me to stay more present 3. What is the relationship between your with those I am working with and to let go of needing to know so that we visible identity and your self-identification, can just engage in where we are so and how is this relationship influenced by that knowing emerges as it needs to. your cultural context? 4. What kinds of assumptions are clients likely to make about you based on your visible identity, your sociocultural context, and the information you choose to share about yourself? 5. How might your areas of privilege affect your work (e.g., your clinical judgments, theoretical preferences, view of clients, beliefs about health care)?

Ned clearly was a person who had thought deeply about cultural influences on himself before this interview. But even if you are highly experienced in the area of diversity, there are always areas in which you can learn more. Now that you have read Ned’s responses, try answering the same questions that he was asked, which are listed below. If you can talk about your answers with a friend or a culturally diverse group of people, all the better.

Doing Your Own Cultural Self-Assessment

Seeking New and Diverse Sources of Information Carefully considering the questions and ideas outlined so far, you may come to recognize key gaps in your experience and knowledge base regarding particular groups. The next step is to begin to search for information that will educate you about the groups you have less experience with. This search can lead to online sources, books, magazines, newspapers, films, theater, workshops, and culture-specific community events. Of course, most people already use these sources of information; what turns them into culture-specific learning opportunities is how you think about them and the questions you ask—that is, critical thinking. Critical thinking about sources of information involves questions that challenge the information itself and simultaneously expand your perceptions, beliefs, and attitudes (Brookfield, 1987). For example, when you read an article about a minority group, do you read between the lines for information about where it’s coming from (e.g., the organization’ or author’s identity, affiliation, or political orientation)? If an article was produced by a minority group member, do you assume that this one person’s opinion represents those of the entire group? Does it occur to you that many written sources regarding minority cultures were written or filmed by members of dominant groups, often without input from members of the minority group? The views and experiences of people of minority cultures are routinely excluded from the mainstream media. Consider the number of popular American films that feature two young White able-bodied heterosexual people (most) versus the number that focus on the love story of an immigrant couple, or an older gay couple, or a couple with disabilities. When minority groups are discussed, it is often from the perspective of members of the dominant culture. For example, despite the plethora of films about the Vietnam War, have you ever seen one that was written and directed by a Vietnamese person? Similarly, how many U.S. newspaper articles about Iraq or Afghanistan or even Muslims in general are written by an Iraqi, an Afghani, or a Muslim? To counter such imbalances, it helps to look for information from media and organizations that originate in and from minority communities themselves. In cities and even in many smaller communities, minority groups often publish their own newsletters and newspapers. A few examples of organizations that offer online information directly from the groups they represent include Mouth Magazine (http://www. mouthmag.com/) and Able (http://ablenews.com), by people with disabilities; Advocate (http://www.advocate.com), National LGBTQ Task Force

55

56

B e c o m in g a C u lt u r ally R e sp o nsi v e T h e r apist

(http://www.thetaskforce.org), and Parents, Families, and Friends of Lesbians and Gays (http://www.pflag.org) by lesbian, gay, bisexual, and transgender (LGBT) groups and their allies; and the National Association of Women (http://www.now.org) by women. To learn from—not simply about— people of diverse minority groups, knowlTry this: Find an article, book, or online edge of culture-specific organizations is source you’ve recently read or listened to, also important. Examples of local resources therapists should be familiar with include and answer the following questions. religious institutions (e.g., mosques, syna1. Who are the authors, producers, or editors gogues, churches, temples, meetinghouses), of this information, and what are their idensupport groups, educational institutions, tities, political orientations, and alignments? recreational centers for elders and peo2. Are people of minority identities and ple with disabilities and their families, views represented? culture-specific community organizations, 3. Is this information directly from people of language-specific social services, LGBT minority groups, or only about them? counseling services, university and community women’s centers, and community 4. Where might you obtain information from support groups and activities for parents more direct or alternative sources? and children.

Relationships and the Influence of Sociocultural Contexts As a field, psychology is oriented toward individualistic work. However, to increase multicultural competence, individually oriented work (e.g., introspection, self-questioning, reading, some forms of research) is not sufficient. Engagement with people of diverse identities is also important, because if the people around you all hold similar identities and share the same privileges, the “universal” nature of your beliefs and worldview will generally be reinforced. It is through relationships with people who differ from us that awareness of our limitations and biases becomes evident. So here is another exercise. Take a minute to consider the people with whom you choose to spend most of your time or those you consider your closest confidants (e.g., your partner, spouse, friends, coworkers, fellow students, and individual family members). Write the names of at least five of these people across the top of the right column in Exercise 3.2. The example of Olivia is provided in Exercise 3.3; Olivia wrote the names of her best friends Gita and Jan, her coworker Gilberto, her sister-in-law Alma, and her mother.

Doing Your Own Cultural Self-Assessment

EXERCISE 3.2 Recognizing the Influence of Your Sociocultural Contexts For each confidant, place a checkmark next to every ADDRESSING influence that matches yours. Do my confidants have the same influences as me in:

Confidants’ names

Age and generational influences? Developmental or other Disability? Religion and spiritual orientation? Ethnic and racial identity? Socioeconomic status? Sexual orientation? Indigenous heritage? National origin? Gender?

The next step in Exercise 3.2 is to go down the ADDRESSING list of influences for each person on your list and put a checkmark next to every ADDRESSING influence that matches yours. As you can see in Olivia’s example (Exercise 3.3), she checked that she and Gita are similar with regard to Age and generational influences, Religion and spiritual orientation, Ethnic and racial identity, Socioeconomic status, EXERCISE 3.3 Recognizing the Influence of Sociocultural Contexts: Olivia’s Examples For each confidant, place a checkmark next to every ADDRESSING influence that matches yours. Confidants’ names Do my confidants have the same influences as me in:

Gita

Jan

Gilberto

Alma









*Religion and spiritual orientation?





Ethnic and racial identity?



*Socioeconomic status?



*Sexual orientation?



Indigenous heritage?



*National origin?





Gender?





*Age and generational influences? Developmental or other Disability?

Mom





























 

 







57

58

B e c o m in g a C u lt u r ally R e sp o nsi v e T h e r apist

Sexual orientation, Indigenous heritage, National origin, and Gender. However, because Olivia has chronic knee problems and Gita does not have a disability, Olivia did not put a checkmark next to Developmental or other Disability for Gita. Of course, everyone’s situation is different, but for many people, this exercise highlights the homogeneity of their social circles, especially among members of the dominant culture. Social psychology suggests that people tend to be attracted to those they perceive as similar to themselves (J. T. Jones, Pelham, Carvallo, & Mirenberg, 2004), and because dominant-culture members are usually a numerical majority, they are more able to choose similar partners and friends. However, because minority members are fewer in number, they often have no choice but to develop relationships with people who are different from themselves. For example, according to Census data, although 10% of heterosexual married couples had partners of a different race or Hispanic origin, 21% of same-sex couples had partners of a different race or Hispanic origin (U.S. Census Bureau, 2014). Now look back at the cultural self-assessment you did in Exercise 3.1 and review the cultural influences you starred as your areas of privilege. Think about the five individuals you wrote down in Exercise 3.2, and ask yourself, “How many in my circle differ from me in these areas of privilege?” Again, if your closest circle holds the same privileges you do, it is so much more difficult to perceive these privileges and recognize how they skew your perspective. Of course, direct personal experience with people of diverse backgrounds is an important part of multicultural sensitivity and understanding, but it is not enough to simply be around people who differ from you. Traveling to different countries, eating in ethnic restaurants, and attending cultural events can set the stage for interaction, but deeper learning comes from relationships between people that are sustained over time. In addition, it is important to remember that power differentials can affect what and how much is shared in a relationship. Relationships with people who are in a less powerful position than you (e.g., clients, students, support staff) may involve learning, but power differences generally mean that one person is in a more vulnerable position and thus less able to speak freely. You are apt to learn more from peer-level, intimate relationships in which both parties hold enough power to honestly and safely share their feelings and thoughts. The development of such relationships is a natural outgrowth of the personal work described so far. However, if members of dominant cultural identities are not engaged in this personal work, their attempts to develop relationships with people of minority identities may backfire. Choosing to develop a friendship because the person holds a particu-

Doing Your Own Cultural Self-Assessment

lar identity may be offensive, because it suggests a greater interest in obtaining cultural information than in knowing the individual.

Conclusion Culturally responsive practice begins with the therapist’s commitment to a lifelong process of learning about diverse people across cultures and lifespans. A first step in this process is to explore the influence of cultural heritage on your beliefs and worldview, recognizing the ways in which privilege can limit your experiences and knowledge base. Equally important is a willingness to seek out new sources of information that will help you learn from and with (not simply about) people of diverse cultures. Forming intimate peer-level relationships with people of diverse identities is an important part of this learning. The reward for these efforts is an appreciation of the richness of diverse people’s experiences, a deeper understanding of one’s clients, and an ability to provide more effective and culturally responsive mental health services.

Practice: Watching for Privilege Throughout this next week, watch for the privileges you experience in relation to your dominant cultural identities for each of the ADDRESSING influences. Regarding age-related privileges, if you are a young adult, notice the positive representations of your age group in the world around you versus those of older adults. If you do not have a disability, pay attention to your physical environment and the way it works for you but would not be accessible, convenient, or even safe if you were living with a visual or intellectual disability, were deaf, or used a scooter or wheelchair. If you are of European American or Christian heritage, pay attention to the ways in which the media, your institution or organization, and your family and friends value, prioritize, and promote perspectives that are similar to yours. These are just a few examples—yours will depend on your particular identity and constellation of privileges.

59

60

B e c o m in g a C u lt u r ally R e sp o nsi v e T h e r apist

Key Ideas

  1. Recognizing the ADDRESSING influences on your life is a first step toward understanding the influence of your cultural heritage on your beliefs and worldview.  2. Unrecognized privilege is dangerous for therapists, because privilege cuts therapists off from information and experiences that help us understand clients.   3. Privilege is contextual: A privileged identity in one cultural context may not be privileged in another.   4. The areas in which we hold privilege are usually those in which we hold the least awareness.   5. Defensiveness tends to block recognition of one’s own privilege.   6. Individually oriented work (e.g., introspection, self-questioning, reading, some forms of research) is necessary but not sufficient for increasing multicultural competence.   7. The views and experiences of minority members are routinely excluded from mainstream media.   8. What turns mainstream sources of information into culturespecific learning opportunities is how you think about them and the questions you ask—that is, critical thinking.   9. Engagement with people of diverse identities is important for multicultural learning, because if the people around you hold similar identities and privileges, the “universal” nature of your beliefs and worldview will generally be reinforced. 10. Intimate relationships that are peer level provide the best opportunities for multicultural learning because both parties hold enough power to honestly and safely share their feelings and thoughts.

Making Meaningful Connections

II

Let’s Talk Finding the Right Words

4

I can only tell you what it [“retard”] means to me and people like me when we hear it. It means that the rest of you are excluding us from your group. We are something that is not like you and something that none of you would ever want to be. . . . We are someone that is not your kind. —John Franklin Stephen, global messenger for the Special Olympics (as cited in Downes, 2013, p. 10)

T

he use of particular words and phrases communicates more than just the words and phrases themselves—one’s word choice also conveys a particular set of experiences and a perspective. If that perspective is backed by the power and privilege of the dominant culture (which is generally biased against minority views), it carries a great deal of weight—more than just the one individual’s viewpoint. This negatively biased viewpoint, reflected in the words one uses as well as the content, may be experienced as what psychologists call a microaggression. The term microaggression refers to the verbal, behavioral, and environmental insults and slights that minority group

http://dx.doi.org/10.1037/14801-004 Addressing Cultural Complexities in Practice: Assessment, Diagnosis, and Therapy, Third Edition, by P. A. Hays Copyright © 2016 by the American Psychological Association. All rights reserved.

63

64

M a k i n g M e a n i n g f u l C o n n e cti o n s

members experience from the dominant culture, often on a daily basis (D. W. Sue et al., 2007). These insults and slights may be intentional or unintentional on the part of the dominant-culture member, but the minority member often doesn’t know which is the case and thus feels hurt, angry, or confused. In some cases, the dominant-culture member may sense a shift in the interaction but not know why or what to do about it. Whatever the case, microaggressions undermine a positive therapeutic relationship, and because psychotherapy is a language-laden practice, when working cross-culturally, the possibilities for micro­ aggressions are great. Although I think it’s safe to say that most therapists do not intentionally offend their clients, unintentional offenses are another matter. No therapist would use the term retard as in John Franklin Stephen’s quote, but until the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) took effect in 2014, Mental Retardation was an official diagnostic category (American Psychiatric Association, 2013). It took a federal statute (Rosa’s Law, 2010) for the dominant psychiatric and psychological culture to replace the term with Intellectual Disability (DSM–5) and Intellectual Developmental Disorder (upcoming 11th edition of the International Classification of Diseases). As of the 2010 Census, over one third of the U.S. population consisted of people of ethnic minority cultures, including Latino, African and African American, Asian, South Asian, Pacific Islander, Middle Eastern, and Native people (U.S. Census, 2011). In 2008, the American Religious Identification Survey found that religious minorities included 2.7 million Jews, 1.3 million Muslims, and 1.2 million Buddhists (Kosmin & Keysar, 2009). An estimated 6% to 10% of the U.S. population are lesbian, gay, bisexual, or transgender (LGBT; Grant, 2014); approximately 13% of Americans are 65 years of age or older (U.S. Census Bureau, 2010); and 19% of Americans have disabilities (U.S. Census Bureau, 2012). Every one of these groups—including groups within the groups—has its own terms for self-identification. And this is within the United States; when you consider the insider language of minority groups in other countries, the task of avoiding offense can seem daunting. So the information in this chapter is not comprehensive but explains the multiple meanings behind many of these terms, along with more empowering terms accepted by many minority group members.

Difficult Dialogues A friend of mine was in a spiritual support group whose members provided each other with a warm, caring environment to share their growth, joy, and pain. Everyone except my friend and her husband were White,

Let’s Talk

Think about this: Have you ever experienced a microaggression or unintentionally committed one? How did you feel, and what did you think at the time?

but this did not seem to be an issue until one meeting, when my friend talked about her pain in response to a racist comment from someone outside the group. Rather than validate her experience, the group asked her questions about why the person would make such a comment. They seemed to be looking for a way to justify it and, in the process, implied that she was overreacting. As the tension built, one member objected to the time being spent on this issue, saying, “You know, this is a spiritual growth group, not an antiracism group.” My friend replied, “But racism is a spiritual issue for me.” Unfortunately, the group members were unanimous in their inability to see this situation from my friend’s perspective, and as a result, she and her husband decided to leave the group. Because multicultural language is complex, emotionally loaded, and continually changing, even talking about one’s language and terms can be challenging. With regard to race, D. W. Sue (2013) explained that such discussion is difficult because it violates three cultural protocols. First, it violates the politeness protocol, which dictates the avoidance of controversial topics such as race, religion, and sex (i.e., it’s rude to talk about uncomfortable topics). Second, it goes against the academic protocol, which favors “objective” intellectual discussion over the sharing of personal experiences and emotions that arise with such topics. And third, talking about race counters the color-blind protocol, which follows the line of reasoning that race shouldn’t matter, so if you call attention to it, you must be racist. Let’s look at the third protocol, color blindness, more specifically. The view of color blindness as an ideal is common among White people, as summarized in the saying “There’s only one race—the human race.” Whites who say this are usually trying to move away from a discussion of differences in an effort to minimize conflict. As Bronson and Merryman (2009) described in their book NurtureShock, a study of 17,000 families found that 75% of the White parents did not talk to their children about race, largely because they believed that drawing attention to race, even in the form of simply talking about it, would reinforce divisions. However, as members of ethnic minority cultures know, race exerts a powerful influence on a person’s life, including one’s educational and job opportunities, access to health care, income, social status, location of one’s home, and even availability of preferred foods, particularly healthy choices. To many people of color, this phrase’s insistence that we are all the same is dismissive of the ways in which race profoundly affects the lives of people of color. If you a well-intentioned White therapist, hearing this interpretation for the first time may be disconcerting. A common reaction to such learning is defensiveness, in the form of thoughts or responses such as ❚❚ ❚❚ ❚❚

“I didn’t mean it that way.” “Nobody I know thinks it’s offensive.” “They’re too sensitive.”

65

66

M a k i n g M e a n i n g f u l C o n n e cti o n s

But remember how I described defensiveness in the previous chapter— as an emotional reaction that calls our attention to something that poses a threat to our connection with the other person or our sense of self. Defensiveness pulls us away from understanding the other person’s perspective and into a rigid stance of justifying our own. It also prevents us from learning because it closes us off from perspectives that contradict our long-held beliefs. If you are a member of a dominant group with regard to race, religion, or any of the ADDRESSING influences, as you read the following alternative perspectives on language, I encourage you to watch for feelings of defensiveness in yourself. When you notice these feelings, try to stay open to the new perspective, even if you disagree. It can help to remember that the more perspectives you understand, the more people you will understand. Knowing the terms that people prefer will decrease the chance of offending clients and increase your credibility with people who differ from you. So let’s take a look at some of these terms and their meanings, beginning with race.

Race Race is a social construct, not a scientific or biological fact (Sternberg, Grigorenko, & Kidd, 2005). The concept was originally developed by European scientists to classify people on the basis of geography and physical characteristics (e.g., skin color, hair texture, facial features) into groups of genetically related peoples (Spickard, 1992). Over the years, researchers created differing classification schemes that emphasized a wide range of factors, including skin tone, tribal affiliations, nationalities, language families, or simply minority status (Thomas & Sillen, 1972). Illustrating the enormous variation in definitions of race, Gates (2011) noted that Brazil has 134 categories of Blackness, whereas the United States has only a few, depending on who is doing the defining. Underlying most racial classifications was the assumption that races were organized hierarchically, with light-skinned Christian Europeans at the top. The politics and beliefs of the time often determined the choice of scheme, which in turn reinforced racist beliefs and laws. For example, the illegality of interracial marriage in many U.S. states until 1967 reflected the common belief that “White blood” could be tainted by “Black blood.” Hence, in nine states at the turn of the century, a child of predominantly European ancestry with even one great-grandparent of African heritage was, for legal purposes, considered a “Negro” (Spickard, 1992). But researchers in the fields of anthropology and evolutionary biology generally agree that racial distinctions fail on three counts: “They

Let’s Talk

are not genetically discrete, are not reliably measured, and are not scientifically meaningful” (Smedley & Smedley, 2005, p. 16). There are no pure gene pools, as human beings of dominant and minority cultures are genetically quite mixed (Betancourt & Lopez, 1993). Furthermore, racial classifications do not reliably account for the enormous variation in physical characteristics within the so-called racial groups; many people who self-identify as White have skin that is visibly darker than some people who self-identify as Black. However, the field of psychology has a long history of conceptualizing race as an independent variable and using it to explain differences in personal abilities. Even as recently as 2002, psychologists were using IQ score differences between racial groups to suggest differences in intelligence between races (see Tummala-Narra, 2007, for a summary of these studies). But as Sternberg, Grigorenko, and Kidd (2005) noted, race is a social construct with no scientific definition, and because intelligence has never been linked to a particular gene, attempting to link the category of race to intelligence is completely erroneous. At the same time, although race is a socially constructed concept, “the consequences of this construction are real in terms of perceptions of similarity and difference” (Altman, 2007, p. 15). Since the 1960s, when Black pride led to increased interest among many African Americans in fam­ily history and cultural heritage (Boyd-Franklin, 2003), some African Americans have used the term Black as a positive self-identification. However, during the past 2 decades, the term African American has become popular in the United States because it emphasizes a person’s ethnic and social heritage rather than physical characteristics such as skin color. The term African American is not used in Canada, however, because it suggests U.S. citizenship, and it is not generally used by people who have emigrated from other countries and self-identify by their country of origin. Because language is continually changing, therapists need to stay flexible and open to clients’ preferences. Whether or not a client uses a racial identification, it is helpful to remember that a racial identity in itself tells little about an individual’s values, interests, relationships, or personhood. What is most important with regard to racial identity is an understanding of its meaning for the individual, for the dominant and minority cultures, and for the therapist (Wang & Sue, 2005).

Ethnicity For the purpose of understanding the beliefs, values, and behaviors of both clients and therapists, the concept of ethnicity often provides more information than that of race. McGoldrick, Giordano, and Garcia-Preto

67

68

M a k i n g M e a n i n g f u l C o n n e cti o n s

(2005) defined ethnicity as a group’s “peoplehood,” including the “common ancestry through which individuals have evolved shared values and customs” (p. 2). Although ethnicity is often understood to involve some shared biological heritage, its most important aspects, in terms of individual and group identity, are those that are socially constructed (e.g., beliefs, norms, behaviors, language, institutions). But the concept of ethnicity, like that of race, also includes complications. For one, the term holds different meanings in different countries. In the United States, where American Indians joined together early on with African Americans, Asian Americans, and Latino Americans to call for equal rights, the term ethnic minority is assumed to include people of Indigenous or Native heritage. However, in Canada the terms ethnic minority and visible minority are used to describe only cultures with a history of immigration. Because Indigenous Canadians emphasize their nativeness to Canadian lands (i.e., they did not immigrate), they do not conceive of themselves as ethnic minority cultures and instead use the term Indigenous (meaning “people of the land”) or self-identify by their specific band (the Canadian word for tribe) or nation (i.e., Indigenous nation). At the same time, some Indigenous Canadians also use terms commonly used by government agencies, including Aboriginal and First Nations. The latter term comes from the understanding that the First Nations were the original people, as distinguished from the Second Nations (i.e., French and English) who came to Canada as colonizers, and Third Nations, which include all subsequent immigrant groups to Canada. But use of the terms Aboriginal and First Nations is starting to decline with the growing view of them as official, dominant-cultural terms and Indigenous people’s desire to name themselves. In addition, the term First Nations does not include the Inuit (i.e., people of the Canadian Arctic) or the Métis (i.e., people of mixed Indigenous and European heritage). And there is a strong international movement to use the term Indigenous to increase awareness of the commonalities among Indigenous people around the world (Carolyn Kenny, personal communication, July 27, 2014; see also AAA Native Arts, 2006). Another problem with the description of people by ethnicity is that ethnic groups are currently labeled very broadly, as in the use of the term Asian for people of Japanese, Korean, Chinese, Vietnamese, Lao, Cambodian, Thai, and even East Indian and Pakistani heritage. Similarly, the term Hispanic combines into one ethnicity the diverse cultures of Central American Indians, South Americans of African and Spanish heritage, Mexican Americans, Cuban Americans, Puerto Ricans, and Dominicans. Native American includes more than 500 Native cultural entities in the United States (U.S. Department of the Interior Indian Affairs, 2014), and Alaska Native includes 20 Indian and non-Indian language and cultural groups (11 Athabascan language groups plus Aleut,

Let’s Talk

Alutiiq, Yup’ik, Siberian Yup’ik, Iñupiaq, Eyak, Tlingit, Tsimshian, and Haida). Although some individuals use the broader terms to identify themselves, many people prefer their more specific identities, particularly their nation of origin. Geographic differences may also lead to variations in ethnic selfidentification. For example, as Comas-Díaz (2001) noted, the term Hispanic (created by the U.S. Bureau of the Census to designate people of Spanish heritage) is offensive to some because it fails to acknowledge Indigenous people and Latin Americans not of Spanish heritage (e.g., Brazilians of Portuguese heritage). Many people prefer the terms Latina (for women) and Latino (for men), particularly those from the Pacific Northwest of the United States and California. However, some people (particularly those in California) self-identify as Chicana or Chicano, whereas many people in Texas use the term Hispanic to describe themselves. (A young man from Texas once told me he didn’t like the term Latino because he thought it made him sound like a gang member.) Recognizing the complications of ethnic identification, Phinney (1996) suggested that misunderstandings persist because ethnicity is commonly conceptualized as a discrete categorical variable. For example, one is considered either Latina or not Latina, despite the fact that there are other possibilities. A person may be bicultural or multicultural, or the salience of his or her ethnic identity may vary over time, in different situations, or with developmental changes (e.g., a biracial adolescent who begins to identify strongly with only one side of his heritage as he joins an ethnically defined peer group; Kim-Ju & Liem, 2003).

Culture Culture is the most inclusive term and thus the most general. Definitions of culture abound, but today most anthropologists agree that the term includes traditions of thought and behavior, such as language and history, that can be socially acquired, shared, and passed on to new generations (Smedley & Smedley, 2005). Although culture is often equated with race and ethnicity, the most commonly accepted definitions of culture say nothing about biological links (which the concept of race implies). As such, these definitions are broad enough to include people of nonethnic minority groups—for example, groups defined as minorities by religion, disability, sexual orientation, gender, and other identifications (i.e., the ADDRESSING influences; Pope, 1995). For example, in the United States, the Muslim population consists of immigrants and multigenerational Americans whose ethnic identities are Arab, Indian, Pakistani, Iranian, East Asian, Indonesian, African,

69

70

M a k i n g M e a n i n g f u l C o n n e cti o n s

African American, European, and even Native American. Across these diverse ethnic groups, a sense of community is reinforced by shared values embedded in the Five Pillars (foundational requirements) of Islam that one must (a) hold a belief in God and in Mohammed as his prophet, (b) follow the daily prayer rituals, (c) give alms to the poor, (d) observe the month-long fast of Ramadan, and (e) make the pilgrimage to Mecca if possible (Abudabbeh & Hays, 2006; Dwairy, 2006). These shared values contribute to a sense of community worldwide, with the mosque as the cultural center that brings together people from diverse backgrounds and countries and provides social, financial, and spiritual support to its members. Experiences of prejudice and discrimination from the dominant U.S. culture may also reinforce Muslim people’s sense of themselves as one culture.

Minority The term minority has traditionally been used in reference to groups whose access to power is limited by the dominant culture (Wang & Sue, 2005). In this sense of the word, a minority group is not necessarily a numerical minority. For example, colonization has usually involved the dominance of one numerically smaller culture over a numerically larger culture—for example, Whites over Blacks in South Africa during apartheid. In North America, the term minority may apply to ethnic, religious, national, and sexual minorities; older adults; people who are poor, less formally educated, or of rural or Indigenous heritage; people who have a disability; and women and children (i.e., those groups highlighted as nondominant in the ADDRESSING framework). All of these populations fit the definition of culture as broadly defined, and all have traditionally been excluded, marginalized, or misrepresented by mainstream psychology; in this sense, they may be considered cultural minorities. (European American children are somewhat of an exception in that although they may be considered minorities in relation to the larger society, they have been the focus of much attention in psychology, beginning with Freud’s developmental interests, but is not true for children of color.) But there is more to being a member of a minority culture than the experience of oppression. Identification with a minority culture or group may also lead to the development of positive traits and qualities that may not develop in people whose lives are buffered by privilege (McIntosh, 1998, p. 101). Minority status can bring with it unique forms of knowledge, awareness, community, and purpose. Minority

Let’s Talk

members are often more flexible because they must navigate between two or more cultures (including their own and the dominant one), and they may be more comfortable in cross-cultural situations, able to see beyond the obvious and appreciate people as human beings with both strengths and weaknesses (Magyar-Moe, 2009). One final point regarding the term minority: Describing a group of people as a minority culture is different from referring to an individual as “a minority.” The latter (e.g., “He’s a minority”) may be perceived as dismissive or pejorative.

More Cultural Descriptors In addition to racial and ethnic descriptors, one’s choice of terms is equally important with any minority group. As noted in the ADDRESSING framework, members of other minority groups include older people; people who have disabilities; LGBT people; religious minorities; and people who live in poverty.

OLDER ADULTS With regard to older people, consider the differences in connotation between the set of descriptors elderly, old, old man, and old maid and a second set that includes elder, older person, and senior. Although the two sets are quite similar, most people would consider the first set to be patronizing and the second as more respectful. In addition, older people are more likely to prefer titles on an initial meeting (e.g., “Mrs. Gonzales” rather than “Juanita”). However, again, people vary in their specific preferences. I remember an 80-year-old Jewish man with a good sense of humor who once told a group of us younger people, “I don’t care what you call me; just call me!”

PEOPLE WITH DISABILITIES, DISABLED PEOPLE With regard to people who have disabilities, people-first language was adopted in the 1970s to make the point that individuals should be seen as primarily people. This effort included replacing the term disabled people with people with disabilities (Olkin, 2002). However, in Great Britain and the United States, there is now a growing movement toward identityfirst language, in which disability is an identity claimed as a source of pride along with the terms disabled people and disabled person. Identityfirst language emphasizes that “disability is a function of social and political experiences occurring within a world designed for nondisabled

71

72

M a k i n g M e a n i n g f u l C o n n e cti o n s

people” (Dunn & Andrews, 2015, p. 259). As some authors have noted, using exclusively person-first language “ignores the recognition of disability as a cultural identity and the fact that many people are proud to call themselves disabled people” (Mona, Romesser-Scehnet, Cameron, & Cardenas, 2006, p. 200). The terms victim, invalid (originally meaning “not valid”), afflicted, and crippled are all offensive, as is saying that someone “suffers from” a disability (an assumption). Saying someone “uses a wheelchair” or other assistive device avoids the assumptions embedded in describing the individual as “confined to” or “wheelchair bound,” which focus attention on the person’s limitations rather than on the disabling social and physical environment. It is generally preferable to note the disabling environment (e.g., “there was no curb cut”) rather than describing a person by his or her limitations (e.g., “physically challenged”; Olkin, 1999). The word accessible in relation to parking and facilities is preferable to handicapped (originally from the phrase “cap in hand” for people who begged). For people who do not have disabilities, the terms nondisabled and people without disabilities are more accurate than normal or healthy, because people with disabilities are normal, and a person can be healthy and have a disability. As Snow (2006) noted, “disability is natural, and it can be redefined as a ‘body part that works differently.’ A person with spina bifida has legs that work differently, a person with Down syndrome learns differently, and so forth” (p. 1). People who identify with Deaf culture (the capitalization denotes the cultural category) do not consider themselves to have a disability; rather, it is the hearing world’s ignorance of their language that is the problem. To members of Deaf culture, “cure—deafness as pathology— is anathema; accommodation—deafness as disability—is more palatable; and celebration—Deafness as culture—trumps all” (Solomon, as cited in Dunn & Andrews, p. 261). At the same time, not all people who are hearing impaired identify with Deaf culture; for most such people, the term hard of hearing is more appropriate (Leigh, 2003; Vernon, 2006). And using the terms blind and deaf as synonyms for ignorant or unaware is always offensive (e.g., “He was blind to the impact of his behavior,” “They robbed him blind,” “He turned a deaf ear to her cry”).

LESBIAN, GAY, AND BISEXUAL PEOPLE LGBT is a commonly used abbreviation for lesbian, gay, bisexual, and transgender. More recently, in conjunction with transgender groups, additional letters have been added, including Q for questioning or queer (the latter term reclaimed and considered affirmative when used by group members), I for intersex (a person whose anatomy is not exclusively male or female), and A for ally (typically a person who is not a

Let’s Talk

group member but aligned with the cause) or asexual (the absence of sexual attraction; Schulman, 2014). Sexual orientation and gender are different concepts, and there is no clear correlation between a person’s gender identity and sexual interests. Gender identity refers to a person’s internal sense of being male, female, or something else, whereas sexual orientation refers to a person’s physical, romantic, or emotional attraction to another person (American Psychological Association [APA], 2011). Thus, a person can be assigned a female identity when born and be attracted to men, then years later, identify as male but still be attracted to men. As Steinmetz (2014) described it, “Sexual orientation determines who you want to go to bed with and gender identity determines what you want to go to bed as” (p. 38). With regard to terminology and sexual orientation, the term sexual preference is offensive because it suggests that one has chosen to be gay or lesbian and thus can “change back.” The term homosexual is also offensive in many contexts, for example, when used as a noun (e.g., “He’s a homosexual” vs. the more acceptable “He’s gay”) because, as Canadian psychologist Kevin Alderson (2013) suggested, when used as a noun, identity labels “essentialize” people. That is, it is better to say “gay men and lesbian women” than “gays and lesbians.” Also offputting are questions that reflect an assumption that heterosexuality is normal and other orientations are not (e.g., asking a client why he thinks he became gay—therapists generally do not ask heterosexual clients why they became heterosexual; Martin, 1982). Although the terms lesbian, gay, and bisexual are generally considered affirmative, they are not used by all cultures or individuals. For example, some men have sex with men but do not identify as gay (abbreviated MSM), and women in various cultures may be sexually attracted to women (WSW) but not identify as lesbian (e.g., see Balsam, Martell, & Safren, 2006, regarding women and men in African American and Latino cultures). And in some Native American cultures, the term two-spirit is used in place of LGB or LGBT (Balsam, Huang, Fieland, Simoni, & Walters, 2004).

TRANSGENDER PEOPLE Transgender is an umbrella term used by diverse groups of people whose gender identity, expression, or behavior does not conform to the gender assigned to them at birth. Whereas sex refers to a person’s biological status and is associated with physical attributes such as chromosomes, hormones, and anatomy, gender refers to the socially constructed roles, behaviors, activities, and attributes associated with boys and men and with girls and women (APA, 2011).

73

74

M a k i n g M e a n i n g f u l C o n n e cti o n s

Think about

Transgender is used by a broad range of people, including those who identify as transsexual (i.e., whose gender identity differs from that assigned at birth) and those who cross-dress (an activity not necessarily tied to erotic behavior or sexual orientation). Individuals who were assigned the identity of female but identify and live as male are known as F-to-M (female to male) transsexual or transmen, whereas individuals assigned the identity of male who identify and live as female are M-to-F transsexual or transwomen (APA, 2011). The term transgender also includes people who identify as genderqueer and consider their gender to be on a continuum between the binary categories of male and female, or something else, and people of many other gender-nonconforming identities, including at least 50 gender choices recently listed as options on Facebook (Ball, 2014). When referring to or addressing a transgender person, one should use the pronoun preferred by the individual (i.e., he, she, or whatever term the person requests), and if you’re unsure, use the person’s first name instead of pronouns until you know the person’s preference. At the same time, keep in mind that some individuals who have made a transition do not wish to be identified as or do not identify themselves as transgender. Note that the terms hermaphrodite and transvestite are both pejorative and should not be used.

this: Are there any other

OTHER GROUPS

cultural

Finally, I’ll mention a few other terms because they come up frequently. Using the terms lame, spaz, and gay as derogatory descriptors is always offensive, as in “That’s so lame,” “I was spazzed out” (an abbreviation for spastic), and “That’s so gay.” When talking about social class, it sounds patronizing to call someone lower or low class or poor; depending on which applies, I use the terms lower income, low SES (socioeconomic status), living in poverty, or working class, although I know these can be awkward when speaking. Regarding religion, people often confuse the terms Muslim and Islam. Muslims are members of the religion known as Islam. Some Muslims refer to themselves as Islamic (the adjective) and Islamist (the noun), but these are more often used by or in reference to historical, conservative, or political groups.

descriptors or terms you are unsure about? If yes, try searching online for an answer from sources staffed by members of the group.

Challenging Complexities As I’ve mentioned, the perspectives in this chapter regarding language and terminology are generalizations and thus are not necessarily preferred by all individual members of minority groups. I recently had

Let’s Talk

an experience with this discrepancy in an initial session with a young woman who was feeling overwhelmed by a schedule that included attending school full-time, working full-time, and raising two children while separated from her husband. At one point, I paraphrased her comments in question form as “Are you saying that you and others always expect you to be this strong woman?” I almost said, “Are you saying that you and others always expect you to be this strong African American woman?” but I didn’t, because I hadn’t heard her identify herself ethnically or racially yet. Later, I was told by the African American scheduler that the client had mentioned to her, in a firm tone, that she did not want to be called African American because she was not African; she considered herself Black. Normally I would have known the client’s preferred language regarding ethnic or racial identity because I ask all my clients to complete a demographic form that asks them their identity (which they write themselves on the form) in advance of our first meeting. I have found a demographic form to be the best way to initially find out about ethnic or racial identity because clients use their own words, and if they don’t want to answer, they can leave it blank. (When and how to ask about identity is a complicated matter, one that I will talk more about in Chapter 5.) However, this particular client interview took place in the context of an educational demonstration, and I realized in the moment that I did not know her preferred identity terms. Although I had asked her about “cultural strengths and supports” in my initial assessment, I should have specifically checked out her preferred terms earlier. In general (although not always), even when I think I know the appropriate term, I usually wait and listen for how people describe themselves before using a cultural identifier. At the same time, even when clients use a term to describe themselves, it is not always acceptable for the therapist to use it. Some minority groups have reclaimed terms that were once used in a derogatory way by members of the dominant culture (e.g., queer for LGBT people, crip for people who have disabilities). This decision to take back the dominant culture’s labels and define them for oneself is a powerful act (Watt, 1999), as C. B. Williams (1999) explained in relation to her biracial identity: The idea that individuals have a right to define their own experience, to create their own personal meanings, to frame their own identity, to claim an “I” that is uniquely their own, shakes up many people’s most dearly held beliefs about race. Courage to claim one’s own experience despite resistance and judgment from others allows biracial people like me to begin to forge an authentic self. (p. 34)

When used by members of a particular group in reference to themselves, these terms become a form of “in-language.” On rare occasions,

75

76

M a k i n g M e a n i n g f u l C o n n e cti o n s

it may be acceptable for nonmembers to use these terms; however, as a general rule, it is not. So when I do workshops incorporating the preceding information, this is the point at which someone in the audience says in a tone of controlled exasperation, “Honestly, Pam, how do you expect us to remember all of this?” My answer is that I don’t. Or at least, not right away. What I do hope is that rather than becoming overwhelmed with the memorization of terms and names, therapists will commit to the ongoing process of learning about cultures of which they are not a member. I emphasize the process aspect of this learning because cultures and languages are changing all the time. Consequently, what one needs to learn is continually changing. With regard to language in particular, I’ve found four guidelines to be helpful: ❚❚ ❚❚

❚❚ ❚❚

Seek out information about the broader cultural meanings of terms. Seek out information about the group-specific (in-group) meanings of terms. Listen for the terms each client uses. When appropriate, ask the client what terms they prefer.

When I do my part by trying to follow these four guidelines, I have found that even if I make a mistake, people who differ from me culturally usually give me the benefit of the doubt.

Practice: Investigating Preferred Terms Find a website or blog about terminology that is authored by one or more members of a minority group from the ADDRESSING list. Starting with at least three examples of terms or statements commonly used in the dominant culture regarding the minority group, find alternative minority perspectives on these terms and the minority group’s preferred terms.

Key Ideas

  1. The term microaggression refers to intentional and unintentional verbal, behavioral, and environmental insults and slights that minority group members experience from the dominant culture, often on a daily basis.   2. Talking about race and other culturally related differences is difficult because it violates the politeness protocol, the academic protocol, and the color-blind protocol.

Let’s Talk

  3. The concept of color blindness is offensive because it ignores the ways in which race profoundly affects the lives of people of color.   4. Researchers generally agree that race is a socially constructed concept—there are no pure gene pools, as human beings of dominant and minority cultures are genetically quite mixed.  5. Although race is a socially constructed concept, its consequences are real, and therapists need to be aware of these consequences and the varied meanings race holds for members of minority and dominant cultural identities.   6. Ethnicity is commonly conceptualized as a discrete categorical variable, when in reality a person may identify as bi- or multicultural or -racial, or the salience of the person’s ethnic identity may vary over time, in different situations, and with developmental changes.   7. The term minority has traditionally been used in reference to groups whose access to power is limited by the dominant culture and not necessarily in the numerical sense.   8. Regarding people who have disabilities, it is preferable to note the disabling environment (e.g., “there was no curb cut”) rather than to describe a person by his or her limitations (e.g., “physically challenged”).   9. Sexual orientation and gender are two distinct concepts—gender refers to a person’s internal sense of being male, female, or something else, whereas sexual orientation refers to a person’s physical, romantic, or emotional attraction to another person. 10. Transgender is used by a broad range of people, including those who identify as transsexual (whose gender identity differs from that assigned at birth), people who cross-dress, and individuals who identify as genderqueer or gender nonconforming and consider their gender to be on a continuum between the binary categories of male and female, or something else.

77

Understanding Clients’ Identities and Contexts

I

5

n her blog entry “This Is Why Poor People’s Bad Decisions Make Perfect Sense,” Tirado (2013) explained why she did things that middle-class people wouldn’t understand: I smoke. It’s expensive. It’s also the best option. You see, I am always, always exhausted. It’s a stimulant. When I am too tired to walk one more step, I can smoke and go for another hour. When I am enraged and beaten down and incapable of accomplishing one more thing, I can smoke and I feel a little better, just for a minute. It is the only relaxation I am allowed. It is not a good decision but . . . the only thing I have found that keeps me from collapsing or exploding. . . . I make a lot of poor financial decisions. I will never not be poor, so what does it matter if I don’t pay a thing and a half this week instead of just one thing? It’s not like the sacrifice will result in improved circumstances; the thing holding me back isn’t that I blow five bucks at Wendy’s. . . . There’s a certain pull to live what bits of life you can while there’s money in your pocket, because no matter how responsible you are you will be broke in three days anyway. . . . http://dx.doi.org/10.1037/14801-005 Addressing Cultural Complexities in Practice: Assessment, Diagnosis, and Therapy, Third Edition, by P. A. Hays Copyright © 2016 by the American Psychological Association. All rights reserved.

79

80

M a k i n g M e a n i n g f u l C o n n e cti o n s

Poverty is bleak and cuts off your long-term brain. It’s why you see people with four different baby daddies instead of one. You grab a bit of connection wherever you can to survive. You have no idea how strong the pull to feel worthwhile. . . . You go to these people who make you feel lovely for an hour that one time, and that’s all you get. . . . We don’t plan long-term because if we do we’ll just get our hearts broken. It’s best not to hope. You just take what you can get as you spot it. I am not asking for sympathy. I am just trying to explain, on a human level, how it is that people make what looks from the outside like awful decisions. This is what our lives are like, and here are our defense mechanisms, and here’s why we think differently. It’s certainly self-defeating, but it’s safer. That’s all. I hope it helps make sense of it. (paras. 10–13)

It’s one thing to know how your client self-identifies and how she is perceived and identified by others. But knowing your client’s identity is not the same as understanding what this identity truly means for her. As Tirado’s (2013) explanation illustrates, when you begin to understand the day-to-day details of a person’s life, that understanding paves the way for compassion and connection. This is true whether your client differs from you in social class, ethnicity, religion, disability, or any of the other ADDRESSING influences. Knowledge of clients’ salient identities gives you clues as to how they see the world, what they value, how they may behave in certain situations, and how others treat them. The more you know about a client’s cultural context, the closer your hypotheses and questions will be to the client’s real life, which then adds to your credibility, efficiency, and accuracy. So let’s look at identity with a focus on how it manifests in the lives of diverse people.

The Complexities of Identity Laura is a 55-year-old woman of bicultural heritage whose European American father met her Japanese mother in Japan just after the end of World War II. The couple decided to settle in Hawaii, where mixed marriages were more accepted. Laura and her older sister attended public schools, and the family lived in a neighborhood where biracial, bicultural children were so common as to be the norm. Looking back on her childhood, Laura remembered being referred to as hapa, the Hawaiian word for “part,” meaning part Japanese. However, as she reached her teenage years, she was more inclined to see herself simply as “local,” meaning born and reared in Hawaii. This identity gave her a feeling of comfort with friends of mixed ethnicities.

Understanding Clients’ Identities and Contexts

After high school, Laura left Hawaii to attend a university on the mainland. Her school was located in a rural area with few people of color. She was frequently asked where she was from and was not sure if the person meant what state or what country. Although she perceived herself to be visibly bicultural, everyone seemed to assume that she was Asian. She began to think of herself more as Japanese American and became interested in connecting with the few Japanese American and Asian American students on campus. After college, Laura moved to San Francisco, where she worked for a large bank. When she turned 30, she married a Chinese American man named Dan. Her daily interactions with Dan’s large family contrasted with her predominantly Anglo work environment and heightened Laura’s sense of herself as an Asian American woman, although among her in-laws, she was also strongly aware of her Japanese roots. In her late 30s, during the birth of her second child, Laura had a stroke caused by a brain aneurysm. Because of moderate cognitive and physical impairments and the paralysis of her right arm and leg, she had to go on leave from her work. Her mother came to stay with her and care for the children. Members of Dan’s family came daily to bring meals and offer support. Laura regained her cognitive abilities within a month. However, the right-sided paralysis persisted, and during this time Laura became depressed and anxious. She worried about whether she would ever regain the mobility she had had before. She worried about her ability to take care of her children over the long haul. And she worried about their finances, because although she was receiving disability insurance income, it did not match her previous salary. Her husband was clearly stressed from coping with the ordeal while maintaining his usual 55-hour-perweek job. It seemed that the disability dominated her entire existence, and only in negative ways. Laura received both group and individual counseling through a rehabilitation program that lasted 6 months. During this time, she gained the use of her right arm, but her right leg remained weak. After 3 months in the program, her depression began to lift—not only because her previous abilities were returning but also because she began to see new ways of looking at her life. Through counseling, she realized that a big missing piece for her was a spiritual practice. She had been brought up in a Protestant church and, during college, was very interested in the “deeper questions,” but she had let go of this part of herself when she entered the workforce. She could see now how she had been “caught up in the busyness” of working, rearing children, and maintaining a marriage and family relations and had had little time to think about the meaning of these activities for her. After 1 year, Laura continued to use a cane to walk. She returned to work part time, and she and her husband and children moved into a

81

82

M a k i n g M e a n i n g f u l C o n n e cti o n s

Think about this: Does your identity differ in different settings? Has it shifted as you’ve grown older?

smaller house to decrease their expenses. Laura became actively involved in a culturally diverse church that one of Dan’s siblings attended. The new relationships she made with church members provided an additional sense of purpose and meaning in her life. Despite the family’s lowered income and her difficulty walking, Laura described herself as happy with her life. With regard to her identity, Laura continued to experience shifts in her sense of self, depending on her situation. At her core, she still felt “local” (i.e., born and reared in Hawaii). With Dan’s family, she experienced her Japanese ethnicity as most salient because it contrasted with their Chinese culture. With friends who had disabilities (most of them European American), she was more aware of herself as an Asian American woman, but in her culturally diverse church group, she thought of herself more as a person with a disability. And now at 55 and with the birth of her second grandchild, she was becoming increasingly aware of her age. Permeating all of these identities was a strong sense of herself as a spiritual person. As Laura’s example illustrates, ethnic and racial identities can interact in complex ways with a variety of self-identifications. Early on, Laura identified as biracial largely because of her social environment (i.e., Hawaii), where multiracial identities are common. In contrast, the predominantly rural European American college environment pushed her to think of herself in more dichotomous terms (Asian American vs. European American). In marrying a man of Chinese heritage, she became increasingly aware of the differences between her Japanese heritage and that of her in-laws. The stroke and disability brought another layer of complexity, including identification with the Disability community and a religious community. And with age, she was beginning to develop a generational identity. In sum, her identity varied with her social context, personal experiences, age, and time.

Identity Research During the past 20 years, multicultural psychologists have given a great deal of attention to describing the development of identity. Although this work initially focused on the racially based identities of Black and White people in the United States (W. E. Cross, 1991; Helms, 1995), attention soon shifted to include the development of identities related to ethnicity (D. W. Sue & Sue, 2003), gender (Downing & Roush, 1985; Kimmel & Messner, 1992; Wade, 1998), sexual orientation (Cass, 1979; McCarn & Fassinger, 1996; Troiden, 1979), disability (Olkin, 1999), and minority status in general (Atkinson, Morten, & Sue, 1993).

Understanding Clients’ Identities and Contexts

These new fields of study heightened awareness of individuals and groups that had been marginalized from and by mainstream psychology. However, the researchers generally approached identity as a unidimensional phenomenon, reflecting dominant cultural assumptions that a person is either a member of a minority group or not. Only in the past few years have researchers begun to address the complexities of identity (sometimes referred to as intersectionality) for most people. Root (1996) was among the first to describe a framework for understanding self-identification in people who hold more than one racial identity. Drawing from Anzaldua’s (1987) ideas regarding “racial borders,” Root explained that biracial people may identify in one of the following four ways (pp. xxi–xxii): 1. The individual may solidly identify with both groups, simultaneously holding and merging multiple perspectives. 2. The individual may experience a shift in one identity, from foreground to background, depending on the sociocultural context. That is, in one setting, one identity may be experienced as primary, whereas in another setting, the other identity may be. 3. The individual may identify primarily as a biracial or multiracial person, thus using the “border between races” as a central reference point. 4. The person may identify primarily with one group but, over time, move in and out of identification with a number of other groups. In recognizing the complex ways in which a multiracial person can identify, Root’s model challenged the idea that a healthy identity must follow a linear path to the ultimate goal of a singular, holistic, unchanging identity. Later, Wijeyesinghe (2001) noted similarly that multiracial individuals may identify themselves on the basis of a variety of factors and that “those who do not reach multiracial ‘wholeness’ should not be considered somehow incomplete” (as cited in Crane, 2013, p. 274; see Crane for an excellent overview of racial identity development theories). Not surprisingly, although early (pre-1980s) studies of multiracial people looked for and found negative effects of a multiracial heritage, as more multiracial psychologists began publishing on the topic and the complexity of self-identification became more evident, subsequent studies found multiracial people’s self-esteem to be positive or similar to that of monoracial individuals (C. C. I. Hall, 2003). More recently, researchers have investigated the complexity of identity in people who have disabilities (e.g., Dunn & Andrews, 2015; Mona, Romesser-Scehnet, Cameron, & Cardenas, 2006) and people who identify as lesbian, gay, bisexual, and transgender (LGBT; e.g.,

83

84

M a k i n g M e a n i n g f u l C o n n e cti o n s

Jamil, Harper, Fernandez, & Adolescent Trials Network for HIV/AIDS Interventions, 2009). As with the multiracial literature, many of these studies were by researchers who belonged to the group they were writing about, adding enormously to the richness and insight of this work. However, there continues to be a gap regarding social class, classism, and people of lower socioeconomic status (SES; Liu, 2011; L. Smith, 2005). There are probably several reasons for the lack of psychotherapy research regarding classism and people of lower SES. For one, people living in poverty have historically been considered poor candidates for psychotherapy. Disinterest in investigating this stereotype and developing more effective approaches is probably related to dominant cultural beliefs that people in poverty are “lesser in values, character, motivation, and potential” (Lott, 2002, p. 108). Also, as H. J. Aponte (1994) noted 20 years ago (and I think it still applies), today’s therapeutic models often carry social messages and philosophies “that reflect the world of the intellectual and the academic” (p. 246). Such models contrast sharply with the traditional customs, lifestyles, and religious beliefs that many clients of lower SES hold. These differences can make it difficult for some therapists to relate to people of lower SES. Another reason for psychology’s neglect of social class and classism is the privilege associated with the profession. Although psychotherapists are an increasingly diverse group, social class is the one domain of the ADDRESSING influences in which all therapists have privilege, whatever their ethnicity, sexual orientation, and so forth. Even if you are a therapist who grew up in poverty and thus have a deeper understanding of its effects, in your current status you still have the privileges that come with a graduate-level education and professional position that clients of lower SES do not have. Whereas research on race and ethnicity has been driven largely by the growth in psychologists of color, the particular obstacles that people in poverty face in becoming psychologists work against their representation in and influence on the profession. A report of the American Psychological Association’s Task Force on Socioeconomic Status (2007) called official attention to the need for more research in this area (Lott, 2012), and a few more articles and books of relevance to therapists have been published (for overviews, see C. Campbell, Richie, & Hargrove, 2003; Liu, 2011; Lott, 2012; P. Minuchin, Colapinto, & Minuchin, 2007; Payne, 2013; L. Smith, 2005). Another growing resource consists of writings outside the field of psychology, namely, in political science, history, sociology, anthropology, social work, and some forms of literature. Regarding the latter, novels can provide a rich description of the experiences of people living in poverty (e.g., see E. J. Gaines, 1997; Gibbons, 1998; Hogan, 1995; Mistry, 2001).

Understanding Clients’ Identities and Contexts

Learning About a Client’s Identity In an initial assessment, the simplest way to learn about a client’s selfidentification is often to ask. However, at times, asking about a client’s identity is complicated or inappropriate. It is still considered impolite and even risky in some settings to discuss race, social class, sexual orientation, age, or disability, and this is particularly true if a client has emigrated from a country where identity is not discussed or is linked to violent conflict. For example, asking a Rwandan immigrant if he is Hutu or Tutsi would be offensive, just as asking someone from Northern Ireland whether she is Protestant or Catholic would be off-putting. Even among many people born in North America, it is considered inappropriate to bring up such topics in “mixed company,” and in some communities it is dangerous to identify oneself as gay or transgender. Clients of minority identities may be reluctant to talk about identityrelated differences because they assume that the therapist holds the same biases as the dominant culture. Hinrichsen (2006) described a poignant example of this reluctance; as a young psychologist born in rural Illinois and raised Catholic, he was gently asked by an older Jewish woman, “Have you heard of the Holocaust?” Straightforward questions about a client’s identity may also be inappropriate when clients perceive the concept of identity to be an abstraction unrelated to their presenting concerns. Identity is an abstract concept— one that may be useful to therapists but not necessarily of interest to clients. Recall the case of Mrs. Sok (the Khmer woman in Chapter 2 of this volume), who would have found a discussion of her identity to be even less relevant to her presenting complaint than the questions she was asked. In addition, the way in which the therapist asks an identity-related question can subtly determine the client’s response. For example, depending on the context, the question “What is your ethnicity?” may be perceived as ridiculous or odd because the client believes the answer to be obvious. When the client’s identity is not self-evident, such a question may be offensive because, in the dominant culture, questions about ethnic and racial identity have historically been used to decide how people will be treated (Root, 1996). People of minority and mixed identities may be especially sensitive to such questions from a therapist who appears to belong to a dominant cultural group. Less direct questions regarding identity are less likely to give offense—for example, “Could you tell me about your cultural heritage or background?” or “What were the most important values you learned

85

86

M a k i n g M e a n i n g f u l C o n n e cti o n s

growing up?” Unlike more specific questions before a client has stated how he or she identifies (e.g., “How is it for you as an African American in your school?”), such phrasing does not assume an identity for the client that the client does not hold for himself or herself. Similarly, asking clients to describe their “religious upbringing” and then asking whether they have a practice today allows for a richer response than simply asking, “What is your religion?” which overlooks the possibility that the client may have grown up in a particular culture or group but currently identifies with another.

DISABILITY IDENTITY In work with people who have disabilities, Olkin (1999) advised against asking individuals, “What happened?” which suggests a search for something or someone to blame. Such a question may also be related to the therapist’s countertransference in the form of seeking reassurance that there is something or someone to blame (Artman & Daniels, 2010). More appropriate inquiries are, “What is the nature of your disability?” and, if the client has not brought up the subject of disability following a discussion of the presenting problem and current situation, “Are there ways in which your disability is part of this [the presenting problem]?” (Olkin, 1999, p. 167). Regarding what and how not to ask, when asking women with disabilities about their sexual health, Mona (2013) pointed out the bias in the question “What problems or concerns do you have related to your disability?” Asking in this way seems to assume that the disability contributes to sexual problems for the client, which may not be the case. Instead, Mona asks, “How satisfied are you with your sex life?” which simply accepts the disability as fact and thus conveys its normality. Although such differences are subtle, it’s these nuances that directly communicate a therapist’s awareness (or lack thereof). When disability is not the focus, therapists may be less sure about what, how, and whether to ask about a disability. But even if it feels intrusive or inappropriate to ask particular questions, therapists still need to consider questions (in their own head) related to the client’s disability because disability is a part of the person’s experience and identity, whether it’s a self-identification or an identity assigned by the dominant culture. Otherwise, there’s a risk of missing information that’s key to understanding the person and his or her life. For example, I once saw an older White, Christian couple for marital conflict. She worked as a part-time receptionist and he was an airplane mechanic at a large airport. In conflicts, she was passive and withdrawn, and he became angry and loud. Because he told me he was hard of hearing (and he didn’t wear a hearing aid), I made an extra effort to speak

Understanding Clients’ Identities and Contexts

more loudly than I usually do. Although I asked about his childhood experiences and he acknowledged being physically hit and berated by his parents, he did not talk about his hearing impairment in relation to these experiences, so I assumed that he had acquired the impairment as an adult working around jet engines at the airport. In a later session, after he’d become more comfortable with me, he told me that he didn’t think I understood the connection between his hearing impairment and who he was and how he acted in his marriage and the world (and he was right). With much emotion, he explained that his hearing problems were central in his development: When he didn’t hear what his parents were saying, they got angry and were more abusive; at school, he couldn’t always hear the teacher, so he did poorly and barely finished high school; and other kids made fun of him, so he didn’t have any close friends and thus never developed friends later as an adult. The low self-esteem, depression, and anger that he attributed to these early experiences profoundly affected his relationships with his wife and only child and led to a demotion in his leadership status at church. If I’d specifically asked about his identity, I think he would have described himself as a father, husband, and “Godly man,” and not as a person with a disability, but clearly the hearing impairment was central to how he thought about himself and his identity in the world.

SEXUAL ORIENTATION AND GENDER IDENTITIES To understand the influence of any client’s gender and sexuality, therapists need to know the individual’s sexual orientation and relationship history, but the degree to which one can ask directly about these topics depends on the setting and client population. For example, in rural community mental health settings, directly asking about a person’s sexual orientation may be perceived as intrusive, offensive, or embarrassing. Homophobic heterosexual men may take the question as implying that the therapist thinks they might be gay, resulting in defensiveness; older clients may be put off by direct questions about their sexuality; and LGBT individuals may feel threatened about disclosing such information to an unknown therapist whom they assume is heterosexual. In such situations, it can be helpful to obtain this information indirectly, for example, through questions about the client’s relationship history. Throughout this process, it is always important to avoid assuming heterosexuality in one’s questions (e.g., avoiding such questions as “Are you married?”; using the term partner instead of husband or wife; asking teens whether they have a “romantic relationship with anyone” instead of asking whether they have a boyfriend or girlfriend).

87

88

M a k i n g M e a n i n g f u l C o n n e cti o n s

With clients who openly identify as lesbian, gay, bisexual, or transgender, the therapist may be more able to ask direct questions regarding gender and sexuality, including their attractions; how and when they disclosed to others and important events in this process; how “out” they are; how accepted they feel in their social environment; and what their experiences of discrimination, harassment, or victimization have been (Balsam, Martell, & Safren, 2006). To understand the meaning of gender for any client (not solely transgender clients), L. S. Brown (1990) suggested the question “What did it mean for you to grow up as a boy [or girl] in your culture and family?” A key aspect of questions regarding gender and sexuality involves the therapist assessing the degree to which those factors play a role in the client’s presenting problem; in some cases, they may be the focus, whereas in others, they may have little to do with the problem (Balsam et al., 2006). Therapists also need to be aware of the influence of European American cultural assumptions in the psychology literature regarding sexual orientation and gender identity. For example, some of the work regarding the coming-out process assumes that it occurs in a linear progression of specific stages, that it occurs only once in a person’s lifetime (i.e., a person is either “out” or “still in the closet”), and that the end result is usually positive (i.e., increased self-acceptance and integration of one’s sense of self; A. Smith, 1997). However, these assumptions are not applicable for all people of European American heritage and for many people of color. Regarding people of color, disclosure of one’s sexual orientation or gender transition may involve the contradiction of cultural norms regarding personal and family privacy and the potential loss of support from one’s cultural group. The loss of support may extend beyond an individual’s ethnic community to other ethnically interconnected groups. For example, in a study of Asian Canadian men who have sex with men, one participant explained, Ethnically I am a Chinese Indonesian and I was involved in a church a lot and it was not a gay friendly church. So that was my initial introduction to my ethnic group in Vancouver, I guess. And then I got kicked out. . . . So, that was kind of my last . . . connection to my ethnic community. (as cited in Nakamura, Chan, & Fischer, 2013, p. 251)

On top of heterosexist prejudice in ethnic minority and religious communities, the individual may experience racism from the gay community, too (Dang & Vianney, 2007). In sum, for LGBT people of color, there may be no completely safe or stress-free social environment; individuals experience racism from gay social supports and antigay het-

Understanding Clients’ Identities and Contexts

erosexism in their own ethnic community (Thoma & Huebner, 2013). In such contexts, a person’s reluctance to disclose may be an adaptive, self-protective response (A. Smith, 1997). It is also important to understand how the coming-out process differs for LGB people and transgender people. For people who identify as lesbian, gay, or bisexual, coming out is typically seen as revealing a truth about oneself that allows others to know them, and being out is considered important to one’s happiness. However, for a transgender person, having transitioned to one’s authentic, selfidentified gender is the truth; some transgender people choose to be public about this aspect of their lives in order to raise social awareness, but it is not considered necessary to one’s happiness in life (GLAAD, 2014). In general, when a client does not wish to explore the relationship between personal and cultural identities and his or her current situation, it is wise to respect this wish, especially before a trusting therapeutic relationship has been built. However, this initial avoidance of the subject does not mean that the therapist should not consider the impact of identity. The therapist still needs to make hypotheses about the client’s identity and seek information to confirm or disconfirm these hypotheses (either from the client or external sources) because understanding the client’s identity and contexts is necessary for a positive alliance, an accurate assessment, and effective therapy. Exhibit 5.1 lists questions therapists can use to ask clients about their cultural influences, and Exhibit 5.2 offers questions for therapists to consider even if they cannot ask clients directly. EXHIBIT 5.1 Understanding Clients’ Identities: General Questions for Clients 1. How would you describe yourself? 2. Could you tell me about your cultural heritage or background? 3. What were the most important values you learned growing up? 4. What was your religious upbringing? Do you have a religious or spiritual practice now? 5. What did your parents do for a living? 6. What was your family’s economic situation growing up? 7. Do you have experience with disability, or have you been a caregiver for someone who does? 8. Are there ways in which your disability is part of [the presenting problem]? 9. Do you currently have a partner? Could you tell me about the significant intimate relationships you’ve had? 10. How was it growing up as a girl [or boy] in your culture and family?

89

90

M a k i n g M e a n i n g f u l C o n n e cti o n s

EXHIBIT 5.2 Understanding Clients’ Identities: Questions for Therapists to Consider 1. What are the ADDRESSING influences on this client (i.e., age and generational influences, developmental or other disability, past and current religion and spiritual orientation, ethnic and racial identity, socioeconomic status, sexual orientation, Indigenous heritage, national origin, and gender)? 2. What are this client’s salient identities related to each influence? 3. What are the possible meanings of these identities in the dominant culture, in the client’s minority culture or cultures, and from the personal perspective of the client? 4. How are my salient identities interacting with those of the client? a. How am I being perceived by this client on the basis of my visible identity? b. Am I knowledgeable about the groups the client identifies with? c. How might my identity and related experiences, values, and beliefs limit my understanding of this client?

Turning Assumptions Into Hypotheses and Questions

Think about this: Can you think of a time when you were surprised and then realized that you had assumed something that wasn’t accurate or true?

At the beginning of any assessment, information about a client’s identity and situation is usually provided by the referral source (e.g., “Mrs. Cheng is a 48-year-old, widowed, Asian American woman who presents with depression”). Using this introductory information, the therapist then formulates hypotheses that shape questions aimed at confirming or disconfirming the hypotheses. Throughout this process, there is a fine line between an assumption and a hypothesis. An assumption is something we take for granted or believe to be true, and obviously we all begin with some basic assumptions—for example, that clients are who they say they are, that they or someone else wants help for them, and so on. A hypothesis is a tentative, explicit assumption made with the understanding that it needs to be proved or disproved and with the intention to find out whether it is accurate or not. In my experience, the best indicator that I have made an assumption is when I am surprised by something, because my surprise signals me that I was assuming something else— otherwise, I wouldn’t have been surprised. In formulating hypotheses and questions, the more background information a therapist holds regarding a client’s cultures, the greater the likelihood that his or her hypotheses (and for that matter, assumptions) will be close to the client’s real situation, and thus the betterinformed his or her questions will be. Well-informed questions convey

Understanding Clients’ Identities and Contexts

an understanding of the client’s world, increasing the therapist’s credibility while soliciting information about the client’s unique experience of that world. I think of this background cultural information as a template for understanding the individual’s unique experience. For example, a therapist who has experience with Asian American people would immediately recognize that Mrs. Cheng’s surname is Chinese. This realization would then allow him to begin to form hypotheses about the client’s cultural context that are more likely to be useful (i.e., hypotheses that are relevant to a widowed Chinese American woman living in the area). At the same time, the therapist’s experiences would keep him aware of the diversity of possible influences in this client’s life, including, for example, the possibility that despite her name, the client is not Chinese American. Of course, once the therapist and client meet, a great deal more observable information is usually available about the client’s identity. The client’s language fluency, national or regional accent, physical appearance, body posture, preferred physical distance during social interactions, mannerisms, clothes, grooming, and apparent age all serve as cues for the therapist’s hypotheses about the client’s possible identities. Again, the usefulness of such information depends on the knowledge base and experience of the therapist. To illustrate this point, consider a much less knowledgeable therapist’s inferences regarding Mrs. Cheng’s report that she was born in Vietnam and came to the United States with her husband and children at the age of 30. From the perspective of the second therapist, this piece of information would raise questions about the client’s experiences of immigration and the Vietnam War and adjustment to life in a new country, and these would be reasonable areas of inquiry. However, because the therapist is unfamiliar with Asian names and people, her observation that Mrs. Cheng appears to be of Asian heritage, combined with Mrs. Cheng’s statement that she was born in Vietnam, might lead the therapist to assume that the client is ethnically Vietnamese, when in fact she is not. In this situation, the therapist’s lack of knowledge of the existence of a Chinese minority culture within Vietnam (as well as any information about this culture) could lead to questions, hypotheses, or interventions that are irrelevant or inappropriate (e.g., consultation with a Vietnamese individual who holds negative attitudes toward people of Chinese heritage). There is no substitute for culture-specific knowledge and experience in providing culturally responsive services. Moreover, what you need to learn depends on your particular cultural identifications, experiences, and contexts. For example, to work effectively with a gay African American client, a therapist who is gay and European American would need to expand his knowledge and experience in ways that are different from the

91

92

M a k i n g M e a n i n g f u l C o n n e cti o n s

ways in which a heterosexual African American therapist would need to expand hers.

How the ADDRESSING Framework Can Help For therapists engaged in the cross-cultural learning process, the most basic level of attention in an initial assessment involves considering what identities may be relevant for a given client. The ADDRESSING framework can be helpful with this process because it provides an easyto-remember list of cultural influences that can cue you to think about minority and dominant identities that you might be inclined to overlook. Although it may not be appropriate to ask the client directly about every one of these influences and the client’s identities, keeping the acronym in your awareness can prevent you from assuming an identity that does not exist for the person. For example, assuming that a client is heterosexual just because she presents as married could lead to questions that convey a lack of awareness or dismissal of the possibility that she is gay or bisexual or that she identifies as neither but is attracted to women or both women and men. Gender is the most commonly assumed identity, but even gender is not always self-evident, and the idea that one can tell who is transgender is false. This systematic consideration of the ADDRESSING influences and related identities is illustrated in the following example. Jean (pronounced Zhahn), a 43-year-old Haitian man, immigrated to Québec at the age of 13 with his uncle and the uncle’s wife, who had no children of their own. Jean completed university in Montréal but had difficulty finding employment with his degree in political science. After many months, he settled on a position as assistant manager of a large, nationally franchised hotel. He subsequently married a French Canadian woman who also worked in the hotel. They had a son, but after 2 years they divorced because, as Jean put it, “she looked down on my family.” Jean was referred to a counselor by his physician, who could find no medical reason for Jean’s recurring migraines. Six months before the referral, Jean had taken a new position as hotel manager, which was a significant move up. The position was so demanding that he had not had a weekend free in 3 months, and many times he stayed overnight at the hotel. His former wife was pressing to change their joint custody arrangement because she knew that Jean was frequently leaving their 8-year-old son with his aunt and uncle. Jean described his headaches as extremely painful and said that he had missed several days of work

Understanding Clients’ Identities and Contexts

and was feeling anxiety and even some panic that he might lose the job and his son. In the initial assessment, the therapist, Marie, a 40-year-old French Canadian woman, spent the first few minutes talking socially with Jean. She told him that she had visited one of the French-speaking West Indies, Saint Martin, which prompted Jean to talk about the similarities and differences between it and Haiti. Marie was aware of the prejudice toward Haitians in Québec and the need for her, as a Québécoise, to demonstrate her respect for Jean fairly quickly. Because she knew he had a university degree, she asked him what he had studied, thus acknowledging his educational status. His response allowed her to draw a connection between their experiences, as her partner also had a degree in political science with a focus on immigration issues. In sharing this information, she communicated her view of Jean as a peer. Once a beginning rapport had been established, Marie explained the purpose of the assessment and asked Jean if he agreed to proceed. He did, so she went on to ask if he would describe himself to her, including “any information that you think I might need to know in order to understand you and your situation better.” He replied, My father was a successful businessman in Port au Prince—he died 10 years ago—and my mother was a teacher before she retired. I have one sister, who is also a teacher, and two brothers, who work in the business my father started. My brothers attended university in Montréal, but they returned to live near our family. We have a large family, and I have many aunts, uncles, and cousins, and my grandparents are still living, too. I stayed here because my son is here. And my aunt and uncle are still here.

Reviewing the ADDRESSING influences in her head, Marie noted those areas in which Jean provided information regarding his identity. The most consistent aspect of his summary was his emphasis on family. In addition, he provided information about his generational and socioeconomic status through the details about his parents’ occupations, his sister being a teacher, and his brothers’ university educations. From this brief description, as well as other observed cues (e.g., his physical appearance, dress, language abilities, and social skills), the therapist hypothesized that Jean’s identity was closely tied to his family relationships, that he considered himself middle class, and that his national origin was a central part of his identity. These hypotheses were accurate primarily because they reflected the information Jean provided, which is summarized in Table 5.1. Marie also noticed that Jean did not mention a religious or spiritual identity, his sexual orientation, his gender, or the presence of any disability. She hypothesized that he had not mentioned gender, sexual orientation, or disability because he assumed that these were obvious.

93

94

M a k i n g M e a n i n g f u l C o n n e cti o n s

TA B L E 5 . 1 ADDRESSING Cultural Influences and Identities: The Case of Jean Cultural influence

Jean’s influences, as noted by Marie

Age and generational influences

43 years old; born in 1972 and grew up under the oppressive Duvalier government (1957–1986). None reported or apparent. Self-identifies as Catholic; I did not ask about, and he did not mention, any Vodou beliefs or practices. Haitian; reports he does not feel Canadian, although he has landed immigrant status (i.e., permanent residency). Middle-class parents; Jean has a university education but is underemployed, probably as a result of discrimination; speaks French fluently (class-related ability). Probably heterosexual. Does not identify as Indigenous. Haitian; speaks Haitian Creole and French fluently; immigrated to Montréal, Québec, Canada, in 1985. Male, single (divorced), father of one son; also a brother and uncle.

Developmental or other Disability Religion and spiritual orientation Ethnic and racial identity

Socioeconomic status

Sexual orientation Indigenous heritage National origin Gender

She also recognized that he might not conceptualize sexual orientation in the same way as the dominant culture (i.e., research suggests that for Haitians, sexual behavior between people of the same gender “is often not correlated with a self-definition as gay or bisexual”; Bibb & Casimir, 1996, p. 103). She asked whether he had had a “partner” since his divorce, and he said that he had gone out with a few women but that he had not developed a serious relationship with anyone. Marie refrained from further questions in this initial assessment but still considered the possibility that Jean could be gay or bisexual. Later, as she learned more about his life and relationships, she ruled out this hypothesis. Marie still needed to find out about religious influences in Jean’s life because this could be a source of support and positive coping behaviors. She asked, “What was your religious upbringing?” Jean said that he was Catholic but attended Mass only when he was “home” (in Haiti), although he prayed “during hard times, like now.” Marie was aware that many Haitians integrate Vodou rituals into Christianity and that such rituals might be helpful to him, providing some relief from the burden he was feeling. She also knew that in contrast to Vodou (sometimes spelled Vodoun, Vodun, or Vodu), which refers to the religion as practiced in Haiti, voodoo as it is often conceptualized by the dominant U.S. culture has a

Understanding Clients’ Identities and Contexts

derogatory connotation (see Ulysse, 2013; Words Between the Spaces, 2009). So instead of asking about Vodou specifically, she asked what Jean thought was contributing to his migraines and what he had tried in order to change these contributing factors or to decrease the pain. He did not mention any Vodou beliefs or practices, so she refrained from asking about this. (See Nicolas, DeSilva, Grey, & Gonzalez-Eastep, 2006, and Sutherland, Moodley, & Chevannes, 2013, for more on health, illness, and Haitian healing traditions.)

Understanding the Meanings of Identities Even when a therapist has a clear description of a client’s selfidentification, this information will not necessarily lead to a deeper understanding of the client. What is important is knowledge of the meaning of these identities (L. S. Brown, 1990). Depending on one’s reference point, there may be more than one meaning for the same identity. That is, a particular identity may have one meaning in the dominant culture, another in a minority culture, and still another, personspecific meaning for the individual. Information about the person-specific meanings of identity usually comes from the client, either indirectly (through descriptive information and views shared by the client) or in response to direct questions (e.g., regarding Jean, “What does your identity as a Haitian man mean to you, in your present situation?”). However, to understand these personspecific meanings, it is important that therapists also understand their culture-specific meanings. To understand the culture-specific meaning of Jean’s identity as a Haitian man living in Canada, it is necessary to have at least a general knowledge of Haitian culture and history. Haiti was originally inhabited by the Arawak (Taino) people, who were brutally oppressed and nearly annihilated by Spanish and then French colonizers, who brought thousands of African slaves. In 1804, the enslaved people overthrew the French, and Haiti became the world’s first independent Black republic. From 1915 to 1934, Haiti was occupied by the United States, and the first group of Haitians immigrated to the United States. Many of them settled in Harlem and integrated into the African American community (Menos, 2005). From 1957 to 1986, Haitians endured the oppressive regimes of Papa Doc Duvalier and his son Baby Doc. The Tonton Macoutes, a secret military police, routinely tortured and persecuted dissenting professionals, politicians, and students.

95

96

M a k i n g M e a n i n g f u l C o n n e cti o n s

The second wave of immigration to the United States began during this period and consisted primarily of the well-educated upper and upper-middle classes, resulting in the loss of many professionals from Haiti. Later groups, from the mid-1960s to 1971 and during the 1980s, consisted mainly of middle-class and poorer people. In the early 1990s, another 65,000 risked their lives to escape political persecution and economic devastation but were intercepted according to a U.S. policy that ordered the Coast Guard to turn away all Haitian boats without screening passengers for refugee status (Menos, 2005). As of 2011, approximately 138,000 Canadians identified as Haitian, the vast majority residing in Québec (Statistics Canada, 2014). More recently, Haiti has continued to experience armed uprisings (e.g., the ousting of the democratically elected Jean-Bertrand Aristide in 2004), foreign intervention (e.g., a U.S.-backed government until 2006), disease (e.g., approximately 4% of the population has AIDS), and natural disasters (e.g., in 1998, Hurricane Georges killed 400 people and displaced 160,000; in 2004, flooding killed 2,000 people; and in 2010, a magnitude 7.0 earthquake killed 200,000 people, followed by a cholera outbreak that killed 8,000 [these figures are estimates]; CNN World, 2013; World Almanac Education Group, 2007). Today, Haiti remains the poorest nation in the Western Hemisphere. Class divisions among Haitians both inside and outside the country are strong. Fluency in French and lighter skin color (related to family histories of intermarriage with the French and thus alignment with French colonial values) are associated with higher social status. In Québec, Haitians who are fluent in French have the advantage of language (i.e., in contrast to Haitians in Vancouver, Toronto, or the United States, who must learn English). However, they are not accepted in the same way as French speakers of European origin, and color-based job discrimination is not uncommon (Bibb & Casimir, 1996). Jean was a lighter-skinned Haitian man who was fluent in French, held a university degree, and came from a middle-class family. In his culture of origin, he held privilege and status. In contrast, in the Canadian context, the same cultural identities held a different meaning. Being Haitian (or, from the dominant cultural perspective, Black) meant that he was seen primarily as an immigrant and a foreigner. The most salient aspects of his identity in Haiti—gender and social class—were eclipsed by his ethnic identity, which visibly set him apart from the majority of Canadians. Although it might at some point be appropriate for the therapist to ask Jean about his personal experience as a Haitian man living in Québec, it would not be appropriate for the therapist to expect Jean to educate her about the general cultural meanings of his identity (i.e., the information provided in the preceding paragraphs), nor would it be wise, because information about a whole culture from the client’s sole

Understanding Clients’ Identities and Contexts

perspective is often quite limited. Obtaining this kind of information is part of a therapist’s own personal learning, most of which should occur outside the therapy setting. As an analogy, consider a therapist who has no direct experience with people who have a dissociative disorder; she would not expect the first client she sees with this disorder to educate her about its common characteristics. Rather, she would obtain this information herself outside the therapeutic relationship and then use the assessment time to explore the client’s personal experience of the disorder. If, with regard to Jean, the therapist is unfamiliar with the general history and culture of Haiti, the impact of political events on Jean’s generation, and the position of French-speaking visible minority cultures (the term used in Canada), she would be more likely to maintain her credibility by admitting these gaps, at least to herself, and, depending on the circumstances, possibly to Jean as well. She could then commit herself to expanding her knowledge for the benefit of her client. This commitment would lead her to seek information and experiences outside the therapy setting and to educate herself about these general meanings. As her knowledge and experience increased, her understanding of Jean’s identity would still be framed as hypotheses, but these hypotheses and the questions that emanated from them would be much closer to the realities of his life.

Conclusion Identity is a complex phenomenon that includes both group-specific and person-specific meanings. Although the concept of identity is not always of interest to clients, it can be helpful to therapists who want a deeper understanding of their clients. Knowledge of a client’s identity allows the therapist to more accurately infer what cultural influences have been important in that person’s life. In turn, such information helps the therapist form hypotheses and ask questions that are closer to the client’s reality. Although information about a client’s personal experience of culture usually comes from the client, it is generally not fair to expect clients to educate the therapist about the broader cultural meanings of their identity. Obtaining the latter information is primarily the therapist’s responsibility and often involves work outside the therapeutic setting. The more committed therapists are to this outside work, the more able they will be to use this background information to understand the client’s personal experience and respond in ways that facilitate assessment and the therapeutic process.

97

98

M a k i n g M e a n i n g f u l C o n n e cti o n s

Practice: Countering Stereotypes Pick one cultural minority group and find at least one way in which members of the group vary in relation to each of the ADDRESSING influences. For example, if you pick Iranian Americans, then investigate the following: ❚❚

❚❚

❚❚

❚❚

❚❚

Key Ideas

With regard to Age and generational influences, find an example of one way in which the lives of younger U.S.-born Iranian Americans differ from those of their immigrant grandparents. For Developmental or other Disability, find an example of how the lives of disabled Iranian Americans are different from the lives of nondisabled Iranian Americans. For Religion and spirituality, find statistics on the number of Iranian Americans who are Shi’a, Sunni, and Sufi Muslim, as well as Zoroastrian, Christian, Jewish, and so forth. For Ethnic and racial identity, find out the specific ethnic groups living in Iran (e.g., Azeris, Balochis, Arabs, Kurds, Pashtuns, Turkmen). Continue down the list of ADDRESSING influences.

  1. In healthy individuals, identity is a complex phenomenon that can vary depending on the person’s context and experiences and over time.   2. Despite the growth in multicultural research regarding identity development and diverse minority groups, there continues to be a gap regarding social class, classism, and effective psychotherapy with people in poverty.   3. Clients of minority identities may be reluctant to talk about identity-related differences because they assume that the therapist holds the same biases as the dominant culture.   4. Straightforward questions about a client’s identity may be inappropriate when clients perceive the concept of identity to be an abstraction unrelated to their presenting concerns.   5. Even if it feels intrusive or inappropriate to ask identity-related questions, therapists still need to consider such questions because not doing so risks missing information that is key to understanding the person and his or her life.   6. A key aspect of questions regarding gender and sexuality involves the therapist assessing the degree to which they play a role in the client’s presenting problem; in some cases, they may be the focus, whereas in others they may have little to do with the problem.

Understanding Clients’ Identities and Contexts

  7. Because lesbian, gay, bisexual, and transgender people of color may have no social environment completely free of prejudice and discrimination, the reluctance to disclose may be an adaptive, self-protective response.   8. Referring to someone’s birth-assigned gender as their “real” gender is erroneous and offensive; for a transgender person, their real, true gender is what they are living or wish to live.   9. The ADDRESSING framework can help therapists formulate likely hypotheses and well-informed questions because it provides an easy-to-remember reminder of cultural influences and identities one might be inclined to overlook. 10. Depending on one’s reference point, there may be more than one meaning for the same identity—an identity may have one meaning in the dominant culture, a different meaning in a minority culture, and still another, person-specific meaning for the individual.

99

Creating a Positive Therapeutic Alliance

M

6

r. Ortega, age 32 and of Costa Rican heritage, arrived for an appointment with the physician in his company’s outpatient clinic. In fluent English with a Costa Rican accent, he explained that during the past 5 months he had had pains in his stomach, had not eaten well, and had lost about 20 pounds. The physician, a European American man in his 60s, did a thorough medical exam and then asked Mr. Ortega if he was experiencing some stress in his life. Mr. Ortega said yes, that he and his wife had not been getting along, that she had gone back to Costa Rica with their daughter to visit her family, and that he was afraid they might not return. The physician responded that this sounded like a very stressful situation. He went on to explain that Mr. Ortega’s problem appeared to be “heartburn” (esophageal reflux), which can be aggravated by stress. While writing a prescription for a medication, the physician asked Mr. Ortega if he would be willing to see the “nurse practitioner therapist” for a few minutes “to talk about stress and diet in relation to

http://dx.doi.org/10.1037/14801-006 Addressing Cultural Complexities in Practice: Assessment, Diagnosis, and Therapy, Third Edition, by P. A. Hays Copyright © 2016 by the American Psychological Association. All rights reserved.

101

102

M a k i n g M ea n i n g f u l C o n n ectio n s

your stomach problems and get some suggestions regarding your health and what you can do to feel better.” Mr. Ortega agreed, so the physician found the nurse practitioner, Sharon, introduced Mr. Ortega to her, and left the two to talk. Sharon, age 38 and of Italian American heritage, greeted Mr. Ortega with a firm handshake and some informal conversation about how difficult traffic had become in the two areas of town in which they each lived. Sharon’s friendly manner and mention of traffic on the way to her children’s day care led Mr. Ortega to talk about his own 2-yearold daughter. During the course of their conversation, he told Sharon that his first name was Manuel. Sharon observed to herself that Manuel was casually but neatly dressed and wearing dark-rimmed glasses. He showed a full range of affect and was friendly, although his facial expression and posture suggested anxiety. Following this casual conversation, Sharon began the formal part of the assessment by describing her training as a nurse practitioner and psychotherapist who works with people who have stress-related problems. As she explained her integrative approach to therapy and gave a few examples of how she had helped people in the past, Manuel’s facial expression became increasingly tense. He told Sharon that he had thought that this meeting “was just to talk to the nurse to get more information about my stomach problems; the doctor was the main one helping me.” Sharon could see that he was feeling embarrassed about the suggestion that he might need counseling. She recognized her own feelings of embarrassment and irritation—embarrassment that he obviously didn’t see how she could be of help, which felt like a jab at her competence, and irritation emanating from her belief—an assumption— that he wouldn’t be reacting this way if she were a man. Taking a deep breath to slow her own reactions, Sharon apologized for the misunderstanding about the meeting’s purpose. She then validated Manuel’s feelings by saying that she could see how he would be confused by the situation and that she and the physician had not been as clear as they could have been. This seemed to ease the tension slightly, so Sharon went on to explain that in their clinic, she and the physicians worked closely together because so many health problems involve both the body and the mind. She talked about how “physical” problems like headaches, stomachaches, and body pains are often related to stress—for example, losing one’s job, making a major move, or being in the middle of a family conflict. She also gave examples of problem solving that clients had done in counseling that helped them feel less worried, which in turn decreased their physical symptoms. Manuel still appeared tense, but he was listening. Realizing the need to establish her own credibility, Sharon said she would like to ask the physician to join them for a few minutes.

Creating a Positive Therapeutic Alliance

Sharon went down the hall and returned with the physician, who apologized to Manuel for the misunderstanding and went on to repeat in his own words the clinic’s intention to help people solve whatever problems might be affecting their health. He said that he and Sharon consulted regularly with each other to provide the best possible care for their patients and that if Manuel were willing to talk further with Sharon, he was sure she could give him some useful ideas on controlling his stomach pain and even eliminating the heartburn. Much of the tension subsided with this, and the physician left. Manuel indicated his willingness to stay for another half hour to “consider” some of Sharon’s suggestions. They talked informally again for a few minutes and then resumed the assessment. As the case of Sharon and Manuel illustrates, establishing a positive, respectful connection is an essential first step in the assessment process. With it, the therapist can proceed toward building a relationship and gathering information, but without it even the most basic questions may lead to a downward spiral of defensive behaviors. From the beginning, Sharon laid the foundation for a good relationship when she engaged in social conversation with Manuel. This initial accommodation to Manuel’s culturally related expectation of personalismo (a warm, friendly approach) and respeto (respect) increased the likelihood that he would stay engaged even if a conflict arose (Organista, 2007). When a conflict did occur, Sharon was able to set aside her own inclination to respond defensively, which allowed her to think about what the client might need to feel more at ease. She hypothesized that Manuel might have more respect for the older male physician, so she chose to involve the latter despite the feelings that this brought up for her. In short, her behaviors paved the way for a positive relationship with Manuel, which facilitated his willingness to consider her help.

The Therapy Relationship In a summary of more than a dozen meta-analyses, the American Psychological Association’s (APA’s) Task Force on Evidence-Based Therapy Relationships concluded that the relationship between therapist and client significantly affects therapy outcomes, whatever the theoretical model or treatment modality (Norcross & Wampold, 2011, p. 98). Recognizing this influence, researchers have given a great deal of attention to elucidating behaviors aimed at building the therapy relationship. Early on, this work focused on the development of specific helping skills, including verbal skills (e.g., paraphrasing, open questions, reflection of feelings) and nonverbal skills (e.g., eye contact,

103

104

M a k i n g M ea n i n g f u l C o n n ectio n s

body posture). Most of this research emphasized behaviors valued by European American culture, such as direct and steady eye contact, forward-leaning posture to indicate interest, and a neutral tone of voice even when a client shares disturbing information (Ivey, Ivey, & SimekMorgan, 1993). In addition, dominant cultural norms have permeated conclusions regarding what is considered appropriate touch, therapist self-disclosure, and titles of address; reasonable expectations regarding time constraints; and expectable therapist availability between sessions (L. S. Brown, 1994). More recently, multicultural researchers have increased attention to the cultural variation in relationship-building behaviors and the need for therapists to adapt their own culturally based behaviors to fit clients’ expectations and preferences. Drawing on this literature, the information in this chapter focuses on verbal and nonverbal relationship-building skills that multicultural researchers have described as important, particularly in minority cultures. Because behavior can vary as much within a culture as between cultures, many of these approaches will be relevant to members of the dominant culture, too. As you’re reading about these behaviors and skills, please keep several things in mind. Information about specific cultures does not explain the behavior of all members of that culture—rather, it opens up new hypotheses that you might otherwise ignore. Hypothesis testing is a continuous process throughout an assessment (and for that matter, throughout therapy). The more possibilities you are aware of, the closer your hypotheses will be to the client’s real situation. And the closer your hypotheses are, the more likely you are to interact in ways that convey respect and build a positive connection.

The Importance of Respect European American culture places great emphasis on egalitarianism in relationships. In individual interactions, differences in power related to social class, ethnicity, disability, and so on are supposedly ignored consistent with the politeness protocol. Peer-oriented exchanges are preferred, and “talking down to,” or interacting with someone in a patronizing way, is considered just as undesirable as being patronized. It may be for this reason that (predominantly European American) psychotherapy researchers have focused primarily on behaviors that build rapport rather than respect. However, the concept of respect is just as important, if not more so, than that of rapport in many cultures, including Latino, African American,

Creating a Positive Therapeutic Alliance

Asian, Arab, and many Indigenous cultures (Abudabbeh, 2005; Iwamasa, Hsia, & Hinton, 2006; S. Kelly, 2006; Organista, 2007; Swinomish Tribal Community, 1991). This assertion does not mean that respect is unimportant to European Americans or that the concept of rapport is not valued in minority cultures; rather, it’s a matter of priorities. European Americans tend to value rapport a little more, whereas other cultures value respect a little more. For example, although it’s uncommon to hear European American parents talk about intentionally teaching their children respect behaviors, traditionally oriented American Indian and Alaska Native parents routinely teach respect behaviors, such as letting elders go first at a potlatch, listening to and valuing elders’ advice, and not interrupting when someone is speaking. Similarly, many Latino people place a high value on formalismo, particularly in situations such as an initial assessment when a relationship has not yet been established. Formalismo refers to the use of words to convey respect and courtesy—for example, the use of the formal usted instead of the familiar tu for “you” (McFarr et al., 2014). I find it helpful to think of respect in two ways: (a) as an internal orientation to the world (i.e., a set of attitudes or a worldview) and (b) as a set of overt behaviors. One of the best definitions I’ve found for the attitudinal form of respect is that of Matheson (1986). From an American Indian perspective, she described the internal orientation of respect as a quality which one carries with him/her, as constantly as his/her heart or spine . . . not a reactive phenomenon, only stimulated in response to specifically measured behaviors or status . . . but a conscious and active awareness . . . between an individual and his/her universe. (p. 116)

What I like about this description is that one starts by respecting others rather than waiting for people to earn it. Respecting a person defines who you are, not who the other person is. Sometimes the value placed on respect reflects traditional beliefs about the importance of honoring those in authority (Iwamasa, Hsia, & Hinton, 2006). For example, in Arab cultures, respect is determined by a number of interactive factors, including age, type of work, family name and reputation, and socioeconomic status. Specifically, greater status and respect are accorded to older people, those with higher levels of education, and those seen as having personal integrity (e.g., families that have lived in the area for many generations, families with a good reputation because of their benevolent works or religious practice; Abudabbeh & Hays, 2006). In Mexican families, respeto is a central value in parent–child relationships and often connotes more emotional dependence and

105

106

M a k i n g M ea n i n g f u l C o n n ectio n s

Think about this: As a child, what did you learn or not learn about respect? Were you taught specific respect behaviors, and if so, what?

dutifulness than does the English respect. Respeto may also be used to reinforce the authority of men over women and children, although increasingly, immigration and social changes have resulted in a wider variation of structures and processes in Latino marriages and family life (Falicov, 2014). Assuming that one holds the attitudinal orientation of respect, how does one demonstrate it behaviorally? One of the initial ways is in the title of address. Members of the dominant culture often assume a first-name basis in an attempt to decrease the social distance between people, whereas some people of ethnic minority cultures (and elders of European American heritage) consider such informality to be offensive (Morales, 1999). For instance, African American adults may interpret the use of first names without permission as disrespectful, because such behavior is seen as related to the demeaning attitudes during and since slavery of European Americans “who refused to use their names, renamed them, and referred to them with terms intended to convey low status (e.g., boy)” (Moore Hines & Boyd-Franklin, 1996, p. 79). Because of the wide variation in customs regarding titles even within cultures, the general rules I go by are as follows: Initially use a formal title with elders of all cultures; generally follow the norms of the client’s culture, if you know them; and when in doubt, ask clients at the initial meeting how they prefer to be addressed. In his work with parents of children with chronic illnesses and disabilities, Davis (1993) explained how making parents the complete focus of one’s attention is a demonstration of respect. This demonstration includes allowing the parents to speak freely, listening to what they have to say, and using all of one’s knowledge and skills to help but not take over for clients in the process of change (Davis, 1993, p. 54). Clients may feel disrespected when the therapist makes inaccurate assumptions. For example, an African American woman may judge a therapist to be disrespectful if she suspects that the therapist assumes he understands the woman’s family solely on the basis of a general knowledge of African American culture (Boyd-Franklin, 1989). The therapist’s assumption that he understands without really knowing the client or her family suggests that he is failing to recognize the enormous variations within African American culture—in other words, that he is stereotyping. In this situation, the therapist needs to distinguish between his general knowledge of African American culture and the client’s individual and family-specific experiences of her culture. Although the therapist would not expect the client to educate him about general cultural meanings, he would recognize his need to learn about the client’s individual and familial experiences directly from the client.

Creating a Positive Therapeutic Alliance

Communication Research comparing individualist cultures with collectivist cultures suggests that members of individualist groups use more direct forms of speech, whereas members of collectivist cultures more commonly use indirect speech, particularly in situations in which conflict is possible (see Yabusaki, 2010, regarding how these differences affect therapy and supervision relationships). But take a minute to think about how these terms—direct and indirect—affect how you think about an interaction. The term indirect has a negative connotation, reflecting the dominant culture’s power to define its preferred approach (i.e., direct) as superior. However, changing the term indirect to subtle and polite takes away this negative connotation and highlights the importance given to harmonious relationships in Asian, American Indian, and Alaska Native cultures that value this form of speech more. Pace of speech is another aspect of communication that can make or break a positive connection. Among many people of Indigenous heritage, there is an expectation that when Person A is speaking, Person B will wait until Person A has finished, pause a second, and then speak. This pause is considered respectful and communicates that Person B is thinking about what Person A has said rather than what he or she wants to say. In contrast, many people of Arab, Jewish, African American, Latino, and European American heritage (particularly on the U.S. East Coast) use an interruptive pace, which is interpreted as being highly attuned to one another. For example, Person A: Did you see Jerry’s new bicycle? It has that cool thing on . . . Person B: Yeah, yeah, I saw it, the one with that special light on the front that comes on automatically as soon as it . . . Person A: Yeah, it lights up as soon as the sun sets. But it doesn’t . . . Person B: I know, I know; it doesn’t always work. Both the pausing and overlapping paces facilitate relationships when people’s paces match. However, when people of different paces interact, the pausers often interpret the overlappers as being rude and selfcentered, and the overlappers assume the pausers are mentally slow or hard of hearing. Overlapping speech is the dominant culture’s preferred pace. It is also dominant in the sense that it cuts off the pauser (whereas the pauser does not cut off the overlapper) and counters the core value of respect held

107

108

M a k i n g M ea n i n g f u l C o n n ectio n s

by many minority cultures. For these reaThink about this: Regarding direct versus sons, I believe it is more the responsibility of overlappers to slow down when speaksubtle speech and overlapping versus pausing with a pauser (rather than expecting a ing dialogue style, what are your tendencies? pauser to talk faster and interrupt more), Can you think of someone with whom you especially in a therapeutic setting. That is, if feel perfectly matched in style and pace and a therapist tends to use a faster, more over­ someone with whom you are mismatched? lapping style, it is incumbent on the theraHow do you feel about each of these pist to adapt to the pauser’s pace. For some therapists who tend to use a slower, pausrelationships? ing style, it may be possible to adapt to a faster style; for others, it will be impossible because they consider it to be disrespectful. At the least, these differences are important to be aware of and, in some cases, to discuss with the client regarding how therapist and client may or may not be able to work together. The use of psychological jargon is another potential barrier to the therapy relationship, especially with clients who speak English as a second language. If you’ve ever been to a physician who used technical medical terms that you didn’t understand, then you know how frustrating this can be. In addition to using the client’s preferred language (i.e., with an interpreter if needed—more on this in Chapter 7), building a positive alliance includes talking and explaining to the client in words that are clear and easily understood. Therapists’ use of theoretically based terms or concepts (e.g., “providing a container,” “cognitive distortions,” and even the idea of the unconscious) may be familiar and comfortable for therapists but alienating to clients. Equally obscure from many clients’ perspective are phrases such as “getting in touch with your feelings,” “sharing personal issues,” “learning to accept all parts of yourself,” and “processing.” When clients use such terms, it can help to ask what they mean by the term, but it is also important that as therapists, we ask ourselves what we mean by a term. Such questioning can bring out the assumptions underlying our pet phrases (e.g., What does “processing” mean, and how do I know if the client has done it or not?). For instance, consider the use of the term dysfunctional to describe a particular pattern of family interactions. Although assumptions are often made about the meaning of this term, cultural norms that define functionality are rarely taken into account. But beliefs defined as functional in the family systems literature are not necessarily functional in the contexts of many low-income African American and European American families. For example, in one study, the dominant definition of functional communication as open and direct was challenged by these families’ equally valid belief that “communication involves a time to speak and a time to be silent” (Westbrooks, 1995, p. 141).

Creating a Positive Therapeutic Alliance

Years ago, when I used the word manipulative to describe a client, my supervisor questioned what I meant by the word. I said something to the effect of “trying to get one’s needs met and not caring if you take something away from someone else in the process.” However, my supervisor pointed out that we all have needs that we’re trying to fulfill, but some people have less education, less effective social skills, or cognitive impairment or live in an environment that decreases their ability to meet their needs in ways that do not infringe on others. It was clear that the judgmental tone of this word did not facilitate my understanding of, or compassion for, the client.

The Human Connection Common to many cultural and other minority groups is the expectation that informal social interaction will precede a formal procedure such as an assessment. This more casual type of interaction is known as personalismo in Latino cultures (recall the positive interaction between Sharon and Manuel). It has also been described as the establishment of a sense of mutuality among older women (Greenberg & Motenko, 1994), a person-to-person connection among African Americans (Boyd-Franklin, 1989), and respect and reciprocity among American Indians (Matheson, 1986). Often, this expectation takes the form of what I call “who-you-know” exchanges. This form of interaction involves asking the other person if they know so-and-so, with the goals being to find common connections and gain a sense of the person’s context. It is distinguished from the European American practice of name-dropping in that it is generally not intended to impress or reinforce power. I remember one such interaction between my friend and colleague Gwen, an African American woman, and a Native American man, who were meeting for the first time. Both had lived in Seattle for many years and knew many Native people in the mental health field. The conversation went something like this: “So, you’re at Antioch. Do you know S?” “No, but did he use to work at ______?” “Yes.” “Oh. I had a friend who worked there for a couple years. Do you know her?” “No, but I know her husband. He’s at ______.”

The exchange ended when they had found several people they both knew; we then went on with the business parts of the meeting.

109

110

M a k i n g M ea n i n g f u l C o n n ectio n s

With regard to Lakota people, Hornby (as cited in Allen, 1998, p. 34) noted that this type of initial interaction involves the view that people and relationships are parts of an interconnected community. Upon meeting, people engage in casual conversation that may touch on social events, activities, or people that the speakers have in common (Allen, 1998). Among people of Indigenous heritage, connections are often similarly made on the basis of one’s familial heritage and geographic origin. This form of connecting is also common among immigrants and among people in rural areas. However, with clients, who-you-know connections are tricky because acknowledgment of the connection may imply that the therapist and the third party have a therapeutic relationship. In very small communities where everyone knows everyone, a therapeutic relationship is not necessarily assumed. However, it can be awkward if a client asks if you know someone you’ve known only as a client. In my small town, I usually answer casually that, yes, I know lots of people in town because I’m from here and my family has lived here a long time. If the person asks directly whether someone was a client, I explain in a friendly way that I can’t say if a person is a client or not because of confidentiality.

Therapist Self-Disclosure Part of what distinguishes a more personalized approach from an engaging professional demeanor is the therapist’s willingness to self-disclose. However, therapist self-disclosure has historically been discouraged, primarily as a result of early psychoanalytic assumptions about the processes of transference and countertransference. I recall being chastised by a psychoanalytic supervisor once when I chatted about the weather with a very nervous 85-year-old female client on our way from the lobby to my office. He told me that everything I said was material for therapy, so I should have waited until we were in the office to say anything to her. I understood his point from a psychoanalytic perspective; however, my client did not hold this worldview and seemed to need the reassurance of a more personal connection. This negative view of self-disclosure is not unique to psychoanalytic or psychodynamic approaches; it is also common among therapists of other theoretical orientations, including cognitive behavior therapy. However, during the last decade or so, the APA and many practitioners have shifted from a rigid stance against self-disclosure to a position that acknowledges its usefulness at times (e.g., see the special section of Psychotherapy, Relational Foundations of Psychotherapy; Hilsenroth,

Creating a Positive Therapeutic Alliance

2014). Just as therapists assess clients, so too do clients assess therapists. Self-disclosure can help clients decide whether a particular therapist will understand them and be helpful, and it can also build trust and deepen the therapeutic relationship. In figuring out what and how much to self-disclose, a useful question for therapists to ask themselves is: How do I share personal information in a way that respects and empowers my clients? In the earlier example, Sharon’s comment about traffic on the way to her children’s day care center casually communicated the information that she had children—something she had in common with Manuel. Of course, she might not share such information with everyone, but Manuel was a regular patient of the clinic and a longtime employee of the referring company, and Sharon felt safe in sharing this piece of information with him. In sum, her willingness to share something about herself led to a more personalized interaction. Opportunities for self-disclosure may also arise during the course of therapy. A common situation is one in which a client who is worried about the normality of certain behaviors or feelings asks the therapist, “Have you ever experienced this?” Often, such a question is simply an attempt by the client to normalize their own behavior in relation to a respected “standard” (i.e., the therapist). Flipping the question back to the client (e.g., “Let’s talk about why it is important to you to know this”) may be perceived as insulting, patronizing, or making a mountain out of a molehill. At times, however, it may be therapeutic for the client to explore the meaning of the question he or she asks if the client can tolerate it. Lovinger (1996) advised taking this approach in work with religious clients, particularly Christian clients who ask, “Are you saved?” However, if the client is unable to explore the significance of the question, Lovinger advised not avoiding the question and answering it directly. But what therapists choose to share about themselves is highly person specific and situation specific. For example, although feminist therapy comes from a consumer orientation in which therapists are expected to share personal information that may inform their professional work, the extent of this sharing varies depending on how the therapist defines her boundaries regarding privacy. Thus, One feminist therapist will be quite comfortable letting clients know that her capacity to work with incest survivors derives in some part from the fact that she is herself a survivor of incest; another will experience this level of sharing as a disrespect of self and will prefer to refer to other sources of knowledge. (L. S. Brown, 1994, p. 214)

At the same time, although sharing a personal experience that parallels the client’s may be intended to communicate empathy, some clients

111

112

M a k i n g M ea n i n g f u l C o n n ectio n s

Think about this: What kinds of personal information do you feel comfortable with your clients knowing about you—for example, your partner or marital status, religion, cultural identity, disability, whether you have children, your place of origin, musical preferences, favorite hobby? Is there information you would never share with any client?

may see this as undercutting the uniqueness of or pulling away from their experience. Knowing how a therapist solved a problem may set a standard in the client’s mind that is impossible to reach and thus may create a feeling of failure. Also, some individuals may feel reassured by a more formal approach. And there are clients with whom therapists will choose to share little or nothing personal out of self-protection (e.g., clients who are potentially dangerous or who have difficulty with personal boundaries).

Multiple Relationships and Ethical Boundaries The preceding points about self-disclosure assume that therapists can choose whether to disclose personal information, but for therapists working in small communities, avoiding some types of self-disclosure is not always an option. For example, in the small Alaskan town where I live, it is not uncommon for me to see my clients at the bank, grocery store, post office, or yoga class or in restaurants and social gatherings. Many of my clients know my family members, and often people come to see me because they know me, my family, or a friend of mine. Many therapists (myself included) began their training with the belief that one should avoid such contact so as to avoid any possibility of multiple relationships. However, in recent years, therapists working in small communities (many of them members of the minority group they are serving) have made a distinction between boundary crossings and boundary violations. Boundary crossings refer to interactions that deviate from professionally recognized therapeutic activity but that are harmless and may even be supportive; in contrast, boundary violations are harmful or potentially harmful (Aravind, Krishnaram, & Thasneem, 2012). In small communities, boundary crossings and multiple relationships are inevitable, and the challenge is not so much avoiding them but rather handling them as ethically and gracefully as possible (Schank, 2010). Therapists working in and as members of Deaf, ethnic minority, LGBTQIA (lesbian, gay, bisexual, transgender [LGBT], queer, intersex, or asexual), rural, and other communities may encounter these ongoing challenges (Guthman & Sandberg, 2002; Haldeman, 2010; Kertész, 2002). For therapists who belong to more than one small community,

Creating a Positive Therapeutic Alliance

the overlap can be especially challenging (e.g., a gay therapist of color who works with LGBT clients but is not “out” to his ethnic community). While recognizing these challenges, I like the approach suggested by Gallardo (2010) that we shift the focus a bit, from the risks that small community work involves to the opportunities it presents. This different emphasis recognizes that our commitments and obligations as professionals are inseparable from our commitments and obligations as citizens and community members. From this view, involvement in and active contributions to one’s community are a part of being a good therapist and often add to the therapist’s clinical judgment and competency and to the client’s assessment of the therapist’s ability to understand and help (Schank & Skovholt, 2006). The “Ethical Principles of Psychologists and Code of Conduct” (APA, 2010, referred to as the “Ethics Code”) describes a multiple relationship as existing when a therapist holds a professional role and a secondary role with a client, is in a relationship with someone closely associated with the client, or plans to begin a secondary relationship with the client or someone closely associated with the client (Standard 3.05). The Ethics Code clearly states that sexual relations and exploitative relationships between clients and therapists are unethical. However, it also clarifies that “Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical” (APA, 2010, Standard 3.05). In deciding whether a multiple relationship is ethical or not, Kessler and Waehler (2005) offered the following suggestions with regard to LGBT clients that are relevant to other small communities, too: ❚❚

❚❚

❚❚

❚❚

If the potential for a multiple relationship exists, openly discuss with the client the possibility of this occurring, the pros and cons of such a situation, the potential impact on therapy, and the topics of privacy and boundaries. Develop a clear rationale for your behaviors. For example, although I have found that group-oriented social relationships with clients and friends of clients are impossible to avoid in a small town, I have a clear boundary that I will not develop an individual friendship with a client or former client. This rule allows for the possibility that clients may return years after therapy has terminated, which has frequently happened in the 15 years I’ve been back in my hometown. Be familiar with and specifically adapt an ethical decision-making model from the literature (e.g., Ridley, Liddle, Hill, & Li, 2001). Such models involve consideration of the type, duration, and clarity of termination of the therapeutic relationship and the type and severity of the client’s presenting problems (Schank & Skovholt, 2006). Consult with therapists in similar communities regarding their suggestions.

113

114

M a k i n g M ea n i n g f u l C o n n ectio n s

Schank and Skovholt (2006) provided additional advice regarding rural and other small communities: ❚❚

❚❚

Engage in scrupulous documentation that clearly demonstrates careful consideration of the ethical issues involved in any decision to enter into a multiple relationship with a client. As with any ethical issue, the client’s needs should always come first. Know yourself, including your own weaknesses and vulnerabilities. Ask yourself whose needs are being met by a secondary relationship—the client’s or your own? Watch for cues that your boundaries are slipping—for example, lack of sleep, illness, increased self-disclosure, or overidentification with clients. (p. 187)

NONVERBAL COMMUNICATION Self-disclosure occurs in nonverbal as well as verbal forms. For example, an initial handshake can communicate a wealth of information. In European American culture, a firm handshake is meant to convey a sense of self-assurance, sincere happiness at seeing someone again, or (if very firm) an air of dominance. In contrast, among many American Indians and Alaska Native people, a handshake involves a more gentle touch, with the point being to receive information about the other person (Swinomish Tribal Community, 1991). Not realizing this, non-Indians may interpret an Indian handshake as weak or unfriendly, whereas the Indian person may interpret the non-Indian handshake as aggressive or disrespectful. Furthermore, an Indian client may assess a therapist’s knowledge of and experience with Indian clients by their handshake: “When a non-Indian shakes hands in the usual non-Indian manner with an Indian, the Indian person knows that this non-Indian is probably not very familiar with Indian culture” (Swinomish Tribal Community, 1991, p. 190). At the same time, even among Native people, there may be differences in handshakes between men and men, women and women, and women and men. And in some cultures, it is inappropriate for men and women to shake hands; for example, a male Buddhist monk wouldn’t shake a woman’s hand, because he’s not supposed to touch women. Similarly, in some Arab and Muslim cultures, traditionally oriented men and women who do not know each other would not shake hands because it involves physical touch. Nonverbal communication may also take the form of bodily movements, preferences for physical space, and facial expressions (Berry, Poortinga, Segall, & Dasen, 1992). People who have disabilities often use facial expressions and bodily movements to augment spoken or sign language (e.g., the term guilt is changed to paranoia in sign language by adding eye movements back and forth; Olkin, 1999, p. 194). Among the Yup’ik people of Southwest Alaska, a “yes” answer is signaled by raising one’s eyebrows. And internationally there are different interpretations

Creating a Positive Therapeutic Alliance

of the same gestures; for example, the American gestures of thumbs up and the OK sign are considered obscene in some countries. In European American culture, direct eye contact is commonly considered a measure of one’s self-confidence or mental health. In therapeutic settings, indirect eye contact is often interpreted negatively as shyness, lack of assertiveness, deception, or depression (D. W. Sue & Sue, 1999). However, in many cultures, indirect eye contact not only is normal but also is considered appropriate and even respectful behavior toward people in positions of authority (e.g., among Navajo students speaking to professors; Griffin-Pierce, 1997). With regard to physical space, early research suggested that Arab, Latin American, and southern European cultures (i.e., those with Mediterranean roots) preferred less physical distance in personal interactions (E. T. Hall, 1966). However, subsequent research found significant intracultural differences on the basis of social class and situational determinants. For example, in one study, Japanese students sat farther apart when speaking in Japanese than did Venezuelans when speaking Spanish. But when both spoke English, they sat at distances similar to those of students in the United States (Berry et al., 1992; Sussman & Rosenfeld, 1982). With people who have disabilities, it is important to note the inappropriateness of touching someone’s assistive device (e.g., walker, wheelchair, prosthetic) without permission. An assistive device functions as an extension of a person’s body. As Olkin (1999) noted, “Wheelchairs are like one’s legs, and I can only presume you don’t rub a client’s legs,” so don’t touch a person’s wheelchair without being asked (p. 194). Adding to the cultural variations in preferences for physical space, individual and family differences make generalizations even more difficult. If therapists do not have experience with a client’s particular cultural group, it is important to stay aware that there are differences so that automatic misinterpretations are less likely to occur. It can be helpful for therapists to consider the arrangement of office furniture, such as how close seats are placed, and to have chairs that are easily movable to allow for client- and family-specific adaptations. Nonverbal communication may also occur in the form of silence. In European American culture, silence is often taken to be a sign of anger or an indication that the speaker is finished and the next person may speak. In contrast, in Chinese, Japanese, Alaska Native, and American Indian cultures, silence is often used to communicate respect for what has just been said or for the speaker (e.g., an elder); it may also be a signal that one is forming thoughts or waiting for a sign to speak. To avoid misinterpreting a client’s silence, it may at times be helpful to ask the client about its meaning. Two other nonverbal behaviors are important to mention. One is that of giving gifts. In many cultures, giving gifts is an expression of

115

116

M a k i n g M ea n i n g f u l C o n n ectio n s

appreciation. Turning down a small gift from a client may unnecessarily offend the client and is not recommended (Abudabbeh & Hays, 2006). The other nonverbal behavior that deserves mention is note taking. With American Indian and Alaska Native clients, taking notes may be perceived as disrespectful because clients may assume that the therapist is not listening carefully (Herring, 1999, p. 37). Because it is usually necessary to take notes during an initial assessment, I let people know before I begin the assessment that I will need to take some notes so that I don’t forget what they’re telling me, and then I try to keep my focus on the client as much as possible, suspending the paperwork when clients are sharing particularly emotional information. I do not take my own notes during therapy sessions; however, I do often write notes, recommendations, reminders, and summaries for clients as we’re working on something and then give them to the client at the end of the session to take home. Regarding the use of computers during sessions, a recent study found no differences in patients’ ratings of the therapeutic alliance when therapists took notes via paper and pencil, tablet, or computer during intake sessions at both a primary care clinic and a community mental health center (Wiarda, McMinn, Peterson, & Gregor, 2014). However, all of the patients for whom ethnicity was recorded were European American. In my own practice, I use paper and pencil, and although initially I was adamantly against the use of computers during assessments, I am gradually changing my view on this because attitudes about technology are changing so quickly. I suspect that over the next generation, the use of computers by health care providers will not only be expected but also considered superior to paper and pencil (e.g., because of the ability to send a client information or look up a medication side effect while the client and provider are still together to discuss it). But currently, I advise caution in the use of computers with clients, particularly when working with older people, people in poverty, and individuals from non-Western countries.

ENVIRONMENTAL CUES Environmental cues are another form of nonverbal communication. As Comas-Díaz (2012) noted, one way that clients of minority identities assess a therapist’s ability to help them is by “reading” their office. In the therapist’s office, the magazines in the waiting room, a calendar in a particular language, desktop photographs, wall hangings, and the books on the shelves all say something about the therapist’s interests and concerns. Even the physical location and architecture communicate whether a therapist has thought about serving particular clients— for example, people who have physical and sensory disabilities. When thinking about the range of clients who may be looking for the therapist’s sensitivity to their own cultural contexts, it can be helpful to

Creating a Positive Therapeutic Alliance

Try this: Pretend you are someone else, and look around or think about your office or space where you meet with clients. What would you guess about yourself on the basis of what you see or know is there?

ask oneself, How do aspects of my office communicate my awareness of and interest in people of different ages and ethnicities; of disabled, spiritually oriented, gay, lesbian, bisexual, or transgender people; and of people with variations in other ADDRESSING factors? Considering the answers to these questions can help you create an environment that helps people feel welcome and comfortable, including, for example, attention to such details as adjusting the room’s light and temperature to the particular sensitivities of a person with a disability (Artman & Daniels, 2010).

TIME One of the most common generalizations regarding time is that people of Indigenous, Latino, and Arab cultures are more past or present oriented, whereas European Americans are more future oriented. The future orientation of the United States and European Americans was provided some support by the early work of Kluckhohn and Strodtbeck (1961), which compared value orientations in five cultures. However, subsequent research suggested a more complex situation. For example, the idea that European Americans are future oriented is contradicted by the dominant culture’s “massive violation of natural resources” to the neglect of future generations (Robinson & Howard-Hamilton, 2000, p. 30). Within a particular culture, individuals of different ages may experience time differently. For example, how long a week feels to a young child, a middle-aged adult, and an older person may be quite different (Dator, 1979). People’s experience of and the meanings they attach to time may also vary depending on the presence of a disability; the person’s socioeconomic status, occupation, or religious culture; or what one is doing in the moment (Dator, 1979; Gonzalez & Zimbardo, 1985). The profession of psychotherapy holds relatively rigid ideas about time, which are grounded in dominant cultural conceptions. Clients and therapists are expected to be on time for appointments and to meet for a set number of minutes. When clients do not follow the time rules for therapy, therapists may assume that they are not committed to change; clients, however, may feel that the therapist is disrespectfully rushing them (D. W. Sue & Sue, 1999). There are many reasons why a client is not on time or fails to appear for an appointment. Low-income clients who do not have a car may use public transportation, which is not always on time; they may not have day care for children or older parents or easy access to a telephone to cancel; and health and family crises understandably take priority over a 1-hour appointment with the therapist (H. J. Aponte, 1994). Clients who have disabilities must also contend with the extra time it takes to do everything, as having a disability also creates tasks that require more time (e.g., ordering and buying a wheelchair or scooter and maintaining

117

118

M a k i n g M ea n i n g f u l C o n n ectio n s

it, finding accessible services and entrances, using special transportation; Artman & Daniels, 2010). Given the variability of attitudes toward time, it is difficult to make accurate generalizations about how a client will perceive the time constraints embedded in psychotherapy. But keeping in mind the possibility of differences and clearly explaining to clients how flexible you can or cannot be will help to minimize misunderstandings.

Client–Therapist Interactions: Beyond Traditional Transference Early psychoanalytic approaches emphasized the therapist’s role as a blank slate or mirror onto which the client’s feelings about parental figures could be projected. The client’s emotional reactions to the therapist, known as transference, were seen as “projections by a client of expectations and distortions based on past experience” (Chin, 1994, p. 207). However, when one introduces the concept of culture into an analysis of client–therapist interactions, it is clear that the emotional reactions of clients to therapists, and vice versa, often reflect differences and power imbalances in the real world. As Pérez Foster (1996) noted, “the fact is that analysts are neither neutral screens nor simple clay for transferential transformation. They are, in fact, formidable characters who often have robust prejudices” (p. 15). Clients’ reactions to a therapist of another cultural identity may be less related to their feelings about their parents than to their daily experiences with people of the therapist’s culture. Recognizing this reality, psychodynamic theorists have broadened definitions of transference and countertransference in ways that open up a consideration of cultural influences (Tummala-Narra, 2016). Consider the situation of a 60-year-old married woman of Guatemalan heritage who is referred to a much younger, U.S.-born Latina therapist. Because the client’s most intimate and long-lasting relationships have been with her husband and children, and because she is older than the therapist, she may be more likely to see the therapist as a daughter than as a parent figure. Similarly, the therapist’s experience of the client may involve feelings associated with her own mother or grandmother. (See Newton & Jacobowitz, 1999, for more on transferential and countertransferential processes with older clients.) But the reactions of this client and therapist to one another may be more complex than those related solely to age. For example, what if the therapist is from a well-educated, uppermiddle-class family and the client is from a poor, rural, Mayan (Indigenous)

Creating a Positive Therapeutic Alliance

background? In this case, the client may remind the therapist more of the woman she has hired to help with household responsibilities and child care, and the therapist may remind the client of the powerful Spanish-speaking landlords in Guatemala or of a demanding employer in her new country. Conceptualizing the client’s distrust as solely a projection of her feelings overlooks the client’s history and day-to-day experiences of oppression by members of the therapist’s culture (see Gleave, Chambers, & Manes, 2005, regarding the sociopolitical history of and U.S. role in suppressing democracy in Guatemala). Despite the negative emotions often associated with the topic, it is important that therapists be comfortable bringing up the topic of culture (including race and other differences) if it appears to be relevant to the therapeutic relationship (Tummala-Narra, 2007). For example, a European American therapist’s straightforward question to a Black family (e.g., “How do you feel about working with a White therapist?”) makes available for discussion what is probably already on everyone’s mind (Boyd-Franklin, 1989). Of course, if the therapist does raise the topic, it is essential that she has “seriously thought through its relevance” (Boyd-Franklin, 1989, p. 25); otherwise, the question may be perceived as patronizing (Greene, 1994). In addition, White therapists need to be prepared for the possibility that this question may elicit feelings of anger, and some family members may even verbalize their reluctance to work with a White therapist. The more able a therapist is to remain nondefensive and nonapologetic while discussing this issue with the family, the greater the likelihood of a therapeutic connection. (BoydFranklin, 1989, p. 102)

One reason minority members may be reluctant to bring up the topic of culture is that many experience microaggressions so regularly that they choose to overlook slights or “edit” their responses (i.e., respond in a way that minimizes conflict or conforms to what dominant-culture members want to hear; Vasquez, 2007). These tendencies are reinforced by experiences of being negatively judged by dominant-culture members when pointing out a microaggression and by the high value that many ethnic minority cultures place on maintaining harmony. For all of these reasons, to gain an accurate understanding of the client and build a positive, respectful alliance, it is important to deliberately seek out and encourage clients’ feedback regarding the therapeutic alliance. But before raising such topics and questions with clients, consultation and supervision with people of diverse identities is essential, ideally on an ongoing basis. At the same time, with some clients, it may not be appropriate to bring up the topic of culture or identity before a feeling of trust has been established. Many older people, of both dominant and minority cultures, grew up in a time when one was expected to hide or minimize differences related to race, social class, sexual orientation, and disability (Sang, 1992).

119

120

M a k i n g M ea n i n g f u l C o n n ectio n s

In addition, many individuals are uncomfortable with direct discussion about another person’s (i.e., the therapist’s) abilities or limitations, fearing that such discussion might suggest that the therapist is not competent. Finally, as mentioned earlier in the case of Mrs. Sok, some clients simply do not see the relevance of the therapist’s identity or their own, and making it an issue before a relationship is established may feel forced.

COUNTERTRANSFERENCE Just as clients’ feelings about therapists may originate in their experiences with members of the therapist’s culture, so too are therapists influenced by their experiences with clients’ cultures. Countertransference in European American therapists often involves issues related to power and difference (Chin, 1994). Out of a desire to form an alliance with clients of color, European American therapists may minimize cultural differences (Quiñones, 2007). And out of a lack of knowledge, they may assume similarities that do not exist. For example, in an effort to establish rapport, a White transgender therapist working with a transgender person of color may overemphasize their shared transgender identity and underestimate differences related to the client being transgender and a person of color. These differences may have profound effects on the client’s life that are invisible to the therapist but important for an accurate understanding of the client and his or her problems, strengths, and supports. Alternatively, if the therapist acknowledges the differences and his or her lack of knowledge regarding the client’s unique experiences and shows a strong willingness to be helpful and to learn, the relationship may be strengthened (Chin, 1994). When the therapist is a person of color working with a client of color (or, for that matter, when the two are matched on any minority identity), countertransference may involve overidentifying with the client. This overidentification may lead the therapist to minimize psychopathology when it is present or to push a particular approach to problem solving that has worked well for the therapist but would not work for the client (Chin, 1994). Also out of a desire to be helpful, the therapist may experience internal pressure, as described by one African American therapist working with an African American client: I think that there is an expectation that I’m really going to understand them, maybe in a way that somebody else wouldn’t. And I think I even have an expectation for myself, that I’m going to be sure this person really gets what they need. I think it feels a little bit like the stakes are higher on both sides. (as cited in Goode-Cross, 2011, p. 371)

However, the strong identification of therapists of color with their clients, along with common idioms, language, and cultural references, often facilitates the relationship (Goode-Cross, 2011).

Creating a Positive Therapeutic Alliance

Therapist–Client Ethnic Match In their attempts to understand why ethnic minority populations under­ use mental health services, researchers have investigated the question of whether clients prefer and do better with ethnically similar counselors. Early studies that used a simple choice method (e.g., “Do you prefer an ethnically similar counselor to an ethnically dissimilar counselor?”) found that people often chose the former. However, when a later study posed more specific choices (e.g., “Which is more important to you— ethnic similarity, similar attitudes and values, a more educated counselor, an older counselor, a similar personality, socioeconomic status, or gender?”), people ranked ethnic similarity as less important than one or more of the other factors (Atkinson, Wampold, Lowe, Matthews, & Ahn, 1998, p. 103). This latter study suggests that what is more important than racial or ethnic matching is a cultural match—that is, similarities in values, attitudes, beliefs, and worldview (B. S. K. Kim, Ng, & Ahn, 2005; Maramba & Hall, 2002). In a more recent meta-analysis of racial and ethnic matching (Cabral & Smith, 2011), the researchers found that across 52 studies, clients of diverse identities reported a moderately strong preference for a therapist of their own race or ethnicity, but racial and ethnic matching had almost no effect on treatment outcomes, with one exception. When African American clients were matched with African American therapists, treatment outcomes were “mildly better.” The researchers hypothesized that this slightly better outcome for African Americans was attributable to “strong racial/ethnic identification and wariness about bias in the mental health services provided by White therapists” (Cabral & Smith, 2011, p. 544). I would add that it may also be related to the pervasiveness of racism toward African Americans—that is, not solely among European Americans but also among other ethnic minority cultures. In some cases, a client may specifically prefer a therapist who is dissimilar. Among clients of minority identities, the preference for a dominant-culture therapist may reflect negative transference toward the therapist and/or internalized “isms” (e.g., racism, ableism, sexism). For example, a client may believe that a therapist of color will be preoccupied with race or less competent because she is a woman or person of color (Comas-Díaz, 2007). In other situations, clients may prefer a therapist of any cultural group other than their own because their ethnic community is small and they do not fully trust an ethnically similar therapist’s commitment to maintaining confidentiality (Tseng, 1999). Given the current impracticality of matching clients with therapists on ethnic and other cultural variables, the approach taken by

121

122

M a k i n g M ea n i n g f u l C o n n ectio n s

most training programs is to focus on multicultural competence for therapists of all identities (Cabral & Smith, 2011). However, the majority of faculty are still of dominant cultural identities, which limits the perspectives and information presented in a program. In addition, few training programs address the particularities of minority therapists working with minority clients or, for that matter, of minority therapists working with dominant-culture clients (e.g., how to respond to microaggressions from dominant-culture clients; Goode-Cross, 2011). For example, I recently heard a Latino and a Latina student talk about being placed in an internship where they were immediately deluged with Spanish-speaking clients. Despite the fact that both were bilingual, they had never been trained to do assessments in Spanish— only in English, using English vocabulary, phrasing, concepts, and so forth. They considered themselves fortunate because once they let their supervisor know, arrangements were made for a bilingual supervisor who could teach them how to do assessments in Spanish. However, this situation was obviously not planned for in advance, and the supervisor’s response represents a best-case scenario.

Conclusion With clients of diverse identities, making meaningful connections is complex, requiring familiarity with a wide range of relationshipbuilding behaviors and attitudes. Of particular importance is the therapist’s ability to be respectful of and responsive to diverse communication styles, language preferences, and value systems. When clients feel respected and appreciated, they are more likely to share pertinent and accurate information and to be open to the possibility of therapeutic intervention. Although a meaningful connection does not guarantee the accuracy of an assessment or the effectiveness of therapy, without it, the likelihood of an accurate assessment and effective therapy is low.

Practice Choose a helpful verbal or nonverbal behavior or environmental change described in this chapter that you previously had little awareness of. Practice it, either in your daily social interactions or with clients, and watch for the effect it has on your relationships.

Creating a Positive Therapeutic Alliance

Key Ideas

123

  1. In a summary of more than a dozen meta-analyses, the APA’s Task Force on Evidence-Based Therapy Relationships concluded that the relationship between therapist and client significantly affects therapy outcomes, whatever the theoretical model or treatment modality.   2. Information about specific cultures does not explain the behavior of all members of that culture, but it opens up new hypotheses that increase the likelihood of conveying respect and establishing a positive alliance.   3. The concept of respect is central in Latino, African American, Asian, Arab, and many Indigenous cultures and involves both an internal orientation to others and specific behaviors.   4. With regard to cultural patterns of speech, changing the term indirect to subtle and polite highlights the importance given to harmonious relationships in Asian, American Indian, and Alaska Native cultures that value smooth relationships over directness.   5. When people of different speech paces interact, pausers often interpret overlappers as rude and self-centered, and overlappers assume pausers are cognitively impaired or hard of hearing.  6. Common to many cultural and other minority groups is the expectation that informal social interaction will precede a formal procedure such as an assessment—for example, the expectation of personalismo in Latino cultures.   7. The APA Ethics Code does not prohibit dual or multiple relationships if they do not present any harm to the client. Sometimes these relationships may even be positive for the client; for example, involvement in and active contributions to one’s community may add to the therapist’s clinical judgment and competency and to the client’s assessment of the therapist’s ability to understand and help him or her.   8. A therapist’s self-disclosure is not completely within the therapist’s control and occurs in nonverbal as well as verbal forms, including one’s choice of words, behaviors, work space, expectations, and community involvement.   9. Out of a desire to form an alliance with clients of color, European American therapists may minimize ethnic and racial differences, whereas therapists of color may overidentify with the client and minimize psychopathology when it is present. 10. A meta-analysis of racial and ethnic matching found that across 52 studies, clients of diverse identities reported a moderately strong preference for a therapist of their own race or ethnicity, but racial and ethnic matching had almost no effect on treatment outcomes, with one exception—when African American clients were matched with African American therapists, treatment outcomes were mildly better.

Sorting Things Out

III

Conducting a Culturally Responsive Assessment

O

7

ne day, a Native worker at the Indian Child Welfare Association (ICWA) told a few of us at the office about a phone call she had received over the weekend. A kindhearted, White foster mom had called to tell her that a young Yu’pik boy had been flown in from a distant village and brought to her house on Saturday after being removed from his parents’ custody. The foster mom said that she had tried everything she could to get the boy to stop crying, but nothing had worked and she didn’t know what to do. The ICWA worker told the foster mom to bring the boy over to her house, so the foster mom brought the boy over and left him with the worker. The ICWA worker said she then sat with the little boy for some time while he cried. Then she gave him some Native food, which he ate a little of while still crying. A few hours later, she gave him a tape of Yu’pik

http://dx.doi.org/10.1037/14801-007 Addressing Cultural Complexities in Practice: Assessment, Diagnosis, and Therapy, Third Edition, by P. A. Hays Copyright © 2016 by the American Psychological Association. All rights reserved.

127

128

S o r tin g T hin g s O u t

elders speaking; he held it to his ear and listened and cried some more. The worker said that she purposely didn’t try to stop him from crying, because he needed to cry—he was mourning the loss of his family, his culture, and everything he knew. As this example illustrates, understanding what a person truly needs—a key part of psychological assessment—requires cultural knowledge. But psychological assessment involves standardized procedures that have been developed and shaped by the dominant culture, which largely ignores or dismisses cultural influences. As a result, cultural questions and considerations are commonly left out. Thus, it is important that the culturally responsive components be made explicit. In the preceding chapters, I described several steps and processes that lay a foundation for culturally responsive assessment, including the following: ❚❚ ❚❚

❚❚ ❚❚

❚❚

ongoing involvement in one’s own cultural self-assessment; learning about diverse cultures, including minority and dominant groups’ views, language, and terminology; understanding of each client’s unique identity and context; consideration of the interaction between the therapist’s and the client’s identities; and establishment of a positive alliance with the client.

When these initial conditions are in process, therapists can then turn their attention toward the specific actions needed for an effective, accurate, and culturally responsive assessment. Although the concept of assessing a person’s needs is relatively simple, in practice psychological assessment is usually a complex endeavor. In most situations, an assessment involves an initial interview with the individual and possibly other informants, some form of standardized assessment (e.g., testing), the collection of collateral information, a formal diagnosis, and a treatment plan. An often unspoken, assumed component of assessment involves the communication of understanding and caring. (Interestingly, the word assessment comes from the Latin term meaning “to sit beside and assist in the office of a judge,” which seems to capture both the helping component and the professional judgment involved.) Depending on the particular client and setting, the number of sessions involved in completing these components will vary. In this chapter, I focus on the initial session consisting primarily of the clinical interview; Chapter 8 focuses on testing, Chapter 9 on diagnosis, and Chapter 10 on treatment planning. Suggestions for case conceptualization are integrated throughout all of these chapters.

Conducting a Culturally Responsive Assessment

A Strengths-Oriented, Culturally Responsive Approach to Assessment To counter the dominant cultural focus on the problems and weaknesses in minority cultures, culturally responsive assessment involves actively looking for the strengths in and around clients throughout the assessment. This intentional search serves three purposes. First, a strengths-oriented approach adds to the therapist’s understanding of the client by providing a fuller picture of the person that includes strengths and supports—not just weaknesses or problems. Second, in contrast to the dominant conceptualization of differences as negative, it recognizes the positive aspects of culture and diversity—a view that is subtly communicated and empowering to clients of minority identities. Third, culture can be a resource for healing and self-help interventions that build on those aspects of the client’s life that are already working or are more likely to be reinforced (T. L. Cross, 2003). I mention the strengths orientation at the beginning of this chapter because active listening for strengths starts at the beginning of the assessment. However, I do not directly ask about strengths and supports until later in the assessment, because this gives me time to take notes on the strengths and supports the client has mentioned (or that I’ve inferred) throughout the assessment. Then when I do ask, if the client is unable to name any, I can name several. Because this information is organized according to the chronological flow of an assessment, I talk about how I ask about strengths and supports later in this chapter. Typically, the clinical interview in an initial assessment session is aimed at obtaining information regarding the presenting problem; developmental, social, and family history; medical, psychiatric, and substance use history; and mental status. The following list of traditional intake assessment domains provides the information used to formulate a case conceptualization with diagnosis and recommendations (for a more detailed list of categories within these domains, see Sommers-Flanagan & Sommers-Flanagan, 2014): ❚❚ ❚❚ ❚❚ ❚❚ ❚❚ ❚❚ ❚❚

presenting problem; developmental, family, and social history; medical, psychiatric, and substance use history; mental status and behavioral observations; summary and case conceptualization and formulation; diagnosis; and recommendations and treatment plan.

129

130

S o r tin g T hin g s O u t

Within each of these domains, there are a number of specific questions and types of information to be looking for when conducting a strengths-oriented, culturally responsive assessment. These questions and information are described in the sections that follow and begin as soon as the client walks in the door.

CLARIFYING EXPECTATIONS Going to see a therapist for the first time can be intimidating, so from the beginning, it’s important to help the client feel as comfortable as possible. One way to do so is to explain clearly to clients what they can expect in this initial meeting and find out what their expectations are. In my own practice, following a little casual conversation on the way into my office (e.g., about the weather or road construction), we sit down, and I ask whether clients have any questions about the consent form that they’ve already filled out, and if they do, we talk about that right away. There are a number of reasons why informed consent may take extra time before beginning the assessment, including the following: ❚❚

❚❚

❚❚

❚❚

if the person is not fluent in English and the consent form is in English; if the individual has a disability that affects reading ability or simply has difficulty reading; if the client is an undocumented worker, is a survivor of torture, or has had negative experiences with officials and is reluctant to sign a document; and if the client is unable to pay or does not trust that Medicaid, Medicare, or other insurance will truly cover it. (La Roche, 2013)

Whatever the case, it is important to take the extra time to explain consent because, as the neuropsychologist Tedd Judd noted, “Consent is not a piece of paper”; rather, it involves confirmation that the client truly understands his or her rights and responsibilities and the expectations in therapy (see Sáez & Judd, 2014). Following the consent process, I explain to clients what they can expect during this initial assessment session. Here’s what I typically say: This initial assessment takes between an hour and an hour and a half, and during that time, I will ask you some questions, listen, and talk with you—and you can feel free to ask me questions—to understand how I might be helpful to you. Then at the end, I’ll stop and summarize for you what I’m thinking and my recommendations. If I think counseling would be helpful, I’ll talk with you specifically about what I would do with you in counseling. Does that sound OK?

Conducting a Culturally Responsive Assessment

With families, I add an additional piece: This initial assessment takes between an hour and an hour and a half, and during that time, I will be asking you some questions, listening, and talking with you—and you can feel free to ask me questions—to understand how I might be most helpful. Right now, I’d like to meet with all of you together for a few minutes, and then at some point, I may ask to meet alone with you [one family member] and then you [any other family members]. Then at the end of our time, I’ll talk with all of you in the room at the same time about my recommendations and where to go from here, just so that we’re all hearing the same thing. Is that OK?

In addition to my explanation of what the client can expect, this is the point where it is equally important to hear what the client is expecting. With clients from cultures for whom psychotherapy is an unknown, obtaining an understanding of the individual’s expectations and presenting problem may take an entire first meeting. As psychologist Karen Ferguson noted about her work with refugees, The idea that if we pose the questions well, we will get a [useful] interview has not been my experience with individuals from poverty and foreign cultures. Frequently, my first meeting needs to be quite circular and really about trying to listen to how the client presents the story, then in a second meeting, I can start to ask questions. But without this initial meeting, we [therapists] can way too easily form ideas and hypotheses based on our own culture and biases. Especially for very different cultures or severe situations—for example, Muslim clients new to the United States or trafficking victims—I find that I have to listen and try to really figure out what they’re trying to tell me is the presenting problem, or my questions will lead us astray and inadvertently focus on an area that sounds important to me but is not what they are most stressed about. . . . I have found myself quite pleased at an intervention only to be told later by a staff member from the same culture as the client, how they really liked working with me but are still suffering from Y—when I worked on X. (personal communication, December 5, 2014)

GATHERING INFORMATION Obtaining information is often conceptualized as a fairly straightforward process, but this conceptualization is based on the assumption that the client will respond according to dominant cultural expectations by providing quick, brief, clearly articulated answers that directly respond to each question in sequential order. But as Ferguson explained, many clients do not respond in this way. Those who do may not include elders; people who speak English as a second language; individuals who have disabilities that slow or impair their speaking, hearing, or comprehension; people who are less verbally oriented; and people who live in poverty.

131

132

S o r tin g T hin g s O u t

Regarding the latter, people who grow up in generational poverty may respond to questions with long explanations that, to a middle-class therapist, sound long-winded and do not address the point of the question. This form of communication reflects what Payne (2013) described as the more casual kind of language that people use with family and friends and is characterized by a smaller vocabulary, incomplete sentences, general (nonspecific) word choice, and nonverbal assists (gestures, facial expressions). When telling a story or imparting information, the speaker begins at the most emotional point or the end point and then tells the rest of the information in interaction with comments from the listener. Linguists refer to this form of communication as casual register to distinguish it from formal register, the language used at school, Think about this: Think about the last converwork, and formal settings, which uses comsation you had with a close friend. Did it fit plete sentences and, when telling a story, this description of casual register? unfolds in chronological order. Formal regNow think about the last conversation you ister is learned at school and reinforced in had in a more formal setting, such as at work, middle-class homes, but because children in generational poverty do not hear it spoin class, or at a clinic. Did it fit this description ken at home, they may never learn it and of formal register? as adults continue to use casual register even in formal settings such as a clinic. In my work in community mental health settings, I’ve found the use of casual register by clients to be quite common during assessments. That is, in response to a question, a client tells me a story that gives much more detail than I need for that particular question and is sometimes difficult for me to follow and write down in chronological order. Although it’s difficult for me to interrupt, in some cases I do with an explanation such as, “You know, I’m sorry to interrupt you here, but I’ve noticed you’re giving me a lot of detail, and I want to be sure I get all the information I need to help you, so if you don’t mind, I may keep interrupting you along the way. Is that OK?” Clients invariably indicate they’re fine with this and often respond with something like “Oh, yeah, sorry about that; I know I tend to go on and on,” to which I respond, “Oh, that’s OK; I know you’re trying to be helpful by not leaving anything out.” On the opposite end of the spectrum are some Alaska Native elders who tend to be more reserved, to be less verbally oriented, and to have a narrative way of speaking and thus may perceive numerous intake questions to be intrusive (D. Dillard, personal communication, September 15, 2003, as cited in Hays, 2006). In such situations, one way for the therapist to obtain information without offending the elder is to allow the elder to provide the information that he or she deems important. The obvious risk with this approach is that not all of the standardized questions will be answered; however, if the client feels bombarded by questions, he or she probably will not return, and the opportunity to help will be lost.

Conducting a Culturally Responsive Assessment

When allowing a client to direct the flow of information, the therapist can still obtain a great deal of information through observation and careful listening. Once rapport has been established, the therapist may then be able to ask questions to fill in the gaps or obtain releases of information so that significant others can provide additional information. Another challenge is the reluctance of some clients to answer certain questions for cultural reasons. Paradis, Cukor, and Friedman (2006) described the case of a depressed young Orthodox Jewish man who did not want to answer questions about his father’s mental health out of fear that speaking of his father’s depression would dishonor his father. The therapist recognized and respected the cultural norm against speaking badly about a parent and did not press the issue. Later, when trust had been established and the client understood that the information about his father would be helpful in understanding family dynamics that contributed to his own depression, he was more willing to talk about it. Questions about spirituality and religion may also be perceived as intrusive to some clients. For example, among American Indians, the degree of openness about spiritual knowledge and practices varies widely. Information may be considered public or highly personal depending on the particular individual, group, or type of information (Swinomish Tribal Community, 1991). The need for spiritual privacy can have a strong cultural basis related to the desire to (a)  preserve one’s special relationship to a spiritual being; (b)  avoid loss of spiritual power; (c)  avoid potential misuse of spiritual knowledge; (d)  avoid ridicule or persecution from non-Indians; and (e) demonstrate respect. (Swinomish Tribal Community, 1991, p. 131)

The use of spiritual rituals, concepts, or symbols by non-Indians (and even by some Indian people) may be considered sacrilegious. Therapists are advised to be cautious as they are learning about Indian people’s spirituality. The best approach is a “quiet and nonintrusive interest” with few questions, allowing the individual to share when and what they choose (Swinomish Tribal Community, 1991, p. 132).

USING A SYSTEMS ORIENTATION Reliance on a client’s report as the sole source of information is risky, especially if the client is distressed and thus thinking narrowly about their situation. For this and other reasons, a culturally responsive assessment is facilitated by an active approach toward learning about the multiple, overlapping systems relevant to a client’s life. These systems include extended family and nonkin relationships, cultural and political contexts, and physical and natural environments.

133

134

S o r tin g T hin g s O u t

Clinicians working with children, elders, and people with disabilities are especially attuned to the need for multiple perspectives in assessment. With children, a comprehensive assessment requires information obtained via a variety of tools and techniques (e.g., observations, interviews, testing, others’ reports) from multiple sources (e.g., teachers, parents, significant family members, the child; Kisiel, Conradi, Fehrenbach, Torgersen, & Briggs, 2014). Similarly, assessments of older adults and people with disabilities are commonly expected to include information from diverse sources (e.g., the client, family members, physician, other care providers), obtained in multiple ways (e.g., clinical interviews, standardized testing, behavioral observation, team meetings of health care providers) with regard to multiple domains (e.g., activities of daily living, social skills, physical and mental health, spirituality, financial status, environmental stressors, barriers, supports; American Psychological Association, 2004, 2012). This multidisciplinary approach has grown with the integration of health care services supported by the Patient Protection and Affordable Care Act passed in 2010 (Cordes, Cameron, Mona, Syme, & Coble-Temple, in press). But a systems approach enhances one’s work with clients of other age groups, too. For example, with people living in poverty or close to it, a systems approach is important for understanding how or whether a client’s basic needs, including safety, food, shelter, and health (and, in cold climates, heat), are being met and, if not, how best to go about meeting them (La Roche, 2013). And with individuals whose cognitive functioning may be impaired, it is essential to include a significant other for the purposes of ensuring both an accurate assessment and follow-through with recommendations. In many cases, clients come to the initial assessment with family members. Children, for example, are often brought by parents, older adults may be accompanied by a partner or adult child, and couples come together. Obtaining information from others requires special attention to respecting the person being identified as the client, especially when family members have complaints about that person. For example, an older man who is having memory lapses may feel defensive about his wife’s concerns and may be reluctant to acknowledge her concerns when she is present (Hays, 1996). When the referral information suggests the possibility of a cognitive impairment (i.e., that the individual may not be able to accurately report their symptoms and history), I always ask for a family member to accompany the person. When more than one person comes to an initial assessment, I usually meet with the family all together at the beginning and end of the assessment, but I decide whether to meet separately with individuals after they arrive depending on the makeup of the family, the type of problem, and relationship dynamics.

Conducting a Culturally Responsive Assessment

In general, I conceptualize my role as similar to the small-town family doctor model in which physicians see multiple members of a family as individuals or together at various points over the life span of members. I often encourage individuals with whom I’m working individually to bring in their partner or spouse at least one time, if they would like, to give me additional information that could help me be more effective with the person seeking services. If the client is an unhappy spouse, this meeting often leads to couple therapy. At the least, it gives me an opportunity to make a positive connection with a key person who then may be on board with supporting the client’s treatment. I always make it clear that I consider the person my client for life and that they can return at any time. People often return years later; for example, an individual I’ve seen in the past for anxiety may return with a spouse for couple therapy, or an adult may ask me to see an older parent, or one member of a couple may bring in an adolescent child months later, and so on. Although there are some cases in which I do not see more than one member of a family (e.g., a couple that is moving toward divorce), in many cases, I do. Of course, in some situations, including family members in therapy is inappropriate. For example, I would not ask a woman whose husband is abusing her to bring him in, particularly when her goal in therapy is to build her self-esteem and strength so that she can leave the marriage. (But even this is a complicated issue with women of cultural minority groups; more on this in Chapter 11.) There may also be culturally related reasons why particular family members should be seen separately. For example, many people of East Asian heritage would consider it inappropriate for parents to discuss their concerns with one another in front of their children (Hong, 1988). For family sessions, the choice of whom to meet with (or speak to) first is an important one and should be determined through the therapist’s consideration of the cultural identities and ages of those involved (e.g., see Rastogi & Wampler, 1998). S. C. Kim (1985) advised therapists to follow the family’s current hierarchical arrangements, an idea I usually use initially as a demonstration of respect. With clients of ethnic minority cultures, this strategy usually involves speaking to and meeting with the elder first or, in the case of a parent with a young child, addressing the parent first. It is not uncommon for low-income clients to unexpectedly bring young children along, and if this occurs, it’s important to address the needs of the child right away (e.g., locating the bathroom, providing toys to play with). If I will be working primarily with one individual and family members are present only for the initial assessment, I also clarify the issue of confidentiality and obtain releases of information when needed.

135

136

S o r tin g T hin g s O u t

Although it may not be possible or appropriate to obtain information from multiple sources for every client, setting this practice as a standard reinforces the view of clients’ problems as multidimensional and complex. More up-front work is involved (e.g., obtaining releases of information, making calls), but in the long run the advantages usually outweigh the extra time needed. For one, the reliability of an assessment is increased when more than one source is consulted. Second, rapport with the client may be facilitated when the therapist is willing to connect with significant individuals in the client’s environment. And third, because the involvement of others can be used to reinforce therapeutic interventions, the likelihood of success in therapy is often increased.

UNDERSTANDING PERSONAL HISTORY IN ITS CULTURAL CONTEXT The following was written by an older woman using the pseudonym Charity V. Schoonmaker (1993): I became 18 years old at the close of World War II. It was a time when men came back from the war to reclaim their “rightful” place in society, i.e., one of dominance. A new wave of homophobia swept the nation as men sought the jobs held by women during the war, expecting the women to return to their previous subservient roles. College deans expelled students for lesbian attachments; my college was no exception. . . . I isolated myself from fellow students and was terrified that discovery of my sexual orientation would end my hopes for a medical career. If even the word homosexual was used in my presence my mouth got dry and my heart pounded. I carefully wiped out any traces of a personal life in my conversations with co-workers, and refused all social invitations. I continued to be alone with my shame. (p. 27)

In mental health assessments, a client’s personal history is commonly organized into a developmental, family, and social history that includes information regarding the person’s early physical and intellectual development, education, family upbringing, childhood experiences including traumatic events, significant relationships, work experience, and medical, psychiatric, and substance use history. Questions aimed at eliciting information in these categories typically assume a passive stance toward clients’ cultural histories. But as Schoonmaker’s (1993) experience illustrates, understanding the cultural events during the historical periods of a client’s life adds to the therapist’s understanding of a person (Rogler, 2002). It can be helpful to think of this historical cultural context as a sort of template into which the individual’s personal history fits—a template that deepens one’s understanding of the individual.

Conducting a Culturally Responsive Assessment

Consider the case of a college-educated, married 80-year-old Japanese American man during an assessment conducted in 2015. Calculating the client’s date of birth immediately leads to questions about the client’s personal history in relation to historical events. A general knowledge of the dominant cultural attitudes toward Japanese Americans during World War II, the probable internment of the client’s family, and the socioeconomic losses of Japanese Americans after the war would lead the therapist to make hypotheses about the impact of the war on the client that are different from those the therapist might make about a European American man of the same age. Furthermore, the greater a therapist’s knowledge of historical events that are significant in the client’s culture, the more relevant the therapist’s questions will be. For example, was his family interned (highly likely), and how did this affect his family’s subsequent life? He turned 18 about the time the Korean War armistice was signed (1953); did he serve in the military during those few months, and if so, what was his experience as a visibly Asian American man? How did the assimilationist attitudes of the late 1940s and 1950s affect him? What impact did the Civil Rights Act of 1964 have on his life and employment opportunities? As an Asian American, what was his experience of the Vietnam War? Recognizing the illegality of interracial marriage in many states until 1967, did he marry a Japanese American woman or not? What did the women’s movement in the dominant culture mean for his marriage? Did his family receive any monetary reparation for World War II internment following passage of the Civil Liberties Act in 1988 (Peterson, 2008)? These questions are person-specific versions of the kinds of questions suggested for your own cultural self-assessment, and although it may not be possible or appropriate to ask the client all of these questions, consideration of them (even to oneself) can open up a wider range of hypotheses about the client. The answers to such questions depend to a great extent on the client’s immigration history, including where he, his parents, and his grandparents were born and grew up. This particular client’s history raises the following questions: Does he identify as issei (the first generation of Japanese American immigrants) or nisei (the second generation, and the first born in the United States)? Or might he identify as kibei, a subset of the nisei who were born in the United States, were sent back to Japan for their education, and then returned to the United States (Matsui, 1996; Takaki, 1993)? If he grew up in Hawaii, did his parents work in the sugar cane fields, as did many Japanese people living in Hawaii in the 1930s, and how did that affect him as a child? Or were they immigrants to the U.S. mainland (commonly California) during a time when anti-Japanese sentiment was building and California law prohibited Japanese immigrants from buying land (Matsui, 1996)? Finally, the therapist should think about and possibly ask the client

137

138

S o r tin g T hin g s O u t

Try this: Create a timeline of your own life, with significant personal events underneath the line and sociocultural events above it.

how it was for him to move into the identity of an older man within his own family, keeping in mind the variety of attitudes toward aging in Japanese, Japanese American, and European American cultures. Although the therapist might not know about all the specific events mentioned in the preceding paragraph, all it takes is a few minutes before or after an assessment to look up a particular era online and get a feeling for cultural events of the times. Takaki’s (2008) and Zinn’s (2005) books on the history of ethnic minority groups in the United States are also excellent resources. For Canadians, I recommend Unequal Relations: An Introduction to Race, Ethnic, and Aboriginal Dynamics in Canada by Fleras (2011). With regard to people who grew up in other countries, the annually updated World Almanac (available as an e-book; see www. worldalmanac.com) is a resource with concise summaries (about one small-print page) of the languages, religions, economic conditions, ethnic identifications, and political events of every country in the world. Good resources for practical descriptions of different religions include The World’s Religions by H. Smith (2009) and Richards and Bergin’s (2014) Handbook of Psychotherapy and Religious Diversity, which also includes suggestions for therapeutic practice. One way to call attention to the historical influences on a client’s life is to construct a timeline that notes sociocultural events in addition to personal events. Figure 7.1 provides an example. As with any timeline, intersecting marks on a horizontal line denote significant dates. However, with this timeline, personal events are written beneath the line and historical sociocultural events above the line. Some clients like drawing the timeline with the therapist, and longer legal-size paper or flip charts are convenient for this work. It is important to note that most of the questions concerning the client’s cultural history (i.e., the top side of the timeline) are not asked directly, because it is the therapist’s responsibility to learn such information outside assessment sessions.

Assessment and Integrated Health Care During the last decade, U.S. federal funding has spurred the integration of primary medical care with behavioral health care, including attention to mental health and the closely related behavioral problems of domestic violence, alcoholism, drug abuse, and other forms of addiction. This integrated care movement fits well with the multicultural and systems emphasis on understanding the client’s context in that it facilitates communication and coordination between multiple care providers. These providers may include a physician, nurse, physical therapist, occupational therapist, audiologist, speech therapist, and, in some

FIGURE 7.1 Interment

WW II Assimilationist period; ends Korean war armistice Civil Rights Act

Women’s Vietnam movement War ends

Strong U.S. economy

Interracial marriage illegal until 1942

1945

1953

b. 1935

1964 1965

1967 1966

Multiculturalism

Civil Liberties Act 1970s 1975

1980s

1988

Rising health Social Security U.S. economic care costs and pensions recession threatened; World Affirmative action Medicare Trade Center Obama overturned in states changes bombing, war elected

1989

1968

1990s

2000s 1996

2007 2008

2001 2003

Interned

Family moved to city

Military service

Married

Son born

Daughter born

Depression Kids go to college diagnosis

Depressed again 1st grandchild

Example of Timeline for an Older Japanese American Man.

2nd grandchild

Conducting a Culturally Responsive Assessment

Retired

139

140

S o r tin g T hin g s O u t

cases, individuals in the client’s community—for example, a religious leader, traditional healer, or teacher (Weisman et al., 2005). With older clients, consultation with medical providers is especially important, because it communicates respect for the client’s physical complaints and provides the therapist with an opportunity to learn more about the person’s specific needs (Sanders, Brockway, Ellis, Cotton, & Bredin, 1999). Because older adults are more likely to have physical problems and take medication, a thorough medical examination is important to rule out or clarify the effects of physical illness, disability, and medication on the client’s mental health and cognitive functioning (see Gatz, 1994). For these same reasons, I recommend a recent medical evaluation including blood work (usually within the last year) for clients of all ages. Multidisciplinary, integrated care is also consistent with a disabilityaffirmative approach that “embraces the values of disability culture, acknowledges marginalization and environmental barriers, seeks information about the client’s specific disabilities, researches local resources, and balances empowerment of the client with the provider’s own advocacy efforts” (Cordes et al., in press). In contrast to traditional medical settings that conceptualize the medical provider as the expert regarding appropriate treatment, disability-affirmative integrated care actively engages the client in articulating his or her goals for health and well-being, along with preferences regarding treatment options (Cordes et al., in press). When gathering information about a client’s medical, psychiatric, and psychological history, it is important to remember the historical changes in conceptualizations of illness, health, and disability (Westermeyer & Janca, 1997). Within the dominant U.S. culture, certain behaviors that were viewed as normal or treated with a bemused tolerance in earlier decades (e.g., alcohol abuse and intoxication) are now seen as indicative of a serious problem. In contrast, some behaviors considered pathological in past years (e.g., sexual behavior between people of the same gender) are now viewed as normal. In addition to historical changes, it’s important to be aware of cultural differences in the conceptualization of health, illness, and disability, because what a therapist sees as problematic may not be so from the client’s perspective. Clients may engage in certain health care practices that to therapists appear useless or even dangerous; however, it is important to recognize the possible function of these practices to avoid overpathologizing or patronizing clients or their culture. For example, Muecke (1983b) described dermabrasive procedures commonly used by Khmer and Vietnamese people for a wide range of prob­lems including headache, muscle pain, nausea, and cough. Sub­ cutaneous hematomas (i.e., bruises) are made by firmly pinching the epidermis and the dermis between two fingers while pulling on the skin, by rubbing an oiled skin with the edge of a coin, spoon or piece of bamboo, or by placing a cup

Conducting a Culturally Responsive Assessment

from which the oxygen has been burnt out over the affected area for 15 to 30 minutes. As the air in the cup cools, it contracts and draws the skin and “air” up and out, leaving an ecchymotic area on the skin. (p. 838)

Such practices reflect Asian theories about health as a state of balance and the role of hot and cold in maintaining this balance. Whether you believe in these practices or not, they can help the person feel nurtured and more in control (i.e., able to do something about the illness), and none of them do any permanent damage (Muecke, 1983a). Moreover, one needs to allow for the possibility that such practices work, even if Western medicine does not understand how. Even within European American culture, the meaning of health and disability can vary. As a person with a disability, Weeber (1999) talked about the different meanings of health and disability for her, her family, and the larger culture in relation to her use of a scooter: We are taught that to walk, no matter how distorted or exhausting, is far more virtuous than using a chair—because it is closer to “normal.” Never mind that my galumphing polio-gait twists my muscle into iron-like sinew that only the hardiest of masseuses can “unknot.” Never mind that my shoulders and hands, never meant for walking, have their future usefulness limited by 40 years of misuse on crutches. . . . My using a scooter is an act that scares my family. They are afraid that somehow giving up walking will make me give up—period! It makes them think that I am losing ground, becoming dependent on the scooter, when they and society need me to act as if I am strong and virile. . . . I have begun to use a scooter for mobility. What an act of liberation—and resistance—this has been! I felt like a bird let out of a cage, the first time I used one! I could go and go and not be exhausted! I was able to fully participate in the conference I was attending, rather than just be dully present. (p. 22)

Even when therapists and clients agree on how they see a situation or problem, their solution preferences may vary depending on what they consider the origin of the problem. For example, in a situation in which anxiety is clearly the problem, the therapist and client may see its cause to be one or more of the following: sinful thoughts or actions; external stressors such as poverty, loss of a job, or an oppressive work environment; bad spirits or supernatural forces; a deficit in the client’s personality or character; working too hard; poor coping skills; lack of social support; difficult upbringing; need for more physical activity and exercise; substance use; or side effects of medication. Belief in multiple causes is common, and in my own practice, I often tell clients that there may be several things contributing to their anxiety, so there will probably be several things we can do about it, and that usually there is not one sole fix but rather a number of different things that contribute to a person feeling better.

141

142

S o r tin g T hin g s O u t

Of course, whichever causes are perceived to be primary will strongly influence the course of action taken. To increase the likelihood that the therapist and client are working together toward common goals, it is important to ask about clients’ understandings and about their health care practices. This is not to say that therapists and clients must always agree on the cause; however, if they don’t, it’s better to know this from the beginning to avoid misunderstandings later.

ASSESSING TRAUMA Although trauma research was international in scope from its beginnings, within the United States, clinical information has focused primarily on male war veterans, and a traumatic experience has been defined as that which is outside the range of usual human experience. Feminist therapists challenged this definition by pointing to the commonality of physical and sexual abuse, domestic violence, and sexual assault in the lives of women (Brown, 2004). Largely in response to these critiques, the definition of trauma was expanded, and increasing attention has been given to what Herman (1992) called complex trauma, defined as the “inter- and intrapersonal effects of multiple and repeated exposures to varieties of interpersonal violence and violation” (Brown, 2008, p. 4). Child abuse and other forms of domestic violence fit this definition, as may traumatic experiences related to armed conflict, experience as a prisoner of war, natural disasters, displacement through forced migration and genocide, human trafficking, prostitution, torture, diagnosis of a severe illness such as AIDS, and the witnessing of violence and life-threatening events. Although most people who experience a traumatic event do not develop posttraumatic stress disorder (PTSD), given the large number of people who have experienced such events, therapists should be prepared for the possibility of PTSD in relation to their clients. As Brown (2008) noted in her book Cultural Competence in Trauma Therapy: Beyond the Flashback, there is no universal response to traumatic events. A person’s response is influenced by a wide variety of factors including individual and cultural beliefs, history, and resources. In response to the same traumatic events, members of minority groups may experience greater vulnerability secondary to personal and cultural histories of trauma (including the transmission of trauma effects across generations) and lesser access to resources and political power that goes along with minority status. For some minority cultures, trauma-related losses may be perceived as spiritual and cultural in nature. For example, Alaska Native people were found to have higher rates than non-Natives of depression, generalized anxiety, and PTSD following the Exxon Valdez oil spill (Palinkas, Downs, Petterson, & Russell, as cited in Norris & Alegria, 2006, p. 323). The most likely explanation for this difference relates to the interruption of Native people’s subsistence activities, which

Conducting a Culturally Responsive Assessment

exacerbated fears of losing the cultural traditions that defined their identities and communities. Membership in some minority groups also increases one’s exposure to traumatic events. One member of the transgender community described such an experience: As a kid, I was physically and verbally attacked on a pretty regular basis, especially in high school. I didn’t identify as anything in particular back then, but I’ve looked flamingly genderqueer basically since preschool, so others’ perceptions of me had more to do with harassment than how I saw myself. High school was a nightmare, between regular death threats and being pelted with rocks and garbage. I never came up with a coherent answer to what motivated this harassment, and really, there didn’t seem to be much thought or intention behind it. As a general rule, taking care of my own safety was more important than psychoanalyzing my enemies. (as cited in Erickson-Schroth, 2014, p. 311)

Conversely, one’s membership in a minority culture may be a strong resource that buffers against trauma. For example, in 2004, following a tsunami in Sri Lanka that killed more than a quarter million people, well-intentioned teams of Western counselors and psychologists rushed in to provide mental health care. Over the preceding decades, the country had been through a brutal civil war, and the dominant view among many foreign health workers was that Sri Lankans would be especially vulnerable to any additional trauma. But as psychologist and native of Sri Lanka Dr. Gaithri Fernando knew, Sri Lankans already had a highly sophisticated, pluralistic health care system of ayurvedic practitioners, doctors, astrologers, religious leaders, mediums, and faith healers—along with strong religious traditions from Buddhism, Hinduism, Islam, and Christianity and ethnocultural beliefs about the spirit world. Even in the face of extreme poverty, youth uprisings, and decades of war, the population had remained functional and hopeful with little outside encouragement or counseling (Watters, 2010, p. 88).

ASSESSING TRAUMA IN CHILDREN Whether in economically impoverished countries or wealthier nations, children of color are at greater risk than adults for developing PTSD, particularly children who grow up in poverty. In the United States, although the majority of people in poverty are White, people of color are disproportionately poor (15% of Asian, 31% of Latino, and 35% of African Americans live in poverty vs. 11% of Whites; Wight, Chau, & Arantani, 2010). And poverty has been clearly linked to higher rates of neglect, abuse, and domestic and community violence—that is, traumatic events. Moreover, traumatic events often generate secondary adversities such as family separations, financial problems, geographic moves, disability, and legal problems that exacerbate the effects of these events on the child.

143

144

S o r tin g T hin g s O u t

For example, a child who has been sexually abused by a parent may—if the parent is convicted—experience the loss of stable housing, schooling, and social supports as a result of the parent’s imprisonment and diminished family finances. The child may then be revictimized by individuals who recognize and take advantage of their increased vulnerability. One of the ways I explain this increased vulnerability to caring parents is as follows: We’re all born with these danger sensors, sort of like fire alarms, that go off when we encounter a person or situation that doesn’t feel safe. But when a child has been abused by, for example, a parent who provides their housing, food, and other necessities, she learns to turn off her danger sensors because she has to in order to survive. So then even when the abuser is no longer around, her danger sensors are still turned off, and as a result, she doesn’t pick up on danger cues that most children would and is easily revictimized by others.

Recent studies point to the profound impact of adverse childhood experiences (e.g., neglect, abuse, violence) on physical and mental health (Bornstein, 2013). Adverse childhood experiences are more common among children in poverty, so it is not surprising that children who grow up poor are also at greater risk for physical problems including diabetes, cardiovascular disease, and cancer in adulthood (Clay, 2014). Studies have also found negative effects on brain development (National Child Traumatic Stress Network, 2012); compared to children with more privilege, children who grow up poor have a greater risk of impaired executive functioning and self-regulatory skills, psychological distress, depression, and behavioral problems (Roy & Raver, 2014). In an attempt to understand the particular experiences of trauma for people of color, Root (1992) called attention to the “insidious trauma” that often begins in childhood when aspects of a person’s identity (e.g., race, gender, sexual orientation, disability) are devalued by the dominant culture and one does not have the psychological capacity to understand racism, classism, and other systemic forms of oppression. For example, a child may be bullied because he is not the preferred color or social class, has a disability, or does not conform to traditional gender norms. Sometimes these events are truly life threatening, but even when they are not, their effects are cumulative and, over time, may be experienced as life threatening. Insidious trauma may be passed down generationally, along with attendant defensive behaviors and a shared sense of helplessness, as a result of a parent’s, grandparent’s, or whole culture’s traumatic experiences (Root, 1992, p. 241). Examples include trauma passed down to the descendants of those who survived the Holocaust, forced labor under the Pol Pot regime in Cambodia, the loss of whole families and large

Conducting a Culturally Responsive Assessment

segments of communities because of AIDS in some African countries, and the disease epidemics and loss of sacred lands and traditions among Native people. Culture profoundly affects a child’s and family’s response to trauma, including the meanings attached to traumatic events such as sexual abuse, physical abuse, and suicide. Culture influences the ways in which families “experience and express distress, disclose personal information to others, exchange support, and seek help” (National Child Traumatic Stress Network, 2012, item 10). And culture affects the resources available for healing and recovery. On the positive side, cohesive communities with strong cultural traditions may facilitate the child’s and family’s healing and contribute to the development of unique coping abilities and resilience (Brown, 2004). However, extreme poverty tends to under­mine cultural traditions and work against community cohesion and support. Because there is so much shame attached to experiences of abuse and trauma, clients often omit or minimize these experiences during an initial assessment. Thus, it is important to assess the possibility of trauma in all clients, including head trauma as a result of brain injury from abuse or accidents. Exhibit 7.1 provides a list of 10 suggestions for doing so, particularly with regard to people who hold a minority status. Generational cultural information can serve as a template into which individual- and family-specific information can be (cognitively) placed.

EXHIBIT 7.1 10 Suggestions for the Multicultural Assessment of Trauma  1. Even before the assessment begins, be aware of how your own cultural identity may trigger a client’s symptoms or make it more difficult for him or her to share traumarelated information. As Brown (2008) noted, if for example you are a European American therapist working with a person of color experiencing workplace discrimination, or a native-born therapist with an undocumented immigrant client, or a straight man with a client who was beaten up for being gay, communicating to the client that you have actively considered who you are as a psychotherapist and what that might mean to the client conveys cultural competence and builds trust.  2. Be cautious about making judgments about what constitutes a traumatic experience until you fully understand the individual’s family and cultural histories; an event that is not life threatening may feel life threatening to a client who has a family or cultural history of trauma or a personal history of insidious trauma.  3. Keep in mind that clients’ perspectives regarding traumatic events, particularly those related to armed conflict, may differ from those of the dominant culture. For example, following the attack on the World Trade Center of September 11, 2001, one study found that people of color in the United States were more likely than White people to attribute the cause of the attack to acts of omission (e.g., a false sense of security or arrogance such as the belief that “it could not happen here”; Walker & Chestnut, 2003). (continued)

145

146

S o r tin g T hin g s O u t

E X H I B I T 7 . 1 (Continued)  4. When asking about trauma, do not assume the client will disclose; minority cultures in particular may have group-protective cultural prohibitions about such disclosure. For example, a Muslim woman may be reluctant to share an experience of domestic violence with a European American therapist out of the assumption that the therapist holds the stereotype of Islam as a “violent” religion. Talking about traumatic experiences can bring up feelings of shame, embarrassment, fear, anger, and even suspiciousness regarding why such questions are necessary. If this is the case, it can help normalize the potential barriers to sharing one’s story by talking with the client about these differences (Brown, 2008) and, in addition, by validating the client’s feelings, providing reassurance, encouraging questions, and being prepared to explain the reasons for a question (Briere & Scott, 2015).  5. Recognize that how the client conceptualizes and understands what he or she has experienced may be quite different from how you conceptualize it, even including what is considered reassuring. For example, Sri Lankan psychologist Dr. Gaithri Fernando described her experience interpreting for a researcher who asked an 8-year-old boy (who had witnessed several massacres and whose father was killed during the violence) what helped him feel better when he became worried about the violence in his community. The boy told her that he felt better when his mother promised him that if they were attacked and killed, they would all die together: “The mother offered no promise of protection or even survival, only togetherness in the face of violence and death. The boy, for his part, appeared deeply reassured by his mother’s promise” (as cited in Watters, 2010, p. 93).  6. Because the language one uses regarding traumatic experiences may be interpreted in different ways, use behaviorally specific definitions. For example, a woman who was forced to perform oral sex may answer no to the question, “Have you ever been raped?” A more behaviorally anchored question is, “Did anyone ever do something sexual to you that you didn’t want or make you do something sexual to them?” (Briere & Scott, 2015).  7. Deliberately look for the client’s internal and external strengths and resources. This strategy can help empower the client and facilitates a fuller and more realistic understanding of the person. A group-based treatment program for Liberian and Sierra Leonean torture survivors used this idea in helping participants work through the trauma of their loved ones’ deaths, many of which involved torture (Stepakoff et al., 2006). Group participants were encouraged to remember as much as possible about their loved ones’ lives toward the goal of cultivating a positive, life-affirming image of their loved ones, which acted as a counterbalance to the horrifying images of their loved ones’ deaths. (Ways to look for culturally related strengths are described later in this chapter.)  8. With children who lack the psychological and verbal abilities to conceptualize and express their experiences, be aware that they may exhibit a wide variety of symptoms including repetitive play that reenacts the traumatic experience (e.g., sexual abuse or violence they have witnessed; American Psychiatric Association, 2013).  9. As a therapist, pay careful attention to your own vulnerabilities and the potential for secondary trauma. As Brown (2008) noted, “the power of trauma itself to distort psychotherapists’ emotional capacities should never be underestimated. It is simply human to wish to distance oneself from the story of trauma” (p. 69). Professional and personal support is essential for all therapists, especially those working in the field of trauma. 10. Do not limit your assessment of trauma to the individual. Also consider trauma related to the client’s culture and community—for example, trauma caused by civil wars that tear apart families of mixed religions and ethnicities, natural disasters that destroy communities, extreme poverty that forces men in a community to leave in search of economic opportunities elsewhere, or loss of cultural traditions and connections in Native communities where land and water have been flooded, polluted, or similarly destroyed and resources such as fish and wildlife wiped out.

Conducting a Culturally Responsive Assessment

To facilitate the gathering of such contextual information, it may be helpful to develop a historical trauma timeline with the client, as described earlier in this chapter. Constructing a timeline can help some clients visualize how trauma is passed down across generations. Balsam, Huang, Fieland, Simoni, and Walters (2004) used the historical trauma timeline in their work with two-spirit people who had experienced individual and intergenerational trauma. (Two-spirit is a term signifying the embodiment of both feminine and masculine spirits within one person, used by American Indian, Indigenous Canadian, and Alaska Native people of diverse gender and sexual orientations.) I have found drawing a genogram to be similarly helpful (Chapter 12 includes an example). For additional resources regarding multicultural competence and trauma work, see the websites of the Harvard Program in Refugee Trauma (http://hprtcambridge.org/about/) and the International Society for Traumatic Stress Studies (http://www.istss.org).

WORKING WITH INTERPRETERS For a while, I had a tutor for Spanish. She was an Argentine woman who was fluent in English but wanted help with some of the pickier points of English, so we exchanged services. During one of our lessons, she was quite distressed about a series of events that had occurred. As she was describing her day (in English), she said something about feeling like she was just “going forth and back.” I interrupted to tell her that in English, the phrase is “going back and forth.” She was annoyed by this and said, “Well, in Spanish, it’s para adelante y para atrás, meaning ‘going forward and then back,’ because you cannot go back until you’ve gone forth!” I could see her point; the English was confusing. Furthermore, the illogic of it only added to her annoyance and distress. When clients are using their second language in the therapeutic setting, their emotional distress may be heightened and affect their ability to describe a stressful or traumatic situation accurately (Bradford & Munoz, 1993), increasing the potential for miscommunication and misunderstanding. Among bilingual individuals, there is evidence that certain memories may not be retrievable in a second language, not because they are repressed but because they were encoded in the first language and thus are accessible only through use of the first language (SantiagoRivera & Altarriba, 2002). A greater reliance on pencil-and-paper tests in English generally does not solve the language problem either. Although clients can take their time reading, their results will still reflect language abilities confounded with whatever construct is being measured (Kaufert & Shapiro, 1996; Wilgosh & Gibson, 1994). When a therapist does not speak the client’s primary language, the ideal solution is referral to a therapist who does. With regard to

147

148

S o r tin g T hin g s O u t

people who identify culturally as Deaf, Olkin (1999) advised that “Deaf clients are best served by Deaf therapists within the Deaf community” (p. 4). But at present, the majority of therapists providing services to Deaf clients are not fluent in the languages used by Deaf people and require an interpreter to effectively serve their clients (C. R. Williams & Abeles, 2004). In general, when there is no available therapist who is fluent in the client’s language, the therapist and client may need to work with a qualified interpreter. (Note that interpretation refers to spoken language and translation to the written form.) In the United States, Title VI of the Civil Rights Act of 1964 states that all individuals and organizations receiving federal funds (including Medicaid and Medicare payments) must provide meaningful access to individuals who have limited English proficiency (Snowden, Masland, & Guerrero, 2007). Meaningful access includes the provision of competent interpretation services and translation of documents. Few states have adopted standards for assessing the competence of health care–related spoken language interpreters, but the National Council on Interpreting in Health Care (2005) has developed national standards. There are university- and hospital-based programs that train interpreters—for example, the National Center for Interpretation at the University of Arizona (see http://nci.arizona.edu), and the Cross Cultural Health Care Program which offers a training program called Bridging the Gap (see http://www.xculture.org). Information about interpreters for the Deaf can be obtained through the national Registry of Interpreters for the Deaf, which also provides certification of qualified interpreters (see http://www.rid.org). There are also mental health interpreter training programs (see, e.g., Center for Health and Health Care in Schools, 2008). There are two main forms of spoken interpretation: (a) simultaneous, in which the interpreter speaks simultaneously with the client, interpreting the client’s words as the client speaks, and (b) consecutive, in which the interpreter waits for the client or therapist to stop speaking before interpreting their words. (Sign interpretation involves different terminology, because sign interpreters do not use consecutive interpreting.) For spoken language, simultaneous interpretation is the favored method in the United Nations, and it has been shown to be effective in therapeutic practice (Bradford & Munoz, 1993). How­ ever, in the mental health world of limited resources, individuals with this high level of skill plus mental health expertise are not in great supply. In my experience, though, consecutive spoken interpretation does have one advantage: It gives the therapist extra time to think and observe the client while the interpreter is interpreting what he or she just said.

Conducting a Culturally Responsive Assessment

A number of suggestions may be helpful in working with an interpreter. The first concerns the task of choosing an individual. To avoid problems with confidentiality, it is important that the interpreter not have a close social relationship with the client. The use of family members as interpreters is never appropriate, because such an arrangement places an unfair load on the person acting as interpreter. It risks offending older family members, who are placed in a lower position when children or grandchildren interpret for them (Itai & McRae, 1994). And family interpretation may even be dangerous—for example, in cases of domestic violence in which the abuser assumes the role of interpreter for the victimized partner, child, or elder. The second suggestion is to talk alone with the interpreter (i.e., without the client) in advance of the initial assessment with the goal of establishing rapport and discussing expectations (Bradford & Munoz, 1993). This meeting should be face-to-face, before the meeting with the client, in case there is a problem with the interpreter’s qualifications or the interpreter–client match. Although ideally interpreters have training in mental health, if they do not, this meeting allows the opportunity to review concepts or vocabulary that may be unfamiliar to the interpreter and any forms that will need to be completed and to make sure that the interpreter understands the commitment to confidentiality (Bradford & Munoz, 1993). If the therapist and interpreter do not know one another, this initial meeting without the client is a good time for the therapist to learn about the interpreter’s background. If raised with polite interest, questions about the interpreter can help increase rapport and demonstrate respect for the interpreter’s expertise and experience. (Similarly, as a form of respect for the interpreter’s professional position, it is important to note the presence and name of the interpreter in written reports; Sáez & Judd, 2014). The information obtained during this initial meeting will also add to the therapist’s understanding of the cultural, social class, political, and even language (e.g., dialect) influences that may affect the interpreter’s work with a particular client (Sundberg & Sue, 1989). Keep in mind that the interpreter may have had traumatizing experiences similar to those of the client (not uncommon among refugee populations), so it’s important to make sure the interpreter is prepared to handle what may arise. In addition, the interpreter may feel pulled in two directions—to ally with the client and the therapist at the same time—and being sensitive to this dynamic can help in facilitating a balance (T. Judd, personal communication, January 2, 2015). Any information the interpreter can provide concerning the client’s culture will be helpful, too. For example, when I was about to hire an interpreter for work in a Vietnamese community, I consulted with the

149

150

S o r tin g T hin g s O u t

community leaders who advised me that there were two main political groups and that if I hired an interpreter even loosely connected to one, I should also hire another who was not, because people aligned with one group would not work with an interpreter who was aligned with the other. Frequently, the gender of the interpreter is also important. With some groups, the choice of a male interpreter may add authority to the therapeutic endeavor, particularly if the therapist is a woman. However, as a general rule, a woman client cannot be expected to share intimate relationship or physical health details with the therapist or interpreter if either one is male. (See Waxler-Morrison, Anderson, Richardson, & Chambers, 2005, regarding gender preferences for health care providers in Cambodian, Lao, Vietnamese, Iranian, Central American, and other cultures.) During the initial assessment with the client present, allowing extra time is important because of the extra speaking time involved. This extra time may also include a get-acquainted conversation between the interpreter and client, which can help decrease the client’s anxiety. The physical positioning of chairs is important. With spoken language, the therapist usually sits facing the client with the interpreter visible but positioned to one side so as to facilitate direct interaction between the client and therapist. For signing, it is extra important for everyone to have a clear line of sight; avoid positioning anyone in front of a bright light or window to avoid glare and shadows that would make it difficult to see the speaker’s lip movements, facial expressions, or bodily movements (Department of Disability Services, Columbus State Community College, & Murray, 2015). It is important that the therapist avoid discussions with the interpreter when the client is present. If the interpreter needs to explain a concept or idea that the therapist has not understood, the therapist should let the client know what is being discussed; otherwise, the client may wonder why the therapist is talking so much about the client’s reply to a particular question. Similarly, although allowing a little time before the assessment starts for the interpreter and client to converse can build the client’s trust in the interpreter, during the formal assessment it’s important that the interpreter and client not hold separate conversations; the therapist should be involved in any clarifications that are needed. And just as a preassessment meeting between the therapist and interpreter is important, so too is a debriefing session between therapist and interpreter to discuss any possible misunderstandings or conceptual inequivalencies after the assessment with the client. When the formal assessment begins, it is helpful to restate in front of the client the commitment to and limits of confidentiality for both the therapist and interpreter. It is important to avoid complex language

Conducting a Culturally Responsive Assessment

and terms and to use short sentences and simple, one-part questions that are easier to interpret and answer than two-part questions. For example, it is better to ask two separate questions, such as “How often have you experienced this dizziness?” and “When did the dizziness start?” than to ask “How often have you experienced this dizziness, and when did it start?” In addition, it is important to recognize that interpreting is not word for word, because there are many concepts and idioms that do not translate directly. With consecutive interpretation, it is important to pause after expressing each main idea to allow the interpreter time to interpret. A skilled interpreter uses the same pronoun as the speaker. For example, if the therapist says, “I recommend this,” the interpreter says, “I recommend this” (not “She recommends this”). To avoid confusion, skilled interpreters refer to themselves in the third person. For example, if the therapist says, “I would like the interpreter to meet with us next week,” the interpreter would interpret this verbatim as “I would like the interpreter to meet with us next week.” The therapist should speak directly to the client (e.g., rather than saying to the interpreter, “Tell him I think he needs a medication evaluation”). Although it may be well intentioned, as a general rule therapists should not to attempt to work in the client’s language without an interpreter unless they have near-native fluency. The poor use of a client’s language puts the client in an awkward position. And clients may be afraid of insulting the therapist by suggesting the need for an interpreter. The complexity involved in speaking a second language fluently was underscored by Pollard (1996) with regard to American Sign Language (ASL). Noting that ASL is a conceptually based language (i.e., not English or aurally based) with its own vocabulary, grammar, and patterns of discourse, Pollard observed the following: Like German, ASL verbs are often at the end of statements. Like Spanish, ASL adjectives follow the nouns they modify. Like Hebrew, ASL does not employ certain forms of the verb “to be.” Like Japanese, feedback signals from the listener are expected in ASL. Like French, there is reflection in ASL sentences and discourse. . . . Too many individuals (and program administrators) wrongly assume that a few courses in “sign” enable one to converse with, or worse, interpret for, a primary user of ASL. (p. 391)

Interpretation is a demanding job, and it is thus unfair to expect bilingual individuals who are not paid for their interpreting services to do interpretation on an as-needed basis for agencies and hospitals. An informal approach to interpretation is another way in which people of minority cultures are expected to do extra work while the dominant culture fails to educate itself. Exhibit 7.2 summarizes guidelines for working with interpreters.

151

152

S o r tin g T hin g s O u t

EXHIBIT 7.2 10 Guidelines for Working With Interpreters  1. Schedule extra time for the assessment.  2. Do not use family members or social acquaintances as interpreters.  3. Hold a preassessment meeting with the interpreter (without the client present) to a. be sure the interpreter is certified or similarly qualified and speaks the client’s dialect (not just their language); b. build rapport and demonstrate respect for the interpreter’s expertise; c. review confidentiality, mental health–related concepts, questions, and other information that will be used in the assessment; and d. learn about the interpreter (e.g., political, social class, and other factors that may influence his or her work) and from the interpreter (e.g., regarding general cultural information that may help you in understanding the client).  4. Keep in mind that the interpreter may have had traumatizing experiences similar to those of the client, and make sure the interpreter is prepared to handle what may arise. In addition, recognize that interpreters may feel pulled in two directions—to ally with the client and the therapist at the same time—and work to facilitate a balance.  5. For spoken language, position chairs so that the therapist and client face one another, with the interpreter to the side, to facilitate interaction between therapist and client. For sign language, be especially sure that everyone has a clear line of sight; avoid positioning anyone in front of a bright light or window that would create glare or shadows.  6. Reassure the client about confidentiality and its limits when both you and the interpreter are present.  7. Avoid discussions between you and the interpreter during the session; if such a discussion is necessary, let the client know that you are discussing a conceptual or linguistic difference.  8. Use simple, one-part phrases rather than complex phrases and questions that convey more than one idea at a time and are more difficult to interpret.  9. With consecutive interpretation, pause after each main idea to give the interpreter time to interpret. 10. Be aware of cultural, class, and political differences between the interpreter and client that might affect the interpreter’s work.

ASSESSING STRENGTHS AND SUPPORTS As mentioned earlier in this chapter, I ask clients about their strengths and supports toward the end of the assessment, because if they are unable to state any, by the end of our time together I have usually learned enough about them to be able to name some things that I have observed or heard. Knowing that I will be asking this question also forces me to actively look for the client’s strengths throughout the assessment. At the same time, many people of Asian, American Indian, and Alaska Native cultures place a high value on being humble and modest, and they may be reluctant or feel embarrassed to answer such a question. In these cases, I ask, “What would your mother [best friend, partner, teacher] say they like about you?” Because I ask this question toward the end of the assessment, by this time I know who the supportive people

Conducting a Culturally Responsive Assessment

are in their lives. I may also note aloud the strengths that I’ve noted or observed and listen for the person’s response. Minority group members have the same range of general strengths and supports that dominant culture members do, but because the dominant culture often views minority cultures as deficient, I think it’s important to actively look for culturally related strengths and supports, too. In addition, if a therapist differs culturally from the client, the therapist may simply not perceive strengths and supports related to the client’s culture. For these reasons, I’ve developed a list of culturally related strengths and supports organized in three categories, shown in Table 7.1. The first

TA B L E 7 . 1 Culturally Related Strengths and Supports Type of strength

Example

Personal strengths

Pride in one’s culture Religious faith or spirituality Artistic or musical abilities Bilingual or multilingual skills Group-specific social skills Sense of humor Culturally related knowledge and practical skills (e.g., fishing, hunting, farming, using medicinal plants) Culture-specific beliefs that help one cope with prejudice and discrimination Respectful attitude toward the natural environment Commitment to helping one’s own group (e.g., through social action) Wisdom from experience Extended families, including non-blood-related kin Cultural- or group-specific networks Religious communities Traditional celebrations and rituals Recreational, playful activities Storytelling activities that make meaning and pass on the history of the group Involvement in a political or social action group A child who excels in school An altar in one’s home or room to honor deceased family members and ancestors A space for prayer and meditation Culture-specific art or music Foods related to cultural preferences for cooking and eating Caring for animals Access to outdoors for gardening, subsistence or recreational fishing, hunting, or farming or for observing stars in the night sky Communities that facilitate social interaction by location or design

Interpersonal supports

Environmental conditions

153

154

S o r tin g T hin g s O u t

category, personal strengths, includes characteristics, beliefs, and abilities that reside within the individual—for example, pride in one’s culture, a sense of humor, and artistic, musical, and language abilities. Personal strengths may also include coping abilities related directly to a person’s minority status. As McIntosh (1998) noted, Those who do not depend on conferred dominance have traits and qualities that may never develop in those who do. . . . In some groups, those dominated have actually become strong through not having all of these unearned advantages, and this gives them a great deal to teach the others. (p. 101)

When looking for personal strengths, I always ask clients if they have a religious affiliation or spiritual beliefs (including any strong connection to nature) that are a source of strength or support for them. Spiritual beliefs and support from a religious community can be a powerful help, providing clients with meaning, purpose, and a sense of connection to something greater than themselves (Royce-Davis, 2000). Because psychology has traditionally been antagonistic toward religion, and because the members of minority religions often experience hostility from the dominant culture (particularly Muslims in recent times), I deliberately ask about this topic when I’m asking about strengths and supports. In this way, I communicate my view of religion as a potential source of strength and support. The second category consists of interpersonal supports. Included in this category are family, friends, group-specific networks, and activities that involve one’s cultural group (e.g., traditional celebrations, political or social action groups, recreational activities). A child who is excelling in school may be a special source of pride for a family. And family may include kinship networks that are broader than traditional definitions of family traced by bloodlines (Moore Hines & Boyd-Franklin, 1996). Because low satisfaction with social support has been found to be a significant predictor of depression and general psychopathology (Fiore, Coppel, Becker, & Cox, 1986), knowledge of clients’ social support is essential to an understanding of mental health. At the same time, therapists must be careful not to assume that people of color or of other minority identities have good support networks. The formation of close and stable relationships may be undermined by the stressors that go along with minority status, as in the case of immigration, migration for jobs, poverty that isolates people, and limited access to members of one’s minority group (e.g., gay, lesbian, and transgender people living in rural areas). The third category includes sources of support and strength in the client’s physical and natural environments. Some of these sources can be created—for example, an altar in one’s home to honor ancestors, a space for prayer and meditation, music, art, or a garden where food and medicinal plants are grown. In addition to meeting cultural and taste preferences, culture-specific foods may also act as a protective factor in one’s health (Marsella & Kaplan, 2002).

Conducting a Culturally Responsive Assessment

Other sources of support may be anchored in the client’s sense of place in the natural world (e.g., see Cruikshank, 1990, and McClanahan, 1986, for richly described first-person accounts of the importance of place among Alaska Native elders). Clients of rural origin or Indigenous heritage may find involvement with or nearness to animals, plants, mountains, and bodies of water to be important sources of spiritual strength (C. T. Sutton & Broken Nose, 1996). Griffin-Pierce (1997) emphasized the importance of place to Navajo people in her description of the emotional trauma many Navajo individuals experience upon leaving their homeland for college or medical care. She noted that such trauma “goes beyond mere homesickness because it is based on an often unconscious sense of having violated the moral code of the universe” by leaving the land, which is considered “a vital source of spiritual strength” (p. 1). The importance of understanding health and illness in relation to losses because of dislocation from the land has also been noted with regard to Aboriginal Australians (Acklin et al., 1999, p. 9). And even among non-Native people in Alaska and Hawaii, a common response to my question about spirituality is, “My spirituality comes from being out in nature.” The importance of outdoor activities, including traditional (e.g., hunting, berry picking) and nontraditional (e.g., snow machining) activities, among some Alaska Natives was documented by Minton and Soule (1990), who found these activities to be the most common response to the question, “What makes you happy?” When such activities are not available because of environmental changes (e.g., pollution, industrialization, a person’s institutionalization), therapists and clients may need to think creatively about alternative ways to get these needs met (e.g., visiting a park, setting up a bird feeder, finding a new place to go fishing or watch the stars at night). As solution-focused therapists like to point out, even if solutions do not appear to be directly related to the problem, simply increasing the strengths and supports in clients’ lives often has a positive effect on their view of the problem, which in turn helps them feel better (deShazer, 1985). Moreover, recent research in the area of positive psychology suggests that a sense of meaning, control, and optimism can be protective of one’s physical as well as mental health (Magyar-Moe, 2009).

ASSESSING UNUSUAL PERCEPTIONS AND EXPERIENCES One of the most difficult tasks in a cross-cultural evaluation involves the assessment of beliefs and behaviors that are unusual in the dominant (and sometimes minority) culture but that are seen as positive and healthy in certain contexts (e.g., belief in the supernatural, communication with spirits, trance experiences). Westermeyer (1987) offered several criteria for distinguishing pathological from nonpathological

155

156

S o r tin g T hin g s O u t

behaviors and beliefs, noting that nonpathological behaviors and beliefs are usually characterized by the following: (a) community and family support; (b) time limitations from a few hours to a few days; (c) socially appropriate, productive, and good coping behavior before and after the experience; (d) a resultant gain in self-esteem and social prestige; (e) the absence of psycho­pathological signs and symptoms; and (f) culturally congruent visions or auditory experiences. (p. 473)

Psychopathological conditions are distinguished by the opposite of these criteria. Although clients’ presentations do not always fit this list (in part because some of the criteria apply to beliefs, some to behaviors, and others to experiences), the criteria can be useful as a general guide. Take the example of a Christian client who told his therapist that God spoke to him on a daily basis. This man was a member of a fundamentalist church that conceptualized the Bible as the literal word of God. His experience of direct communication with God was supported by his family and church community and was “contained”—that is, the communication was of an expected duration and did not interfere with other activities. In addition, the content of the communication was constructive and perceived as helpful. Although the client was experiencing anxiety and depression, his spiritual experiences seemed to be a source of support and strength, not a maladaptive response. Attention to the cultural aspects of this client’s presentation prevented the therapist from mis­ interpreting the client’s experience as pathological. In contrast, just as therapists risk pathologizing and overdiagnosing clients whose cultures are unfamiliar, therapists may also overlook pathology and underdiagnose because they frame a belief, behavior, or experience as cultural and thus automatically accept it (Paniagua, 2005). This mistake almost occurred on a geropsychiatry hospital unit when an older Filipina woman was admitted for treatment of “probable depression.” Although the woman was noted to be “talking to the spirits of dead people,” the intake nurse decided that these were not pathological hallucinations because she knew that “in some Asian cultures, people talk to their deceased relatives.” In this case, however, the nurse’s limited knowledge was misleading. A closer look at the accompanying behaviors and experiences of the client revealed that the client was distressed by these “conversations,” that she was coping poorly both before and after them, and that the voices inhibited her ability to care for herself and engage with her family and caregivers. In addition, the voices were telling her to do destructive things that were not congruent with her culture and Catholic faith. A more thorough evaluation found the client to have moderate dementia and hearing impairment that were contributing to her auditory hallucinations and depressed mood. Antidepressant medication

Conducting a Culturally Responsive Assessment

subsequently lifted her mood, which helped a little with her orientation. She refused to wear a hearing aid, but her impairments resulted in her admission to a nursing home, where she had more social interaction and auditory stimulation (i.e., more people around her who would speak loudly, engagement with music activities).

AVOIDING ERRORS OF OMISSION AND COMMISSION A set of similar errors in clinical judgment when working cross-culturally is what Kemp and Mallinckrodt (1996) called errors of omission and errors of commission. An error of omission occurs when the therapist fails to ask about a crucial aspect of the client’s life. Such errors are common when therapists lack knowledge of a client’s cultural context and may reflect unconscious, dominant cultural assumptions about what is important and what’s not. An example of an error of omission would be a therapist who mistakenly assumes that older adults and people with disabilities are incapable of or not interested in sex and as a result does not think to ask if the sexual part of a relationship is satisfactory for a client who presents with relationship concerns. In contrast, an error of commission occurs when the therapist focuses too intently on a topic that is not particularly relevant to the client’s presenting problem. Again, such errors often emerge out of dominant cultural assumptions about what is most important in minority cultures. For example, a well-intentioned heterosexual therapist who asks numerous questions about a gay student’s identity and coming-out experience may be perceived as insensitive or intrusive if the student is seeking help solely for academic problems and career questions.

WRAPPING UP THE INITIAL ASSESSMENT SESSION Toward the end of the initial assessment, it’s important to give clients something more than they came in with. In most cases, this means providing an explanatory summary of the information the client has shared, your diagnosis, and your recommendations. When such an explanation is not possible because there is a need to obtain additional information from other sources or via testing, at the least it’s important to provide some sense of hope and direction. In my own practice, once I’ve asked all of my questions, I say to the client, “Well, it looks like that’s about all the questions I had. Is there anything you can think of that I didn’t ask that might be important for me to know?” Following this query, I provide an explanatory summary. The following is an example of the kind of summary I typically give, using the example of Yasmine, a 48-year-old, recently divorced, multiracial mother of a stable 30-year-old daughter (Adrion), a 22-year-old

157

158

S o r tin g T hin g s O u t

son (Jermain) who is homeless and addicted to drugs, and a 12-year-old adopted niece (April) who has a mild fetal alcohol spectrum disorder: OK, then, let me go ahead and summarize for you what I’m thinking. [pause] When I’m trying to understand a person’s situation, I look at three main things. The first thing I look at is a person’s vulnerability to anxiety, depression, and anger based on their childhood experiences, because we know that growing up in an abusive or chaotic home can predispose a person to these kinds of problems. Based on what you’ve told me, it sounds like you had a pretty difficult childhood, with your parents’ alcoholism and then all of the fighting and arguing and the multiple moves. So it sounds like you probably do have some vulnerability based on your childhood experiences. But that’s not to discourage you, because there are ways to counter this vulnerability, and I’ll talk with you about that in a minute. The second thing I look at are the stressors in a person’s life—chronic stressors that go on and on, and also even little day-to-day stressors that can start to feel overwhelming. As you’ve been talking, I’ve been keeping a list of all the stressors I’ve heard you mention. Number 1, there’s Jermain, with all of his ups and downs related to homelessness, drug addiction, calling you for money, and so on. Number 2, there’s your youngest, April, and the challenges of raising a child with a disability pretty much by yourself, which has become especially challenging now that she’s approaching adolescence. Number 3, finances are really stressful, and even though your former husband pays some child support, it doesn’t begin to cover the half of what you need. Number 4, your workplace sounds pretty oppressive, with a supervisor who is not supportive, and then some of the institutional policies you described. And finally, Number 5, your physical health is suffering because you don’t have time to exercise and are not eating as well as you could. So you know, what you’re dealing with is huge. [pause] And given all that, I’m not at all surprised that you are feeling overwhelmed. So then, the third thing I look at is social support. One thing we know about stress is that the more support a person has, the more stress they can handle. But if you don’t have a lot of support, even little day-to-day aggravations can feel overwhelming. It sounds like you do have some good support from Adrion and her partner, your best friend Michelle, and your church, but it sounds like at the same time you could use more, especially given all of the stressors in your life. So based on all this and the symptoms you’ve described, it’s not surprising that you’re feeling overwhelmed and some depression, anger, and fear about the future; I think most people in your situation would feel the same way. In terms of a technical diagnosis, I think you meet criteria for depression; what do you think? [pause to hear client’s input on the question of diagnosis; discussion and clarification of what diagnosis will go in the written record] So this brings us to the question of how to help you feel better.

Conducting a Culturally Responsive Assessment

Following a brief discussion, I go on to talk with clients about my recommendations and what I would do with them in counseling if they want to return. (Because I’m presenting this information in the chronological order of the assessment, I will talk more about this discussion at the end of Chapter 9, on diagnosis, and in Chapter 10, on therapy).

Conclusion An accurate and helpful initial assessment involves obtaining a holistic understanding of the individual in their historical and cultural context. General historical and cultural information is best obtained primarily outside the therapy setting and provides a template for understanding specific individual and family details. Assuming that the therapist is engaged in ongoing self-education, specific steps that can be taken during the assessment include a systems orientation that seeks out multiple sources of information obtained in multiple ways regarding multiple domains. The use of a client’s preferred language is recommended, but when this is not possible, a number of strategies are available for facilitating work with an interpreter. Finally, culturally responsive assessment assumes a strengths-oriented approach in which therapists deliberately look for general and culturally related strengths and supports at the individual, interpersonal, and environmental levels.

Practice: Identifying Strengths and Supports Read the following case example, and make a list of all the strengths and supports you perceive in Juan’s life. Feel free to infer a little bit—the point is to take an active, strengths-oriented approach to this client’s life and situation despite the problems he presents. Juan is an 18-year-old high school student whose father is White and mother Puerto Rican. He was born and grew up in the city. He began drinking and using drugs at 12. His father was physically abusive, and Juan dropped out of school and left home at 16 to live with a variety of extended family members and friends. He reports that his relationships are primarily with people who drink and use drugs, although he stays connected to his mother and one sister via phone calls and visits. He had 2 months clean and sober once following a domestic violence

159

160

S o r tin g T hin g s O u t

incident with his girlfriend, but he admits he is now drinking and smoking marijuana. He continues to have contact with the girlfriend. He has had a variety of jobs, is currently working part-time at a gas station, and sporadically attends an alternative high school. He is angry at the police, his father, and his girlfriend but also says he knows that part of his problem is himself.

In the workshops I teach, I ask participants to do this exercise in triads, and there’s always at least one group that comes up with more than 20 strengths and supports.

Key Ideas

 1. During the initial assessment, include time for obtaining informed consent to allow for the possibility of a client’s limited language or comprehension abilities, fear about signing official documents, distrust of authorities, or financial concerns.   2. Recognize cultural norms that may prevent the client from answering certain types of questions or questions posed in a particular way—for example, questions regarding spirituality or a family member’s problems.   3. Think systemically, and whenever possible, seek out multiple sources of information in multiple ways regarding multiple domains.   4. Use the cultural history as a cognitive template into which specific individual and family information can be placed to increase your understanding of the client.   5. Stay aware of changing conceptualizations and cultural differences regarding illness, health, and disability over time.   6. Ask about the client’s conceptualization of their problem, situation, and health care (including self-care) practices.   7. When assessing for trauma, be cautious about making judgments as to what constitutes a traumatic experience until you fully understand the client’s family, community, and cultural histories.   8. Facilitate use of the client’s preferred language, if necessary through referral to another therapist or the involvement of a well-qualified interpreter.   9. Look for culturally related strengths and supports at the individual, interpersonal, and environmental levels. 10. In distinguishing pathological from nonpathological behaviors and beliefs, remember that the latter are usually preceded and followed by good coping, lead to increased self-esteem, and receive the support of family and community.

Using Standardized Tests in a Culturally Responsive Way

M

8

y initial exposure to cultural issues in testing occurred during my doctoral studies at the University of Hawaii in the mid-1980s. Through academic lectures and reading, I became aware of the continued lack of consensus on the definition of intelligence. I learned that definitions vary across cultures because different cultures value different skills and knowledge (Berry, 2004; Sternberg & Grigorenko, 2004). For example, in some traditional African cultures, a person who is cognitively quick but lacks social responsibility is generally not considered intelligent (Serpell & Haynes, 2004). Even within cultures, definitions of intelligence can vary depending on what skills and knowledge are valued during that particular period in history. Although it is possible with deep knowledge of a culture to delineate the skills and knowledge considered intelligent, the most commonly used tests of intelligence come from the United States or Great Britain and represent knowledge and competencies relevant to urban industrialized societies (Poortinga & Van de Vijver, 2004).

http://dx.doi.org/10.1037/14801-008 Addressing Cultural Complexities in Practice: Assessment, Diagnosis, and Therapy, Third Edition, by P. A. Hays Copyright © 2016 by the American Psychological Association. All rights reserved.

161

162

S o r ti n g T hi n gs Out

With this knowledge in hand, I was granted a 1-year practicum that primarily involved testing children in Hawaii public schools. Most of these children were of Asian, Pacific Island, or mixed cultures. After my first couple of months, I asked my supervisor, a thoughtful Japanese American woman with children of her own, about the ethics of using such Eurocentric tests with children who were not European American. The gist of her reply was that yes, the tests were biased, but this was not an ideal world, and if these children were to get anywhere in life, they had to first succeed in the European American-dominated school system. She went on to say that the tests we were conducting helped demonstrate these children’s specific learning needs so that they could get the help they needed. This was over two decades ago, and since then, awareness has continued to increase of the biases inherent in IQ testing, particularly for children who have limited English proficiency (LEP). Previously, eligibility for special education was commonly determined under the category of specific learning disability (SLD) when there was a discrepancy between the child’s Full Scale IQ on a test of intelligence and cognitive ability such as the Wechsler Intelligence Scale for Children (Wechsler, 2003) and the child’s score on an achievement test and when the child’s low performance could not be explained by other factors such as language, lack of opportunity, or community factors but rather represented a processing problem of some sort. However, this emphasis on discrepancy could miss an SLD, especially for LEP students, because a low Verbal Scale Score could pull down the Full Scale IQ enough so that there was no discrepancy relative to the child’s low achievement score, making it difficult to determine a true processing disorder (Liz Angoff, personal communication, February 10, 2015). For the purposes of SLD identification in schools with LEP students, a partial solution is the use of language-reduced tests such as the Kaufman Assessment Battery (K-ABC; Kaufman & Kaufman, 2004), the Leiter International Performance Scale (Roid, Miller, Pomplun, & Koch, 2013), the Universal Nonverbal Intelligence Test (Bracken & McCallum, 1998), or the Comprehensive Test of Nonverbal Intelligence (Hammill, Pearson, & Wiederholt, 2009). However, even with language-reduced tests, the discrepancy model still has its problems, and as a result, the federal government no longer requires it, allowing states to continue to use it or another research-based option such as Response to Intervention, or RtI, which has its limitations, too (Maryam Bassir, personal communication, January 15, 2015). In sum, the use of tests is complicated, whether conducted as part of a larger school, neuropsychological, forensic, or other cognitive or psychological assessment. To begin to understand and work within this complexity, this chapter begins with an overview of five approaches

Using Standardized Tests

to decreasing Eurocentric bias that have been presented in the testing literature. The suggestions that follow move beyond critiques to a description of specific strategies for using standardized tests, including tests of intellectual abilities, mental status, neuropsychological functioning, and personality assessment, in a culturally responsive way. To illustrate some of these suggestions, a case example is described of an older Korean man brought in for an assessment by his adult daughter, who was concerned about his memory difficulties. One of the dilemmas in presenting information on culturally responsive testing involves the need for both general multicultural testing information and culture-specific information. General information regarding, for example, procedures such as testing the limits can provide guidance in situations in which testing conditions, norms, and procedures do not match the client’s cultural context. However, at the same time, because culture is so specific in its effects on emotions, cognitions, and behavior, clinicians also need to know and consider information that is highly specific to each client’s identity and context (information that could fill more than one book for each culture). In this chapter I have tried to strike a balance by providing the more general information with a few culture-specific examples to illustrate main points.

Testing Biases A recent survey of 74 clinical psychology doctoral programs found that the 10 most commonly used cognitive and psychological tests were as follows (Ready & Veague, 2014):   1. Wechsler Adult Intelligence Scale (Wechsler, 2011)   2. Wechsler Intelligence Scale for Children (Wechsler, 2003)   3. Minnesota Multiphasic Personality Inventory (MMPI; Butcher et al., 2001)   4. Beck Depression Inventory (A. T. Beck, Steer, & Brown, 1996)   5. Woodcock–Johnson Tests of Achievement (Schrank, Mather, & McGrew, 2014)   6. Beck Anxiety Inventory (A. T. Beck & Steer, 1993)   7. Wechsler Memory Scale (Wechsler, 2009b)   8. Personality Assessment Inventory (Morey, 2007)   9. Achenbach System of Empirically Based Assessment (Achenbach & Rescorla, 2001) 10. Wechsler Individual Achievement Test (Wechsler, 2009a). Because such tests typically originate from a European American worldview, they reflect the skills and abilities valued by European American

163

164

S o r ti n g T hi n gs Out

culture. Critics note that such tests are commonly developed by a panel of predominantly European American academic experts (an even narrower culture) and validated via correlation with similarly developed instruments. Those tests that consist of multiple choice or forced choice items impose a particular response set on the client, limiting a person’s responses to those judged as representing intellectual or psychological functioning from a European American perspective (Pace et al., 2006). For these reasons, it has been argued that standardized tests should not be used with members of ethnic and some other minority cultures. For example, in the now well-known case of Larry P. v. Riles (1979) in California, the court ruled that psychologists there could no longer use IQ tests to assess African American students for special education purposes. A 1986 settlement related to this ruling clarified that IQ tests include “any test which purports to be or is understood to be a standardized test of intelligence” (Leonard, Aung, Bronson, Dunn, & Thomas, 2013, p. 7); this includes the Wechsler scales, the Leiter International Performance Scale, the Stanford–Binet Intelligence Scales (Roid, 2003), the Cognitive Abilities Test (Lohman & Hagen, 2001), the K-ABC mental processing subtests, and many others. However, as my supervisor suggested, it is possible for some standardized tests to be used in ways that help individuals as well as groups, including minority groups for whom the tests were not originally developed. For example, since 1971, the U.S. Department of Education has used a standardized achievement test called the National Assessment of Educational Progress to assess the progress of students across the United States (Warne, Yoon, & Price, 2014). The results of this test have shown an achievement gap between White students and students of color—information that has been used by educators and policymakers to address and correct the factors contributing to these differing achievement scores. As a result, over time, “reading achievement has increased for White, Hispanic, and Black students,” and the achievement gap between White students and the latter two groups has dramatically narrowed (Warne et al., p. 578). Increased diversity within many nations and within the field of psychology has contributed to an explosion of cross-cultural research focusing on tests and testing practices that compares cultural groups within one country and between countries (Byrne et al., 2009). However, a recent survey found that major challenges persist, including a lack of appropriate norms, tests, and expert consultation and referral sources; limited training in multicultural testing competence; testing in a second language by assessors with limited second-language proficiency; an underrepresentation of ethnic minority psychologists; and a lack of consensus within the International Neuropsychological Society, the

Using Standardized Tests

National Academy of Neuropsychology, and the American Psychological Association (Elbulok-Charcape, Rabin, Spadaccini, & Barr, 2014). Similar problems exist regarding testing of members of nonethnic minority groups—for example, standardized assessments with people who have disabilities (Reesman et al., 2014). In an effort to address the biases that result from such limitations, researchers have used a number of approaches; one of the most common involves the use of restandardized instruments. Restandardization is a complex process that includes the collection of norms from samples that are more representative of the population at large. It can lead researchers to make changes in the original test, including deletion or modification of items that are found to be invalid across cultures and addition of items, scales, and subtests that are more cross-culturally valid. It offers the advantage of a starting point that has been well established with at least one group (i.e., the dominant culture), based on the belief that it is possible for an instrument developed for one culture to be relevant to another. However, restandardization does not address all potential forms of bias, particularly when tests are translated from English into another language. A second solution to biases in testing involves the establishment of separate norms for specific racial, ethnic, and language groups. However, with this approach, there are also problems, as described by Cagigas and Manly (2014). Although race and ethnicity hold powerful social meanings for minority and dominant group members, they say relatively little about a person’s intellectual abilities, personality, interests, and experiences. In reality, race and ethnicity may be less influential than other variables such as socioeconomic status, language proficiency, and the quality of a person’s education (e.g., minority members may receive poorer educations). In addition, the use of separate norms for specific groups raises questions regarding which norms to use with the growing number of multiracial and -cultural people. And, as is true of restandardization, separate group norms can still have the problem of test items that do not accurately assess cognitive functioning because the particular items do not capture how cognition is expressed within the cultural group (Cagigas & Manly, 2014, p. 143). For example, aphasia has been found to manifest differently in Spanish than in English (Ardila, 2001). A third solution to test biases is to start from scratch with the creation of new tests that emanate from underrepresented cultures themselves and that assess the skills and knowledge that are valued by those cultures (Lindsey, 1998). This approach includes the use of a test medium that is familiar to members of that culture rather than dominant cultural media such as paper and pencil, computer, blocks, and drawings. For example, in their development of a culture-specific measure of

165

166

S o r ti n g T hi n gs Out

intelligence in Zambian children, Kathuria and Serpell (1998) took into account prior research showing that Zambian children more accurately reproduced patterns using twisted strips of wire than did their English counterparts, whereas the English children surpassed their Zambian peers when reproducing the same patterns using paper and pencil. The authors developed the Panga Munthu Test, which involves showing children a model of a person, then asking them to build (panga) their own model of a person (munthu) using clay. The test was designed to tap into a set of skills that are actively cultivated in the daily lives of Zambian children, particularly those growing up in rural areas, where the authors noted that making models of people, animals, and domestic items such as pots and bowls may serve a developmental function comparable to the activity of drawing in Western societies. In addition to the assessment of intelligence, this third solution of developing culture-specific approaches has been used to develop instruments that assess affective constructs. Examples include the Hispanic Stress Inventory (Cervantes, Padilla, & Salgado de Snyder, 1990), the Vietnamese Depression Scale (Kinzie et al., 1982), the Adolescent Nervios Scale (Livanis & Tryon, 2010), some of the instruments in the Handbook of Tests and Measurements for Black Populations (R. L. Jones, 1996), and the Awareness of Connectedness Scale with Alaska Native people (Mohatt, Fok, Burket, Henry, & Allen, 2011). The Awareness of Connectedness Scale is unique in that it focuses on a construct—connectedness—that is highly valued in Native cultures. The development of this scale grew out of a grassroots desire to change the deficit focus on Native communities by looking at Alaska Native strengths, including pathways to sobriety. The scale assesses awareness of connectedness (rather than depression, anxiety, or similarly negative constructs), because connectedness to family, community, and the natural environment was identified by community members as a strong protective factor. But although this third approach of developing culture-specific tests may be ideal for some purposes, the resources required to develop such tests are scarce. A fourth approach to countering test bias involves the use of adjustments based on acculturation level. Cuéllar (2000) proposed using an index of correction for culture, derived by correlating a measure of acculturation with the criterion variable; an individual’s score on the test is then adjusted by this correction factor. However, as Cuéllar noted, standardized procedures for this approach have not been established, and perhaps more importantly, the conceptualization of acculturation as a linear process is now seen as much too simplistic (Miller et al., 2013). A fifth approach to test bias involves a more fluid, dynamic approach, in which specific strategies are added on to standardized procedures. These strategies are aimed at gathering “additional qualitative data about the examinee” that help with a fuller understanding of the

Using Standardized Tests

client’s test performance (Cuéllar, 1998, p. 76). They may include a number of procedures known as testing the limits (described later in this chapter) as well as information obtained through interviews, active listening, direct observation, informant reports, and culture-specific tests. It is important to note that with this approach, test selection is not arbitrary but rather involves a clear rationale for one’s choice of tests and procedures.

Assessment of Intellectual Abilities Too often, educational level and experience have been confounded with culture, resulting in the interpretation of lower test scores as evidence of lower intelligence in people of minority cultures. For example, some immigrants from rural areas of Latin America have limited literacy skills and are unfamiliar with the procedures and skills taught in school, negatively affecting their performance on U.S. tests of intellectual abilities (Sáez et al., 2014). However, many of these same individuals are able to survive and thrive in a foreign and often hostile new country, find a job, obtain a driver’s license, buy a home, and sponsor family members to come to the United States—activities that require exceptional flexibility and intelligence (Pérez-Arce & Puente, 1996). A relatively recent development in cognitive research involves the distinction between academic intelligence (used to solve academic questions and typically measured by quantitatively oriented instruments) and practical intelligence (used to solve day-to-day problems and performance in real-life situations; Sternberg & Grigorenko, 2004; Sternberg, Wagner, Williams, & Horvath, 1995). Whereas academic intelligence is facilitated by academic knowledge, practical intelligence increases with one’s tacit (silent) knowledge, or common sense. Tacit knowledge is action oriented (i.e., it involves knowing how to do things) and practical (in contrast to academic knowledge, which is often irrelevant to people’s daily lives), and it is usually acquired without the help of others, which means that it is often unspoken and poorly articulated (unlike academic knowledge, which is practiced and reinforced by the academic environment and the dominant culture; Sternberg et al., 1995). Research has shown that it is possible to develop measures of tacit knowledge relevant to job and school performance (Sternberg, Wagner, & Okagaki, 1993). Because the dominant culture values academic knowledge more, tacit knowledge and intelligence often go unrecognized and are even dismissed. Stephen O’Brien (2010), a principal working in an Alaska

167

168

S o r ti n g T hi n gs Out

Native village, described an example of this in his experience with two very intelligent high school seniors, one of them raised traditionally (presumably Native) and the other a member of the dominant culture who moved to the village with his parent who was a teacher there. One wintry night, the two boys were riding home together on their snow machines, and a blizzard forced them to stop and spend the night in the snow. The traditionally raised boy saved their lives with his survival (i.e., tacit) knowledge and skills. But as the principal knew, on the national high school exam, this boy scored a low 35%, whereas the boy who grew up in the dominant culture and probably would have perished without his friend scored 90%. Think about this: In assessing everyday life functioning 1. Write down the name of the most intelli(i.e., practical knowledge and skills) among gent person you know personally (i.e., not Aboriginal Australians, Davidson (1995) a historical figure). suggested that what is needed is an ideo2. Now write down the abilities, qualities, graphic approach in which the skills and knowledge used to assess a client’s funcor characteristics the person has that you tioning are those considered important for consider intelligent. that particular person and should be mea3. Do these abilities, qualities, or characterissured in relation to his or her baseline; thus, tics reflect your own values? what is assessed may vary with each client: Those who quibble with the notion that cognitive assessment can be ideographic may consider the possibility of a psychologist asking the question “Which of these two individuals is more schizophrenic?” When it comes to clinical diagnosis we are more concerned about whether, and the extent to which, both individuals are functional in everyday-life contexts rather than whether one individual has more psychopathology than the other. Why then are we not prepared to adopt an ideographic approach to cognitive assessment? (p. 32)

As Davidson suggested, there are times and situations in which an ideographic approach is ideal, particularly when prior test data are available for comparison. However, this is usually not the case in most outpatient settings. For example, neuropsychological assessments are commonly used to diagnose cognitive decline, but rarely does the individual being assessed have a prior evaluation available for comparison purposes; consequently, the person’s premorbid abilities must be estimated on the basis of comparison to population norms and tests of “crystallized” functions that tend to be fairly constant over time. In addition, sometimes it is necessary to compare an individual’s performance to a set of norms, for example, as my former supervisor suggested, with those of children who need to be able to perform at a certain level in the mainstream educational system to gain access to future opportunities. However, with both children and adults, an additional emphasis on practical

Using Standardized Tests

intelligence can be helpful in calling attention to a person’s strengths and avoiding the pathologization of difficulties. Along these lines, some psychologists and educators now emphasize the need to move beyond a focus on classification and rating (exemplified by the IQ score) to an approach that emphasizes understanding and guidance or description and prescription (Samuda, 1998, p. 173). This approach involves more than simply evaluating whether a person can perform a task or not. Rather, the focus is on understanding the reasons for an individual’s performance with the goal of providing recommendations for helping them. With regard to the assessment of intelligence, this approach may involve dropping the concept of IQ, which represents only a composite of one’s scores on a variety of tasks. Instead, the results of specific subtests are used to provide details about what the individual can do, cannot do, and might be able to do with help. This approach also involves considering cultural influences on a person’s test performance and functioning. For example, the emphasis of U.S.-based tests on speed of response and completion of tasks without help corresponds to the value European Americans place on cognitive quickness, personal independence, and competitiveness (Pérez-Arce & Puente, 1996). In contrast, many cultures place a higher value on careful thought, cautious behavior, and cooperation with others—values that may negatively affect performance on such tests but facilitate functioning in the person’s environment. Recognizing that European American instruments are commonly exported and used in many nonindustrialized countries, researchers continue to look for ways to increase the validity of intellectual assessment across diverse cultures around the world (Uzzell, Ponton, & Ardila, 2007). In many previously colonized countries (as well as in U.S. history), intellectual testing was used primarily for selection purposes, resulting in the unintentional and sometimes intentional elimination of poor and Indigenous people from the formal educational system. Unfortunately, even when such exclusion is not deliberate, it has the same result when standardized tests are used to determine advancement to the next grade or level. As Serpell and Haynes (2004) noted with regard to African countries, a more socially productive and less culturally invasive approach involves prioritizing the guidance function of assessment over the selection function—advice that is similar to the description and prescription emphasis mentioned earlier in this section. Wong, Strickland, Fletcher-Janzen, Ardila, and Reynolds (2000) made the following practical suggestions for cross-cultural neuro­ psychological assessments, which seem equally relevant to most testing situations: ❚❚

Make sure the testing environment is culturally responsive. Many of the suggestions in Chapter 7 regarding the physical milieu,

169

170

S o r ti n g T hi n gs Out

❚❚

❚❚

❚❚

❚❚

respectful behavior, informed consent, a systems orientation, consideration of trauma history, and so on are applicable. In addition, the tester should provide a thorough explanation of the testing procedures so that the client knows what to expect, keeping in mind that some clients will be uncomfortable with, unfamiliar with, and even fearful of testing. Always conduct a thorough clinical interview in conjunction with testing. A clinical interview allows the tester to obtain information regarding cultural influences on the client that may affect test scores. For example, level of education has been shown to have a significant effect on test scores, but it is important to understand not only the number of years of education but also the quality and nature of that education. Not all educational experiences or degrees are equal; for instance, African Americans are more likely to receive a less adequate education than are European Americans, even though they live in the same country (Nabors, Evans, & Strickland, 2000). Across countries and areas, the differences may be extreme. For example, consider the differences between the high school education of a 76-year-old Peruvian man who attended a rural one-teacher school and the high school education of a 76-year-old European who attended an urban, college-preparatory school. Among children, the differences may be similarly extreme—for example, the sixth-grade education of a child in an impoverished rural area versus the sixth-grade education of a Canadian child using present-day technology and knowledge resources. When writing the report, include information on limitations and potential cultural biases, including limitations of the translated version, the tester, your interpretations of the results, and testing conditions, including the use of an interpreter. In general, do not use translated versions of tests unless their validity and reliability have been clearly established, and do the research to be sure that no reliable and valid tests or translations exist. If you are unable to find or obtain such a test, state so in the report (i.e., never claim “none exists” unless you are sure there is none). In general, standardized tests (particularly intelligence and neuropsychological instruments) should be administered by a tester who speaks the client’s language (i.e., not with an interpreter), because understanding the nuances of a client’s language and subtle behaviors is key to accurate interpretations.

Regarding the suggestions that only reliable and valid translations be used and that the tester speak the client’s language fluently, Judd and DeBoard (2010) noted that requiring these conditions for all testing

Using Standardized Tests

situations raises an ethical dilemma. On one hand, psychologists must not discriminate against people on the basis of language abilities or disability, whereas on the other, we’re obligated not to practice beyond our expertise. But currently the reliability and validity of many English language tests have yet to be established, and there are not enough fluently bilingual psychologists to conduct culturally competent testing in a second language. There are no easy answers to such dilemmas—every case is unique. In addition to the suggestions offered in this chapter, one thing to keep in the forefront of your mind is the APA’s definition of evidence-based practice in psychology (EBPP). EBPP is the “integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (APA Presidential Task Force on Evidence-Based Practice, 2006, p. 273; emphasis added). With regard to interpreters, because there is no systematic training or certification for interpretation in testing, Judd (2014) also recommended a practical approach that allows either for an interpreter to be involved or for psychologists to use their second language, depending on the situation and assuming a high level of skill in such work (in Sáez & Judd, 2014). In judging one’s own competency in a second language, Judd made the important point that one must take into account the practice domain and the related level of risk of harm from possible language errors. For example, the possible harm from language errors when conducting a cognitive screening of a hospitalized inpatient would differ significantly from the possible harm caused by language errors in an intellectual disability evaluation for a court case that has the death penalty.

Mental Status Evaluations With clients of minority identities and experiences, it is important to recognize that the questions included in standardized mental status evaluations are not reliable indicators of every client’s functioning (Paniagua, 2005). For example, in a study of Native and non-Native elders in Manitoba, 45% of the Native elders had no formal schooling at all, and dates were considered less important as time markers than events such as the beginning of hunting and fishing season (Kaufert & Shapiro, 1996). The Native elders had difficulty naming the current and former prime ministers of Canada (questions on the adapted Mental Status Questionnaire developed by Kahn, Goldfarb, Pollack, & Peck, 1960). When the elders were asked what year they gained voting rights and when the community obtained electricity, relatively few could answer the first question, but a higher proportion answered the second correctly. The

171

172

S o r ti n g T hi n gs Out

authors attributed these findings to the cultural and ecological significance of electrification: The hydroelectric dam that produced electricity resulted in the flooding of hunting, trapping, and fishing territories, which in turn contributed to decreased self-sufficiency and a sense of alienation among community members. One of the most commonly used questionnaires for assessing mental status is the Mini-Mental State Examination (MMSE; Folstein & Folstein, 2010). The MMSE is only a screening test and has limitations in assessing individuals who have not had formal schooling in North America. For example, the test requires individuals to draw a geometric design to screen for visuospatial perceptual difficulties. But nonliterate people with normal visuospatial abilities may have difficulty with this task because they rarely use a pencil and may never have learned to draw. Basic questions concerning orientation may be misleading with clients who do not use watches or the Christian calendar or with those who do not follow a structured daily routine (Jewell, 1989). For Spanish-speaking people, the MMSE has been found to yield higher error rates on questions as simple as “Can you tell me the season?” and “What state are we in?” (Escobar et al., 1986). Many Spanish-speaking people come from tropical and subtropical areas, which have two seasons—rainy and dry—rather than the four seasons of temperate climates. And the term state can be interpreted to mean both a country and divisions within a country (Ardila, Rosselli, & Puente, 1994). Again, knowledge of clients’ cultural history and context is important in making accurate interpretations of their responses to standardized questions. Take the case of an older man from Mauritania (a predominantly Muslim country in western Africa) who was deeply religious, worked as a farmer, and came to the United States after his wife died to live with his son. The man subsequently had a stroke, and the psychologist needed to assess whether there had been a change in his cognitive functioning. Knowing that the man had 5 years of schooling, the psychologist could easily have underestimated his premorbid level of functioning on the basis of the European American view of 5 years as a low level of education. However, the psychologist did his homework and learned that this man came from an area where 5 years in a strict Koranic school (which emphasized memorization and recitation of the Koran) was highly respected, particularly for a man born in Mauritania in the 1930s. He also learned from the client’s son that in addition to being a farmer, the man was an imam whose advice was sought by many. This information helped the psychologist (with the help of the son and a cultural consultant) develop questions that more accurately assessed the man’s mental status.

Using Standardized Tests

As this example illustrates, with immigrant clients who are not educated in the European American school system, another strategy (in addition to learning about the cultural history) is to enlist the help of a family member or someone else who has an intimate knowledge of the client’s culture (i.e., a cultural consultant). In some cases, the cultural consultant may be another therapist who does not know the client, and no personal identifying information is needed or given. (For example, Washington State certifies ethnic minority mental health specialists, and therapists working in community mental health centers are required to review their minority clients with the appropriate specialist annually.) When a cultural consultant outside one’s agency is involved and the inclusion of identifying information (regarding the client) is unavoidable, then a signed release of information from the client will be necessary. If the cultural consultant is not a family member, involving the family member in addition to a cultural consultant is helpful, because family members can often provide personal details a cultural consultant doesn’t know. With clients who do not reference European American norms regarding time, Manson and Kleinman (1998) suggested the use of life history charts in which clients’ symptoms are tied to significant events rather than dates. The client chooses events, which may be important for either personal reasons (e.g., “the crying started the year my husband died”) or larger sociocultural reasons (e.g., “I remember first feeling that way just before the last harvest”). Visual symbols and pictures could be used to make the chart more comprehensible to nonliterate clients. The timeline described in Chapter 7 (with historical cultural events above the line and personal events beneath it) might be modified to incorporate these ideas. The assessment of mental status and cognitive functioning with people who have disabilities, particularly of sensory and motor functions, presents unique challenges, in part because most tests are designed for people who are not physically disabled, blind or visually impaired, or Deaf or hard of hearing. For example, people who are Deaf and hard of hearing may use a number of different forms of communication. Some individuals use American Sign Language (ASL), oral English, cued speech, or Signing Exact English (SEE); some have minimal or no language skills because of language deprivation; and some experience language difficulties attributable to a brain injury or mental illness (Wilson & Schild, 2014). Regarding the assessment of mental status with Deaf and hard of hearing clients, the use of written language in an emergency situation in which no interpreters are immediately available may seem like a reasonable approach but can lead to serious errors in clinical judgment. As Leigh, Corbett, Gutman, and Morere (1996) noted, because “ASL

173

174

S o r ti n g T hi n gs Out

grammatical structures differ from English, written communication by Deaf signers who are weak in English may appear aphasic or psychotic to the unsophisticated practitioner” (p. 367). Similarly, English-based tests of intellectual functioning may not accurately reflect the client’s cognitive abilities because they are confounded with the client’s English language abilities. Although it may seem logical to use standardized tests of nonverbal abilities, even this is complex; performance on so-called nonverbal tests of reasoning skills and problem solving may still be affected by a person’s verbal reasoning skills or lack of such skills. In addition, that the Deaf or hard of hearing client’s primary language is not English is not a reason not to assess his or her language abilities. One resource for testing Deaf and hard of hearing adults is the Psychometric Toolkit Project from the National Science Foundation-funded Visual Language and Visual Learning Center (http://vl2.gallaudet.edu; Morere & Allen, 2012). Tests for the assessment of children are still being developed and piloted, but Reesman et al. (2014) provided an excellent Test Review Scorecard of tests currently being used with children (Table 1, p. 103). The score card includes notations as to whether each of the 13 tests includes administration and accommodation guidance, score interpretation guidance, a described Deaf and hard of hearing group in the test manual, empirical reports in the literature, and empirical assessments of possible bias. An additional tool that has been used to assess memory and, to some extent, other cognitive functions with people who have auditory and visual disabilities is the Fuld Object Memory Evaluation (FOME; Fuld, 1977). The FOME has been used extensively with older adults, for example, as an effective screening tool for Alzheimer’s disease in older African Americans (Mast, Fitzgerald, Steinberg, MacNeill, & Lichtenberg, 2001) and in the evaluation of possible dementia in multiethnic and nonEnglish-speaking populations (J. C. Chung, 2009; Fuld, Muramoto, Blau, Westbrook, & Katzman, 1988; La Rue, Romero, Ortiz, Liang, & Lindeman, 1999; Yassuda et al., 2009). It may also be helpful in assessing culturally diverse children with severe cognitive impairments (Prigatano, Gupta, & Gale, 2007). The FOME involves asking the client to put his or her hand into a bag that contains 10 small objects (e.g., key, cup, ring) and then name the item he or she feels before pulling it out and looking at it (or if he or she cannot name it, pull it out, look at it, and then try to name it). The person names every object in this way and then, following a distraction task (e.g., word generation), is asked to name as many objects as he or she can remember. The tester tells the client the objects he or she forgot, and another distraction task is performed, followed by the request for another recall of the 10 items. This procedure is repeated five times

Using Standardized Tests

and yields a measure of the person’s learning and memory abilities over time with practice, along with verbal fluency measures from the distraction tasks. I have found this to be a fun test that lends itself to humorous comments later (e.g., at one nursing home where I carried the FOME bag with me, one older resident affectionately referred to me as “the bag lady”).

The Case of Mrs. Sok When standardized procedures and tests appear culturally inappropriate or irrelevant, it may be necessary to assess the client’s mental status and general functioning in less standardized ways. Toward this end, a place to start is a preassessment meeting with a cultural consultant with the goal of figuring out a way to assess the client’s mental status and general functioning as accurately as possible. Let’s return to the case of the Cambodian (Khmer) woman, Mrs. Sok, whom I described in Chapter 2. Ideally, before the preassessment meeting, the therapist would do her own independent research to educate herself about Mrs. Sok’s culture, including experiences common to nonliterate women of her generation (e.g., farm work, motherhood, forced labor in camps during the war, experiences of being a refugee and of immigrating). Then, during a preassessment meeting with a cultural consultant, the therapist could ask the cultural consultant questions to help her better understand the specific skills and knowledge valued in Khmer society over the course of Mrs. Sok’s life and what Mrs. Sok might be reasonably expected to know. The therapist might want to discuss specific standardized measures with the consultant—for example, with regard to Mrs. Sok, the Cambodian version of the Harvard Trauma Questionnaire (Harvard Program in Refugee Trauma, 2004), the FOME, and the Informant Questionnaire for Cognitive Decline in the Elderly (Jorm & Jacomb, 1989)—to obtain the consultant’s input on whether these tests might provide some useful information. Of course, in community mental health practice, a preassessment meeting with a cultural consultant is often not possible, because either such an individual is unavailable or the therapist doesn’t know the client’s culture in advance. In some cases, the preassessment meeting with the interpreter may be a place for obtaining this information. However, it’s important to remember that just because an interpreter speaks the client’s language doesn’t mean they share the same culture. The therapist might also use the standard mental status categories of orientation, attention, speech, language, short- and long-term

175

176

S o r ti n g T hi n gs Out

memory, visuospatial abilities, psychomotor functioning, and executive functions to generate additional relevant questions. However, the content of these questions would need to reflect Mrs. Sok’s sociocultural upbringing and environment rather than the therapist’s. In addition, the therapist should include categories of questions that reflect the client’s culture’s values (e.g., questions that assess good social judgment). She would need to keep in mind that speed (of cognitive processing and responses) would not be as important in Mrs. Sok’s culture of origin as in European American culture. The questions would also need to be framed so that the therapist can obtain confirmation of correct answers. Asking Mrs. Sok to recall her own or her children’s birthdates as a screen for long-term memory difficulties would not be particularly helpful if Mrs. Sok doesn’t know this information or knows it but not by the European calendar. Alternatively, asking the names of her father’s sisters might be one indication of her long-term memory ability, but only if this information could be confirmed by family members. Questions that would tap more commonly held knowledge and give some indication of Mrs. Sok’s longterm memory might address the name of the place in Cambodia where she was from, the name of the camp where she lived before immigrating, and the foods she used to prepare a particular Khmer meal and steps in preparing it. All of this information could be obtained from or confirmed by the cultural consultant and family members for accuracy. However, a significant problem with the approach of simply asking Mrs. Sok a set of questions (albeit a more culturally relevant set) involves the confounding of Mrs. Sok’s verbal abilities even in her own language (e.g., naming, fluency, word generation, verbal memory) with her functional abilities. That is, she may know and be able to describe how a traditional Khmer meal is prepared but be unable to carry out the specific tasks involved in preparing it. Or she might be unable to describe how to prepare the meal, despite the fact that she prepares such a meal daily. Or her description of the steps or components involved in making the meal might not follow the temporal sequence expected by a nonCambodian therapist and thus might sound disorganized or confused to the latter. The therapist would also need to consider whether Mrs. Sok was describing the meal preparation as she would to a non-Cambodian or to another Cambodian; for the latter, Mrs. Sok might assume a common knowledge base and thus leave out some details. For all of these reasons, a home visit might be helpful. A home visit could allow the therapist to directly observe Mrs. Sok’s activities and thus assess more fully how Mrs. Sok functions in her own environment. The therapist might still include some of the culturally relevant questions but would not depend solely on Mrs. Sok’s verbal answers as a screening for mental status. At the same time, given the unlikelihood

Using Standardized Tests

of a psychotherapist having the time to do a home visit, a more practical approach could be to obtain information about Mrs. Sok’s functioning in her environment from collateral sources (e.g., a case manager or family member), possibly using the Informant Questionnaire for Cognitive Decline in the Elderly. It is important to note that the case of Mrs. Sok lies at one end of a continuum regarding the relevance versus irrelevance of standardized tests. First and foremost, with any test, it’s important to be clear about why the test is being used—that is, what is the question one is trying to answer? A test is not in itself valid or invalid; rather, it depends on how it is used and its interpretation. As Judd notes, if I want to know whether a non-English-speaking person can drive a car or not, I could give him the driver’s licensing exam in his language to assess this (assuming that he knows enough English to read street signs relevant to performance of the driving portion), but I would not make any cultural allowances for the way he drives, just as the British are not allowed—even for “cultural reasons”—to drive on the left side of the road in the United States. In addition, I might use the written portion of the test with an asymmetric interpretation; that is, if he passes it, then I know that he has the cognitive abilities and knowledge base necessary to drive, but if he fails the written portion, I can’t assume that he doesn’t have the knowledge base or ability to drive, because there may be some other reason why he didn’t pass the written portion (e.g., severe anxiety that negatively affected his score, inaccurate translation of the written portion; T. Judd, personal communication, January 1, 2015). In summary, a flexible and dynamic approach to evaluation of mental status is more time consuming and does not offer the confidence level of a more standardized approach. However, with clients for whom standardized tests are culturally foreign, not using this approach may result in responses and information that are relatively meaningless. Exhibit 8.1 lists some additional behaviorally based questions that can be helpful when assessing a client’s mental status and intellectual functioning.

Neuropsychological Assessment Neuropsychological assessment typically involves the evaluation of specific cognitive functions, including attention, concentration, shortand long-term memory, language, reasoning, visuospatial perceptual and constructive abilities, psychomotor functioning, and “higher level” executive functions such as abstraction, awareness, insight, judgment, planning, and goal setting. Such assessments are performed for a variety

177

178

S o r ti n g T hi n gs Out

EXHIBIT 8.1 Behavioral Observations: Assessment Questions to Consider ❚❚  Does

the client provide a detailed personal history or become confused about the sequence of events being recounted? ❚❚  Might the client’s style of recounting personal history differ from what I would expect but still be normal in the client’s cultural context (e.g., in terms of the content or a style that is linear, circular, or some other form)? ❚❚  Does the client know information that most people of the client’s culture and age would know, and do I know enough about the client’s particular cohort to assess this? ❚❚  Does the client show communication problems such as word-finding difficulties or paraphasias (i.e., made-up or misused words), taking into account the client’s fluency level in English? ❚❚  Does the client show appropriate concern and knowledge about the client’s health problems, consistent with their educational background? ❚❚  How does the client interact with me (e.g., aggressive, hostile, disinterested, confused)? ❚❚  Might there be cross-cultural dynamics related to any of the ADDRESSING influences that account for this behavior? ❚❚  Might there be cultural explanations related to any of the ADDRESSING influences for a client’s behaviors or beliefs that appear to me to be unusual or abnormal?

of purposes. For example, a neuropsychological assessment may help in determining a client’s competence to handle his or her own finances, make life decisions, or parent effectively; in educating the family about what to expect of a family member who has experienced a head injury or stroke or who has been diagnosed with a disease that affects the person’s functioning; in determining eligibility for disability benefits; in determining a person’s competency to stand trial; and in providing recommendations for treatment planning, rehabilitation strategies, educational approaches, and placement issues (e.g., how independently the person can live). Neuropsychological assessment may also be used to clarify whether an individual is experiencing impairments in cognition, behavior, emotion, or personality related to a psychological problem such as depression or to some form of brain dysfunction caused by head injury, exposure to toxins, substance abuse, cerebrovascular disease, Alzheimer’s disease, or other disease (Parsons & Hammeke, 2014). Along with its diagnostic and descriptive functions, neuropsychological assessment can also be used to track the progression of a person’s functioning over time. At present, when neuropsychological researchers and practitioners consider the influence of culture, they often focus solely on ethnicity or limited English proficiency. Related variables such as education and acculturation are conceptualized as independent variables with the goal of controlling for these influences so as to improve the test’s sensitivity and specificity (Cagigas & Manly, 2014). As a result, “the dialogue is fre-

Using Standardized Tests

quently framed as having to do with the impact of culture and language on cognitive testing and is thus conceptualized as being relevant only to special populations” (Cagigas & Manly, 2014, p. 132). Cagigas and Manly (2014) proposed a much broader and more realistic approach, referred to as cultural neuropsychology, that—like the ADDRESSING framework—recognizes that no individual’s behavior and functioning can be understood without a thorough understanding of his or her cultural identity and context. Unfortunately, this broader approach is not yet the norm, and the available research regarding culture focuses mainly on ethnic and language influences. Ethnic differences on neuropsychological tests have been documented and may result in the overidentification of cognitive impairments in members of ethnic minority groups (Mungas, Reed, Haan, & González, 2005). Biases have been found on nonverbal as well as verbal tests. For example, the Color Trails Test (Maj et al., 1993) was designed as a culture-free analog of the Trail Making Test (Reitan, 1958; see also Kelland, Lewis, & Gurevitch, 1992), but although the two tests were highly correlated for English speakers (indicating that they measure the same ability), they were not highly correlated for a group of Hong Kong Chinese people, suggesting that in the Hong Kong Chinese group the two tests were measuring different abilities (Lee, Cheung, Chan, & Chan, as cited in Chan, Shum, & Cheung, 2003; see Chan et al., 2003, for a review of neuropsychological tests in Asian countries). In clinical practice, the most common approach to neuropsychological assessment is called the hypothesis-testing approach, and fortunately it fits well with the cultural neuropsychology orientation. That is, one begins with an initial set of hypotheses based on the referral question, the client’s history, and one’s initial observations, then chooses specific tests that will best assess that particular client’s capabilities. As testing progresses, the psychologist refines these general hypotheses into more specific ones. Gradually, the “successive elimination of alternative diagnostic possibilities” leads to a relatively conclusive diagnosis (Lezak, 1995, p. 112). Assuming that one has obtained cultural and personal histories for the client, the strategy known as testing the limits can be helpful in interpreting the results of neuropsychological tests and measures of mental status and intellectual functioning. Testing the limits of standardized tests involves exploring, beyond standard administrative procedures, the possible reasons for a client’s poor performance. Because this exploration is done after the standardized test procedure for an item, testing the limits does not affect standardized scores (Lezak, 1995). In addition, testing the limits offers the opportunity to move beyond the constraints of the test and, because the tester may ask clients why they think they missed an item, can also facilitate discussion and rapport with clients (Morris, 2000).

179

180

S o r ti n g T hi n gs Out

A specific example is the Picture Completion subtest, now an ancillary subtest of the Wechsler Adult Intelligence Scale. This subtest asks the client to name the important part missing from a picture for a series of different scenes within time limits. If a client is unable to provide correct answers to the items on this subtest and the tester simply accepts the client’s incorrect answers as an assessment of the client’s ability, the tester may be missing a great deal of potentially valuable information. If, however, the tester recognizes that a score does not indicate how or why the person had difficulty with this task, the tester could gain more information in several ways, as described in the paragraphs that follow. Note that retesting within a few months may preclude the use of some of these strategies, but the degree to which a practice effect occurs depends on the particular test. For example, retesting may have little effect on tests of attention, more so on tests of memory, and profound effects on tests of executive functions that involve a specific solution or strategy. Following the standard administration, the tester may return to each item and ask the client to look at the picture again and describe in detail what he or she sees. The underlying hypothesis at this point is that the client is capable of seeing the missing piece but simply missed it when asked. To assess the influence of time pressure, the tester can ask the client to try to answer each item again, but this time without time limits. Time limits may contribute to the underestimation of a person’s true abilities, particularly in the case of people who require additional time because of age, disability, language differences, cultural factors, chronic illness, sensory or motor impairment, or simply nervousness (Lezak, 1995). When these factors are present, testing without time limits is important to give a fuller picture of the client’s capabilities. Granted, there are no normative data with which to compare time-free responses on certain items. However, the point is to find out whether or not the individual can perform the task at all. If the person can, it is then necessary to figure out whether timelimited performance of the skills is important. For example, in the case of an older woman who can do Picture Completion only without time limits, does her performance represent a deficit that could be dangerous in an independent living situation? Or, given that she experiences little time pressure in her home environment and does not drive, is the issue of time relatively unimportant in assessing her visuospatial abilities? Even if she can perform a task requiring visuospatial abilities with extra help, if the help is unavailable or it takes so much time that it’s not functional, then the answer might be that yes, she is capable of doing the task but unlikely to have the support she needs to do so. In a second strategy, the tester may inform the client of the correct answer and ask if he can now see the missing piece. (This strategy

Using Standardized Tests

should not be used if the person needs to be retested within the next year.) A look of surprised recognition is often apparent if the person then sees it. The psychologist may then ask the client to point to the missing piece to confirm that he does see it. Third, the tester may ask the client directly if she has an idea why she had difficulty with a particular item on the subtest. The answer may be as simple as fatigue, disinterest, preoccupation with a problem, or physical pain that distracted the client. Similarly, a misunderstanding of the directions or impaired vision or hearing can account for poor performance. For example, as an intern in a Department of Veterans Affairs nursing home, I used the Geriatric Depression Scale (Sheikh & Yesavage, 1986; Yesavage et al., 1982–1983) in assessing some of the older male residents. When the first question asked to a couple of older men, “Are you basically satisfied with your life?” elicited the response “Oh, yeah, she’s been a pretty good old gal,” I learned to find out before testing whether a person had hearing difficulties. Fourth, with individuals who speak English as a second language, Cuéllar (1998) suggested that after administering the failed item in English, a bilingual psychologist may ask the client the same item in the client’s native language. This questioning can indicate whether or not the problem is related to language comprehension. Similarly, on a broader scale, when assessing a bilingual child’s ability to succeed in an English-language educational system, assessing the child in both languages provides the required data but also offers a fuller understanding of the child’s real needs and strengths (Geisinger, 1992, p. 33). Again, though, it is important to note that assessing bilingual people is a highly complex endeavor (see Judd, 2014, for a description of considerations in testing bilingual people). As the field of neuropsychology continues to develop, resources for cross-cultural learning include the Hispanic Neuropsychological Society (HNS), the International Neuropsychological Society, the International Journal of Neuropsychology, the International Test Commission guidelines for adapting tests in diverse languages (www.intestcom.org), and guidelines for the neuropsychological evaluation of Hispanic–Latino people published by the HNS and the National Academy of Neuropsychology (Judd et al., 2009).

Assessment of Personality Personality is commonly defined as an enduring pattern of inner experience and behavior and a personality disorder as a pattern that “deviates markedly from the expectations of the individual’s culture, is pervasive

181

182

S o r ti n g T hi n gs Out

and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment” (American Psychiatric Association, 2013, p. 645). Although these definitions may sound so general as to be universal, the idea of the self as an “autonomous individual, free to choose and mind his own business,” cut off from the interdependent whole, is not shared by all cultures (Shweder & Bourne, 1989, p. 132). Personality is a European American construct, and its measurement involves many cultural assumptions, beginning with the ideas that the concept of a personality disorder is universally useful, that it consists of behaviors and beliefs that would be considered universally disturbing, and that these behaviors and beliefs can be quantified or scored. There are some situations in which the assumptions embedded in standardized personality tests would differ so much from a client’s cultural context and being that it raises the question of whether such tests would provide any useful information. Conversely, there are other situations in which cultural differences exist but standardized testing may be useful in answering a specific referral question.

MINNESOTA MULTIPHASIC PERSONALITY INVENTORY The most commonly used personality assessment is the Minnesota Multiphasic Personality Inventory and its revision, the MMPI–2 (Butcher et al., 2001). A related version for adolescents, the MMPI–A, also exists (Butcher et al., 1992; Graham, Archer, Tellegen, Ben-Porath, & Kaemmer, 2006). The original MMPI was based on a standardization sample of 724 rural White friends and relatives of patients at the University of Minnesota hospitals (Graham, 1990). In response to criticisms of the limitations of such a culturally homogeneous group, the MMPI was restandardized with new norms to include samples of African, Asian, Latino, and Native Americans representative of the U.S. population in the 1980 census. Subsequently, controversial changes have been made, including publication of the MMPI–2 Restructured Form (MMPI–2–RF) in 2008, which used the Restructured Clinical (RC) Scales in place of the MMPI–2 well-validated Clinical Scales (Ben-Porath & Tellegen, 2008). The RC scales are not just alternative or shortened forms of the MMPI–2 Clinical Scales but rather represent new measures that require their own empirical validation (see Butcher & Williams, 2009, for more on the problems with the RC scales and MMPI–2–RF). The MMPI and MMPI–2 have been translated into many languages, and extensive research has been done to investigate their applicability with diverse ethnic and national groups (see Butcher, Mosch, Tsai, & Nezami, 2006, for an overview). Because of the scope and variability of this research, it is difficult to make any broad generalizations about

Using Standardized Tests

its validity and reliability across cultures (i.e., because validity and reliability vary depending on the cultural group). For example, in a meta-analysis of 25 comparative MMPI and MMPI–2 studies of African Americans, European Americans, and Latino Americans, the researchers concluded that neither instrument unfairly portrays African or Latino Americans as pathological, although they also noted the need for further research on the MMPI–2 (Hall, Bansal, & Lopez, 1999). In contrast, a more recent study of African American and White chemical dependency inpatients found “consistent group differences in prediction of select psychiatric diagnoses by race” (Monnot, Quirk, Hoerger, & Brewer, 2009, pp. 149–150). A study of the MMPI–2 with members of two American Indian tribes found the MMPI–2 to inaccurately pathologize Indigenous worldviews, knowledge, beliefs, and behavior; this study was unique in that it involved tribal elders in an investigation of the test’s cultural relevance (Hill, Pace, & Robbins, 2010). Considering dominant cultural influences on the development of the original test, on procedural norms in personality research, on the definition of the construct of personality, and on definitions of ethnic groups that lump together people of diverse smaller cultures and languages (and confound race with culture), extra caution is advised in the use of the MMPI–2 with members of ethnic minority cultures, including individuals from countries other than the United States. The following paragraphs provide a few suggestions for using the MMPI–2 in culturally appropriate ways. One of the most important strategies involves considering the client’s symptoms and test scores in his or her “bio-psycho-social-culturalhistorical-political-linguistic context” (Pace et al., 2006, p. 321). The interpretation of clients’ scores from this holistic knowledge base and point of view opens up a much wider range of hypotheses, which in turn facilitates more accurate interpretations. Along these lines, Garrido and Velasquez (2006) provided a list of culture-specific hypotheses for therapists to consider regarding Latino clients’ scale scores. One example involves the L (Lie) score, which is normally associated with test resistance, a lack of insight, an unrealistically positive self-presentation, or a lack of sophistication in creating a personal impression. The researchers noted that the L score tends to be higher in Latino than in non-Latino populations. When interpreting these higher L scores, it is important to consider the culturally sanctioned Latino tendency to present oneself positively in structured inquiries with non-Latinos and to protect one’s family’s reputation. The psychologist should also consider the extent of acculturation, because less acculturation is associated with higher L scores (Garrido & Velasquez, 2006, p. 499). Similarly, Pace et al. (2006) offered culturally relevant hypotheses for American Indians’ elevated scores on several scales. For example, with regard to members of an Eastern Woodland Oklahoma tribe and a

183

184

S o r ti n g T hi n gs Out

Southwest Plains Oklahoma tribe, the researchers noted that elevated scores on Scale 8 (Schizophrenia) could reflect “the alternative epistemological perspectives and religious beliefs, which constitute ‘nonordinary and ecstatic’ world-views as reflected in the Native American Church and Stomp Dance” (Pace et al., 2006, p. 329; see also Hill et al., 2010). These are just two examples; Garrido and Velasquez (2006) and Hill and colleagues (2010) provided many more culturally related hypotheses regarding scores on other MMPI–2 scales. (Also see Butcher, Cabiya, Lucio, and Garrido, 2007, for more on using the MMPI–2 with Hispanic clients.) When considering use of a translated version, it is important to remember that there are significant linguistic and cultural differences among people who speak the same language (Rogler, 1999). For example, whereas one Spanish version may be appropriate for a client of Mexican origin, it could yield inaccurate results for a Spanish speaker from Argentina (Nichols, Padilla, & Gomez-Maqueo, 2000). (For a list of translated versions and a discussion of methodological issues including several types of equivalence, see Butcher et al., 2006.) Finally, it is important to keep in mind that clients’ reactions to taking such a test may preclude its use. For example, I once worked on a geropsychiatry hospital unit where elders who had physical and mental health problems were routinely asked to complete the MMPI–2. Help was often given in the form of reading each item to each client, but still, more than 500 true–false questions were overwhelming to some individuals, as it might be to someone who speaks English as a second language, does not like to read, or perceives taking a test as too impersonal.

PERFORMANCE-BASED (PROJECTIVE) TESTS The term performance-based is used in place of projective for certain personality tests because, unlike self-report paper-and-pencil approaches, these tests require the individual to “perform a defined activity with an examiner (i.e., generate a story or identify images),” and there is evidence that such tests do not depend on or require projections but rather reflect a person’s “perceptions, classifications, and cognitive–emotional templates or internal representations” (Kubiszyn et al., 2000, p. 120). Hence, as Kubiszyn et al. (2000) noted, the descriptor performance-based is more accurate than projective. Most of the widely used performancebased personality tests started from a European American cultural base and, as such, are also susceptible to cultural biases (Costantino, Flanagan, & Malgady, 1995; Cuéllar, 1998). For example, the Thematic Apperception Test (TAT; Murray, 1943) consists of pictures that clients are asked to describe; clients’ responses are considered indicative of their beliefs and views. But the original TAT pictures were of characters and situations relevant primarily to

Using Standardized Tests

European American culture. Over the years, the TAT pictures have been redrawn to depict people and situations of diverse cultures (see Costantino & Malgady, 2000, for an overview). However, as “optimism concerning TAT reliability and validity research has waned” (Dana, 1999, p. 178), the use of the TAT has declined significantly both in doctoral training programs and in general assessment practice (Ready & Veague, 2014). The Tell-Me-a-Story (TEMAS) test (Costantino, Malgady, & Rogler, 1988; Costantino, Malgady, & Vasquez, 1981) “was developed to revive the TAT technique for culturally and linguistically diverse children and adolescents” (Costantino & Malgady, 2000, p. 484). Research using the TEMAS suggests that the cultural identity of characters does make a difference in clients’ responses (Suzuki & Kugler, 1995). The TEMAS has been described as the only “adequately validated multicultural thematic test employing cards to depict Hispanic or Black, Asian, and White adolescents” (Dana, 1998, p. 6) and has been described as an improvement over existing personality measures used by school psychologists (Flanagan & Di Giuseppe, 1999). The Rorschach Comprehensive System (RCS; Exner, 1993) avoids the problem of respondents’ perceptions of characters’ identities by using inkblots. But although one might hypothesize that inkblots would be less culturally laden, the interpretation of clients’ associations to these stimuli is especially susceptible to misunderstanding by clinicians whose cultures differ from their clients’. For example, the dark areas of the color cards have traditionally been associated with death and mourning, but in India, “white, not black, is the color associated with mourning and death” (Jewell, 1989, p. 306). An increasing number of normative studies of the RCS internationally have found significant variations in local norms compared with norms in the United States (see Andronikof-Sanglade, 2000; Ephraim, 2000; Pires, 2000; Vinet, 2000). Controversy over the clinical usefulness of the RCS in general led to a special section on the RCS in the journal Psychological Assessment that included reviews of the literature by experts on both sides of the debate (C. Reynolds, 2001). In a summary article, Meyer and Archer (2001) concluded that the literature “does not lead to an expectation of ethnic bias” (p. 494) but added that cross-cultural applications are an understudied issue and that research regarding differential validity across large ethnic examples would be valuable. However, as with the TAT, a recent survey found use of the Rorschach to be declining (Ready & Veague, 2014). (See Dana, 2000, for a more detailed critique of the cultural influences on the RCS.) In summary, the tests described in this chapter are only examples; there are other tests and other domains that may be helpful to consider, depending on the referral question, the client, and the cultural context. For example, the Child Behavior Checklist (Achenbach, 1991) has been

185

186

S o r ti n g T hi n gs Out

validated for use with children across many cultures, and in response to the elimination of IQ tests in California’s school system, California school psychologists have adopted a number of alternatives (see review by the Cultural and Linguistic Diversity Committee of the California Association of School Psychologists; Leonard et al., 2013). And with regard to adults, the Cross-Cultural Personality Assessment Inventory offers a combined emic (i.e., culture-specific) and etic (i.e., crosscultural) approach to the study of personality and culture (Cheung, Cheung, & Fan, 2013).

The Case of Mr. Kim The case of an older Korean man who was brought to a psychologist by his daughter illustrates the importance of a flexible, dynamic, hypothesistesting approach to assessment and includes some of the suggestions described in this chapter. The psychologist was trained in standardized procedures; however, she recognized this assessment as one requiring a more dynamic approach. Because she was able to make adaptations during the process, she was able to successfully assess Mr. Kim’s and his family’s needs. The case description includes the key questions in Exhibit 8.1, which she used in assessing this client’s mental status in the moment. Mr. Kim, a 70-year-old, high school educated, second-generation Korean American man, was referred by his physician to a 37-year-old biracial (Latina/Filipina) psychologist, Dr. Aquino, for an assessment of “memory loss.” Dr. Aquino had no other prior information about Mr. Kim until, on her way to meet him in the waiting room, she was handed a demographic form that indicated his age, ethnicity, health status, and presenting problem. Dr. Aquino warmly greeted Mr. Kim and his daughter Insook who was accompanying him, escorted them to her office, and offered them tea and coffee. She had noticed from Mr. Kim’s address on the demographic sheet that he lived in an area with a beautiful park she knew well, so she chatted briefly with the two about her memories of visiting this park, the ducks, and the miniature boats she liked to watch as a child. As she did so, she noticed that Insook smiled and gave her direct eye contact, whereas Mr. Kim was polite but his affect was moderately flat and he did not give her as much eye contact. Dr. Aquino sensed some tension from both of them. Dr. Aquino began the assessment by initially directing her attention to Mr. Kim and asking how she might be of help. He indicated that he had come in because Insook wanted him to, at which point

Using Standardized Tests

Insook said—with apparent discomfort—that she was worried about him because since her mother had died 3 years previously, he was still very sad, was losing weight, and seemed disinterested in things. At this point, Dr. Aquino felt herself drawn toward asking Insook questions instead of Mr. Kim, because Insook felt similar to her in assertiveness, professionalism, and age and because Insook engaged easily in the formal question-and-answer format that made Dr. Aquino’s assessment easier to complete. However, recognizing that asking Insook questions about Mr. Kim in front of him would be offensive, Dr. Aquino refrained from doing what was most convenient and comfortable for her and instead asked Mr. Kim if he would be willing to meet alone with her for about half an hour so that she could talk with him about his health. So as not to offend Insook, she gave Insook eye contact as well and added, “if you don’t mind, and then I will meet alone with you afterward.” Both Mr. Kim and Insook agreed, and Insook went to the waiting room. Dr. Aquino then turned her attention to Mr. Kim and asked whether he perceived any problem with his health, including how he had been feeling. Mr. Kim said that he had some aches and pains, was slower than he used to be, and sometimes forgot things, but he attributed these to old age. Dr. Aquino agreed with Mr. Kim that yes, these things can happen with age, but sometimes a person can have some aches and pains and be a little more forgetful, and the changes are actually attributable to something that can be fixed. She gave the example of an older man she had once seen who was having some memory problems, and an assessment found that he had an infection, and when they treated the infection, his memory improved. She said that if he would be willing to talk with her and answer some questions, she would try to figure out if there were any things that might help him feel better. He indicated that he would be willing to go ahead with the assessment, although his affect did not change. At this point, Dr. Aquino wanted to obtain a quick sense of Mr. Kim’s cognitive functioning, and on the basis of his second-generation status and high school education, she judged that the Mini-Mental State Examination would be appropriate and useful as a screening. However, she was aware that moving too quickly into an assessment of his cognitive functioning could be threatening, so instead she began with questions about his medical history. In response to her questions, Mr. Kim reported that he was on a medication for high blood pressure and another for lowering his cholesterol (he didn’t know the medication names), that he did not drink alcohol or use any other drugs, and that he had no major medical problems (and the physician referral information confirmed this). Dr. Aquino then linked Mr. Kim’s medical history to his family’s medical history, augmented by a genogram of his family, which she

187

188

S o r ti n g T hi n gs Out

drew on a whiteboard they both could see. This activity also gave them something to look at, decreasing the eye contact that Dr. Aquino sensed was uncomfortable for Mr. Kim. Although Mr. Kim did not volunteer information, he seemed to become a little more comfortable with her questions and told her some of what he knew about the health and social histories of extended family members, including his maternal and paternal grandparents, all of whom died in Korea. Dr. Aquino also asked about his family’s religion, which he described as Buddhist with Confucian teachings. She then asked a few questions about his work history and social situation. He told her that he had run a restaurant for 30 years, which took up all of his time until he turned 65 and sold the restaurant. Since then, he said, he had spent most of his time at home, took a walk every day, cooked his own breakfast and lunch, read the newspaper, watched TV, and went to the Asian community center (where they had a program for older adults), although he admitted he had been to the center less frequently in the last few months. As Mr. Kim spoke, the psychologist realized that she had inadvertently assumed that he was more impaired than he was. Rather than ask him directly about his mental status, she watched for signs of cognitive dysfunction while they completed the genogram and asked herself the following questions: ❚❚

❚❚

❚❚

❚❚

Does Mr. Kim provide a detailed personal history, or does he become confused about the sequence of events being recounted? He provided good details for past events but couldn’t recall some dates that the psychologist considered important—for example, the year he was married. However, Dr. Aquino thought that this might not be unusual for an older Korean man who had been married for over 30 years and widowed for 3. Might Mr. Kim’s style of recounting his history differ from what I would expect but still be normal in his cultural context (e.g., in terms of the content or a style that is linear, circular, or some other form)? His style of recounting events was relatively chronological, although Dr. Aquino recognized that the order was created mostly by the order of her questions. None of his responses expressed feelings; rather, they were more focused on places, events, and experiences, but she hypothesized that this was normal for an older Korean American man. Does Mr. Kim know information that most Korean American men his age would know, and do I know enough about his particular cohort to assess this? Dr. Aquino did not and recognized her need for consultation. Does Mr. Kim show communication problems such as word-finding difficulties or paraphasias (i.e., made-up or misused words), taking into account his fluency level in English? He spoke English fluently with

Using Standardized Tests

❚❚

❚❚

❚❚

a slight accent and occasional grammatical errors that appeared congruent with his educational level. Is Mr. Kim’s understanding of his health problems consistent with his educational background? It was. Although he knew the reasons for his medications, he did not know the specific names, but Dr. Aquino knew this was not uncommon. How does Mr. Kim interact with me, and might there be a cross-cultural dynamic that accounts for his reaction? Dr. Aquino realized that Mr. Kim’s reserved manner might be related to any combination of his Buddhist, Confucian, or Korean heritage; his older age; and his gender in response to her identity as a younger Latina/ Filipina woman. Might there be cultural explanations for any behaviors or beliefs that appear to be unusual or abnormal—that is, explanations related to Mr. Kim’s age or generation, possible disability, religion or spiritual orientation, or any of the other ADDRESSING influences? Dr. Aquino correctly interpreted his infrequent eye contact as being the result of embarrassment about the situation, and she also hypothesized that it could be partially cultural and partially about having to interact with a young woman. Otherwise, there were no beliefs or behaviors that she considered unusual.

After about 30 minutes, Dr. Aquino asked Mr. Kim if he would be willing to answer a few questions to test his memory. She said that some of the questions were very easy and some more difficult but that she had to ask the whole range of questions to get a feeling for whether there was a problem or not. He agreed, and she administered the MMSE. Mr. Kim was able to answer all of the questions correctly, except that although he knew the day of the week, month, and year, he did not know the exact date, and he could not recall one of the three short-term memory items after 5 minutes. To understand whether the item had been stored in his memory, Dr. Aquino added an additional question (i.e., she tested the limits) by naming three objects (only one of which was one of the original items) and asked which of the three was the one she had asked him to remember. He chose the correct object, which told her that he had paid attention and stored the information but had difficulty spontaneously recalling it. Dr. Aquino was aware that spontaneous recall (i.e., remembering without any cues) is more difficult than recognition recall (as in a multiple choice test) and that mild spontaneous recall errors commonly occur with depression in older adults. Following the interview with Mr. Kim, Dr. Aquino walked with him to the waiting area and offered him another cup of tea. She then met with Insook, who spoke more freely about the problems she had observed in her father—increased irritability, poor appetite, mild memory

189

190

S o r ti n g T hi n gs Out

problems such as losing his keys and leaving the stove on, and less interest in going to the Asian community center. She told Dr. Aquino that she hadn’t wanted to list these problems in front of her father, although he seemed to be aware of them at home. She also confirmed that her father did not have any serious physical problems and did not drink alcohol. In a brief closing period with Mr. Kim and Insook together, the psychologist summarized her conceptualization of the situation by saying that she could see that they had both been through some difficult times with the loss of Mrs. Kim and, for Mr. Kim, with the challenges and changes that come with growing older such as retirement, loss of family members and friends, different activities, physical changes, and so on. She added that she could see they both cared for each other and that she was glad they came in because she thought there might be some things she could help with. Speaking directly to Mr. Kim, she told him that she was concerned that he might be a little depressed and that this would be understandable, given the loss of his wife and other changes he had experienced in recent years. However, before making any specific recommendations regarding what to do about this, she said she would like to consult with a colleague and then get back to them if they would be willing to return. Both agreed and seemed less tense as they said good-bye. The success of this assessment was in jeopardy from the beginning, because the identified patient, Mr. Kim, came in only because his daughter and his physician wanted him to. However, Dr. Aquino’s flexible, culturally responsive approach engaged both Mr. Kim and Insook, beginning with the offer of tea and coffee and social conversation to put them at ease. Her decision to meet separately with Mr. Kim and Insook, in that order, was a good one, as it demonstrated respect and allowed each to respond without concern for the other’s reaction (see B. L. C. Kim, 1996, regarding therapists’ demonstration of respect with Korean families). When she met alone with Mr. Kim, she immediately recognized her incorrect assumption that he was too impaired to speak for himself. She let go of the internal demand to find out certain pieces of information in the way in which she had been trained, through direct test-type questions and as quickly as possible. Instead, she evaluated Mr. Kim through the collaborative task of completing the genogram and observed his responses to less direct questions; then once Mr. Kim appeared to be a little more at ease, she was able to use the MMSE to further assess his cognitive functioning. Through her observations and her own internal hypothesizing and questioning, she developed a working hypothesis that Mr. Kim’s cognitive deficits and decreased interest in social activities were attributable to depression; she wasn’t sure whether his flattened affect was culturally normal or related to depression (although later she would learn

Using Standardized Tests

that emotional restraint is often seen as a sign of maturity and problems are considered a fact of life among people of Korean and Buddhist cultures; W. J. Kim, Kim, & Rue, 1997). She knew that depression, particularly in elders, can cause mild cognitive deficits that are reversible if the depression is successfully treated (American Psychological Association, 2004), but because she realized her need for more culturally related information, she considered this diagnosis tentative until she could do her own research and consult with a Korean American clinician.

Conclusion Standardized tests can be enormously helpful in clarifying a person’s strengths, abilities, challenges, problems, behavioral and social tendencies, and needs. However, if used without a solid understanding of the client’s cultural identity and context, standardized instruments hold the potential for causing damage. In the not-too-distant past, people of ethnic and other minority identities were seriously hurt by the misuse of such tests. Thus, it is essential that psychologists be aware of the cultural biases embedded in standardized tests of intelligence, mental status, neuropsychological functioning, and personality. This awareness, combined with specific steps aimed at obtaining culturally relevant information, can significantly improve the accuracy and usefulness of one’s diagnosis—the topic of Chapter 9.

Practice: Deciding Whether to Use Tests Jorge (pronounced hor-hey) is a 35-year-old single man from El Salvador who is referred to you by the Office of Vocational Rehabilitation (OVR) for an assessment of his mental health and cognitive abilities; the OVR specifically wants to know if he is capable of benefiting from a 2-year vocational training program in refrigerator repair. The referral information states that Jorge was hit by a car when he was 8 years old, which resulted in the amputation of his right hand (he was left-hand dominant even before the accident) and some hearing impairment in his right ear. The referral further states that he dropped out of high school at 16 and worked at odd jobs until coming to the United States with his family at the age of 32.

191

192

S o r ti n g T hi n gs Out

1. What information would you need to learn before seeing Jorge? 2. What actions would you need to take before seeing Jorge? 3. What factors would you take into account when considering whether to use any standardized tests to assess his psychological and cognitive functioning?

Key Ideas

  1. Major challenges persist regarding research on culturally responsive tests and testing practices, including a lack of appropriate norms, tests, and expert consultation and referral sources; limited training in multicultural testing competence; testing in a second language by assessors with limited second-language proficiency; underrepresentation of ethnic minority psychologists; and lack of consensus within the International Neuropsychological Society, the National Academy of Neuropsychology, and the American Psychological Association.   2. Too often, educational level and experience have been confounded with culture, resulting in the interpretation of lower test scores as evidence of lower intelligence in people of minority cultures.  3. Tacit knowledge is action oriented (i.e., it involves knowing how to do things), practical (in contrast to academic knowledge, which is often irrelevant to people’s daily lives), and usually acquired without the help of others, which means that it is often unspoken and poorly articulated (unlike academic knowledge, which is practiced and reinforced by the academic environment and the dominant culture).   4. Composite test scores (e.g., IQ) say little about a client’s functioning, whereas focusing on specific measures of strengths and weaknesses is more informative and useful.   5. During an assessment, the therapist must make sure that the testing environment is culturally responsive, with attention to the physical milieu, respectful behavior, informed consent, a systems orientation, consideration of trauma history, and a thorough explanation of the testing procedures.   6. The therapist must always conduct a thorough clinical interview in conjunction with testing.   7. In general, translated versions of tests should not be used unless their validity and reliability have been well established, and the tester should speak the client’s language.  8. Recognizing the ethical dilemma that can occur regarding translated tests and therapist language ability, guidance is provided by the American Psychological Association’s definition of evidence-based practice as the “integration of the best available

Using Standardized Tests

research with clinical expertise in the context of patient characteristics, culture, and preferences” (emphasis added). The final report must always describe limitations and potential cultural biases.   9. The flexible, dynamic, hypothesis-testing approach involves choosing tests that match the referral question and the client’s characteristics, culture, and preferences; exploring possible reasons for a client’s test performance; and following standardized procedures, using the strategy of testing the limits to gain a deeper understanding of the reasons for the client’s performance. 10. No individual’s behavior and functioning can be understood without a thorough understanding of his or her cultural identity and context.

193

Making a Culturally Responsive Diagnosis

W

9

hile I was working on a geropsychiatry unit, a physician asked me to evaluate a 63-year-old Mexican American man who had no physical or emotional complaints. Mr. García had been born in the United States, obtained a ninth-grade education, and spoke English with an accent. In the late 1960s, he began working as a custodian for a large corporation. He was well liked and a hard worker, and over the years he was promoted to a supervisory position that required that he keep track of equipment. However, during the past 5 years, he had begun losing requests and forgetting orders. He had also been “talked to” for some odd behaviors, such as taking his shirt off on the work floor (he said he was hot). As a result, his responsibilities had gradually been reduced to sweeping floors and other cleaning tasks. Although Mr. García was not concerned about his work situation or health, his wife was deeply distressed. She reported that he did things that scared her—nothing abusive, but things like driving through red lights and draping a blanket over an

http://dx.doi.org/10.1037/14801-009 Addressing Cultural Complexities in Practice: Assessment, Diagnosis, and Therapy, Third Edition, by P. A. Hays Copyright © 2016 by the American Psychological Association. All rights reserved.

195

196

S o r t i n g Thi n gs Ou t

electric heater. She had tried everything she could think of to help her husband, including rearranging things in the house and talking to his supervisors, family members, and friends. But no one had a reasonable explanation for why Mr. García was acting the way he was. She went to her priest, who prayed with her, and finally she went to the doctor, who conducted a thorough medical exam of her husband. Because the physician could find no physical reasons for the changes in Mr. García, he recommended a neuropsychological assessment. Following a lengthy assessment, which included consultation with the physician, interviews with Mr. and Mrs. García, reports from a work supervisor, and neuropsychological testing, I concluded that Mr. García had moderate dementia probably as a result of Alzheimer’s disease. Normally, I dread having to share this information with patients and their families. But because of the extent of Mr. García’s impairments, I guessed that he would not be disturbed by this information, and in fact, he was not. Telling Mrs. García, I believed, would be a different matter. I assumed that she would be crestfallen and maybe even angry at me, the bearer of bad news. To my surprise, she did not become upset, but rather expressed relief and appreciation. As she explained, she was exhausted from trying to figure out her husband’s strange behaviors and personality changes. At least now she knew that she was not imagining things or over­reacting. Although she was realistically sad about what lay ahead, she was also ready to hear about available resources and begin planning for the future. As this case illustrates, much of the power of a diagnosis comes from the meaning it gives to a confusing situation. Ideally, this new understanding leads to specific actions that can eliminate the problem or reduce its harmful effects. Even when the problem can’t be solved, an accurate diagnosis may suggest new ways of thinking about the problem and coping with it. For example, although nothing could be done to reverse Mr. García’s Alzheimer’s disease, as a result of learning that this was the primary problem, Mrs. García stopped questioning and blaming herself. Mr. García left his job, which he was no longer able to perform anyway, obtained disability benefits, and began attending a day program that provided social interaction for him and a break for Mrs. García. A diagnosis is “a culturally agreed-upon expression of internal distress” (Watters, 2010, p. 33), and making a helpful diagnosis assumes the existence of a diagnostic system that a culture agrees is valid and reliable. With the recent publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–5; American Psychiatric Association, 2013), U.S. adoption of the International Classification of Diseases (ICD), 10th Edition, Clinical Modification (ICD–10–CM; Centers for Medicare and Medicaid Services & National Center for Health Statistics, 2010), and upcoming publication of the ICD–11, diagnosis has become a controversial topic, in part reflecting cultural shifts in the way health and illness

Making a Culturally Responsive Diagnosis

are defined. To help in making a culturally responsive diagnosis, this chapter begins with a brief comparison of each of these systems. Next, a summary of the major changes between the DSM, Fourth Edition, Text Revision (DSM–IV–TR; American Psychiatric Association, 2000) and the DSM–5 is provided, followed by a description of the cultural components of the DSM–5. Guidelines for making a culturally responsive diagnosis are then provided and illustrated via a case example of a Tunisian immigrant couple.

International Classification of Diseases and Diagnostic and Statistical Manual of Mental Disorders Around the world, the most widely used diagnostic system is the International Classification of Diseases, developed by the World Health Organization (WHO; 1992b). Approximately 95% of the world’s health care professionals (including physicians, nurses, and psychologists) use the 10th edition of The ICD–10 Classification of Mental and Behavioral Dis­orders: Clinical Descriptions and Diagnostic Guidelines, also known as the Blue Book (WHO, 1992a; see also Goodheart, 2014, p. 4). The ICD–10–CM can be downloaded for free from the Centers for Disease Control website (http://www.cdc.gov/nchs/icd/icd10cm.htm#icd2016). The American Psychological Association Practice Organization (APAPO) also offers a web-based application for APAPO members that features diagnostic codes for ICD–10–CM mental, behavioral, and neurodevelopmental disorders that can be accessed by searching for key words, browsing a list of diagnoses, or exploring graphic interfaces (APAPO, 2014). Recognizing the need for culture-specific adaptations, the World Health Organization allows each country to adapt the ICD–10 as needed. The U.S. adaptation is signified by the initials CM, meaning Clinical Modification, and is referred to as the ICD–10–CM. The historical use (or rather, lack of use) of the ICD–10–CM in the United States is a complicated issue. Goodheart (2014) provided details, but the short version is that as of January 2015, there are only codes for each disorder—no clinical descriptions—in the ICD–10–CM (and its predecessor, the ICD–9–CM), which clearly limits its usefulness to health care providers. However, as a member of the World Health Assembly, the U.S. government is committed to joining the rest of the world in implementing the ICD (October 1, 2015 was the U.S. compliance date for transitioning to the ICD–10 code sets) and eventually in implementing the upcoming ICD–11.

197

198

S o r t i n g Thi n gs Ou t

Many clinicians were unaware until recently that the codes listed next to the clinical descriptors in the DSM–IV–TR are identical to the ICD–9–CM codes; in other words, clinicians using the DSM–IV–TR were using the ICD–9–CM codes all along. In an effort to harmonize the DSM–5 with the upcoming ICD–11, the DSM–5 now contains both the ICD–9–CM and the ICD–10–CM codes and is organized to match the structure of the upcoming ICD–11 (American Psychiatric Association, 2013, p. 12). But all of this can feel a bit confusing if you are a U.S. therapist just getting used to the DSM–5 with its ICD–10–CM codes, knowing that you’ll soon be required to use the ICD–11 codes (Goodheart, 2014). The dominance of the DSM–5 in the United States (and slowness to adopt the ICD) is a reflection of the powerful influence of European American culture. This resistance to the ICD from U.S. institutions persists despite the advantages of the ICD over the DSM–5. Specifically, the ICD is a global, multidisciplinary, multilingual (i.e., inclusive) project designed specifically to be useful to all countries. It is free of charge, and it covers both physical and mental disorders. In contrast, the DSM–5 covers only mental disorders, costs money (i.e., clinicians must purchase it), is less flexible than the ICD system (Goodheart, 2014), and is a large source of revenue for the American Psychiatric Association, which is also the entity that developed and approved it (Reed, Khoury, & Evans, 2013).

Moving From the DSM–IV–TR to the DSM–5 As the United States catches up with the rest of the world’s adoption of the ICD, it is likely that U.S. clinicians will continue to use the DSM–5 clinical descriptions. To help with the transition from the DSM–IV–TR to the DSM–5, Niemeyer (2013) summarized the 15 most significant changes in the DSM–5:   1. overall mission creep, also referred to as diagnostic inflation—that is, relaxed criteria for some diagnoses—which tends toward pathologizing normal behaviors and experiences;   2. discontinuation of the multiaxial system—that is, elimination of Axes II, III, IV, and V;   3. greater biomedical orientation and presumed etiology in the hope of finding underlying biological and neurological origins for all mental disorders;   4. inclusion of Section III: Emerging Measures and Models, which includes a measure of cross-cutting symptoms characteristic of different disorders; a severity rating measure; the WHO Disability

Making a Culturally Responsive Diagnosis

Assessment Schedule 2.0 (Üstün, Kostanjsek, Chatterji, & Rehm, 2010), which replaces the Global Assessment of Functioning and Axis V; the Cultural Formulation Interview (CFI; more on this later in this chapter); alternative diagnostic models for personality disorders; and conditions for further study;   5. dimensionalization of disorders (e.g., autism spectrum disorder, schizophrenia);   6. reclassification and recombination of disorders;   7. addition of disorders not from the Appendix (e.g., disruptive mood dysregulation disorder); in prior editions of the DSM, a controversial disorder was first listed in the Appendix before it eventually was published as a full disorder;   8. removal of the bereavement exclusion in major depression; bereavement can precipitate a major depressive episode, and it can last longer than the DSM–IV–TR’s specification of 2 months;   9. addition of nonsubstance addictive disorders (e.g., gaming); 10. addition of mild neurocognitive disorder, introducing the idea of a risk diagnosis, which is difficult to distinguish from normal aging changes; 11. movement toward clinical utility (i.e., usefulness) versus validity; 12. listing of personality disorders on the single axis (because there is no longer an Axis II); 13. replacement of “not otherwise specified” (NOS) with “other specified” and “unspecified”; 14. movement from Roman to Arabic numerals in the title because the DSM–5 will have future revisions of 5.1, 5.2, 5.3, and so on; and 15. opacity over transparency in decision making through the requirement that DSM–5 committee members sign a confidentiality agreement. The DSM–5 also includes a section “Highlights of Changes From DSM–IV to DSM–5” that describes changes in specific disorders (American Psychiatric Association, 2013, p. 809). In addition to these general changes, specific culturally related changes have been included in the DSM–5. To give you a context for these changes, it helps to consider what preceded them.

ATTENTION TO CULTURE In 1991, in response to criticisms of ethnocentrism in earlier editions of the DSM, the National Institute of Mental Health appointed a Work Group on Culture and Diagnosis “to advise the DSM–IV Task Force on how to make culture more central to DSM–IV” (Lewis-Fernandez, 1996, p. 133). Over the next 3 years, this group, composed of about

199

200

S o r t i n g Thi n gs Ou t

100 clinicians and social scientists, conducted extensive literature reviews and wrote detailed proposals for culturally related modifications to the new version (Kirmayer, 1998). Unfortunately, though, as one member explained later, “Many of the substantive recommendations made by the task force . . . were not incorporated into the body of the manual, in spite of strong empirical data from the cross-cultural research literature” (Good, 1996, p. 128). The cultural additions to the DSM–IV (and the DSM–IV–TR) that did make it into the final publication consisted of five main components:   1. “Specific Culture, Age, and Gender Features” consisted of a paragraph on this topic under some diagnoses but not all.   2. A revised and expanded Axis IV: Psychosocial and Environmental Problems included problems especially relevant to minority populations such as discrimination, acculturation difficulties, homelessness, extreme poverty, inadequate health services, being the victim of a crime, and war.   3. The section “Other Conditions That May Be a Focus of Clinical Attention” added three V codes—(a) identity problem, (b) rel­ igious or spiritual problem, and (c) acculturation problem—that provided a way to diagnose problems that commonly affect people of minority group membership without pathologizing the individual.   4. The “Outline for Cultural Formulation” consisted of helpful questions to ask but included no culture-specific information.   5. A “Glossary of Culture-Bound Syndromes” provided descriptions of 25 such syndromes. The first four components offered helpful information, although the placement of the fourth (the “Outline for Cultural Formulation”) in the Appendix, rather than integration into the multiaxial system, deemphasized its importance and reinforced the idea that culture is relevant only to members of minority groups. The “Glossary of CultureBound Syndromes,” also in the Appendix, was problematic for the same reasons. In addition, the concept of culture-bound syndromes was problematic because it implied that some behaviors and experiences are bound to particular cultures—namely, cultures considered minorities or foreign from a European American perspective—when in fact no psychiatric disorder, behavior, or experience can be understood apart from the culture in which it occurs (Marsella & Yamada, 2000). The developers of the DSM–5 attempted to address cultural influences in a more integrated way, and they took some significant steps beyond the DSM–IV–TR. As with the DSM–IV–TR, the easiest way to explain these changes is in terms of the five components listed previously. The first component, “Specific Culture, Age, and Gender Features,” is now separated into three separate paragraphs under most diagnoses—

Making a Culturally Responsive Diagnosis

a paragraph called “Cultural Issues,” a paragraph called “Develop­ men­tal and Lifespan Considerations,” and a paragraph called “Gender Differences.” Also, at the beginning of the text there is a brief overview of how the DSM–5 incorporates these topics throughout the text. The usefulness of the information provided by these paragraphs varies depending on the available research, but in general this is a step forward. The second component, Axis IV: Psychosocial and Environmental Problems, has been eliminated because the multiaxial system is no longer being used. Unfortunately, its elimination deletes a very visible documentation of social and environmental stressors that disproportionately affect minority members. The third component, “Other Conditions That May Be a Focus of Clinical Attention” (formerly V codes, now Z codes), has changed significantly. This section has been expanded, with excellent detailed descriptions of social and environmental problems, including codes and descriptions for child and adult maltreatment and neglect and problems related to the social environment, such as social exclusion and rejection and being a target of adverse discrimination or persecution. There’s also a code for “unspecified problems related to social environment” for domains not included in this section. Specific codes for “identity problem” and for “religious or spiritual problem” are omitted, and acculturation problem is now acculturation difficulty. The fourth component, the “Outline for Cultural Formulation,” has also changed significantly, and for the better. It now includes a detailed interview protocol, the Cultural Formulation Interview, for assessing the influence of culture on key aspects of a person’s clinical presentation and care. The CFI contains questions that cover four domains: (a) cultural definition of the problem; (b) cultural perceptions of cause, context, and supports; (c) cultural factors affecting self-coping and past help seeking; and (d) cultural factors affecting current help seeking (American Psychiatric Association, 2013, p. 751). There is also an informant version for clients unable to provide information themselves (e.g., children, cognitively impaired individuals). One particularly positive element of this section is that it goes beyond attention to cultural features that create vulnerability to include those that build resilience. The fifth component, the “Glossary of Culture-Bound Syndromes,” is now called the “Glossary of Cultural Concepts of Distress,” eliminating the concept of the culture-bound syndrome, and it has been reduced from 25 such syndromes to nine “cultural concepts of distress.” The cultural concepts of distress are more integrated into the main body of diagnoses in the text under the subheading “Culture-Related Diagnostic Issues.” For example, ataque de nervios (“attack of nerves”) is also included under the “Culture-Related Diagnostic Issues” subheading of “panic disorder” and under “other specified anxiety disorder.” Similarly, taijin kyofusho (extreme fear of offending others, found in Japan and Korea)

201

202

S o r t i n g Thi n gs Ou t

is included under social anxiety disorder/social phobia, and khyâl cap (“wind attack” of dizziness, shortness of breath, and catastrophic cognitions among Cambodians) is under posttraumatic stress disorder. However, there is some inconsistency regarding which of the cultural concepts of distress are integrated into the main diagnoses. For example, although the Glossary lists shenjing shuairuo (“weakness of the nervous system” found in China) and notes that major depressive disorder is a related condition, shenjing shuairuo is not mentioned under the diagnosis of major depressive disorder. This is an important point because if the cultural concepts of distress are listed only in the Glossary (i.e., in the Appendix) and not under the main diagnoses, it is highly unlikely that clinicians will consider or even see them.

DIAGNOSTIC INFLATION In addition to these five components, there are at least a couple of other changes with important implications for particular minority groups. The first of these changes is the relaxing of diagnostic criteria mentioned above in relation to children and people in poverty. Allen Frances, head of the DSM–IV Task Force in 1994, has been an outspoken critic of diagnostic inflation, which preceded but has increased in the DSM–5. Diagnostic inflation is characterized by criteria for particular diagnoses that have become loose to the point that normal behaviors and experiences are diagnosed as pathological, resulting in unnecessary, inappropriate, and even harmful treatments. Frances (as cited in Wylie, 2014) noted that diagnostic inflation has been going on for over 30 years and attributed it to the following four causes:   1. the expanding influence of the DSM, as psychiatric diagnosis is now used to make decisions in an array of domains—for example, to make decisions about “school placement, disability decisions, courtroom verdicts, who could adopt a child, even who can fly a plane” (p. 33);   2. the enormous influence of pharmaceutical companies in convincing people that they are sick (i.e., that they have a psychiatric diagnosis that a medication can fix);   3. the insurance company requirement that a diagnosis must be made before services are covered, resulting in diagnoses made before sufficient information is gathered; and   4. recognition of a marketing opportunity by drug companies in that although there are “only about 40,000 psychiatrists, there are more than half a million primary care doctors” (p. 33; there are even more when you count other prescribing primary care providers), and these providers could be targeted with the message that psychiatric diagnosis is simple and attributable to a chemical imbalance that can be remedied via a medication.

Making a Culturally Responsive Diagnosis

Nowhere is diagnostic inflation more evident than in the skyrocketing numbers of children and adults being diagnosed with attentiondeficit/hyperactivity disorder (ADHD). Between 2011 and 2012, the demand for dextroamphetamine and amphetamine (Adderall), methylphenidate (Ritalin), and other stimulants used to treat ADHD outstripped supply, and the U.S. Drug Enforcement Agency had to raise the quota for production of such drugs (Novotney, 2014). The rapid increase in ADHD has been especially pronounced among children living in poverty. In a detailed investigation of contributing factors, researchers Hinshaw and Scheffler (2014) found that social policy regarding school funding was strongly associated with this increase. Specifically, between 2003 and 2007, in U.S. schools in which funding suddenly became dependent on test scores, there was “a 59 percent increase in ADHD diagnoses among children who were within 200 percent of the federal poverty limit” (Hinshaw, as cited in Novotney, 2014, p. 28). As Scheffler noted, If you want to improve test scores, one way of doing that is to have children diagnosed so you can get extra money from the school districts to help tutor them or put them in smaller classes. Basically, you diagnose kids because improving their performance helps the school’s performance. (as cited in Novotney, 2014, p. 29)

A remarkable increase has also occurred in recent years in the number of children diagnosed with bipolar disorder. Psychiatrist Stuart L. Kaplan (2011) explained, I have been a child psychiatrist for nearly five decades and have seen diagnostic fads come and go. But I have never witnessed anything like the tidal wave of unwarranted enthusiasm for the diagnosis of bipolar disorder in children that now engulfs the public and the profession. Before 1995, bipolar disorder, once known as manic–depressive illness, was rarely diagnosed in children; today nearly one third of all children and adolescents discharged from child psychiatric hospitals are diagnosed with the disorder and medicated accordingly. The rise of outpatient office visits for children and adolescents with bipolar disorder increased 40-fold from 20,000 in 1994–95 to 800,000 in 2002–03. (p. 1)

If all of these children, particularly children in poverty, and their families were provided evidence-based behavioral interventions, the risks of overdiagnosing might not be as serious, because a diagnosis would not automatically result in stimulant medications that are prescribed for years and have significant side effects including appetite suppression, interference with sleep, increased blood pressure, and, among adolescents who do not truly have ADHD, addiction. But drug companies have successfully convinced the public and many providers that particular diagnoses must be treated with a medication, and ADHD and bipolar disorder are two of these diagnoses.

203

204

S o r t i n g Thi n gs Ou t

Think about this: Considering on a continuum the risks with diagnostic inflation (i.e., overdiagnosing) and the risks with stricter diagnostic criteria (i.e., underdiagnosing), in which direction do you lean?

Adding to the pressure to treat psychological distress and behavioral problems with medication, therapists working in public agencies that serve people in poverty usually have huge caseloads consisting of especially ill people. As a result, medications may be the first line of treatment despite their risks. People with higher incomes have access to alternatives (e.g., for children: a sports team, an after-school tutor, a hobby, or another activity to provide more individual adult support and opportunities to learn social and other skills and to excel in something). But people in poverty often don’t have access to such activities and supports because they cost money; even if an activity is free, it still costs money to get a child to the location of the activity. In fairness to the DSM–5, it is important to note that diagnostic inflation represents one side of a dilemma. On one hand, insurance companies will not pay for services if there is no diagnosis, and people in poverty or with limited incomes are usually unable to pay for services unless they are covered by Medicaid or Medicare, which require a diagnosis. On the other hand, a diagnosis does pathologize the individual, and the associated stigma may have harmful consequences for the person’s life. And the DSM–5 does address concerns about the overdiagnosis of children. For example, this concern with regard to bipolar disorder led to the inclusion of the new diagnosis of disruptive mood dysregulation disorder for children up to 12 years old who present with severe, persistent irritability and “frequent episodes of extreme behavioral dyscontrol” (American Psychiatric Association, 2013, pp. 155–156).

DIAGNOSIS AND TRANSGENDER PEOPLE With regard to transgender people, the controversial diagnosis of gender identity disorder (GID) has been replaced by gender dysphoria (American Psychiatric Association, 2013, p. 814). In the past, transgender people seeking gender-affirming treatments such as hormones or surgery were required to see a therapist for an assessment of eligibility and readiness, and the diagnosis of GID was key in this assessment. However, the diagnosis also presented a dilemma—on one hand, if a person didn’t receive the diagnosis, then the treatments were often assumed to be unnecessary and medical providers would not provide them, but on the other, the diagnosis automatically pathologized people whose gender did not match the gender they were assigned at birth. Because the diagnosis of gender dysphoria is given only if the person is distressed about incongruence between his or her experienced or expressed gender and assigned gender, this diagnosis removes the pathologization of being transgender. For this reason, many trans­gender and trans-affirmative providers see it as an improvement, although some do not (see Erickson-Schroth, 2014, for examples of first-person differ-

Making a Culturally Responsive Diagnosis

ing viewpoints). At the same time, there has been a shift away from the mental health provider as gatekeeper model to an informed consent model based on new treatment guidelines published by the World Professional Association for Transgender Health (Coleman et al., 2012). With this approach, a letter may still be required, but its purpose is to confirm that “the client is ready and able to give informed consent, and it is also intended to give the treating provider a sense of the client as a person, to help support the client’s individualized care” (Rachlin, as cited in Erickson-Schroth, 2014, p. 299). With this new model, a gender dysphoria diagnosis may not be necessary to obtain treatments, but it may be necessary for an insurance company to cover it. But as Erickson-Schroth (2014) noted, although some insurance companies require a gender dysphoria diagnosis in order to cover treatment, others have a treatment exclusion for such care. In summary, the DSM–5 includes some significant improvements with regard to multicultural practice. Cultural considerations are more integrated into the body of the text (compared with the DSM–IV–TR), the ethnocentric concept of culture-bound syndrome has been eliminated, and the Cultural Formulation Interview is a valuable resource for obtaining cultural information relevant to assessment, diagnosis, and treatment planning. Some limitations persist, however—most notably, the front-and-center position of psychosocial and environmental problems (i.e., Axis IV) has been eliminated, and information that highlights the impact of positive and negative social, cultural, and environmental influences is relegated to the Appendix.

Making a Culturally Responsive Diagnosis Building on the guidelines in Chapters 7 and 8 for a culturally responsive assessment, therapists can take additional steps to increase the probability of making a culturally responsive diagnosis using the DSM–5.

THINKING SYSTEMICALLY WHEN MAKING A DIAGNOSIS The first step in culturally responsive diagnosis involves moving beyond the DSM focus on individualistic diagnoses to think systemically and consider relational disorders (Kaslow, 1993) and, I would add, cultural and environmental influences. This is no easy task because, as Kirmayer (1998) explained, diagnosis is in itself an “essentializing” process; the

205

206

S o r t i n g Thi n gs Ou t

DSM–IV–TR reinforced the focus on “decontextualized entities whose characteristics can be studied independently of the particulars of a person’s life and social circumstances” (p. 342), and the same can be said of the DSM–5. Although the DSM–5 includes categories of relational problems (e.g., parent–child, spouse/intimate partner, sibling) and other social and environmental problems, they are all listed as Z codes in the Appendix, with the implication that these diagnoses are of secondary importance. In addition, several non-DSM factors work against a systemic orientation, including the individualistic focus of health care in the United States, in the profession of psychotherapy, and among most psychotherapists. Mental health facilities and individual providers typically require that records list one identified patient, even when it’s a couple or family who want help. Insurance companies generally do not reimburse for Z codes unless there is also a mental disorder diagnosed. Rules set forth in the Health Insurance Portability and Accountability Act of 1996 prioritize individual confidentiality over the family’s right to know, even when a person’s actions may wreak havoc with the family’s needs and thus indirectly with the individual’s own needs (e.g., people experiencing a manic episode who are not in danger of physically harming themselves or others but who want to spend all of the money in their personal retirement account). And graduate training programs typically focus on individual therapy, with family, couple, and group therapies taught as separate courses.

CREATING A CULTURAL PROFILE To counter this individualistic bias, the second step in culturally responsive diagnosis is for therapists to create a Cultural Profile to include with the client’s diagnosis (examples are provided later in this chapter in the case example of Mouna and Majid). The Cultural Profile consists of the ADDRESSING acronym listed vertically, and then next to each letter, the salient cultural influences and identities for that client. Because information needs to be abbreviated in this format, if you are unsure of what to include next to each ADDRESSING category, the questions outlined in Exhibits 5.1 and 5.2 in Chapter 5 on understanding clients’ identities can help. In the previous edition of this book, the multiaxial system was still being used, so I described the Cultural Profile as a sixth axis. The idea of a sixth cultural axis was one of the original suggestions proposed by the DSM–IV Work Group on Culture and Diagnosis. However, it was eventually rejected in favor of the DSM–IV “Outline for Cultural Formulation,” with the intention that this framework would be placed at the beginning of the manual, which did not happen (Lewis-Fernández, 1996).

Making a Culturally Responsive Diagnosis

One of the work group’s primary concerns about a sixth axis was that it might “just add a sixth list of essentializing descriptors” (LewisFernández, 1996, p. 135). I share this concern, and certainly the Cultural Profile has the potential to be misused in this way. To counter this tendency, it’s important to remember that its use assumes that the therapist is engaged in the ongoing learning process about clients’ cultures described earlier in this book. As you learn more, the Cultural Profile can be continually expanded to include more information about the client’s identity and context.

USING CAUTION REGARDING PERSONALITY DISORDERS The third suggestion for making a culturally responsive diagnosis is to be especially cautious regarding the diagnosis of personality disorders. Because a personality disorder “reflects difficulties in how an individual behaves and is perceived to behave by others in the social field” (Alarcón & Foulks, 1995, p. 6), the specific criteria constituting a personality dis­ order will vary depending on the interpersonal skills and attitudes valued by a culture at any given point in time (Alarcón, 1997). Consider, for example, the attitudes and behaviors constituting a paranoid personality disorder as defined by the DSM–5: “a pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following criteria . . .” (American Psychiatric Association, 2013, p. 649). These criteria include (among others) a preoccupation with unjustified doubts about the trustworthiness of others, a reluctance to confide in others because of unwarranted fear that information may be used against oneself, and a tendency to perceive attacks on one’s character or reputation that are not apparent to others. Without a consideration of cultural influences, these criteria might seem reasonable. But who decides whether or not a client’s suspiciousness, doubts, and fears are justified or unwarranted? Suspiciousness, fear, and distrust have been described as a realistic reaction to the racism experienced by African Americans (Grier & Cobbs, 1968) and Middle Eastern immigrants living in the United States (Bushra, Khadivi, & Frewat-Nikowitz, 2007). Even the DSM–5 notes that such attitudes and behaviors may be normal in anyone persistently exposed to oppressive conditions (e.g., members of ethnic and other minority groups, immigrants, and refugees; American Psychiatric Association, 2013, p. 692). To illustrate how dominant cultural values (particularly masculinebiased assumptions) regarding personality traits and styles have affected DSM categories, M. Kaplan (1983) noted that despite the existence of a dependent personality disorder, which is disproportionately diagnosed

207

208

S o r t i n g Thi n gs Ou t

in women, there is no such thing as an independent personality disorder; apparently, one can be too dependent but never too independent. Similarly, the DSM–IV–TR does not have a diagnosis for individuals who are racist, misogynistic, or homophobic (McGoldrick, 1998). Although such beliefs and behaviors are considered offensive, undesirable, and even dangerous, they are generally not seen as evidence of any mental disorder by mainstream culture. To accurately diagnose a personality disorder, the therapist needs to know the client’s culture well enough to judge whether the client’s behavior represents a marked deviation from it. In addition, because personality disorders by definition involve disturbed interpersonal functioning and misperceptions about the actions of others, the therapist may also need information from people who have known the client for many years in a variety of situations. Because such information is rarely available in an initial assessment, therapists must gather this information or the diagnosis of a personality disorder will be premature.

EXPLAINING YOUR DIAGNOSIS The last suggestion for making a culturally responsive diagnosis is to clearly explain your diagnosis, how you came to it, and what you’re recommending. This explanation needs to be made and discussed first with the client, then put in written form for the record. The specifics of your explanation to the client will vary depending on the client and the setting. As the example of Yasmine in Chapter 7 illustrated, in my own practice, when talking with clients, I summarize my diagnosis by explaining three main influences I consider in making the diagnosis: (a) the person’s vulnerability to anxiety, depression, anger, or whatever the presenting problem is based on their childhood experiences; (b) past and current stressors (including past traumatic events that may have lingering effects); and (c) strengths and supports. Obviously, I consider other influences, too, but these three areas provide a straightforward way of summarizing for clients the rationale behind my diagnosis. After discussing the diagnosis, I give my recommendations, including an explanation of what I would do with the person in therapy if he or she is willing to return (the topic of Chapter 10). After explaining and discussing the diagnosis with the client, the therapist also needs to explain the diagnosis to other relevant providers, typically in the form of a written report. The clinical summary or case formulation needs to be succinct but also highly informative, because it is often the only part of the report that other providers will read. Its contents will vary somewhat depending on the referral source and question and the particular type of assessment performed. For general mental health evaluations, I use a four-part format that consists of (a) the diagnosis with

Making a Culturally Responsive Diagnosis

a list of the symptoms that justify it, (b) contributing factors, (c) resilience factors (i.e., supports and strengths), and (d) recommendations. In summary, I believe that it is possible to make a culturally responsive diagnosis using the DSM–5. The likelihood of such a diagnosis is increased by conceptualizing clients’ presenting problems systemically, creating a Cultural Profile, using caution regarding the diagnosis of personality disorders, and providing a clear and comprehensible explanation of the diagnosis and recommendations, both directly to the client and in the written report. To give an idea of how these suggestions may work in practice, the case example of Mouna and Majid illustrates a therapist’s assessment with one couple.

Case Example of Mouna and Majid At the time of the initial assessment, the therapist, a European American woman in her early 50s, had little knowledge of the clients’ cultures. However, she was committed to the learning process and was able to use the suggestions outlined in this chapter to make a helpful and culturally responsive diagnosis. Majid, a 34-year-old Tunisian man, brought his wife, Mouna, a 27-year-old Tunisian woman, to his female physician for an appointment. In fluent English with an Arabic accent, Majid explained to the physician that during the past 5 months, Mouna had been “very unhappy, sleeping too much, and crying every day.” Mouna did not speak English, but through Majid’s interpretation, she appeared to confirm his description. The physician knew that Majid and Mouna had recently been married and that Mouna had moved to the United States to live with Majid 8 months earlier. Following a medical checkup that ruled out any hormonal, neurological, or nutritional deficiencies that might have contributed to Mouna’s mood change and hypersomnia, the physician referred the couple to a psychologist who specialized in women’s issues and couple therapy.

FIRST ASSESSMENT SESSION At the initial assessment session, the psychologist greeted Mouna and Majid warmly and introduced herself as Dr. Kate Smith. They chatted briefly, with Majid interpreting for Mouna, about the difference between the weather in the northeastern United States and Tunisia. Kate observed to herself that Mouna appeared very dressed up, with

209

210

S o r t i n g Thi n gs Ou t

carefully done makeup, a stylish short haircut, and noticeable perfume. Mouna was alert and her affect seemed sad, but she smiled at appropriate times and, despite the language difference, always looked directly at Kate when Kate spoke. Majid was dressed neatly, although more casually. He showed a full range of affect but appeared tense. The couple seemed comfortable interacting with each other; for example, twice Mouna spoke sharply to Majid, and he responded with an irritated look but she did not stop what she was saying. Kate began the assessment by asking Majid to explain why they had come in to see her. Majid said that he did not think they needed a psychologist but that the doctor couldn’t find anything wrong with Mouna and told them they ought to see her. Kate sensed some embarrassment on his part. She said that she hoped she could be helpful and that she would like to start by hearing a bit more about their concerns. As Majid repeated the information he had told the physician, Kate periodically made eye contact with Mouna. After about 15 minutes of talking with Majid, Kate asked him if he would interpret a few questions for her directly to Mouna. He agreed, and through this process, Kate learned that before marrying Majid, Mouna had lived with her parents and two brothers in the capital city of Tunis. Through a meeting arranged by family members, she was introduced to Majid on one of his visits home; they corresponded for a year and then married. Mouna left her work in a hospital and moved to the United States with Majid. During their first few months together, she was happy with her new life, but then she began to miss her family, her friends, and her home. She also began to worry about not being able to have children, because after 8 months of marriage she had not yet become pregnant. When asked what she wanted, she said that she wished to return to Tunisia with Majid, but in the same sentence she acknowledged that she knew he couldn’t leave his work. Because of the interpretation process, this initial assessment took the full 90 minutes scheduled. Although she did not complete her evaluation, Kate considered the meeting successful because Mouna brightened a little when questioned directly about her thoughts and feelings, and Majid appeared less tense than when he had arrived. When asked, both Mouna and Majid agreed to return for a second assessment session.

CONSULTATION TIME At this point, Kate was well aware of her own limitations in working with Mouna and Majid. She had some experience working with people who had immigrated from South America and Europe, and she was familiar with some of the values and behaviors more common in Mediterranean cultures (e.g., the emphasis on family, the value placed on

Making a Culturally Responsive Diagnosis

motherhood, and expectations of marriage and children for both men and women; see Abudabbeh & Hays, 2006; Ali, Liu, & Humedian, 2004). However, Kate had no personal or professional experience with Tunisian, Arab, or Muslim people. After listening to Majid, Kate realized that she held some assumptions about Arab and Muslim men’s attitudes toward women. For example, she was surprised by the sincerity of Majid’s concern for Mouna and by their apparent comfort level with one another. In thinking about her surprise, she realized that she had assumed that given their arranged marriage, the couple would be quite formal with one another and that Majid would care about Mouna’s health only insofar as it affected his needs. But this clearly was not the case. Kate realized that changing her biases would require work outside the therapy session. Before their next session, Kate found information about Tunisia. She learned that Tunisia is a North African country of approximately 11 million people who are predominantly Arab and Sunni Muslim (Central Intelligence Agency, 2015). The country was colonized by France and was a protectorate until it gained independence in 1956. Tunisia has a high literacy rate and mandatory schooling for boys and girls, and French is a commonly spoken second language. For decades, Tunisia has been a leader in the Arab world on the subject of women’s rights, including minimum age for marriage, requirement of consent by both women and men for marriage, legal abortion, legal right of women to initiate divorce, and family planning services offering free contraceptives across the country. More recently, Tunisia has been credited with starting the Arab Spring revolution, and protests over economic inequality, corruption, and political repression led to the overthrow of the dictator President Zine el-Abidine Ben Ali in early 2011. The Tunisian government sends university students abroad for graduate study in particular fields, and although most go to France, some are sent to the United States, and many of these individuals become permanent residents (Hays & Zouari, 1995). Kate also consulted with an Arab American therapist, who advised her that she should have arranged for an interpreter before their first session. Kate telephoned Majid to talk with him about this, but he reacted defensively. Kate realized that he took her suggestion to mean that he was not sufficiently fluent in English or that he could not represent Mouna’s views fairly. Kate explained that neither was the case but rather that she wanted Majid to feel free to express his own concerns without the pressure of needing to attend to Mouna’s needs simultaneously. Majid finally agreed to an interpreter on one condition–that he know the name of the person beforehand to be sure that they were not in the same social circle, the Tunisian community in their city being relatively small. He and Kate agreed on a Lebanese woman who spoke

211

212

S o r t i n g Thi n gs Ou t

Arabic and did interpretation for a large hospital. Before their next assessment session, Kate talked with the interpreter on the telephone, asking questions about her expertise, confirming her understanding of confidentiality, and generally establishing rapport. During her consultation with the Arab American therapist, Kate described her impressions of Mouna and Majid and mentioned their arranged marriage. The consultant sensed some judgmentalism on Kate’s part and explained that arranged marriages are still common in Tunisia and that they help ensure that families as well as individuals are well matched. She added that divorce is relatively uncommon. Her comments challenged Kate to think further about her assumptions regarding arranged marriages. Kate also expressed concerns about the impact on Mouna and Majid of current political events. She said that she had not been sure of whether to ask about this, so she had refrained, but at the same time she did not want them to think that she agreed with all of the U.S. government’s actions abroad, particularly in the Middle East. The consultant validated Kate’s wish to be respectful and said that given the pervasiveness of antiArab, anti-Muslim sentiment and its possible effects on a person’s mental health, this topic was important to consider. The consultant explained that in addition to the U.S. invasion of Iraq, Kate needed to consider an ongoing series of events affecting Arab and Muslim people. She named the U.S.-led coalition against the Iraqi invasion of Kuwait during the Gulf War that resulted in the deaths of thousands of Arab people, the abuse of Arab Muslim prisoners by U.S. soldiers at Abu Ghraib, the ongoing U.S. support of Israel over the Palestinians, and the U.S. supply of weapons to Israel during the latter’s bombing of Lebanon in 2006. She added that following the attacks on the World Trade Center, hate crimes in the United States against Muslims and Arab people increased dramatically (America after 9/11, 2003). The consultant explained how all of these actions, on top of a history of negative stereotypes and prejudice against Arabs and Muslims, could contribute to feelings of anger, frustration, distrust (i.e., of Americans), and hopelessness among Arab and Muslim people. She suggested asking Mouna and Majid, “Have you experienced discrimination or racism during your time here in the United States?” as part of the assessment of chronic and acute stressors in the couple’s lives. She said that if Mouna or Majid did not want to talk about this, Kate would probably sense it from their responses, and she could refrain from further exploring the topic until trust was more firmly established. (Muslims and Arab people may be slow to disclose information related to religion or politics until trust has been established; Ahmed & Amer, 2011.) The consultant also called Kate’s attention to the assumption embedded in Kate’s statement that she did not want Mouna and Majid to assume

Making a Culturally Responsive Diagnosis

that she agreed with the U.S. government’s actions. The consultant told Kate that although it was likely (considering the couple’s more recent immigration, Majid’s strong Muslim identity, and the current political climate) that the couple disagreed with U.S. policies, it was also possible that they did not. The consultant explained that although more recently immigrated Arabs and Muslims tend to be less satisfied with U.S. foreign policy, up until the 1980s the majority of Arab Americans were Republican and tended toward assimilation into the dominant culture (Erickson & Al-Timimi, 2001). The consultant reminded Kate that there can be just as much diversity in the way Arab and Muslim people see the world and themselves as there is among other ethnic and religious cultures. She encouraged Kate to continue her reading and look for community events at which she might meet a wide variety of Arab and Muslim people outside the clinical setting.

SECOND ASSESSMENT SESSION At the second session, Kate introduced the interpreter, who was about 50 years old and preferred to be addressed as Mrs. Salem. Mrs. Salem shared that she was married to a Lebanese man with whom she had immigrated to the United States as an adult. She was familiar with the Tunisian dialect of Arabic (something Kate realized she had not thought to ask) because she had worked in a Tunisian-owned travel agency for many years. She had also been trained as a peer counselor and had worked as a volunteer at the local mental health center. Kate reiterated their commitment to confidentiality, primarily to reassure Majid; she and Mrs. Salem had already discussed this concern before the session. The assessment resumed with an emphasis on completing the histories of Mouna and Majid.

Mouna’s History Mouna reported that she was born and grew up in the same house in Tunis, along with her parents, two older brothers, and paternal grandmother. Her father was a university professor and her mother an elementary school principal. Her two older brothers (ages 28 and 30) left home in their early 20s to attend university in Paris. Mouna wanted to join them but said that her parents worried too much about her safety to allow her to move to France. While living at home, Mouna completed a master’s degree in biology at the University of Tunis and then obtained a position as a research assistant in a hospital, where she worked for a year before marrying Majid. Mouna described her family as very close, noting her parents’ pride in her educational accomplishments. Because everyone except her

213

214

S o r t i n g Thi n gs Ou t

grandmother spoke French fluently, the family’s language was a mixture of Tunisian and French. Although they observed religious holidays and never drank alcohol in their home, Mouna’s family members were not practicing Muslims (i.e., they did not perform the prayers five times a day, nor did they intentionally follow a religious diet). Mouna referred to her family and herself as Tunisoise (pronounced too-neez-’wahz), the feminine form of a term used to describe the well-educated middle- and upper-middle class of the capital city. To better understand the meaning of Mouna’s identity, Kate asked Mouna to describe her life as a young woman in a Tunisoise family. Mouna responded by describing her typical day as “busy and mostly happy.” After waking early to help her mother prepare a breakfast of bread, olive oil, and coffee for the family, Mouna would then get dressed and go to work. She enjoyed the walk to the hospital and being part of the hustle and bustle of the city. She liked her work, too, where she had many female friends. She would return home to have lunch with her family (the largest meal of the day, prepared by a maid), then take a nap and talk a little with her mother before returning to the hospital to complete her work there. In the evenings after dinner, she and her mother frequently entertained at home or visited female friends and relatives while Mouna’s father and brothers went to the cafe to see their male friends. In response to Kate’s questions about Mouna’s experience in the United States, Mouna said that during her first few months, she continued to awaken early to prepare Majid’s breakfast and sit with him while he ate. However, getting up in the morning became increasingly difficult for her, and she eventually stopped. She tended to wake up closer to noon now and described her only activities as cleaning the house, watching television (although she understood little), and preparing dinner beginning in the late afternoon. She said that she’d gone out a few times but that when she tried to buy something at the local grocery store, the clerk was rude to her. Another time, she was frightened when a man in a car shouted something angry at her (she didn’t understand the words). Now she didn’t like going out alone and mostly stayed in the apartment. Although she looked forward to Majid’s return all day, she felt angry when he arrived home, especially when he didn’t want to take her out. She did admit that he drove her to English classes two nights each week, went out with her most Saturdays and Sundays, and had arranged several dinners with couples who were his friends.

Majid’s History Majid reported that he, too, grew up in a close family. His grandparents on both sides were poor but very religious. His father attended Koranic school and eventually bought and ran his own small grocery store,

Making a Culturally Responsive Diagnosis

which provided a modest income for the family. Majid’s mother completed elementary school and worked in the home preparing meals, maintaining the household, and caring for Majid and his older brother and younger sister. Majid’s parents were both practicing Muslims, and he himself had practiced the prayers and followed the required diet until he left home. Majid’s parents held high expectations of him, and at school he was known for his intelligence and hard work. He won a government scholarship to a U.S. university, where he completed a master’s degree in electrical engineering. He subsequently obtained work as an engineer in a medium-sized company, which allowed him to obtain permanent residence status in the United States. He worked for 4 years, saving money for a dowry and a nice apartment, and then began looking for a wife. He stated that his family was very proud of him but also disappointed that he did not return home after university. Majid described his early years in the United States as “hard” but added that “everybody has to go through the same thing when they move here.” In response to Kate’s questions about his experiences of racism, he said that he’d had people be rude, stare at him, ignore him, and shout things like “Go home!” at him from a distance. He said that most Americans he met “just don’t know any Muslim people personally, so they have some pretty strange ideas about Islam.” He said that generally he found most Americans to be respectful once they got to know him, although he added, “but then there are always those crazy people on the edge that you have to be on the lookout for.” In response to Kate’s questions about what had helped him adjust, Majid said that he considered a key element to be his focus on learning English, because “once you speak English, you can do almost anything.” When pressed by Kate to think of other things that had helped him adjust, he recalled learning to cook some Tunisian dishes, playing Tunisian music, and finding a cafe frequented by North Africans. In addition, a “turning point” occurred when his brother came to visit; Majid said that showing his brother around the city made Majid realize how much he liked living in the United States. Although Majid intended to return to Tunisia to retire, he did not want to live and work there now, because even during visits he became impatient with the “slow pace” and could no longer stand the heat in summer. When asked about his marriage, Majid said that despite their frequent arguments, he thought he and Mouna had a good relationship and that the problem was her homesickness. He had tried everything he could to help her: He took her out as much as possible and encouraged her to take more English classes. He was starting to worry about their ability to have a baby, and he was beginning to think that she might have some sort of physical problem.

215

216

S o r t i n g Thi n gs Ou t

UNDERSTANDING THE CLIENTS’ IDENTITIES As Kate listened and recorded information about Mouna’s and Majid’s lives, she began forming hypotheses about their identities and the salient cultural influences in their lives. She used the ADDRESSING framework to help her organize this information and be sure that she was not ignoring potential influences.

Mouna’s Identity For Mouna, Kate asked herself which of the ADDRESSING factors Mouna had mentioned and which she had not (see Exhibit 9.1). Although Mouna had mentioned influences related to age and generation, nationality, religion, and social status, she did not mention those related to disability, ethnicity, sexual orientation, gender, or Indigenous heritage. Kate was guided by her own general knowledge, sensitivity, and intuition to ask about some of these factors and to refrain from asking about others. As a part of her history taking, Kate did ask more detailed questions about Mouna’s religious upbringing. But she did not ask about Mouna’s ethnicity (because she already knew that Mouna was ethnically Tunisian Arab), gender (which she hypothesized was female), disability or Indigenous heritage (because these did not appear to be relevant), or sexual orientation (which she knew was a topic too sensitive to explore with an Arab heterosexual couple in an initial assessment).

EXHIBIT 9.1 Mouna’s Cultural Profile ❚❚  Age

and generational influences: 27 years old; born several decades after Tunisian independence in 1956. Mouna was in a generation of girls entering school several decades after it became mandatory, with high expectations for their accomplishments. She is the youngest child and only daughter in a Tunisoise (upper-middle-class, urban) family. ❚❚ Developmental or other Disability: None reported or apparent. ❚❚ Religion and spiritual orientation: Parents both Muslim but nonpracticing; Mouna’s personal beliefs are Muslim, but she has a secular lifestyle. ❚❚ Ethnic and racial identity: Mother and father both of Arab Tunisian heritage; family of Tunisoise heritage. First language is Tunisian Arabic, but French is also spoken in the home; Mouna does not yet speak English. ❚❚ Socioeconomic status: Parents both university educated and of upper-middle-class backgrounds. ❚❚ Sexual orientation: Probably heterosexual. ❚❚ Indigenous heritage: None. ❚❚ National origin: Tunisian; recent immigrant living as a permanent resident in the United States. ❚❚  Gender: Female; youngest child and only daughter in family of origin. Newly married with no children, but has expectations of motherhood as central to her life and identity as a woman.

Making a Culturally Responsive Diagnosis

To gain a better understanding of the meaning of the cultural influences salient in Mouna’s life, Kate sought information about Tunisian cultural norms in three ways. First, she asked Mouna about her friends’ situations. For example, with regard to Mouna’s wish to study in France, Kate learned that in Mouna’s social circle, her parents’ insistence that she stay in Tunisia was considered well intentioned and reasonably protective, rather than sexist or punishing. Second, Kate listened for differences between Mouna’s and Majid’s descriptions of their situations. Hearing Majid’s description of his Muslim upbringing alerted Kate to the differences in practices among Muslims and, more importantly, the differences between Mouna’s family and Majid’s. Third, between and after sessions, Kate consulted with the Arab American therapist and Mrs. Salem. By the end of the second session, it was clear that Mouna’s personal norms regarding women’s roles and behaviors corresponded closely to those of the dominant Tunisian urban middle class. Kate hypothesized that Mouna’s attitudes and worldview would soon be challenged by her new cultural context. However, she understood that although she was there to help this couple consider possible new behaviors and views, she would need to be careful not to impose her own beliefs regarding relationships and men’s and women’s roles.

Majid’s Identity Although Majid’s identity was as firmly connected to his culture and family of origin as Mouna’s, the meaning of this connection was quite different. Majid was not from a Tunisoise family; the lower social class and the strict religious practice of his family set them apart from Tunisian society’s more secular ideal following independence from France. Even before he moved to the United States, Majid had felt “different.” Through his family, Majid had developed a deep sense of himself as a religious and spiritual person. Although nearly all of the Muslims he met growing up were Tunisian, his parents taught him to think about Muslims around the world as one community. After arriving in the United States, he attended a mosque for a few years and was delighted to meet Muslims who were Cambodian, Indonesian, Nigerian, and African American. Majid identified himself primarily as a Tunisian man; however, during his 14-year residence in the United States, he had learned that most Americans know little if anything about Tunisia. Thus, when describing himself to Kate, he added information that he would not have added for a Tunisian listener (e.g., that he was Arab and Muslim). Although he did not specifically refer to himself as a member of an ethnic minority culture in the United States, his experiences had led him to identify with diverse people of color rather than with the European American majority. With regard to his expectations and beliefs about marriage and the influence of gender, Majid’s point of reference was a mélange of

217

218

S o r t i n g Thi n gs Ou t

EXHIBIT 9.2 Majid’s Cultural Profile ❚❚  Age

and generational influences: 34 years old; middle child of three. Majid was in an early generation of boys educated after independence for whom expectations of success were extremely high. His generation expected to live a secular lifestyle, but Majid was brought up in a religious and spiritual home. ❚❚ Developmental or other Disability: None reported or apparent. ❚❚ Religion and spiritual orientation: Parents both practicing Muslims; Majid has a deep sense of himself as a religious and spiritual person, although not currently practicing. ❚❚ Ethnic and racial identity: Mother and father both Arab Tunisian. Arabic is spoken in their home; Majid is fluent in French and English, too. ❚❚ Socioeconomic status: Parents had elementary school educations and were working poor; family lived in Tunis but was not Tunisoise. ❚❚ Sexual orientation: Probably heterosexual. ❚❚ Indigenous heritage: None. ❚❚ National origin: Tunisian, living as a permanent resident in the United States; has considered obtaining U.S. citizenship as well. ❚❚  Gender: Male; middle child but youngest son. Newly married, with a strong desire to be a “good husband” (meaning in an egalitarian, mutually supportive relationship, as primary breadwinner). No children, but has expectations of fatherhood as central to his life and identity as a man.

Tunisian, Muslim, and American influences. He described his belief in the equality of men and women and his marriage as an egalitarian relationship in which he and Mouna should “support each other to be good people and to do our best.” From his years of living alone, he was used to cooking and cleaning up after himself, although Mouna always made dinner now. He wanted Mouna to make friends and return to working outside the home again, even after having children, if that would make her happy. He assumed that he would be the primary breadwinner but imagined that once Mouna was fluent in English, she would manage their money, as his mother had in his family. Since their marriage, he had tried to make important decisions in collaboration with Mouna (e.g., about decorating the apartment, where to go on outings, planning for the future), and he expected that she would start driving once her English was sufficient to pass the driver’s test. Exhibit 9.2 summarizes the salient ADDRESSING influences in Majid’s life.

CASE CONCEPTUALIZATION AND DIAGNOSIS With this understanding of the salient cultural influences on Mouna and Majid, Kate was in a position to consider what would be the most accurate and useful conceptualization and diagnosis for their case. She was knowledgeable enough about the stressors involved in immigration to realize that Mouna’s depressive symptoms (crying, excessive sleeping,

Making a Culturally Responsive Diagnosis

sad mood and affect) are common responses to the enormous changes involved in such a transition. She understood how Mouna’s acculturation difficulties might be exacerbated by the current political climate and racism in the dominant culture. Thinking systemically, Kate also recognized the adjustment difficulties that Majid was experiencing as a result of the marriage and his new role as a husband. And from the consultant, she learned that a huge missing piece in the adjustment of both Mouna and Majid was the social support from extended families that they would have received as a newly married couple in Tunisia. Majid’s distress did not meet criteria for a DSM–5 diagnosis. For Mouna, the Z code acculturation difficulty was clearly justified, but the question remained whether this would be a sole, primary, or secondary diagnosis. Mouna’s symptoms suggested the possibility of a major depressive episode or adjustment disorder with depressed mood. Kate ruled out the first diagnosis because Mouna did not report at least five of the required symptoms, but the decision to rule out an adjustment disorder was more complex. Diagnosis of an adjustment disorder requires the development of “emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s)” (American Psychiatric Association, 2013, p. 286). The symptoms or behaviors must be characterized by either (a) “marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation” or (b) “significant impairment in social, occupational, or other important areas of functioning” (American Psychiatric Association, 2013, p. 286). Immigration and discrimination qualify as stressors (or more accurately, a collection of stressors), and Mouna’s symptoms had begun within 3 months after her move. However, her distress was not in excess of what one would expect for a woman of her age and culture who immigrates to a host country with widespread racism against people of her culture. The difficult question was deciding whether or not her symptoms were significantly impairing her social, occupational, or academic functioning. Mouna was not impaired in her ability to relate to people or to form new relationships; she simply lacked opportunities and was limited by the language barrier. She continued to carry out most of her household responsibilities (although she no longer cooked breakfast), and she was progressing in her English class. However, one could argue that her depressive symptoms were interfering with her marital relationship. With this information in mind, Kate chose to conceptualize the case as one in which extraordinary stressors were affecting both Mouna and Majid individually and in their relationship as a couple. Mouna was clearly more expressive of her distress and thus more easily seen as “the patient.” Her symptoms were marginally diagnosable as an adjustment

219

220

S o r t i n g Thi n gs Ou t

disorder. In an ideal world, Kate noted to herself, she would not diagnose Mouna so as to avoid pathologizing her. However, in their current situation, the insurance company would pay only for treatment of a mental disorder (i.e., not for a Z code such as acculturation difficulty or spouse/intimate partner relational problem). In addition, Kate suspected that Mouna and Majid would not return if their insurance did not cover the therapy. (For more on reimbursement and ethical issues related to managed care, see Cooper & Gottlieb, 2000, and Eisman et al., 2000.)

CONSIDERATION OF THE CLIENTS’ VIEWS Toward the end of their second assessment session, Kate summarized for Mouna and Majid the information in the preceding sections. She reviewed with them the social and cultural stressors in their lives and talked about common responses to those stressors. Kate stated that she saw Mouna’s difficulties as primarily caused by the stressors related to immigration and their relationship difficulties as a result of the challenges of beginning a marriage without the usual social support. She added that the current political climate in the United States was also an ongoing stressor. She validated the need for Mouna to develop a level of caution about going out alone that acknowledged real dangers but at the same time was not unreasonably limiting. She explained how important social support is as a counter to such stressors and how the absence of their immediate family support probably made the stressors feel even greater. At the same time, Kate said, she saw Mouna and Majid as having many strengths. She cited their strong family ties, despite the physical distance from Tunisia; their faith, particularly Majid’s involvement with the Muslim community; their commitment to and caring for one another; their intelligence and histories of success in education and work; and their willingness to try new things—for example, counseling. She added that with all of these strengths, she was confident that they could find ways to help Mouna feel happier and to help the two of them get along better. Majid and Mouna appeared relieved by Kate’s summary. They agreed that they would be willing to attend several counseling sessions. Kate then explained that their insurance would cover only the diagnosis and treatment of one person. She described two solutions to this dilemma: (a) They could pay for couple therapy themselves, or (b) because Mouna could technically be diagnosed with an adjustment disorder, Kate could make this diagnosis and be paid by the managed care company. In the latter case, the stated goal would be to facilitate Mouna’s adjustment to a new country and life and to marriage, but couple counseling could be the method chosen to address this goal and their relationship. Mouna and Majid chose the latter option and returned for couple counseling. Kate

Making a Culturally Responsive Diagnosis

EXHIBIT 9.3 Mouna’s Diagnosis and Clinical Summary Report 309.0/F43.21 Adjustment Disorder with Depressed Mood V62.4/Z60.3 Acculturation Difficulty Mouna’s moderately depressed affect, along with her self-reported symptoms of depressed mood, excessive sleeping, daily crying, and decreased motivation (confirmed by her husband Majid), meet criteria for an Adjustment Disorder with Depressed Mood. Contributing factors appear to be her recent move to the United States, her new marriage, and related stressors including adjusting to a new physical and social environment (including racism), learning a new language, and losing immediate family, social, and cultural support. Majid is also distressed but is less emotionally expressive. Both Mouna and Majid have significant strengths and supports, including strong family ties (although long distance), religious faith, a history of educational and work success, financial stability, and multilingual skills (Mouna: Arabic and French; Majid: Arabic, French, and English). Majid has the additional supports of friends, a positive work environment, religious connections, and a history of successfully adapting to U.S. culture. Regarding my recommendations, both have already had recent medical evaluations that ruled out any physical factors in their distress. I have talked with them about couple counseling, and both agreed to try it with a focus on improving Mouna’s mood and adjustment to the United States and improving their interactions with each other. Interventions aimed at both of these goals may include specific cognitive strategies, behavioral activation, and environmental changes.

wrote her assessment incorporating this goal and the treatment plan as shown in Exhibit 9.3.

Conclusion Kate was not the ideal therapist in the case of Mouna and Majid. She did not speak her clients’ language, she had only a general familiarity with Arab cultures, and she held some prejudices about Arab Muslim men and about arranged marriages. In addition, she made some mistakes. For one, she neglected to obtain an interpreter before the first session, an oversight that might have ended the chance of therapy with some clients. She also forgot to ask about the Lebanese interpreter’s familiarity with Tunisian Arabic; fortunately, the interpreter was aware enough to have thought about dialect differences. However, Kate was committed to providing culturally responsive services to Mouna and Majid. She did her homework in learning about her clients’ cultures (i.e., reading, consulting with an Arab American therapist, and obtaining the help of an interpreter). She was also

221

222

S o r t i n g Thi n gs Ou t

careful to obtain a detailed history, including information about each person’s cultural context and identity. And she paid attention to differences between Mouna’s and Majid’s stories as cues about what was normative in their families’ contexts. In her thinking about a diagnosis, Kate started with the Cultural Profile and considered the salience of each ADDRESSING influence in Mouna’s and Majid’s lives. Although she recognized that Mouna’s symptoms met criteria for an adjustment disorder, she was quick to see the larger context, including contradictory pressures (e.g., that the diagnosis of Mouna would reinforce the idea that Mouna was the problem, but that finances were also a concern for the couple). She included both Mouna and Majid in the diagnostic process using straightforward language and a systemic perspective that acknowledged the impact on both Mouna and Majid of Mouna’s recent immigration, racism in the dominant U.S. culture, their newly married status, and decreased social support. And in her final assessment, she gave special attention to the couple’s culturally related strengths and supports. In sum, Kate’s diagnosis was not ideal, but it was ethical, culturally responsive, and likely to lead to help for this couple. As Chapter 10 illustrates, culturally responsive assessment and diagnosis pave the way for effective interventions.

Practice: Examining Your Diagnostic Decision-Making Process Write a brief summary explaining how you come to your diagnostic decisions. To help with this, ask yourself, “What factors or domains do I consider key to understanding individuals or families and their situation?”.

Key Ideas

  1. Approximately 95% of the world’s health care professionals (including physicians, nurses, and psychologists) use The ICD–10 Classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnostic Guidelines, also known as the Blue Book.   2. The DSM–5 contains both the ICD–9–CM and the ICD–10–CM codes and is organized to match the structure of the upcoming ICD–11.

Making a Culturally Responsive Diagnosis

  3. Diagnostic inflation, which preceded but has increased in the DSM–5, is a factor in the skyrocketing numbers of adults and children diagnosed with attention-deficit/hyperactivity dis­ order and bipolar disorder.   4. Adding to the pressure to treat psychological distress and behavioral problems with a medication, therapists working in public agencies that serve people in poverty usually have huge caseloads consisting of especially ill people, and as a result, medications are often the first line of treatment despite their risks.   5. Because the new diagnosis of gender dysphoria is given only if the person is distressed about incongruence between their experienced or expressed gender and assigned gender, many transgender and trans-affirmative providers see it as an improvement over the old diagnosis of gender identity disorder; however, not everyone agrees.   6. To increase the probability of making a culturally responsive diagnosis using the DSM–5, a first step involves moving beyond an individualistic focus to think systemically and consider relational disorders and cultural and environmental influences.  7. The DSM–5 includes some significant improvements with regard to multicultural practice: Cultural considerations are more integrated into the body of the text, the ethnocentric concept of a culture-bound syndrome has been eliminated, and the Clinical Formulation Interview is a valuable resource for obtaining cultural information relevant to assessment, diagnosis, and treatment planning.   8. A limitation of the DSM–5 is elimination of the front-and-center position of psychosocial and environmental problems (i.e., Axis IV), which provided information highlighting the impact of positive and negative social, cultural, and environmental influences that is now relegated to the Appendix.   9. The Cultural Profile consists of the ADDRESSING acronym listed vertically and, next to each letter, the salient cultural influences and identities for that client; it provides information supporting the diagnosis. 10. Part of making a culturally responsive diagnosis is to clearly explain your diagnosis and how you came to it; this may include consideration of three elements: (a) the person’s vulnerability to anxiety, depression, anger, or whatever the presenting problem is, based on their childhood experiences; (b) past and current stressors (including past traumatic events that may have lingering effects); and (c) strengths and supports.

223

Beyond the Treatment Manuals

IV

Culturally Responsive Therapy An Integrative Approach

I

10

first began hearing the term evidence-based practice (EBP) when I was working part-time at a rural community mental health center, with seven 50-minute client sessions scheduled every day. I wrote my progress notes, reports, and made phone calls to obtain collateral information during the 10 minutes in between sessions and the half hour on either end of the workday. At the time, increasingly more approaches were being designated as EBP, and I remember thinking, “My clients would never go for a highly structured, manual-based therapy, and even if they did, how on earth can a therapist with a full caseload be expected to know all of the validated EBPs to pick the one that fits their particular client?” At the time, I was mistakenly assuming that only empirically supported treatments (ESTs) supported by randomized controlled studies (RCTs) and administered according to a manual could be considered EBPs. RCTs and ESTs are the

http://dx.doi.org/10.1037/14801-010 Addressing Cultural Complexities in Practice: Assessment, Diagnosis, and Therapy, Third Edition, by P. A. Hays Copyright © 2016 by the American Psychological Association. All rights reserved.

227

228

B e y o n d the T reatme n t M a n u a l s

standard for most researchers because they are designed to be replicated, and replication is strong evidence of their effectiveness (Laska, Gurman, & Wampold, 2014). Like other sources of evidence (e.g., case studies, expert opinion, cohort studies, case reports), RCTs and ESTs also have weaknesses, the biggest one being poor generalizability to clinical populations that are much more diverse and complex than most research populations. Fortunately, since my initial introduction to EBPs, the American Psychological Association (APA) has officially defined EBP in a way that provides a useful road map for practitioners. EBP in psychology is now considered “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (APA Presidential Task Force on Evidence-Based Practice, 2006, p. 273). This definition allows for the inclusion of both RCTs and ESTs, if they are available, and acknowledges that even if they are available, they still need to be tailored to the particular client’s individual preferences, characteristics, and culture. Emphasizing the importance of this tailoring process, the APA Presidential Task Force further noted that whereas “ESTs start with a treatment and ask whether it works for a certain dis­order or problem under specific circumstances, . . . EBPP [evidence-based practice in psychology] starts with the patient and asks what research evidence (including relevant results from RCTs) will assist the psychologist in achieving the best outcome” (as cited in Laska et al., 2014, p. 2). In general, research shows that cultural adaptations of psychotherapy have been effective with people of ethnic minority cultures. In a meta-analysis of 65 experimental and quasi-experimental studies, adapted therapies were moderately more effective than nonadapted therapies, and approaches with the greater number of adaptations were more effective than those with fewer adaptations. In addition, cultural adaptations specific to a particular ethnic group were several times more effective than general adaptations (T. B. Smith, Domenech Rodríguez, & Bernal, 2011). Another meta-analysis of 21 studies similarly found culturally adapted psychotherapy to be more effective than nonadapted psychotherapy (Benish, Quintana, & Wampold, 2011). And although a third meta-analysis did not find any difference between adapted and nonadapted therapies, sometimes adaptations did provide extra value and other times they did not (Huey, Tilley, Jones, & Smith, 2014). Taken together, these studies suggest that adaptations are indeed helpful, with the most culturally responsive, ideal approach being therapies developed specifically for (and with) particular groups (e.g., see Bernal & Domenech Rodríguez, 2012). Because the majority of therapists are likely to work with clients of diverse cultures, one place to start

Culturally Responsive Therapy

in learning about such adaptations involves widening one’s repertoire of cultural adaptations that can be used with diverse people in diverse settings. This chapter focuses on an integrative approach that is grounded in the home theory of cognitive behavior therapy (CBT). Other major psychotherapies also have addressed cultural considerations, including psychodynamic (Berzoff, Flanagan, & Hertz, 2011; Chin, 1994; TummalaNarra, 2016), interpersonal (Budge, 2013), self-psychology (Hertzberg, 1990), existential (Vontress, Johnson, & Epp, 1999), family systems (Boyd-Franklin, 2003; McGoldrick, Giordano, & Garcia-Preto, 2005), and feminist therapies (Brown & Ballou, 1992; Comas-Díaz & Greene, 1994). CBT, however, is one of the most widely practiced approaches. A survey of more than 2,000 counselors, social workers, and psychologists found that 69% reported using CBT (“The Top 10,” 2007), as did 89% of a poll of 470 practicing psychologists in the United States (Meyers, 2006). CBT is also practiced around the world; approximately 40 countries have national CBT associations (http://www.the-iacp.com), and CBT is the focus of large international conventions and organizations, such as the World Congress of Behavioural and Cognitive Therapies, and the International Association of Cognitive Psychotherapy. For this reason and others described in the following section, I will focus on an integrative approach I call culturally responsive CBT.

The Case for an Integrative Approach Although the terms eclectic and integrative often are used interchangeably, researchers make a distinction. An eclectic approach is one that does not emphasize any single orientation over another, whereas an integrative approach allows “the process of therapy to be guided by a single overarching theoretical framework, while incorporating and adapting interventions from outside the ‘home’ intervention” (Petrik, Kazantzis, & Hofmann, 2013, p. 392). Currently, the 24-plus models of psychotherapy integration all are based in a home therapy of one particular orientation (Stricker, as cited in Wolfe, 2014). Although a fair amount of controversy exists over whether the use of a single theoretical orientation versus an integrative approach is most effective (e.g., for opposing views, see Dimaggio & Lysaker, 2014, and Govrin, 2014), the APA Resolution on Psychotherapy Effectiveness states that “comparisons of different forms of psychotherapy most often result in relatively nonsignificant differences, and contextual

229

230

B e y o n d the T reatme n t M a n u a l s

and relationship factors often mediate or moderate outcomes” (APA, 2013, p. 103). Research investigating common factors across different forms of psychotherapy confirms this conclusion. Specifically, studies show that approximately 40% of the variance in treatment outcome is due to factors outside the therapy, that is, to clients themselves or external influences. The next largest contributor is the therapeutic relationship, which accounts for 30% of the variance, and another 15% is due to client expectations. Only about 15% of this variance is due to the therapist’s theoretical orientation and use of treatment-specific techniques (Norcross & Lambert, 2011). Whatever theoretical orientation a therapist holds, the relationship is the most important factor within the therapist’s direct influence. That is, a therapist may have a high level of expertise in a particular theoretical orientation, and the client may have high expectations and no interfering external influences, but if the therapist is unable to develop a good working relationship with the client, success is unlikely. At the same time, all of these factors work synergistically to produce a successful outcome. Expertise in a particular theory tends to increase the self-confidence of the therapist (in part because theories provide guidelines for what to do, especially when you are stuck), and the therapist’s self-confidence is subtly communicated to the client, which contributes to the client’s confidence and expectations, which in turn contribute positively to the relationship. Although I initially was trained almost exclusively in behavioral and cognitive behavioral approaches, I have found the integrative approach to be much more realistic for work with diverse people. CBT is my home theory because it provides me with an overarching theoretical conceptualization that is flexible enough to include ideas and approaches from other evidence-based practices, even those of psychodynamic therapy, which often is seen as an opposite approach. To use this example of CBT and psychodynamic therapy, I consider them complementary. (Interestingly, CBT founders Aaron Beck and Albert Ellis originally were trained psychoanalytically.) Although CBT offers a wider array of strategies and tools for tailoring therapy to the particular client, and more measurable procedures for assessing progress, psychodynamic theories offer a richer set of ideas for exploring personal identity and relationship dynamics. In addition, I cannot imagine trying to work with a client without understanding their family of origin and childhood experiences—a domain that is often thought of as the realm of psychodynamic therapy. Along these lines, results of a recent survey suggested that cognitive behavioral therapists pay greater attention to the client’s cultural context—for example, when exploring the environmental influences on dysfunctional thought patterns—but psychodynamic therapists are more likely to consider racial dynamics through an analysis of transference and countertransference (Tummala-Narra, Singer, Li, Esposito, & Ash, 2012).

Culturally Responsive Therapy

Cognitive Behavior Therapy People often assume that CBT is simply about teaching positive thinking, but it is more complex than this. Cognitive behavioral assessment focuses on the evaluation of five specific client-related domains— thoughts, emotions, behaviors, physical symptoms, and environment— and the interactions among these domains (Greenberger & Padesky, 1995). The therapeutic process of CBT involves problem solving, including making practical changes in the client’s physical and social environments, increasing coping skills, making behavioral changes, building social support, and fostering cognitive restructuring. The goal of cognitive restructuring is not simply positive thinking, but rather more realistic, helpful thinking that enables clients to manage overwhelming emotions, replace self-defeating behaviors with helpful behaviors, and minimize or eliminate distressing physical symptoms. Multicultural therapy (MCT) is well suited for integration with CBT in a number of ways (Hays, 2009). Although I use MCT as shorthand for the MCT literature, in practice, I see MCT as more of an orientation than a therapy per se. First, both emphasize the empowerment of clients— CBT through specific skill building and MCT through a focus on the client’s cultural identity and strengths. Both acknowledge the need to adapt therapy to the particular needs and strengths of each client (versus one treatment modality for all). Both emphasize the role of the environment in shaping emotions, behaviors, thoughts, and physical symptoms (CBT from a behavioral perspective, and MCT from a cultural one). Both encourage the incorporation of a client’s naturally occurring strengths and supports into therapy. And CBT focuses on conscious processes that can be easily articulated and assessed, which is helpful when language and cultural differences exist. Note that CBT’s usefulness with people of minority cultures and groups may be limited by the following factors: (a) an assumption of value neutrality when, in fact, values permeate all psychotherapies; (b) an individualistic orientation that places greater value and focus on the individual when this is not the client’s orientation; and (c) a focus on the present to the neglect of the past. These limitations, however, can be minimized by a careful consideration and systematic integration of cultural influences.

Culturally Responsive CBT Culturally responsive CBT (CR-CBT) builds on the steps outlined in previous chapters, specifically, the therapist’s personal work; consideration of the client’s culture; culturally responsive behaviors that establish a

231

232

B e y o n d the T reatme n t M a n u a l s

warm, respectful relationship; and a systemic perspective. In addition, some steps specific to CBT can be taken to make the therapy more culturally responsive. The following examples are not comprehensive because what makes CBT culturally responsive will vary depending on the particular client and their cultural identity and context. But they will give you some examples to build upon.

CR-CBT CASE CONCEPTUALIZATION CR-CBT, like CBT case conceptualization, can be thought of as a template that helps therapists understand their clients as deeply and fully as possible, including how their clients came to develop the problems that they hope to address in treatment; what maintains these problems; and the typical cognitive, behavioral, emotional, and physical reactions their patients have to life events. In collaboration with the client, this conceptualization becomes richer and more intricate over time, and it provides guidance at key decision points regarding the best course of action (Wenzel, 2013). Toward the end of the initial assessment (as described in Chapter 7 of this volume), I provide an explanatory summary of the information the client has shared. The first part of this summary (provided directly to the client) includes my conceptualization of the client’s situation based on three main factors: (a) the client’s vulnerability to stress or the presenting problem based on childhood experiences, (b) stressors, and (c) strengths or supports. At this point, I also explain and collaboratively discuss the diagnosis and recommendations with the client. Once I’ve done this, I then move into an explanation of what the client can expect if they return for counseling sessions. This explanation represents, in lay language, how I conceptualize CBT. Because the phrase cognitive behavior therapy sounds so academic, and because it includes only the words cognitive and behavior but omits other words important to many clients, such as spiritual, family, and cultural, I rarely use the phrase in my rural practice with Native and non-Native people. I conceptualize and describe the therapy to clients as follows: I use an approach that divides problems and their solutions into two main categories. The first category are those that are more external to you, where the stress is caused by a person or situation outside of you, and/or there is some action you can take that will make the problem better or decrease the stress for you. These actions may involve changing something in your environment, or learning some information or a new skill that helps to decrease the stress you are experiencing, or learning new communication skills like assertiveness or conflict resolution skills. It might also involve increasing your social support or increasing your self-care. And with self-care, I’m not talking just about physical self-care like exercising and eating well, but also emotional [and spiritual—

Culturally Responsive Therapy

if valued by the client] self-care. Anyway, with these kinds of problems, I help people figure out what can be done, come up with a plan, and then carry it out. The second category of problems consists of those things that you can’t change or for some reason decide not to. For example, if you have a chronic illness and you’ve done everything you can practically and medically to minimize your difficulties, there is still a lot of stress related to hospital visits, medication changes, the physical pain, and so on. Or you may have a supervisor who is very unfair, but you only have 9 months until you retire, so you decide you cannot quit. Even though these kinds of problems can’t be changed directly, there is something you can do to feel better, and that is, change the way you’re thinking about the situation. One thing we know in this field is that the way we think affects how we feel. So with this group of problems, I help people figure out what thoughts, images, or beliefs they may be repeating or holding onto that increase their feelings of stress, and help change them to more helpful, realistic ways of thinking. This doesn’t mean just smearing happy talk over a bad situation, rather, it’s about realistic self-talk, because whenever any of us is stressed, our thoughts skew toward the negative and we just don’t see the positive. So this is about recognizing there’s a problem, but also realistically recognizing that there are positive possibilities too. (For examples of this explanation in practice with different clients, see DVDs by Hays, 2012, 2015.)

CLARIFYING EXTERNAL VERSUS INTERNAL SOURCES OF STRESS As my previous explanation suggests, a key step in CR-CBT involves defining which part of the client’s stress is externally genyour life that brings you unwanted feelings, erated by the environment, including social such as anger, anxiety, or hopelessness. What and cultural influences as well as physical part, if any, of this problem is due to factors barriers, and which part is internally genexternal to you or outside your control (e.g., erated by the client’s thoughts, beliefs, and someone else’s behavior, a medical problem, images. These sources of stress often overlap, an unreasonable workload)? What part, if for example, when a person’s self-defeating cognitions are creating distress that preany, does your thinking contribute to these vents them from taking action that would unwanted feelings? eliminate an environmental stressor. But whether or not stressors overlap, this distinction is helpful because it provides guidance regarding the most effective areas of intervention If an emotional, physical, or behavioral stress response is primarily generated by the client’s thinking, then cognitive interventions are often indicated. But if it’s a genuinely stress-inducing environment, then action aimed at changing the environment (or the person’s interactions Think about this: Think of a problem in

233

234

B e y o n d the T reatme n t M a n u a l s

with it) is usually the place for attention. This latter point is especially important from a multicultural perspective because it calls attention to oppressive environmental influences. And recognition of oppressive environmental influences helps to prevent what I call premature cognitive restructuring. Premature cognitive restructuring involves moving into thoughtchange strategies inappropriately or too quickly, that is, before exploring environmental influences that may be realistically causing distress. Trying to change a client’s beliefs about an oppressive situation without first (or simultaneously) addressing the situation may be interpreted as blaming the individual, when the real problem is an abusive relationship or a racist, sexist, heterosexist, or disability-hostile environment. Consider the case of an African American client who, in an initial assessment, tells a White therapist about an experience of racism from a coworker. If the therapist responds with questions aimed at eliciting alternative explanations for the coworker’s behavior (e.g., “Could it be that your coworker meant something else by that statement? Are there any other explanations for your coworker’s behavior?”), the client is likely to interpret the therapist’s questioning as racist or naïve. In such situations, Kelly (2006) advised always beginning with the validation of a client’s report of experiences of racism. Although such an approach may seem obvious, remember that CBT emphasizes the exploration and challenging of beliefs that may be contributing to a person’s distress. Validating a client’s experience does not mean that therapists will never explore or question clients’ reports of oppressive experiences; however, this exploration and challenging should not be attempted before a very strong trust is present. Once the client feels believed and validated, the therapist may then consider assessing the relevance of an incident to the client’s presenting problem. Similarly, when working with people who have disabilities, therapists need to be careful not to minimize the impact of physical barriers and negative social attitudes, especially if the therapist does not have a disability (Mona, Romesser-Scehnet, Cameron, & Cardenas, 2006). Also with transgender clients, therapists need to recognize the objective aspects of the dominant culture that create real obstacles, including housing discrimination, ostracism by family members, workplace discrimination, loss of custody of children, difficulty obtaining legal recognition of marriage, severe ridicule, and transgender identity-related violence (APA Presidential Task Force on Evidence-Based Practice, 2006; Erickson-Schroth, 2014). Attention later may be given to the ways in which these experiences shape the cognitions that work against a person’s long-range goals (e.g., “I can’t get a good job because I am transgender” or “They will never be able to accept the real me”), but

Culturally Responsive Therapy

moving too quickly into changing such beliefs implies that the primary problem is the client’s thinking rather than the dominant culture (Maguen, Shipherd, & Harris, 2005, pp. 486–487). In their work with transgender clients, Austin and Craig (2015) illustrated the relationship between societal oppression and internalized beliefs, with a transdiscrimination inverted pyramid worksheet to illustrate the effects of discrimination on an individual’s mental health. The top level of the inverted pyramid represents oppressive cultural beliefs and messages in the dominant culture. The second level down represents the institutional level of discrimination, including laws, government, businesses, media, religious, and other big institutions. The third level down is the interpersonal level, which represents how family, friends, and people in one’s immediate environment treat the client and react to their identity. At the bottom tip of the inverted pyramid is the individual level, which consists of how individuals think and feel about themselves. This conceptualization helps clients to “move away from a view of themselves as ‘disordered’ or ‘pathological’ toward an affirming view of themselves as ‘doing their best to cope with complex and often hostile environmental circumstances’” (Austin & Craig, 2015, p. 24). In addition to exploring supportive as well as oppressive environmental influences related to culture, CR-CBT involves a consideration of cultural influences on the cognitive, emotional, behavioral, and physio­ logical components of the client’s problem. Culture clearly shapes cognitions in the form of values, beliefs, a person’s interpretation of events, definitions of rationality, and views of what is adaptive versus maladaptive behavior (Dowd, 2003). Culture also affects the expression, reporting, and experience of emotions; for instance, studies show that people of Latin American identities tend to report high levels of positive affect, whereas East Asians tend not to (Diener, Oishi, & Lucas, 2003; Okazaki & Tanaka-Matsumi, 2006). And culture certainly accounts for differences in behavior, including the expression of physical and mental symptoms and illness. This includes not only the Cultural Concepts of Distress listed in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013), but all disorders (e.g., consider the way that European American cultural beliefs about women’s bodies contribute to anorexia).

Developing a Treatment Plan Once it’s clear what parts of a person’s stress are being caused by external factors versus internal (i.e., cognitive), it is easier to develop a treatment plan. As I’m developing the plan with a client, and considering

235

236

B e y o n d the T reatme n t M a n u a l s

whether and when to focus on environmental, behavioral, or cognitive change, I usually ask the client for their opinion and go with their preference. With clients who prefer a more authoritative approach, Pan, Huey, and Hernandez (2011) noted that in their work with some Asian American clients, it works better for the therapist to say something like, “Let’s have you try this.”

ACTION INTERVENTIONS I use the term action interventions to include strategies aimed at changing the environment (which shapes behavior) and strategies aimed at changing behavior (which interacts with the environment). Action interventions involve physically doing something (i.e., taking action), whereas thought-change (cognitive) interventions involve mentally doing something (i.e., changing the way one thinks about a situation). For stress that primarily is generated by environmental factors or by one’s behavior in interaction with the environment, interventions often will involve taking some sort of action, whether it is changing the environment or changing a behavior. I use the acronym CLASS to summarize these action interventions (see Exhibit 10.1). You may notice that these categories correspond to the types of change I included in my explanation of CBT to clients. Although some domains overlap, this is not a problem because the point of the acronym is simply to help generate and remember positive possibilities for environmental and behavioral change. When taking action aimed at changing the environment or behavior, the adaptations that make an action culturally responsive will depend on the client’s particular identity and context. When making such adaptations, it’s important to look not only for oppressive cultural influences but also for the positive, healthy environmental influences within minority cultures that can be reinforced.

EXHIBIT 10.1 CLASS Actions That Counter Stress and Build Well-Being ❚❚  Create

a healthy environment; Learn a new skill or information; ❚❚ Assertiveness, conflict resolution, and other communication skills; ❚❚ Social engagement and support; and ❚❚  Self-care activities ❚❚

Note.  Adapted from Creating Well-Being: Four Steps to a Happier, Healthier Life (p. 125), by P. A. Hays, 2014, Washington, DC: American Psychological Association. Copyright 2014 by the American Psychological Association.

Culturally Responsive Therapy

For example, when an intervention focuses on creating a healthy environment, an Asian Buddhist client may choose to set up an altar in her home to honor ancestors and provide a space for quiet contemplation. Or a person who recently has immigrated may play their culture’s music, display culture-specific artwork, or find a grocery store that sells their preferred foods. (More ideas on culturally supportive environments can be found in the Environmental Supports list in Chapter 7 of this volume.) When a client is experiencing abuse or oppression in their environment, a culturally responsive approach may involve helping the client leave the situation, for example, in the case of a woman being abused by a partner. In the case of an individual being harassed or oppressed in a hostile workplace, creating a healthy environment may involve talking to a supervisor, filing a grievance, or taking some similar type of action. When learning a new skill, consideration of culture with Orthodox Jewish clients, for example, would involve ensuring that when the client practices the new skill, they are not seen by neighbors who might infer that they are in therapy (even the suggestion of mental illness in one’s family can affect a person’s marriage prospects; Paradis, Cukor, & Friedman, 2006). If a client is learning a new skill to interact more effectively with dominant-culture members in a workplace, a culturally responsive approach makes it clear that dominant-culture social skills are not superior to the minority-culture skills. To emphasize this point in their work with American Indian clients, LaFromboise and Rowe (1983) explained the usefulness of bicultural competence (i.e., having skills in both cultures). They also chose situations targeted for change by consulting with tribal leaders, groups, and agencies, and they designed social skills trainings that paralleled American Indian traditions of role modeling, apprenticeship training, and group consensus. When teaching assertiveness, conflict resolution, and other communication skills, a culturally responsive approach involves recognition of cultural norms regarding communication. For example, with Latino people, particular communication protocols are important for ensuring smooth, nonconfrontational interactions (sympatía) between people of different status (Comas-Díaz & Duncan, 1985). With regard to child–parent relationships, respeto (respect) is another strong value that, in traditionally oriented families, includes the concept of obedience to authority. In teaching assertiveness skills to the wife and son of a traditionally oriented Mexican American man who periodically exploded, Organista (2006) incorporated both concepts by suggesting the son and wife use phrases advised by Comas-Díaz and Duncan, including, “With all due respect papa . . . ,” or ask “Would you permit me to express how I feel about that?” For the same reason, in a parenting program with Puerto Rican adolescents and their parents, facilitators emphasized to parents

237

238

B e y o n d the T reatme n t M a n u a l s

that the adolescents’ assertiveness was not an attempt to disrespect them (Saéz-Santiago, Bernal, Reyes-Rodríguez, & Bonilla-Silva, 2012). And in working with Chinese immigrant parents who objected to the idea of praising kids because praise was seen as sugarcoating and because “the more you praise them, the more you’ll spoil them,” one therapist simply changed the word praise to encouragement (Lau, 2012). Regarding social engagement and support, reengagement with individuals or groups outside the therapy setting that have been a positive influence in the past is ideal because reinforcing a behavior that is supported by the client’s culture is most likely to stick. For example, in my work with a young, recently separated African American Christian woman, I asked questions to help her think about who had been supportive of her in the past. In addition to her parents, with whom she and her children were living, she mentioned the church, although she had stopped attending months before. After exploring whether returning to the church would be helpful to her, she decided it would, and made attending the next Sunday her first homework step (Hays, 2012). In some cases, a therapy or peer support group may be a helpful option. For example, Alcoholics Anonymous and Narcotics Anonymous are powerful sources of support for many people in recovery, as is Al-Anon for individuals living with someone who is abusing substances or in recovery. I’ll talk more about group therapy in the next chapter on diverse interventions. Finally, with regard to the CLASS action domains, a culturally responsive approach to finding and implementing self-care activities involves consideration of the client’s resources, and ability to implement such activities in their own environment. For example, in working with single low-income women who have small children, even taking a hot bath in the evening can be challenging because it involves planning details such as whether or not to lock the bathroom door (if there’s a bathtub or a lock), how to keep kids busy (e.g., plan a reward if they allow mom 30 minutes without interruption except for emergencies), and so on. Because clients, especially caregivers for children and older adults, often have difficulty generating ideas for self-care, and because money can be an obstacle, I have a list of mostly free activities that prompts me to ask questions that help the client generate ideas. On rare occasions, I give the list to the client (see Exhibit 10.2). Because it is important that the activity be something the client genuinely enjoys or finds nurturing, a list or standardized inventory—unless it is culture specific— may not be helpful. For example, in working with an older Chinese American man, Lau and Kinoshita (2006) found that although the client chose activities from the Older Person’s Pleasant Events Schedule (Gallagher & Thompson, 1981) and said he would do them, he did not follow through. But when he was helped to generate his own list, which

Culturally Responsive Therapy

239

EXHIBIT 10.2 Self-Care Activities taking a walk outside burning a scented candle sitting with a warm blanket in your favorite chair drinking herbal tea in your favorite cup reading the funnies snuggling with your partner petting your dog or cat painting your nails laughing and playing with kids watching a funny movie reading a good book buying your favorite magazine cooking a special dinner arranging fresh cut flowers taking time for morning devotions, prayer meditating sitting outdoors

attending a religious meeting/group enjoying a favorite food wearing fleece clothing listening to your favorite music listening to an inspirational talk going out to eat creating, growing, or building something talking with/calling a friend planning a fun trip planning something to look forward to gardening fishing joining a support group attending counseling getting a massage watching/feeding birds painting, drawing

Note.  Adapted from Creating Well-Being: Four Steps to a Happier, Healthier Life (p. 181), by P. A. Hays, 2014, Washington, DC: American Psychological Association. Copyright 2014 by the American Psychological Association.

included tai chi, Chinese calligraphy, reading the Chinese newspaper, and visiting Chinatown, his homework compliance was 100% and his mood improved.

SETTING GOALS It is important that therapists work collaboratively with clients to set goals and decide on interventions. Of course, there are exceptions, for example, when a client’s cognitive abilities are too impaired; but even in these cases, collaboration with caregivers is essential. Such collaboration reinforces the idea that clients know more about their particular contexts and needs than a therapist ever can, especially a therapist who differs culturally from the client. It also means that there will be times when clients choose goals that do not fit with the therapist’s expectations or preferences. Take the case of a middle-class Greek American woman who came to therapy “for help in making my daughter behave.” The mother had been separated from her husband for 10 years (they were never legally divorced), and she and their sole daughter lived together. The daughter was making good grades at the community college she was attending, but she wanted to do things that the mother did not like (e.g., go to

240

B e y o n d the T reatme n t M a n u a l s

movies with friends at night, wear baggy pants). When the daughter tried to explain her desires and reason with her mother, the mother would interpret this as “talking back” and become furious and shout at her daughter. The therapist realized that the mother’s behavior was understandable in relation to some childrearing practices and views in Greek culture (e.g., the questioning of authority and disobedience being seen as disrespectful; Tsemberis & Orfanos, 1996). With further discussion, it became clear that the mother was unwilling to change her conceptualization of the problem or her own behavior, and the father (who was contacted by phone) would not become involved in what he perceived as a “mother– daughter problem.” The therapist’s initial inclination was to help the daughter become more independent and eventually move out on her own. Neither the mother nor the daughter, however, was interested in this solution. Thus, the therapist worked with the daughter to help her find more effective ways to interact with her mother. Through therapy, the daughter came to realize that when she spent more time with her mother, her mother was more likely to let her go out or bring friends home. The two continued to have disagreements about clothes, but the conflicts over the daughter’s socializing subsided, at least to a more acceptable level for the pair. In sum, by joining with the clients in pursuing their goals, the therapist was able to help them both. At the same time, in some situations, behaviorally oriented goals may not be appropriate. For example, some American Indian people come to counseling primarily for support and want someone who will listen and provide encouragement, reassurance, practical suggestions, and caring but realistic feedback (Swinomish Tribal Community, 1991, p. 226). Similarly, with clients experiencing grief over the death of a loved one, the most helpful approach may be supportive counseling that provides a safe place to cry and reassurance that the experience of bereavement is a normal process. (For information on what constitutes normal bereavement in diverse minority cultures, see Irish, Lundquist, & Nelsen, 1993, and Shapiro, 1995.)

THOUGHT-CHANGE (COGNITIVE) INTERVENTIONS The main task of cognitive interventions involves recognizing the cognitions and cognitive processes that may be contributing to a client’s emotional distress, unwanted behaviors, or physical symptoms. The form of cognitive restructuring known as rational emotive behavior therapy (REBT) focuses on changing irrational thoughts to more rational ones, with the expectation that more rational thoughts help a person to feel better and engage in more constructive behaviors (Ellis, 1997). The

Culturally Responsive Therapy

advantage of REBT is that it consists of a relatively simple model that is easy to explain and learn. One problem with REBT, however, is its reliance on the concept of rationality. Definitions of rationality are heavily influenced by a person’s culture, and the dominant culture tends to perceive many minority group beliefs as strange and irrational. If the therapist does not know the client’s culture well, he or she may jump to the conclusion that a client’s belief is irrational, when in fact, it is normal in the client’s culture. The most well-researched form of CBT is known as cognitive therapy (A. T. Beck, Rush, Shaw, & Emery, 1979; J. Beck, 2011). Rather than challenge rationality, cognitive therapists generally prefer to question how functional or dysfunctional a belief is. Questions commonly used to do so include, “What is the evidence for this thought or belief?” and “Is there an alternative explanation?” Theoretically speaking, these questions challenge the validity rather than the utility of a client’s belief. Other questions are used to challenge the utility. Although challenging the validity of the client’s belief may be helpful in some situations, it is risky when the therapist and client differ culturally. Challenging the validity of core cultural beliefs is even riskier unless the client and family are open to this challenge. A safer approach is to avoid the question of rationality and validity altogether and focus instead on a collaborative exploration of the helpfulness (i.e., utility or usefulness) of a thought. The therapist may simply ask, “Is it helpful for you to say this to yourself or to hold on to this belief or image?” This question recognizes that ultimately, the client is the judge regarding the helpfulness of thoughts and behaviors (Kemp & Mallinckrodt, 1996). Functionality is obviously implied in the concept of helpfulness, but the term helpfulness sounds less academic. Often cognitive restructuring will involve changing unhelpful thoughts and images specific to a particular situation. Consider the example of a 58-year-old bilingual man who began using a walker for mobility following a car accident that also led to the loss of his job. Cognitive restructuring involved countering the thoughts of “What am I gonna do? I know I’m never gonna get another job, I’ll probably never work again, we’ll have to move out of our house, we’ll probably lose everything . . .” by changing them to “Okay, wait a minute, I’m still recovering, so I don’t know for sure yet what kind of work I’ll be able to do, but there are lots of different kinds of jobs, and remember that list the DVR (Department of Vocational Rehabilitation) guy showed me—there are jobs I could do even if I have to use a walker.” Note that a middle-class therapist who thinks in terms of rationality versus irrationality might believe that this client is engaging in catastrophic thinking, but if the client does not have financial resources, such thoughts might be completely rational, even though they’re not helpful.

241

242

B e y o n d the T reatme n t M a n u a l s

Sometimes clients may benefit from more generic self-talk, that is, repetition of thoughts and images that are not necessarily specific to a particular dilemma. If a client has difficulty coming up with empowering self-talk, it can be useful to go back to the list of culturally related strengths and supports described in Chapter 7 of this volume. The list of personal strengths in Table 7.1 can be used as empowering selfstatements; the list of interpersonal supports provides evidence that the client is valued by others; and, for spiritually oriented clients, the list of natural environmental supports may be a reminder that a higher power cares for them. To use the same example, when this man was feeling discouraged, he used his list to remind himself of the following: “I have gifts that many people don’t—I have a strong faith, I speak two languages, I’m a good storyteller, and I have experienced pain and disability that have made me strong [personal strengths]; I have a wife, children, and friends who love me, and a spiritual community that cares about me [interpersonal supports]; and I live in a safe place, I have a comfortable home, and, wherever I am, if I can go outdoors by some trees and listen to the birds and feel the sun on my face, I feel a sense of peace” [supportive environment]. When a client chooses to use their list of strengths and supports to develop more general, empowering self-talk, repetition of this self-talk often becomes a form of homework in which they read their list aloud to themselves on a daily basis. In such cases, using an idea adapted from Thich Nhat Hanh (1992), I explain that initially they may not notice any difference in how they feel, but to think of it like planting a seed in a flowerpot: After you plant the seed in the pot, you water it, then you walk away. Then the next day, you go back to it, look inside, and you see nothing but dirt. But you don’t throw the pot out. You water it again, then you go away, and come back the next day, you look again and see nothing, but you water it again, and you keep doing this, until after a week or so, you start to see a tiny green sprout coming up. And that’s how changing feelings with self-talk works—you may not notice anything right away, but if you keep at it, with time you’ll start to feel a difference.

Culturally Responsive Adaptations In addition to the practice of questioning the helpfulness of cognitions (which I consider the basic form of cognitive restructuring), over the years, I’ve collected a number of different ways to engage diverse clients

Culturally Responsive Therapy

with this process. These variations include practices and exercises that work to a greater or lesser extent depending on the particular person and their context. They include compassion voice, looking for suffering, the most generous interpretation technique, wise elder, attitude of gratitude, growth opportunity, values compass, the use of metaphors and sayings, and cognitive restructuring adaptations for children—in particular, anxiety remote control, the magic three-step technique, and the worry hill.

COMPASSION VOICE Compassion voice is based on Buddhist writings about compassion, and it involves replacing harsh judgmental cognitions with compassionate thoughts and images. I have found that spiritually oriented people often like this approach; one Christian woman I worked with called it her grace voice. In addition, some nonspiritually-oriented people also find it useful because it can be understood from a strictly cognitive perspective, too. When a person is engaging in harsh critical, judgmental self-talk and holding onto such beliefs, I start by explaining the idea of judgmentalism and how it creates an emotion and a physical sensation of irritation that pushes people away: Of course we all have to make judgments, for example, about what is healthy to eat, what is helpful for our children, what is the kindest thing to do, and so on. But judgmentalism is different—it’s not intended to help us or anyone else; rather, it involves a shaming, superiority component. If the judgmentalism is aimed at another person, the superiority message is “I know better than you, and I am better than you . . .” If the judgmentalism is aimed at ourselves, the message is “I’m so stupid, hopeless, unlovable, etc. . . .” When we go over and over these judgmental thoughts, they create irritability which in turn leads to disconnection from others. There’s a saying, “The greatest source of human unhappiness is disconnection from one another” [His Holiness the Dalai Lama & Cutler, 1999]. This feeling of being disconnected or disliked, or irritated by others, is painful. Kindness and compassion feel much better than irritation and anger. And the feeling of compassion is incompatible with the feeling of irritation—that is, you can’t feel them both at the same time. [Sometimes at this point, I ask the client to imagine holding a puppy, and ask them how this feels.]

I then talk with the client about this idea of judgmentalism in relation to their own critical self-talk, and their relationships. Often this involves an exploration of the origins of their critical voice, for example, from abusive critical parents, the dominant culture, or others. At some point, the work turns toward helping the client replace their critical, judgmental voice with a more compassionate one. As an example of this, I may tell the

243

244

B e y o n d the T reatme n t M a n u a l s

story of a man I worked with who suffered from irritability and anger that was fueled by the harsh voice he had internalized from his father. After explaining the idea to him, he came in the next week and said, Pam, I saw a great example of what you were talking about— I had to ride for three hours with the moron who works as a driver for our company. He was a completely incompetent driver and I was really p.o.’d, but I just held it in because I was afraid I would explode but then afterwards, I went to our boss and told him he needed to fire the idiot. My boss said, “Oh, I’m glad you told me—must be Joe didn’t get the training he needed. I’ll talk to him and be sure he gets what he needs to be a better driver.”

Although the client was not yet using compassion voice himself, he recognized it in his supervisor, and saw how it could decrease his anger. Compassion voice is not a self-indulgent attitude. Rather, it is intended to counter unrealistically harsh self-talk. It involves talking to oneself as you would talk to a good friend or your child. So for example, if your friend or child does something wrong, you acknowledge that it’s wrong, but you don’t beat them into the ground about it. You talk with them in a way that shows you care about them and want to help them do better next time.

LOOKING FOR SUFFERING A number of ways can help clients grow their compassion voice. When the problem is a critical view of someone else that is negatively affecting their relationship, one way is to ask questions that help the client recognize how the other person suffers. I call this the looking for suffering exercise, as it comes from the Buddhist idea that recognizing the suffering of another tends to increase compassion. When a client doesn’t know the other person well enough to recognize this, a related strategy is to ask questions that help the client hypothesize difficulties in the other person’s life, for example, “Is it possible that their spouse is leaving them for another person? Is it possible that they have a child that has a severe chronic illness? Is it possible that they struggle with their weight and don’t feel good about themselves?”

MOST GENEROUS INTERPRETATION TECHNIQUE A related approach is what I call the most generous interpretation technique. Here’s how I explain this approach: When we say something hurtful to someone, we often give ourselves the benefit of the doubt, explaining our behavior with “Well, I was just really tired, and I hadn’t eaten, and I still had all this work to do, so I snapped at her, but I didn’t really mean it.” In contrast, if someone says the same thing to us, we may say, “What a jerk.” So with the most generous interpretation technique, you just tell yourself the most generous explanation

Culturally Responsive Therapy

of the other person’s behavior that helps you feel more compassionate, or at least less irritated by them, for example, “Maybe her dog died today. Or maybe she just tested positive for cancer. Or maybe her spouse just told her she doesn’t love her.”

WISE ELDER

Try this: Step 1.  Close your eyes (or look at the floor) and think about a problem in your life that seems unsolvable and creates feelings of stress in you. Step 2.  Now imagine yourself as 95 years old. Think about all the life experience and knowledge you have at 95. When you are able to imagine yourself as 95, go to the next step. Step 3.  Now with your eyes still closed, imagine what your 95-year-old self would say to your present-day self about this problem or situation.

The wise elder technique (adapted from Dolan, 1991) is helpful when a client has difficulty coming up with supportive thoughts in reaction to a stressor, particularly if the stressor is one without any clear solution. It involves asking the client to imagine themselves as much older, and then imagine the advice their older self would give them today. Almost always, the advice is encouraging, as in messages, such as “It’ll get better; in 20 years this will seem minor; or whatever happens, it’ll be okay, and you’ll be okay.” This message can then be used as a form of encouraging self-talk.

ATTITUDE OF GRATITUDE Attitude of gratitude is an exercise derived from the work of positive psychology researcher Lyubomirsky (2007), who found that when people were asked to keep a list of things they were grateful for, over time, their mood improved. I’ve found this technique particularly helpful with couples. I introduce it by explaining the idea, and then depending on the couple, I may include the following self-disclosure piece: I decided I wanted to make gratitude a daily habit, and my husband agreed to do it with me. Over time, we shaped it into a game in which we each say five original things we are grateful for every day. The first person to remember the exercise that day, gets to go first, which is a little easier because the second person has to add five more original things to the first person’s list. At first it was really hard, but over time it’s gotten easier. And it has a nice effect on our relationship, because if one of us is being pretty negative, the other one can say, “Let’s do attitude of gratitude,” and it sort of shifts the mood. Also, we thank each other more for things we notice during the day.

If the couple wants to try this exercise, I suggest beginning with one thing each day that they are grateful for, in keeping with the “small-step” approach to homework (see the following section Culturally Responsive Homework). Sometimes this initial gratitude item will be for something their spouse did, but it doesn’t have to be.

245

246

B e y o n d the T reatme n t M a n u a l s

GROWTH OPPORTUNITY Growth opportunity is a form of reframing, and it comes from the Buddhist view that obstacles are opportunities for growth. As a form of cognitive restructuring, it involves looking for a positive possibility in or aspect of a problem. For example, a major medical problem may lead a client to be more patient with the slowness of change because her own healing is so slow; to appreciate little things throughout the day that give her a positive feeling; and to feel more empathy toward others because she considers the possibility that a difficult person may be ill or have a nonvisible disability.

VALUES COMPASS This exercise involves helping people recognize what they value most in life, including in themselves and others, then using this value as a guide to make decisions and take action. It can be helpful when a person is frustrated with their own difficulty in making long-term change because it takes the focus off the negative experience of trying to change the behavior and puts it on the positive idea of human values. Judgmental self-talk is replaced by compassion voice with thoughts such as “Okay, I’ve tried my hardest, but for now, I need to accept myself as I am, including my weaknesses because everybody has weaknesses. I need to focus on my strengths, and live my life anyway.” For example, if a client feels stuck after trying for years to fix a difficult work relationship, and he strongly values kindness, he might use as a guide in his interactions with others and himself the question, “What would a kind person do in this situation?” (This exercise is similar to the idea behind acceptance and commitment therapy developed by Stephen Hayes [e.g., Hayes & Smith, 2005].) Ideally, if the client is able to accept themselves in this way, they may experience a shift in the resistance that allows the behavior to come more easily.

METAPHORS AND SAYINGS Metaphors and sayings can serve as powerfully supportive replacement thoughts for negative cognitions. In the development of treatment manuals for low-income ethnic minority populations at San Francisco General Hospital, Muñoz and Mendelson (2005) used culturally relevant images, metaphors, and stories to illustrate key concepts. For example, the phrase “La gota de agua labra la piedra [Drops of water can carve a rock]” was used to explain how thoughts can gradually change one’s view of life into a more positive view that eliminates depression. In their CBT work with Ma¯ori people, Bennett, Flett, and Babbage (2014) used metaphors and prayer relevant to the session at the opening

Culturally Responsive Therapy

and closing, and integrated cultural sayings to facilitate cognitive shifts (e.g., “Turn your face to the sun and shadows will fall behind you”). In addition, upon the recommendation of a Ma¯ori advisory group, they developed a visual picture of the traditional Ma¯ori house (whare) to illustrate how thoughts affect feelings and behaviors. In this illustration, the foundation of the whare represents significant childhood experiences, the first floor represents core beliefs, the second floor represents intermediate assumptions and rules for living, and the roof represents coping strategies. Culturally relevant metaphors and sayings can be found via an online search, or in some cases, clients may remember one they’ve heard and liked. Alcoholics Anonymous has many such sayings, for example, the Serenity Prayer (“Grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference”). For spiritually oriented individuals, I’ve shared the following metaphor (which I heard from a Navajo man) to help clients be gentler with themselves: It’s said that we are all born with a cord attached to the Creator, and every time we do something hurtful to someone else or ourselves, the cord breaks. So then we have to repair the cord by tying a knot in it. And over a lifetime, as we make mistakes, and break the connection, then we repair it, the cord becomes shorter, and by the end of our life, we are much closer to the Creator.

Another helpful American Indian metaphor is that of coyote thoughts. The coyote is known as a trickster in many Indian Nations, and as Beau Washington (2012) explains, One coyote thought isn’t much of a problem. [But] a pack of coyotes will take you down. If you don’t chase the coyote thought away, it bring others. When we dwell on things the coyotes start to gather, creating bigger and bigger problems. . . . Knowing the names of the coyotes brings them out of the dark into the light. Recognizing them is our best chance of ending the darkness and pain they bring. (para. 8)

COGNITIVE RESTRUCTURING ADAPTATIONS FOR CHILDREN Many adaptations of CBT are appropriate for children, even relatively young children. As with adults, the incorporation of culture-specific norms and values is important. For example, in teaching behavioral interventions to Mexican American parents, a culturally responsive therapist would need to consider that active ignoring of unwanted behavior, which operates on the principle of extinction, may not be accepted by some parents, and opportunities for family rewards for children’s good

247

248

B e y o n d the T reatme n t M a n u a l s

behavior are just as important as individual rewards because of the high value placed on family (Barker, Cook, & Borrego, 2010). The following are just a few examples of the ways in which CBT has been used with children, some of which have been used with children living in poverty or children of ethnic minority cultures.

Anxiety Remote Control This approach is based on an anxiety management program for children at the Yale University Child Study Center, in which the idea of “changing your channel” via a mental remote control is used to help children learn how to change worries and scary feelings by changing their thoughts (E. R. Anderson, Smith, & Christophersen, 2011). The program emphasizes the involvement of parents as coaches to help children learn how to implement specific coping skills, and it is careful not to promote the avoidance of anxiety. (Obviously, it is intended for children whose families use modern-day technology such as remotes.) For the first channel, the child is taught a breathing exercise called the leaky tire technique in which they learn to take a deep breath then exhale, making the continuous “s” sound until the breath is expelled, then take another deep breath to relax. A second channel uses visual imagery to imagine a fun and relaxing place, with parents coaching the child to pay attention to all of the senses in the imagery. The cheerleading or coaching channel consists of helpful self-talk, such as “I can do this, it’ll be hard but I’ve done it before.” For older kids, the facing my fears channel includes exposure activities. Once they’ve learned to use these and other coping skills, children are asked to pretend they have a remote control on which each channel corresponds to a particular skill. They then learn to “change the channel” on worries by mentally going into their relaxation channel, visual imagery channel, coaching channel, humor channel, and so on. One suggestion for making visual imagery exercises such as this more culturally responsive comes from La Roche, D’Angelo, Gualdron, and Leavell (2006) who found that because many Latino clients have an allocentric (i.e., social) orientation (versus a more individualistic focus among European Americans), it was helpful to ask individuals to imagine “sharing a moment with a person who makes you feel at peace” (versus the typical “imagine yourself alone in a beautiful place”). This suggestion may be helpful with children of Latino and other dominant and minority identities. Similarly, at an Alaska Native counseling center, clinicians liked the idea of using hardening clay with young kids to create pretend remote controls they could carry with them—an idea that could work with Native and non-Native children.

Culturally Responsive Therapy

THE MAGIC THREE-STEP TECHNIQUE This strategy is adapted from the work of Sommers-Flanagan and SommersFlanagan (2007), and it involves three steps. In the first step, feel the feeling, the child is helped to experience and express emotion in constructive ways. When I worked with a young, Christian 10-year-old I’ll call B. J. who was angry at his mom’s new boyfriend, this included stomping around outdoors (rather than indoors), using a mirror to make angry faces, and doing angry scribbles on paper. The second step, change the feeling, involves teaching the child how to change a feeling by changing their thoughts or behavior. With B. J., after we did a couple of anger exercises, I asked him how he was feeling and he said, “mad.” Then I asked, “Hey, have you ever heard of the magic three-step technique?” Of course he hadn’t, and he wanted to know what it was. So I said, “Okay, let me ask you something. Can you tell me something funny that happened this week at school?” He thought briefly and then said “Johnny told the teacher ‘Bite me.’” He knew this was “a bad thing” to say but thought it was hilarious. He started laughing so hard that he made me laugh (at the same time I was internally chastising myself for laughing at an inappropriate way to talk to a teacher). But in the middle of our laughter, I said, “Hey, how are you feeling right now?” He said, “happy!” I then pointed out how his mad feeling had changed when he changed what he was thinking about, and we talked a little about this. The third step, pass it on, involves explaining that emotions are contagious, and that just as we can change our own emotions, we can positively affect the emotions of others. In this case, I asked B. J. questions to help him recognize how what he said and did affected his mother in hurtful ways. Then I said, “I bet you know how to make your mom happy.” He went on to agree that, yes, he knew that he could make her smile by saying, “I love you” or giving her a hug, which led to the idea of practicing this. He also suggested that he could make his mother over-the-top happy if he cleaned the toilet bowl, which he had never done before, and he decided he would try this. The next week, his mother told me he hadn’t cleaned the toilet bowl, but he did give her a hug and tell her he loved her.

THE WORRY HILL The worry hill (Wagner, 2008) is a four-step approach to treating obsessive-compulsive disorder (OCD) in young children. When and only when the child expresses readiness to change, the program con­sists of the following four phases: stabilization, communication, persuasion, and collaboration. The communication phase uses the drawing of a bell shaped curve that illustrates how anxiety increases

249

250

B e y o n d the T reatme n t M a n u a l s

with exposure to the feared situation until it peaks. Then, if the child persists in resisting anxiety-avoidance strategies, the anxiety begins to decline. Wagner (2008) explains it to the child and parents as follows: Learning how to stop OCD is like riding your bicycle up and down a hill. At first, facing your fears and not doing your rituals feels like riding up a big Worry Hill, because it’s tough. You have to work hard to huff and puff up a hill, but if you keep going, you can get to the top. Once you get to the top, it is easy and fun to coast down the hill . . . [But] you can only coast down the hill if you first get to the top. Likewise, you can only get past your fears if you face them. You have to stick it out without doing your rituals until the bad feeling goes away. Then you’ll see that your fears don’t come true. But if you give into the rituals, it’s like rolling backwards down the hill. (p. 64)

The exposure phase of the program involves development of a fear ladder (exposure hierarchy) of feared activities that are rated on a 10-point scale called the fearometer. It also uses the RIDE acronym to summarize the cognitive process: rename the thought, insist that you are in charge, defy OCD by doing the opposite, and enjoy your victory (for more on this approach, see Wagner, 2005). In addition to this approach, Chorpita’s (2007) book Modular Cognitive-Behavioral Therapy for Childhood Anxiety Disorders contains a detailed evidence-based protocol on how to use exposure with children with OCD and anxiety disorders, based on its effectiveness with culturally diverse families in Hawaii. With regard to American Indian and Alaska Native children in particular, the evidence-based practice of trauma-focused CBT has been used successfully in an adaptation known as Honoring children, Mending the circle, which incorporates CBT concepts that parallel traditional beliefs and practices (BigFoot & Schmidt, 2010). For example, to counter intrusive thoughts, during many traditional ceremonies and activities, traditional healers instruct participants to “leave bad thoughts at the door” or “come in with good thoughts” (BigFoot & Braden, 2007, p. 21; also see Indian Country Child Trauma Center at http://www.icctc.org). Glickman (2009) has adapted CBT for children and adults with language and learning challenges, including deaf individuals. This approach is oriented around the acquisition and development of psychosocial skills, all of which are presented and taught using hundreds of specially developed pictures. And one final resource, the APA Public Interest Direc­ torate’s Office on Socioeconomic Status, together with the Office on Children, Youth, and Families, have produced a free resource for lowincome parents and other caregivers aimed at bolstering resilience among children in poverty. This Resilience Booster: Parent Tip Tool outlines practical applications, such as developing family routines, talking about emotions, role modeling, and problem-solving strategies, and is available for free online (http://www.apa.org/topics/parenting/resilience-tip-tool.aspx).

Culturally Responsive Therapy

Culturally Responsive Homework Finally, CR-CBT involves weekly homework assignments with an emphasis on client direction. With children and teens, I use the word practice instead of homework, for obvious reasons. To facilitate the development of culturally responsive homework, at the end of each session, I ask clients, “Based on what we did or talked about today, what is the smallest possible step you could take that would feel like you are making progress?” (adapted from Dolan, 1991). For spiritually oriented people, I sometimes use the word healing instead of progress. Also, the word healing may be more appropriate with people who have chronic illnesses that will never completely disappear, because it has the connotation of personal and spiritual growth despite the illness. I explain that the step needs to be as small as possible because we want to build a feeling of success quickly, so that clients are more likely to take a next small step, which will lead to another step, and so on, and until after a few weeks, they will begin to see significant results. Earlier, I mentioned the example of a Chinese client who did his homework only when it reflected his own personal and cultural interests. For this reason, and also because the likelihood of a client following through increases if it’s their idea, I almost never suggest a specific homework. Rather, if the person cannot come up with something themselves, I ask questions to help them brainstorm. Most of the time, my role in developing homework involves simply helping the client to pare their chosen step down into an action step or a cognitive step that by their own report, they are 100% likely to do. (For additional suggestions on making CBT more culturally responsive with both adults and children, see Bernal & Domenech Rodríguez, 2012; and Hays & Iwamasa, 2006.)

The Case of Dee Dee came to see me for help in controlling her anger following an altercation with one of her children’s schoolteachers. She was a large European American woman—6 feet tall, 300 pounds—who spoke loudly and bluntly and had a few teeth missing. She lived with her two children, plus a neglected neighbor child she had taken in and a dog and two cats, in a three-bedroom trailer in an impoverished rural community in which alcoholism, drugs, guns, and sex offenders were common. She supported herself and the children on a small disability income supplemented with food stamps and occasional temporary “under the table”

251

252

B e y o n d the T reatme n t M a n u a l s

jobs she was able to find. Every trip into town for medical appointments and groceries was an ordeal, because her car was old and frequently broke down. Dee admitted to screaming, swearing at, and even threatening teachers, store employees, and family members who she said gave her “a hard time.” Dee, however, was also intelligent and insightful and had a wonderful sense of humor and a soft heart for kids. I worked with Dee for several months, helping her to recognize that what she experienced as the “normal” difficulties of daily life (i.e., normal for her because she’d always had such problems) would be considered chaos by most people. I reassured her that anyone living in her situation would feel stressed and that she was not crazy for feeling angry, depressed, and overwhelmed. (See Lott & Bullock, 2001, and Nicolas & JeanBaptiste, 2001, regarding the shame, disrespect, insecurity, hopelessness, and repeated failures experienced by women living in poverty.) Dee understood the cognitive behavioral case conceptualization. With help and frequent validation of the stressors she faced, she was able to distinguish between these environmental stressors and the ways in which she mentally exacerbated her feelings of anger, anxiety, and depression. The environmental, or externally oriented, portion of our work involved looking for ways to decrease Dee’s overall stress level by making practical changes in her environment, including the addition of self-nurturing activities, keeping in mind the constraints that poverty placed on her options and looking for activities that cost nothing (Scarbrough, 2001; L. Smith, 2005). For example, the commonly chosen activity of taking a hot bath to relax was not an option for Dee, because her well water smelled and was discolored. She was eligible, however, for free aqua therapy at the community pool, which she found relaxing and provided the possibility of a clean shower afterward. The internally oriented (cognitive) part of our work involved the normalization of Dee’s feelings and some education regarding the differences between assertiveness and aggression. Dee learned to recognize a pattern in which denigrating and hopeless self-talk kept her from speaking up when she was frustrated until her feelings grew to such a level of anger that she would blow up, resulting in feelings of guilt and shame that reinforced the denigrating self-talk and further decreased her willingness to speak up. Through cognitive restructuring, she began to use more realistic, helpful, and empowering self-talk to manage her emotional reactions, with an emphasis on remembering long-term goals over the short-term satisfaction of venting and getting her way immediately. After several weeks of this work, Dee came in excited to tell me about an incident she said she had handled exceptionally well. That week, her 13-year-old daughter had told her that a 21-year-old acquaintance said he would pay her $20 if she took off her shirt for him. (Her daughter did

Culturally Responsive Therapy

not accept.) Dee was furious, but instead of taking her usual aggressive approach, she decided to practice her assertiveness skills. She told me, I remembered what we talked about, so I took three deep breaths and kept my cool. Then I marched over to the uncle’s trailer where that boy was staying and knocked on the door, and when he came out, I got right up in his face. I looked him straight in the eye and said in a calm, low voice, “If you ever try anything like that again, you mother f—ing son of a b—, you’re mine.” I was so good; I didn’t punch him or poke him in the chest with my finger, or even scream at him. I didn’t even take a gun. I just walked away. And I got my point across—he looked really scared! You would’ve been so proud of me!

Needless to say, I had a little difficulty trying to decide on an appropriate response. I knew what most middle-class people would say she should have done: call the state troopers (she was out of city limits for police) and let them handle it. However, when I considered this from Dee’s perspective, including her previous negative interactions with and lack of trust in the troopers as well as all of the other constraints of her social and physical environment, I could see how her particular adaptation of the skills we had discussed worked for her. Her long-range goals were to protect her daughter and permanently intimidate the guy, and she focused on these instead of doing what she felt like doing (i.e., killing him). Moreover, she did not take a gun with her, she did not physically touch him, and she did not make a specific threat of physical harm. She also added a strategy of telling everyone she met about the incident, which she said “might keep the guy in check, or maybe he’ll get fed up and move out.” I tried to help Dee explore the possible ramifications of her actions. I still had some concerns for her safety and believed that she should have reported the incident to the troopers, at the least to have the incident on the young man’s record, but at the same time, I did not want to dampen her sense of success. It took a lot of courage and effort to do what she did, so rather than suggest that she did something wrong, I shared my delight with her savvy resolution. As therapists, we can teach clients specific coping skills, including new behaviors and a range of assertive responses, but clients must take into account the neighborhoods in which they live, community norms, and the reliability of community supports. And sometimes significant risks are associated with using these new behaviors. For example, Wood and Mallinckrodt (1990) emphasized the risks for members of minority groups in using dominant cultural behaviors in the example of an African American man waiting in a movie line when a White man cut in front of him. Although in some parts of the United States it would be considered appropriately assertive for the African American man to say, “Excuse me, I believe that the end of the line begins behind me,” the authors made the point that in some areas of the country, such a

253

254

B e y o n d the T reatme n t M a n u a l s

statement could place an African American man in physical danger (1990, p. 6). They advised therapists to help clients develop as wide a repertoire of responses as possible, but because the client is the best judge of what is right and safe, the client is the one who should decide what constitutes appropriately assertive behavior in any given situation. This approach also communicates the therapist’s respect for the client’s intelligence and decisions.

Conclusion Culturally responsive therapy involves an integrative approach that begins with expertise in an evidence-based home therapy, and flexibly incorporates ideas and strategies from other sources. CR-CBT is one example of an integrative psychotherapy, which makes use of the CBT research base on EBPs and also emphasizes clinical expertise in using these practices. CR-CBT emphasizes the integration of cultural considerations because culture has been relatively neglected within the psychotherapy research literature and the field of CBT. This emphasis includes particular attention to oppressive environmental conditions that may be contributing to the client’s distress.

Practice: Clarifying Your Approach Write a brief, general description that explains your approach to therapy. Practice it with a friend who will give you feedback, and tweak it until you have a description that accurately represents what you do, and that your clients will understand.

Key Ideas

  1. The American Psychological Association’s definition of EBPP is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.  2. An integrative approach to psychotherapy is guided by one overarching theoretical framework (i.e., home therapy) that also incorporates interventions from outside this home therapy.   3. A key step in culturally responsive cognitive behavior therapy (CR-CBT) involves defining which part of the client’s stress is

Culturally Responsive Therapy

externally generated by the environment, including social and cultural influences, and physical barriers, and which part is internally generated by the client’s thoughts, beliefs, and images.   4. Premature cognitive restructuring involves moving into thoughtchange strategies inappropriately or too quickly, that is, before exploring environmental influences, such as racism, sexism, and other physical and social barriers that may be realistically causing distress.   5. Action interventions involve physically doing something (i.e., taking action), whereas thought-change (cognitive) interventions involve mentally doing something (changing the way one thinks about a situation).  6. CLASS summarizes action interventions, including creating a healthy environment; learning a new skill; assertiveness, conflict resolution, and other communication skills; social engagement and support; and self-care activities.   7. Challenging the validity or rationality of a belief is risky, particularly if it is a core cultural belief; instead, a collaborative exploration of the helpfulness of a thought recognizes that, ultimately, the client is the judge regarding the helpfulness of thoughts and behaviors.  8. Compassion voice is a form of cognitive restructuring that involves replacing harsh judgmental cognitions with compassionate thoughts and images about oneself and others.   9. The development of culturally responsive homework can be facilitated by asking clients at the end of the session, “Based on what we did or talked about today, what is the smallest possible step you could take that would feel like you are making progress?” 10. As therapists, we can teach clients coping skills, including new behaviors and a range of assertive responses, but clients must take into account the neighborhoods in which they live, community norms, and the reliability of community supports; and sometimes significant risks are associated with using these new behaviors.

255

Indigenous, Traditional, and Other Diverse Interventions

W

11

hen I was living in North Africa, an Arab Muslim man who knew that I was a psychologist asked if he could talk with me about a problem he was having. He told me that he was experiencing anxiety related to worries about money and his work. He had always been an intense person, and these were ongoing worries, but suddenly he found that he was unable to swallow. He would put food or drink in his mouth but couldn’t get it to go down. As a result, he had lost quite a bit of weight, and he was extremely uncomfortable because it was summer and the heat made him unbearably thirsty. (During the summer, he also had more free time to sit and worry.) He did not want to talk about his feelings in any depth, and I was not in a position to be of any help professionally. However, I listened, encouraged him by saying that this was a problem that I knew could be solved, and suggested that he see his doctor (there were no psychologists in his country at the time).

http://dx.doi.org/10.1037/14801-011 Addressing Cultural Complexities in Practice: Assessment, Diagnosis, and Therapy, Third Edition, by P. A. Hays Copyright © 2016 by the American Psychological Association. All rights reserved.

257

258

B e y o nd t h e T r e a t m e n t M an u a l s

Several months later, when I was back in the United States, I learned that although the problems in his life still existed, his anxiety had decreased, and he was no longer having difficulty swallowing. He had gone to see a doctor, but that was not what had helped. What made the difference was that he began practicing the religious requirements of Islam. The essentials of these requirements are commonly called the “Five Pillars of Islam” and include the following:  1. The Shahaada, a profession of faith in the one God and Mohammed as his prophet;   2. The daily prayers;   3. Giving alms to the poor (zakat), a form of worship also intended to correct social inequalities;   4. Fasting during the holy month of Ramadan, which celebrates Mohammed’s initial revelation from God and his journey from Mecca to Medina; and   5. The hajj, a pilgrimage to Mecca, made toward the end of one’s life if at all possible (Ali, Liu, & Humedian, 2004). Of these requirements, the prayers involve the greatest commitment of time and effort on a daily basis. In Muslim countries, the call to prayer is made from the mosques (more recently, over loudspeakers) at regular intervals five times each day. In response to the call, devout believers stop what they are doing and perform special washing rituals, which cleanse one’s body and also symbolically purify the soul. The prayer begins in dignified, upright posture but climaxes when the supplicant has sunk to his or her knees with forehead touching the floor. This is the prayer’s holiest moment for it carries a twofold symbolism. On the one hand, the body is in a fetal position, ready to be reborn. At the same time it is crouched in the smallest possible space, signifying human nothingness in the face of the divine. (H. Smith, 1991, p. 246)

The act of praying in the direction of Mecca, along with the knowledge that Muslims around the world are also turned toward Mecca, saying the same prayers at similar intervals, “creates a sense of participating in a worldwide fellowship, even when one prays in solitude” (H. Smith, 1991, p. 246). Regarding this Muslim man, you could take a strictly cognitive behavioral perspective that his improvement was due to the highly structured behavioral components of praying five times a day, regularly giving alms to the poor, and observing Ramadan. You might infer that a cognitive shift occurred when he began spending more time on these positive, religious activities than on worrying, and that these behavioral and cognitive changes worked to relax his body to the point that his physical symptoms disappeared. In addition, you might emphasize the increased social and cultural support for the changes he made.

Indigenous, Traditional, and Other Interventions

You also, however, could view the man’s healing from a spiritual perspective, emphasizing the peace that comes from letting go of worries, the social support from fellow Muslims and spiritual comfort from God, and possibly an experience of transcendence obtained through his practice. Or, you might see his improvement as involving all of these aspects of being human—behavioral, physical, cognitive, social, cultural, and spiritual. What’s important is that what he did worked for him, much more effectively than an imported, Western-style psychotherapy. In many cultures, psychotherapy is a treatment of last (if any) resort. In economically developing and poorer countries, it is often unavailable, unaffordable, or practiced in a way that is relevant only to highly educated upper-class individuals. Within wealthier countries, psychotherapy may still be unavailable or unaffordable, as for example, in many rural areas of the United States, where mental health centers are nonexistent, and if they do exist, have difficulty recruiting and keeping well-qualified providers. Even when psychotherapy is available and affordable, often the stigma associated with mental health problems prevents people from accessing those services (Yeh, Inman, Kim, & Okubo, 2006). For all of these reasons, it is important that therapists be knowledgeable about diverse approaches to healing. This chapter begins with examples of therapeutic practices that are indigenous to particular minority cultures, some of which can be integrated into psychotherapy. Next is a section on the expressive and creative therapies, particularly art and play therapies, which can be helpful with children and adults who have language difficulties, are less verbally oriented, or have language deficits resulting from dementia or head injury. Within this section, some suggestions regarding play therapy with children of diverse identities are included. The next sections describe the use of family, couple, and group therapies with culturally diverse people, followed by suggestions for systems-level interventions that promote social justice. Finally, information is provided regarding cross-cultural considerations with medications.

Indigenous and Traditional Therapies When you think about the ways in which treatments develop out of cultures embedded in particular geographic locations, it makes sense that the most effective approaches are often those developed locally. A Rwandan talking with the Western journalist Andrew Solomon explained: We had a lot of trouble with Western mental health workers who came here immediately after the genocide and we had to

259

260

B e y o nd t h e T r e a t m e n t M an u a l s

ask some of them to leave. They came and their practice did not involve being outside in the sun where you begin to feel better. There was no music or drumming to get your blood flowing. There was no sense that everyone had taken the day off so that the entire community could come together to try to lift you up and bring you back to joy. There was no acknowledgment of the depression as something invasive and external that could actually be cast out of you again. Instead they would take people one at a time into these dingy little rooms and have them sit around for an hour or so and talk about bad things that happened to them. We had to get them to leave the country. (Solomon, 2014, podcast)

Around the world, indigenous methods and traditional healers are the first choice for many people of minority and dominant cultures. In recent years, dominant European and American cultures have embraced many of these approaches, which are now commonly referred to as complementary and alternative medicine and are being integrated into the practice of psychotherapy (Barnett, Shale, Elkins, & Fisher, 2014). Marsella and Kaplan (2002) provided a list of 27 healing systems or therapies, including curanderos, ho’oponopono, acupuncture, Ayurvedic medicine, Morita, Naikan, tai chi chuan, yoga, and Zen. Following are a few examples. For many people of Central and Latin American heritage, one such healing system is curanderismo, which involves a number of treatments, including “herbal remedies, breathing exercises, sweating, massage, incantations, and ritual cleansing treatments” (Falicov, 2014, p. 207). Curanderos (male healers) and curanderas (female healers) are sought out for help with problems, such as depression, impotence, alcoholism, and menstrual cramps, as well as with traditional Latino illnesses, such as susto (fright), mal de ojo (evil eye), and empacho (indigestion). They are known for creating a warm, supportive atmosphere, observing the value of family connectedness by including family members, and communicating confidence that they will be able to help the individual. In addition, these traditional healers, along with many Latino people, often recognize the value in modern medicine and embrace a cooperative approach to health care (Falicov, 2014). Traditionally, Native Hawaiians have used a form of family therapy known as ho’oponopono, which involves a formally organized family meeting in which relationships are “set right” through a process of “prayer, discussion, confession, repentance, mutual restitution, and forgiveness” (Pukui, Haertig, & Lee, 1972, p. 60). In response to a problem, the family gathers together in a spirit of honesty and sincerity (Rezentes, 1996). A healer or family elder leads the meeting and guides discussions, questions participants, and controls disruptive emotions. Emphasis is placed on the value of lokahi, in which everything is perceived to be interconnected, and on a sense of balance between the person, family, nature, and spiritual world (Gaughen & Gaughen, 1996). Although it would be inappropriate for a therapist to lead a ho’oponopono unless he or she has been

Indigenous, Traditional, and Other Interventions

trained to do so, the therapist may work with a family elder or healer to arrange it—an approach integrated into a substance abuse program in Hawaii (Gaughen & Gaughen, 1996). One traditional helping strategy that can be incorporated into mainstream psychotherapy is the practice of storytelling. Storytelling is one of the most common forms of verbal learning in indigenous cultures (Brendtro, Brokenleg, & Van Bockern, 1998). Used as a helping strategy, the speaker does not directly advise the listener, but rather tells a story through a metaphor that offers a social message. The listener is then free to draw a conclusion if he or she is ready to do so (Swinomish Tribal Community, 1991). In the movie Smoke Signals (Rosenfelt, Estes, & Eyre, 1998), storytelling as a therapeutic strategy is illustrated in an interaction between a handsome angry young man named Victor and his mother. In the movie, Victor lives with his mother on the Coeur d’Alene reservation in Idaho. He has painful childhood memories of his father’s drinking. He pretends not to care that his father left them when Victor was a boy. But one day, when Victor is in his 20s, his mother gets a phone call. The woman on the other end says that Victor’s father has died and that she has his things if someone wants to come to Arizona to get them. There is no question that Victor will go; the problem is how. They have no money and no car. Then a nerdy young man named Thomas offers his jar of savings on one condition: Victor has to take Thomas with him. Thomas is like a pesky younger brother to Victor; his constant talking, upbeat attitude, pigtails, and goofy grin all annoy Victor to no end. Neither of them has ever been off the reservation, and Victor does not want his first trip complicated by having to deal with Thomas. As Victor’s mother is cooking fry bread in the kitchen, Victor explains his disinterest in Thomas’s offer. In response, Victor’s mother asks Victor if he knows how she learned to make such good fry bread. He replies that he knows she makes it all by herself. She smiles and then goes on to tell him about all the people who have helped in making her fry bread delicious—her grandmother, who taught her how to make it; her grandmother’s grandmother, who passed down the recipe; and all the people who had eaten it over the years and said, “Arlene, there’s too much flour” or “Arlene, you should knead your dough more.” And, she adds, “I watch that Julia Child. She’s a good cook too, but she gets lots of help.” The point is not lost on Victor, who eventually accepts (albeit begrudgingly) Thomas’s offer.

RELIGION Religion can be a powerful source of healing, in part because religion is comprehensive in a way that psychotherapy is not. The world’s major religions address the needs of the whole person including spiritual,

261

262

B e y o nd t h e T r e a t m e n t M an u a l s

emotional, physical, and social needs. Religion offers a belief in something bigger than oneself, and with that belief, comes meaning and a sense of purpose. And because religion develops within a cultural context, it is integrated in a way that supports its beliefs and practice throughout the culture. It’s not surprising then that studies show people who practice a religion report greater happiness and well-being than people who are not religious (Lyubomirsky, 2007). For a beginning understanding of key concepts in the world’s major religions, I recommend The World’s Religions (2009), by Huston Smith, who has practiced Christianity, Buddhism, and Islam (sequentially) over the span of several decades. The book also includes chapters on Judaism, Confucianism, Australian Aboriginal spirituality, and a number of other religions, and it is a helpful resource in working with clients of diverse beliefs. In addition, Richard and Bergin’s (2014) Handbook of Psychotherapy and Religious Diversity provides specific suggestions on applying such information in psychotherapy. Therapies indigenous to particular cultures also share religious assumptions while not being religions per se. For example, the five therapies of Morita, Naikan, Shadan, Seiza, and Zen are indigenous to Japan and share the goals of helping the individual refocus attention away from self and everyday self-consciousness and slow the pace of thought, which in turn helps to deepen it (Reynolds, 1980, p. 103). Like Buddhism, emphasis is placed on the acceptance of suffering as an integral part of life. In contrast to mainstream psychotherapies, talking is discouraged; instead, clients are placed in quiet isolation (with some guidance provided by the therapist) to facilitate the development of the “natural inner strength” that can lead to “a more enlightened understanding” of oneself (Reynolds, 1980, p. 104).

MINDFULNESS MEDITATION Meditation is a mind–body practice with roots in several religious traditions, and as such, consists of a number of different approaches, each with its own procedures, goals, and benefits (Barnett et al., 2014). In recent years, meditation has gained substantial research support for its health benefits, particularly an approach known as mindfulness meditation. Mindfulness meditation begins with the concept of mindfulness, which is defined as simply paying attention to the present moment without judgment (Kabat-Zinn, 2005). Because mindfulness involves suspending judgment of oneself and others, it can be helpful in many ways. It facilitates concentration and working memory, and it creates an open attitude that increases compassion and recognition of the positives in life. In addition, because it slows emotional reactivity, it can help in making decisions that fit with one’s values and long-term goals. Research

Indigenous, Traditional, and Other Interventions

shows that mindfulness positively affects physical health by improving immune system functioning (Davis & Hayes, 2012). To experience a moment of mindfulness right now, take a deep breath and notice the feeling of the air moving in through your nostrils and then out through your nostrils. As you pay attention to your breath, you may notice a relaxing feeling in your body. Mindfulness has a calming effect on the human arousal system because focusing on the breath draws attention away from worries about the past and fears about the future. Because mindfulness involves taking a mental step back from and observing your own experience, it changes your relationship to stressors and stress. This little bit of distance decreases the experience of physical and emotional suffering that makes stressors and pain feel bigger. Along with behavioral and cognitive changes, the practices of “stopping,” calming oneself through conscious breathing, paying attention, and simply “being” in the present moment can facilitate a shift in consciousness. As the Vietnamese Buddhist monk Thich Nhat Hanh (1992) explained, If we practice mindfulness, we get in touch with the refreshing and joyful aspects of life in us and around us, the things we’re not able to touch when we live in forgetfulness. Mindfulness makes things like our eyes, our heart, our non-toothache, the beautiful moon, and the trees deeper and more beautiful. If we touch these wonderful things with mindfulness, they will reveal their full splendor. When we touch our pain with mindfulness, we will begin to transform it. (p. 29)

I have found mindfulness to be helpful in my clinical practice, in several ways. For one, it helps me to stay with the client’s experience of pain but at the same time not be engulfed by it. Emotions are contagious, and by paying attention to my body’s physical reactions to a client as they describe their experiences, I am able to take a step back from powerful emotions that might lead me to emotionally disconnect from the client. In addition, I often teach the following mindfulness technique to clients (Exhibit 11.1), particularly when they are experiencing a great deal of anxiety. First, as the client is experiencing anxiety in the moment, I ask her to rate its intensity on a scale of 0 (no anxiety) to 10 (highest level). I then ask where in her body she is most experiencing the anxiety, tension, stress, or pain. On rare occasions, a client may be unable to state a physical place, in which case, I adapt the exercise to a more general body sensation. Next, I describe the body as a treasure chest of information about who we are and what we need. I ask the client if she is willing to try a brief exercise that is not a relaxation exercise, but rather, an exercise in

263

264

B e y o nd t h e T r e a t m e n t M an u a l s

EXHIBIT 11.1 Try This: The Mind–Body Focus Step 1. Begin by sitting or lying comfortably, with eyes closed or gaze lowered. Turn your attention to your breath and, as you focus on your breath, notice the feeling of the air moving in through your nostrils, and the air moving out through your nostrils. If you notice your attention being pulled away by noises around you or thoughts that pop into your head, gently pull your attention back to your breath, letting go of any judgment about the distractions or what you are doing. Remember, this is not a relaxation exercise; the exercise is only about paying attention without any judgment about what you’re noticing. Step 2. Now turn your attention to the part of your body where you hold tension, stress, or pain. You may notice a difference in texture, color, vibration, or sensation in this area, or you may not notice any difference at all. With your eyes closed, direct your mental awareness toward the top of this area. Slowly walk your attention to the right side of this area, then to the bottom of the area. Continue by slowly turning your mental attention to the left side, and then back to the top of the area. Now taking a three-dimensional perspective, move your attention from the front of the area through to the back, again noticing anything there is to notice. As you do the exercise, there is no need to try to relax, because this is not a relaxation exercise; rather, it is simply an exercise in paying attention. Step 3. When you are ready, bring your attention back to your breath, and slowly return your awareness to your present surroundings. Note. Adapted from Creating Well-Being: Four Steps to a Happier, Healthier Life (p. 54), by P. A. Hays, 2014, Washington, DC: American Psychological Association. Copyright 2014 by the American Psychological Association.

beginning to pay attention to the body’s signals. I add that the exercise takes about 5 minutes, and during that time, I will ask her to close her eyes and listen to my voice, as I guide her to focus on her breath and then the area of her body where she’s experiencing the stress. If she is willing, I then guide her in the following exercise, using a slow, calming voice with frequent pauses. You might want to read the exercise first, and then try it yourself. It’s important to note that I do not use this exercise with someone who has severe posttraumatic stress dis­ order. For such individuals, simply closing their eyes can feel unsafe, and focusing on the breath can create an overwhelming feeling of letting go of things the individual is not ready to let go of. At the conclusion of this exercise, I wait about a minute for the client to react. If she doesn’t say anything, I wait a little longer, and then depending on the person, I usually ask, “How was that for you?” Often the person describes an experience of relaxation, including some particular insight regarding the experience. For example, one client focused on her heart, and said that as she was doing the exercise, she noticed that the front of her heart was happy, light, and bright, but when she went to the back side of her heart, that area was dark and heavy. She linked this experience to the insight that in her daily life, she presented

Indigenous, Traditional, and Other Interventions

with a cheerful front, but behind the cheerfulness was deep pain that she tried to avoid thinking about. This led to a discussion exploring what she was hiding, including her fears about paying attention to her feelings and thoughts. At some point during the discussion that follows this exercise, if a client describes it as a relaxing experience (which usually is the case), I ask them again what their anxiety level is on the 0 to 10 scale, which usually reflects the change. I may then comment, “Isn’t it interesting how, even though this wasn’t a relaxation exercise, when you pay attention to your body, even if you’re paying attention to the pain, it has a calming effect?” This leads me to an explanation provided by Thich Nhat Hanh (although if the client might be put off by the idea of Buddhism, I just describe it as the work of a particular person who has studied pain and suffering). Here’s what I say: There’s a Buddhist monk named Thich Nhat Hanh who gives an interesting explanation of this experience. He says that when we’re hurt or we do something that hurts ourselves or someone else, a knot is tied inside of us (I make a knot with my fist), and this knot is located somewhere in our physical being. If, after we say or do the hurtful thing, we quickly pay attention to the knot, we are more able to let go of it, or it loosens. But often what we do instead is push the knot down or away, and then it becomes tighter. And the longer we wait to address it, the tighter the knot becomes.

I then ask the client if this makes sense to them, and if so, what they think about the idea in relation to themselves and the stress they’ve been experiencing. This can then lead into an exploration of what they need in their lives right now. And often the client will choose this exercise to practice as homework during the coming week. Ameli (2014) described a helpful approach to integrating the two aspects of mindfulness—attention and compassion—to all experiences, including thoughts and emotions. Her book contains many helpful suggestions for integrating mindfulness into daily living. Using the acronym RAIN, the client is encouraged to Recognize the thought (or emotion), and bring full attention to it; Accept the thought (or emotion)—consider it a guest and invite it in; Investigate the thought (or emotion)—with an attitude of curiosity, pay attention to its qualities—Is it busy, clear, confused, small, large, mild, intense? Does it include images? Is it connected to a physical sensation? Does the physical sensation shift as the thought (or emotion) shifts? Nonidentify with the thought (or emotion)—Get to know your thoughts and emotions, and the ways in which they come and go, without getting lost in the story they tell. Think of awareness as the sky, and your thoughts and feelings as clouds in the sky that come in, linger for a while, then go away. (Summarized from Ameli, 2014, pp. 181–182)

265

266

B e y o nd t h e T r e a t m e n t M an u a l s

Taking mindfulness a step further, clients may find many types of meditation helpful for their particular situations. Buddhist approaches include insight meditation, loving-kindness meditation, Zen meditation, walking meditation, Tonglen (willingness to stay open and available to pain and suffering in oneself and others), Dzoghen (allowing experiences to unfold naturally, like clouds passing through an open sky), and many others (Chögyam Trung Rinpoche, 2014). Several forms of meditation have been formally integrated into the practice of psychotherapy. The approach known as mindfulness-based stress reduction (Kabat-Zinn, 2005) incorporates the concept of mindfulness meditation in particular, and has substantial research supporting it (Barnett et al., 2014). Other approaches that have been integrated with psychotherapy include mindfulness-based cognitive therapy (Segal, Williams, & Teasdale, 2012), acceptance and commitment therapy (Hayes & Smith, 2005), and dialectical behavior therapy (Linehan, 2014). Clinicians who are interested in integrating mindfulness practices and meditation are advised to obtain specialized training.

EXPRESSIVE AND CREATIVE ARTS THERAPIES All of the major psychological theories are heavily language dependent. This reliance on verbal skills as the dominant mode of expression places many people at a disadvantage, including people who speak English as a second language, individuals with particular intellectual disabilities, people who have dementia or brain injuries that limit their language abilities, and young children. In addition, some individuals who speak English as a first language and have no impairments are simply less verbally oriented. Solutions to the language-centered bias of psychotherapy may be found in the expressive and creative arts therapies, which incorporate art, music, body movement, dance, and play (Dulicai & Berger, 2005; Hiscox & Calisch, 1998; Hoshino, 2003; Malchiodi, 2005; O’Connor, 2005; Sutton, 2002). Such modalities can facilitate interaction and elicit responses when verbal modalities fail. With clients whose cultural frame of reference renders direct eye contact uncomfortable or inappropriate, creative arts therapies may be more effective because they give clients something to look at and something to do with their hands. Itai and McRae (1994) described one such example in which clinicians used gardening to engage Japanese American elders. The arts offer a powerful mode of expression that can incorporate cultural traditions and at the same time facilitate healing. For example, among Aboriginal Australians, hand-painted Indigenous healing cards depicting various life stories have been used as prompts for clients to tell

Indigenous, Traditional, and Other Interventions

their stories (Cameron, 2010). The power of this approach is evident in some of the clients’ story-line responses for one of these cards: 1. “They came and took my children, those White bastards, never seen them again, the sickness is still in my stomach.” 2. “I don’t know my mother, father, family, they took me away cause my skin was White.” 3. “They came and took my baby, cause her skin was fairer, I never saw her again.” 4. “I was adopted as a child, the government said it was to protect me and give me a better life, I was constantly abused and raped by my adoptive father, it doesn’t make sense. I don’t trust many people.” (Cameron, 2010, p. 406)

In another program with Aboriginal Australians, storytelling and drawings were incorporated into group therapy. Both parents and children were asked to draw their stories, and then use these drawings in the telling and sharing of their experiences. The authors noted that this sharing of stories via the expressive use of art engaged and supported the group participants, and it empowered parents to recognize their own personal resources (Stock, Mares, & Robinson, 2012). A common misperception regarding art therapy is that therapists directly interpret the meaning of clients’ drawings (e.g., that a drawing of a person without limbs means the client feels powerless). On the contrary, art therapists generally are trained to avoid interpreting clients’ creations and instead are trained to allow clients to interpret their own work (J. Hoshino, personal communication, September 25, 2006). This approach eliminates the problem of misinterpretation, which is more likely when therapists differ culturally from their clients. In her integration of art and cognitive behavioral therapies, Malchiodi (2005) made several recommendations, including the following. First, she avoids the words draw and art because they can be intimidating; instead, she asks the client to “create an image” of their anxiety, depression, anger, or other emotion. Second, she may ask the client to create a therapeutic image that counters the first image, for example, showing “how I can prepare for a stressor” or “step-by-step management of the problem.” In one example of a woman who drew a picture illustrating hatred of her own body, the woman’s subsequent therapeutic image showed her husband’s arms wrapped lovingly around her body. Third, clients may be encouraged to create a visual journal, for example, by cutting and pasting magazine photos and other pictures or written words onto a piece of cardboard. In a similar idea, another group of therapists recommended helping transgender clients create a “Trans-Affirmative Hope Box” of inspiring and affirming items, such as photos of supportive people, a list of future goals, symbols of safe and joyful places (e.g., LGBQ&T community center logo, genderqueer pride button, postcard from a vacation), favorite

267

268

B e y o nd t h e T r e a t m e n t M an u a l s

lyrics, mantras, and poems (Craig, McInroy, Alloggia, & McCready, 2014). Austin and Craig (2015) also suggest use of the “Virtual Hope Box” cocreated by the client and clinician working together (available as a smartphone application for users and as clinician’s guide; National Center for Telehealth & Technology, n.d.). Regarding therapists’ use of clients’ artwork, Hammond and Gantt (1998) suggested that artwork could be viewed as equivalent to verbal communication and subject to the same protections. For example, clients’ artwork should not be displayed without clients’ permission (and even then, with confidentiality protected), and therapists need to take special care in their inclusion of clients’ artwork in clinical records, where it could be misinterpreted or “susceptible to inappropriate exposure” by others (Hammond & Gantt, 1998, p. 273). Because clients of any age may feel inhibited, overwhelmed, or frustrated by art activities, Weiss (1999) advised that therapists give clients an explanation of the types of art media available, demonstrate their use, and offer a varied selection (e.g., colored pencils, fine-tip magic markers, pastels, acrylics, oils). Different media have varying degrees of flexibility and ease of use and thus can elicit different emotions. Weiss provided specific art exercises for work with older adults, such as “Making Your Own World,” “Tree of Life,” and “Draw Your Future”—exercises that also may be helpful with people of other age-groups (Weiss, 1999, pp. 193–195). Additional resources include Herring’s (1999) description of the variety of creative arts used in American Indian cultures, a description of methods for engaging people of diverse spiritual perspectives in the creative process (Fukuyama & Sevig, 1999), and the use of the ADDRESSING framework in art therapy with families of minority cultures (Hoshino, 2003; see also Calisch, 2003, regarding multicultural training in art therapy).

PLAY THERAPY Because children under the age of 11 years generally do not have a fully developed ability to think abstractly and thus are unable to verbally express complex feelings, motives, and concerns, play therapy can provide an opportunity for them to more naturally express themselves (Bratton, Ray, Rhine, & Jones, 2005). Play therapy is therapeutic because it provides a space in which children can act out problems or conflicts and practice possible solutions. The therapist facilitates this process by establishing a safe environment, giving his or her undivided attention to the child during play, and occasionally making well-timed interpretations or suggestions that help the child’s understanding and development of new skills (Swinomish Tribal Community, 1991). Research has shown play therapy to be effective in improving children’s emotional and behavioral problems, particularly the form of play therapy known as filial therapy, in which therapists teach parents how

Indigenous, Traditional, and Other Interventions

to play with their own children (Bratton et al., 2005; Van Fleet, 2013). Play therapy research, however, is only beginning to address cultural influences and continues to be hindered by several ethnocentric assumptions: (a) that children’s play behavior is the same across cultures (for significant cultural variations, see Roopnarine, Johnson, & Hooper, 1994), (b) that the direct expression of feelings is essential for effective conflict resolution (in contrast to preferences for more indirect and subtle solutions in other cultures), and (c) that a relatively unstructured and casual relationship with the play therapist is preferable (O’Connor, 2005). Countering these assumptions, O’Connor (2005) suggested the following strategies. First, include a selection of culture-specific and cultureneutral toys and materials in the therapy setting. Canes, wheelchairs, and adaptive devices for pretend play figures can reflect different physical abilities; dolls of different ethnicities and genders should include enough of each gender for the possibility of two mothers, two fathers, and extended family members; and religious symbols should include decorations that celebrate a variety of religious traditions and holidays. Keep in mind that the typical dollhouse reflects a middle-class, singlefamily environment, so it’s important to include house-type structures with relevant furnishings. Second, O’Connor (2005) noted the importance of recognizing that some parents (e.g., of Asian heritage) may expect a more active, directive, and goal-oriented approach that helps their children build specific skills; they also may expect the therapist to tell them what has happened in each session. Some Asian parents may disagree with the practice of teaching children to directly and overtly express their opinions, viewing this behavior as confrontational or disrespectful. Similarly, some African American parents may consider children calling the therapist by his or her first name to be disrespectful. Recognizing these cultural preferences, O’Connor encouraged therapists to “negotiate a balance between the needs of their child clients and the families and the community systems in which they are embedded” (2005, p. 569). Part of this balance involves emphasizing the strengths of each child’s culture, a practice that can occur naturally when the child mentions something unique about his or her culture and through the use of culture-specific stories, games, songs, and poems (O’Connor, 2005; see also Gil, 2006). Third, when using expressive and creative arts therapies, the setting may play a role in clients’ comfort level with these approaches. Whereas these therapies may be viewed as “normal” in residential or educational facilities, adult and elder clients in behavioral health or medical clinics may view these approaches as the therapist treating them like children. To avoid this assumption, a thorough introduction and explanation of the approach is important. In addition, if you intend to use expressive and creative arts modalities in your work with clients, training in these therapies is strongly advised.

269

270

B e y o nd t h e T r e a t m e n t M an u a l s

FAMILY THERAPY For many people of ethnic minority cultures, family therapy is the therapy of choice. In working with multigenerational families, Duffy (1986) emphasized that older family members are central figures with desires and needs of their own, not simply resources for younger members. He suggested the use of telephone conference calls, letters, and audiotapes to include members who are unable to attend therapy sessions because of distance or disability. He also advised home visits and creative scheduling—for example, three 1-hour sessions on 3 consecutive days rather than one exhausting 3-hour session. Using a combination of strategic (Haley, 1963) and structural (S. Minuchin, 1974) approaches, S. C. Kim (1985) described an approach to working with Asian American families (that may also apply to other minority cultures) in which the therapist carefully assesses the power structure of the family system; does not overtly challenge the leadership of those in authority; and uses a directive, problem-focused (rather than person-focused) approach that provides clients with a sense that practical suggestions will be aimed at changing the situation as quickly as possible. Although insights and emotional expressiveness may come as a result of these situational changes, they are not the primary focus. With South Asian (e.g., East Indian, Pakistani, Bengali) families in particular, Tewari, Inman, and Sandhu (2003) noted that it may be helpful to meet separately with each family member (in addition to family sessions) to give all members the opportunity to express their thoughts and feelings. When working with ethnic minority families and in rural areas, it can be helpful to conceptualize one’s role as similar to that of a family doctor who sees individuals and family subsystems on an as-needed basis for whatever problems may arise (Hong, 1988). It is important to recognize the variety of definitions of family—for example, children may have more than one mother or father, may consider a grandparent to be the primary parent, or may include non-blood-related individuals as family (Matthews & Lease, 2000). Particularly in rural areas, where resources are limited, therapists need to be generalists, willing to work flexibly with families and their individual members (Harowski, Turner, LeVine, Schank, & Leichter, 2006). Advantages to being considered the family’s care provider include decreased time and costs (compared with a different therapist seeing each person) and a decreased need to establish trust with each new family member.

COUPLE THERAPY Keeping in mind the ADDRESSING framework’s influences and identities that two individuals may hold, it is not surprising that couples’ conflicts often emerge in relation to differences in worldviews and values.

Indigenous, Traditional, and Other Interventions

Understanding the origins of these differences as individual, familial, or cultural is often key to helping clients to accept and make changes. Recognizing that a particular behavior has come from a client’s family or cultural upbringing may decrease an individual’s sense of guilt and allow him or her to consciously decide whether he or she wants to continue the behavior. Similarly, recognizing cultural influences on a partner’s views can facilitate the development of understanding and the acceptance of differences (Hays, 1996). Consider the situation of a 28-year-old Indonesian man married for 3 years to a 28-year-old European American woman. Amin left his family in Indonesia to attend university, where he met his wife, Liz, who graduated at the same time. Both biologists, they decided to forgo having children for 5 years and live in a small one-bedroom apartment to save money. Conflict arose when Amin’s family decided to send his younger sister to university with the expectation that she would live with Amin and Liz. To Liz, it seemed that the decision had been made without her consent. Amin, however, could not understand Liz’s resistance—it was his sister who would be living with them, not a complete stranger; furthermore, if she did not live with them, she would not be able to leave their parents’ home. In a counseling session with the couple, it became clear that Liz and Amin both placed a high value on family relationships. Liz’s family and culture, however, emphasized independence, self-sufficiency, and plenty of physical space as necessary ingredients for a well-functioning family. In contrast, Amin’s family placed more value on physical proximity and interdependence, with young adult Indonesians commonly living at home until they marry (Piercy, Soekandar, & Limansubroto, 1996). Among intermarried couples, it is not uncommon for one or both individuals to either focus on their differences as insurmountable or to minimize the differences and thus not perceive how cultural influences have shaped their views. For Amin and Liz, simply recognizing the differences in their values was the first step toward a resolution. Next, exploring the influence of culture on these values helped Liz and Amin step back from their assumptions about what “should be” or “must be.” What seemed like enormous differences in their viewpoints was reconceptualized as only different degrees of emphasis. Liz also valued interdependence, just a little less than Amin. Similarly, Amin liked having his own physical space, but he didn’t need as much as Liz. This reconceptualization helped the couple to come up with new ideas for solutions and eventually decide on a compromise. Because it would cost extra for his sister to live with them, Amin asked his parents for a larger monthly allowance for her living expenses, and they readily agreed. This extra money allowed them to rent a nicer two-bedroom apartment, which gave the sister her own room and satisfied Liz’s need for space.

271

272

B e y o nd t h e T r e a t m e n t M an u a l s

Although value differences are an obvious source of conflict for crosscultural couples, they can be especially problematic for families with a recent history of immigration. Intergenerational conflict often occurs as older members support traditional values, language, and behaviors but younger members are pulled toward more current expressions of their own culture or the dominant culture. In such situations, it is important that therapists be clear about their own leanings and be willing to share this information with families in transition. More specifically, therapists may need to let clients know when their values conflict with client goals. For example, it may be necessary for therapists to tell couples at the outset whether they lean toward placing more emphasis on the happiness of each individual or on the preservation of the relationship. This type of self-disclosure needs to be handled cautiously, however, because too much sharing can shift the focus to the therapist’s unresolved value conflicts. When in doubt, the therapist should consult with someone who shares or knows the client’s value system well. Regarding issues of power in family and couples therapy, therapists need to be able to accept and work with the value systems of their clients—the view promoted by the multicultural counseling field in general. For example, therapists working in families with clearly defined hierarchies may need to address elders first (i.e., parents before their children) and show respect for family members who hold more authority (S. C. Kim, 1985; Murgatroyd, 1996). Such a stance does not require that therapists completely agree with their clients; value differences can have a positive effect of opening up a wider range of options for the client’s consideration. It does mean, however, that therapists may have to settle for the small changes desired by clients rather than fundamental structural changes in clients’ relationships. As a feminist, this is a difficult position for me to take, because it suggests support for relationships defined by patriarchal assumptions. As L. S. Brown (1994) noted, feminist therapy aims to change patriarchal assumptions, beliefs, and structures that cause distress in people’s lives: “It attends as well to prescribed ‘normal’ patterns of being with which people may be comfortable but which are ultimately destructive to their integrity” (p. 19). The practical application of these ideas can be difficult, to say the least. B. L. C. Kim (1998) provided concrete examples of couples consisting of an Asian woman (Korean, Filipina, or Japanese) and an American man, both working on a U.S. military base near their home. The woman is likely to hold a low-status, low-paying job in comparison to the man, whose position, although not necessarily high status in the United States, is associated with the most powerful military presence in the world. In addition, the woman may have experienced abuse, neglect, poverty, or economic exploitation. In this context, “sexist expectations

Indigenous, Traditional, and Other Interventions

and cultural colonialism” create a special form of racism in which “the husband’s superior and dominant position in such a couple’s relationship is affirmed and reinforced” (B. L. C. Kim, 1998, p. 311): For a woman who comes to such a marriage with low socioeconomic status and low self-esteem, her dignity and identity are further diminished. Moreover, the arduous tasks of learning English and becoming acculturated to the American lifestyle are placed upon the wife, whereas the husband is nearly always exempted from learning his wife’s language and culture. . . . The clear message to the wife is that her own heritage of language and culture is unworthy of her husband’s attention or respect. (p. 311)

From a feminist perspective, the therapist’s work with couples whose power is so imbalanced would be to help them recognize the imbalance and then consider the advantages but also the costs of maintaining such a relationship, with the ultimate goal being to help the couple become more egalitarian in their interactions (Sims, 1996). But the couple may not share the values embedded in this goal. As B. L. C. Kim (1998) noted in relation to couples in the situation described previously: Very often the partners are quite satisfied with small changes in the relationship, along with clarification of misunderstandings and miscommunications. Many wives are happy when their husbands move from the role of dictator to that of benevolent although still-domineering husband. Nearly three-quarters of the couples I have seen have terminated therapy at this point. Only about one-fifth are motivated to go on with treatment and seek further growth. (p. 317)

The question then becomes, “Is it possible to help people work toward ‘better’ relationships when their definition of better is different from the therapist’s?” I believe that it is, but at the same time, I recognize that therapists vary in what they are willing (and not willing) to help clients do. For example, some feminist therapists may believe that it compromises their ethics to work with couples who prefer a power differential in their relationship. I also think, however, that it is important to consider how therapists’ own cultural heritage and context influence their sense of what is ethical. The exception to my suggestion that therapists try to avoid imposing their values on the client is when there is a risk of harm to the client or someone else. Such a statement might seem obvious, but a perception among many European Americans suggests that minority groups, particularly those with patriarchal traditions (e.g., Latino, Asian, Arab, Muslim), condone domestic violence. But one could make the same observation regarding European American culture, which also has patriarchal traditions and a high rate of violence against women (APA, 1996). Although patriarchal relationships tend to increase the likelihood

273

274

B e y o nd t h e T r e a t m e n t M an u a l s

of violence, just because a culture is patriarchically organized it does not mean that violence is normative or that a given family will view it as such. In therapeutic settings, domestic violence is largely a hidden problem; clients rarely come to therapy stating that they are being abused or abusing someone else. Rather, they bring other problems that are often related to, caused by, or exacerbated by abuse. For this reason, therapists need to be sensitized to the signs and symptoms of abuse. One of the best ways for female therapists to gain this sensitivity is to work or volunteer in a shelter for abused women and children. For male therapists, such experience is usually less easily obtained; however, men may gain a knowledge base through volunteer work with a women’s resource center, reading, and consultation. Culture should never be used as an excuse for violence, but the ways in which a therapist addresses domestic violence may vary depending on the culture (C. K. Ho, 1990). For example, the involvement of community and family elders may be helpful in cases of domestic violence in Asian and Asian American communities. By giving the woman permission from a position of authority to escape the dangerous situation, elders can help to bypass the problem of a woman’s loyalty to an abusive husband (C. K. Ho, 1990, p. 146). Although research on power in relationships traditionally has focused on heterosexual couples, power differentials related to gender role socialization may be equally influential for same-sex couples. As Farley (1992) noted with regard to gay men, therapists should consider how each partner defines masculinity, including how they view competition and aggression within relationships. Because men are more often socialized to fear a loss of control or power, holding back from a commitment to intimacy may be an issue for male couples. In contrast, because women are more often socialized to make relationships their center, bonding in lesbian couples may result in “fusion, with the struggle becoming one of individuation” (Farley, 1992, p. 235). With clients of all cultural identities, it is important to look for the ways in which power is organized in the family. Although one might be inclined to assume a patriarchal organization, the variation between and within cultures is so great that it is safer to start with well-informed questions. These questions may be generated using the ADDRESSING framework, as in the following examples: ❚❚

❚❚

❚❚

Age and generational influences—Does the couple have a large age difference that contributes to a power differential? Developmental or other disability—Is power held or withheld on the basis of disability? Religion and spiritual orientation—Do religious beliefs dictate that certain members have more authority?

Indigenous, Traditional, and Other Interventions

❚❚

Think about this: Think about the group of people you

❚❚

❚❚

consider family. Then, using

❚❚

the ADDRESSING acronym, consider how power is organized in your family.

❚❚

❚❚

Ethnic and racial identity—Who holds the dominant cultural identity in bicultural or multicultural couples and families? Are there differences in status related to skin color or other physical or ethnic characteristics? Socioeconomic status—Who makes the money or holds the highest status by income, education, or occupation? Sexual orientation—Does one family member receive less social support or status on the basis of his or her sexual orientation? Indigenous heritage—Does one family member hold greater authority or status related to a stronger Native heritage (e.g., both parents are Native versus one Native parent and one non-Native parent, or someone with a more traditional upbringing)? National origin—Who is a citizen or holds a work visa? Who speaks the dominant language most fluently? Gender—Is power based on gender identity?

With some families, therapists may be able to ask and discuss these questions directly. However, with others, such an approach would be much too threatening, and these questions are best used to raise therapists’ awareness of possibilities. Whenever a therapist suspects that violence may be occurring, the first priority is always to ensure the safety of the abused individual(s).

GROUP THERAPY Group therapy is another systemic intervention that can be helpful in creating an environment in which clients can learn from others, practice new behaviors, and obtain support. Culturally diverse therapy groups have the added advantage of increasing members’ opportunities for growth through interactions with people of different perspectives. When problem solving is a focus, diverse therapy groups offer a broader information base and a wider range of potential solutions for group members. Of course, diversity has its down side, namely, the conflict that often occurs with differences. Because groups can easily replicate oppressive conditions in the larger society, therapists must pay special attention to the needs of individuals who are in the minority in a group. For example, in referring a gay African American man to a predominantly White gay and lesbian group, the counselor would first need to find out whether the group therapist is knowledgeable about and sensitive to African American culture. Otherwise, as Gutierrez and Dworkin (1992) have noted, “the referral could backfire if [the client] experiences insensitivity from the other group members and/or the facilitator” (p. 149). Group therapy may be problematic in rural areas or within closeknit minority groups, because confidentiality is difficult to ensure (Schank & Skovholt, 2006). For example, Paradis, Cukor, and Friedman

275

276

B e y o nd t h e T r e a t m e n t M an u a l s

(2006) described the particular challenges in conducting group therapy with Orthodox Jewish patients who live in close-knit communities, including the task of ensuring confidentiality, patients’ discomfort with therapy groups, and cultural restrictions regarding the appropriateness of certain topics. One way around the limitations of small communities is to offer time-limited educational or experiential classes or workshops that provide information and allow a structured format for discussion as well as indirectly involve social support (Droby, 2000; Organista, 2006). Peer support groups can be especially powerful for minority members who face exclusionary attitudes in their own communities. One such group for women and girls with disabilities facilitated participants’ development of self-confidence, disability pride, and a sense of belonging both with respect to being a woman and with respect to being a part of society in general (Mejias, Gill, & Shpigelman, 2014). Peer support groups also give participants an opportunity to help others, and this experience of being the “helper” instead of the “helpee” can bring with it a sense of meaning and purpose because, as one Asian Indian immigrant elder put it: “I would like to help others. If there is another older senior than me, I am willing to do that rather than just being taken care of” (Tummala-Narra, Sathasivam-Rueckert, & Sundaram, 2013, p. 6).

SUBSTANCE ABUSE TREATMENT An especially important source of psychotherapeutic help is available through the grassroots movement of self-help groups known as Alcoholics Anonymous (AA). Related groups include Adult Children of Alcoholics, and Narcotics Anonymous. The format and structure of AA groups vary, but in general, meetings begin with a formal statement of the purposes of AA, followed by a reading of the Twelve Steps, a set of guidelines for recovery: Step 1:  [We] admitted we were powerless over alcohol [drugs]— that our lives had become unmanageable. Step 2:  Came to believe that a Power greater than ourselves could restore us to sanity. Step 3:  Made a decision to turn our will and our lives over to the care of God as we understood Him. Step 4:  Made a searching and fearless moral inventory of ourselves. Step 5:  Admitted to God, to ourselves, and to another human being the exact nature of our wrongs. Step 6:  Were entirely ready to have God remove all these defects of character. Step 7:  Humbly asked Him to remove our shortcomings. Step 8:  Made a list of all persons we have harmed and became willing to make amends to them all. Step 9:  Made direct amends to such people wherever possible, except when to do so would injure them or others.

Indigenous, Traditional, and Other Interventions

Step 10:  Continued to take personal inventory and when we were wrong, promptly admitted it. Step 11: Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out. Step 12:  Having had a spiritual awakening as the result of these Steps, we tried to carry this message to alcoholics [drug abusers] and practice these principles in all our affairs. (J. A. Lewis, Dana, & Blevins, 1994, pp. 119–120)

Several culture-specific groups have grown out of AA, and when referring clients, it is helpful to be familiar with the norms of these groups. In American Indian AA groups, the expectation of anonymity may be rejected, participation may be open to anyone in the community, meetings less structured in terms of procedures and arrival and departure times, and potlatches held to celebrate anniversaries of sobriety (Jilek, 1994). For Native people who have limited literacy or speak English as a second language, AA meetings and 12-step programs may be conducted in the local first language and use fewer written materials (Weaver, 2001). Men in Recovery is a 12-step program whose membership consists primarily of African American men. This group objects to the ideas of admitting one’s powerlessness and “surrendering,” which are seen as detrimental to African American men (Hopson, 1996). Similarly, Women for Sobriety rejects the concept of dependency and instead stresses “healthy self-esteem, autonomy, and individual responsibility” for women in recovery (Hopson, 1996, p. 538). In general, with clients who do not identify completely with the AA philosophy, Herman (1997) suggested focusing on the components that work for the individual. (For more on ethnic-specific approaches to substance abuse treatment, see Straussner, 2001.)

Use of Medication When a client’s treatment plan involves medication, therapists should remember several points. First, women and ethnic minorities are at higher risk for receiving inappropriate medication because of mis­ diagnosis (Tulkin & Stock, 2004). Older people of any culture are more likely to be taking medications prescribed by different health care providers who are not coordinating with one another. Asking about prescription medications, nonprescription treatments, and self-medication is important. When I see older clients for the first time, I ask them to put all of their medications in a bag and bring the bag to the assessment

277

278

B e y o nd t h e T r e a t m e n t M an u a l s

session. This way I do not depend on their understanding or recall of what they are taking. Of equal concern are cultural differences in expectations. Many people of Asian, Central American, and Arab heritage are likely to expect medication and may feel that they are not being taken seriously if one is not prescribed (Gleave, Chambers, & Manes, 2005; Paniagua, 1998). Among American Indian clients, a more common view is that medication is not healthy, whereas many African Americans see medication as too impersonal (Paniagua, 1998). At the same time, as Falicov (2014) explains, with the exception of antibiotics (which are widely accepted by many people, particularly Mexicans), many Latin Americans’ reluctance to take medications involves a complexity of reasons. One of these reasons is a suspicion of chemicals in general, including food additives and sugar-free or fat-free foods, which are much more common in the United States. In addition, there can be a concern that medications are similar to street drugs and thus addictive—a belief that may increase the reluctance of parents to give medication to their children (Falicov, 2014, p. 175). When medications are necessary, compliance may be complicated by the belief that “Western medicine” is too strong (particularly among people of Chinese, Southeast Asian, Indian, Pakistani, and other South Asian countries; Assanand, Dias, Richardson, Chambers, & Waxler-Morrison, 2005; Lai & Yue, 1990). It is not uncommon for people who hold this belief to reduce prescribed dosages themselves or to take the medication only until the symptoms disappear (Lai & Yue, 1990). It’s also important to recognize that middle-and upper-class people have greater access to psychotherapy and other costly, health-related alternatives, and greater access to information regarding the advantages and disadvantages of medication. In contrast, people in poverty cannot afford complementary approaches, such as yoga, meditation, or exercise classes; they often live in places where healthy foods are unavailable and where outdoor activities such as walking are unsafe; and the mental health services they do receive are often of lesser quality. Particularly in low income and rural areas, mental health services may be limited or nonexistent. Because medication takes less time for both client and provider, involves fewer staff resources, and often costs much less than psychotherapy, it often is assumed to be the best treatment. In addition, largely because of pharmaceutical company advertising in the United States, a widespread belief persists that medication is the necessary and only treatment for some disorders, such as bipolar disorder and attention deficit hyperactivity disorder. For all of these reasons, it is important to take a cautious approach with regard to medications; this includes asking clients about their expectations and beliefs regarding medication, and providing a care-

Indigenous, Traditional, and Other Interventions

ful, easy-to-understand explanation (i.e., without medical jargon) as to why medications are being recommended. When appropriate, involving family members in such discussions can be especially helpful. Of course, sometimes therapists and clients will disagree about the need for medication, and when this happens, remember that, ultimately, the client is the one who has to live with the results of the decision to take medications or not. (For a detailed consideration of cross-cultural ethical issues involved with medications, see Fadiman’s 1997 book The Spirit Catches You and You Fall Down.)

Systems-Level Interventions and Social Justice Although the history of psychology is rife with injustice, including eugenic philosophies and discriminatory testing practices, over the past few decades, the commitment to social justice has grown among leaders and grassroots psychologists (Vasquez, 2012). In addition to family and group therapies, systems-level interventions move beyond the therapy setting to the community, with the goal of promoting social justice on a societal level. A therapist’s approach to social justice in the community context may vary depending on one’s situation, experience, and concerns. Chung and Bemak (2011) have described how action aimed at helping individual clients can lead to systems-level interventions in the larger community. Their examples include educating a Bosnian community about the problem of gambling addiction after a woman complained of her husband’s gambling in counseling; and educating women shelter employees about the impact of Somali women being “forced” to leave a violent husband, with an explanation of how it cut the woman off from her cultural supports and increased her fear because of the similarity to militias taking people away. Systems-level interventions may be helpful in energizing therapists who feel discouraged by the slow pace of psychotherapeutic change. For example, a therapist frustrated by the limitations of being a professional for Child Protective Services may become involved in lobbying to increase legal protections for children. A psychologist who works with crime victims may work to pass a law that ensures compensation by offenders to those who have lost property or a loved one. Or a school counselor who works with the children of Latino migrant workers may become involved in protests against inhumane housing and working conditions in the farming business.

279

280

B e y o nd t h e T r e a t m e n t M an u a l s

Conclusion Culturally responsive therapy involves a systemic, integrative perspective that recognizes diverse approaches to health and healing. This includes the different forms in which psychotherapy best meets the needs and preferences of clients, whether at the level of the individual, family, couple, or group. It also includes the respectful consideration of Indigenous and traditional cultural practices, the adaptation of “mainstream” psychological theories (e.g., culturally responsive cognitive behavior therapy), the use of expressive and creative arts, and consideration of cultural beliefs and behavior regarding medication. And systems-level interventions that promote social justice on the community and societal level offer a way to indirectly address clients’ needs and provide an avenue for empowering one’s own commitment to multicultural work.

Practice Using the ADDRESSING framework, pick a cultural group with which you are unfamiliar (e.g., an ethnic or religious group; people with a particular disability; the lesbian-gay-bisexual-transgender community) and find out everything you can about its within-group perspective on health and approaches to healing. Keep in mind the existence of within-group diversity as you do your search.

Key Ideas

  1. Develop a knowledge of Indigenous and traditional therapies.   2. Consider religion as a potential source of strength and support.   3. Consider incorporating mindfulness into the therapeutic setting to facilitate therapy and provide clients with a tool for managing difficult emotions outside the therapy setting.   4. Become familiar with expressive and creative arts therapies, and obtain additional training when appropriate.   5. Conceptualize “family” broadly to include gay and lesbian parents, single parents, elders as central, relatives, and nonkin family members.   6. Be willing to see individual members or subsystems of the family on an as-needed basis.   7. Recognize family member power differentials related to each of the ADDRESSING framework’s domains.

Indigenous, Traditional, and Other Interventions

  8. When providing services in small communities where confidentiality is of heightened concern, consider offering services in the form of classes that provide information, allow for structured discussion, and involve social engagement and support.   9. Consider interventions aimed at institutional and political levels when appropriate and possible. 10. Be aware of different cultural expectations and beliefs regarding medications.

281

Pulling It All Together A Complex Case Example

T

12

he case study in this chapter pulls together the main suggestions I have made for understanding clients’ identities, establishing a respectful relationship, conducting a culturally responsive assessment, making a culturally responsive diagnosis, and implementing culturally responsive therapies. In this case, the therapies included a systems intervention involving the whole family, an attempt at life review therapy with the older family member, and individual cognitive behavior therapy with the primary caregiver. The therapist in this case was Robert, a 33-year-old, bicultural geropsychologist. Robert’s mother was European American and his father was African American, and he grew up with close connections to both of his parents’ families. Robert was working in a mental health center located in an ethnically diverse urban community in the Los Angeles area.

http://dx.doi.org/10.1037/14801-012 Addressing Cultural Complexities in Practice: Assessment, Diagnosis, and Therapy, Third Edition, by P. A. Hays Copyright © 2016 by the American Psychological Association. All rights reserved.

283

284

B e y o n d the T reat m e n t Ma n u al s

Referral Robert received a phone call from a woman who introduced herself as Janet and said that she was calling about her mother. Janet told Robert that her mother, Mrs. Penn, was 75 years old, widowed for 9 years, retired, and living with her in Janet’s home, along with Janet’s husband, their recently divorced 32-year-old daughter, and the daughter’s 9-year-old daughter. Although Mrs. Penn had lived in her own home most of her life, Janet said that about two years earlier, her mother had experienced a stroke and had moved in with Janet and her husband. Janet stated that Mrs. Penn had gradually recovered most of her physical and mental abilities since the stroke but still experienced some weakness in her left leg. Janet’s present concerns had developed over the past few months. Her mother had begun sleeping more than usual, and Mrs. Penn’s unwillingness to follow a diet despite her diagnosis of diabetes had resulted in several trips to the hospital when she became sick from eating too many sweet foods. Janet told the therapist that she was feeling frustrated with her mother because “she doesn’t do anything anymore— doesn’t see friends or go to church or do anything around the house, doesn’t even make her bed, and only takes a bath if I get after her about it.” She added that because she had to work, she couldn’t stay home to take care of her mother, but she “could never put her in a home.” Over the phone, Robert responded to Janet’s story by validating the difficulty of her situation, and he suggested that she and her mother come in for an assessment within the next week. He told Janet that he would like to talk with both her and her mother and that the meeting would take about an hour and a half. He asked that they bring with them the name, address, and phone number of Mrs. Penn’s physician, a bag with all of Mrs. Penn’s current medications in it, and reading glasses or hearing aid if she used either.

Initial Assessment Janet and Mrs. Penn arrived 15 minutes early for their appointment with the requested information and items. Robert greeted them warmly, showed them to his office, and asked if they would like a cup of tea or coffee. He noticed that Mrs. Penn, an African American woman, appeared to be of average weight and had slight difficulty walking and that her clothes were wrinkled and worn. He also noticed a slight smell

Pulling It All Together

of body odor and recalled Janet’s comment about Mrs. Penn’s resistance to taking baths. Mrs. Penn declined the cup of tea or coffee, chose to keep her coat on, and clutched her purse to her stomach throughout the session. Her demeanor was subdued. She did not seem distracted, and she answered questions when asked but volunteered no information. In contrast, Janet, an African American woman in her late 50s, appeared well dressed, talkative, and stressed; she rolled and unrolled a tissue in her hands as she spoke. After a few minutes of social conversation about their neighborhoods, Robert asked Mrs. Penn if she wanted anything from their meeting, and Mrs. Penn said no, that she had just come in because Janet “made me.” Robert then explained to Mrs. Penn that Janet had called him because she was concerned about her (Mrs. Penn’s) health. He said that he had told Janet that if Mrs. Penn was willing, it could help for them to come in together to talk about how things were going at home. He asked if she was willing to do this, and when she nodded her head yes, he went on to outline the kinds of questions he would like to ask them so that he could have an accurate picture of their situation. As he talked, Janet seemed to relax a little, but Mrs. Penn’s facial expression remained somewhat flattened. Robert began by looking at Mrs. Penn’s bottles of medications, which included insulin pills and an antidepressant. Janet said that her mother had not liked taking the antidepressants and did so irregularly, finally stopping completely several months earlier. Robert tried to ask Mrs. Penn questions about her health, but in the pause before Mrs. Penn answered, Janet frequently answered for her. Robert suggested that it would be helpful for him to gain an understanding of each person’s concerns by meeting separately with each of them for about 30 minutes; then they could all meet together at the end for a final discussion. Neither Mrs. Penn nor Janet seemed bothered by this plan. Robert met first with Mrs. Penn. He asked if anything about her health was bothering her, to which she replied, “I don’t feel good.” In response to more specific questions, Mrs. Penn denied any disturbing thoughts or perceptions, but she admitted being hungry often and sleeping “a lot, except for last night, because I was worried about what this meeting would be about.” She said that she had noticed her memory “isn’t as good as it used to be.” She denied hearing difficulties but said that she needed glasses to read. Putting aside any mental status tests until he felt some rapport develop between them, Robert told Mrs. Penn that he would like to hear more about her life both before and after moving in with her daughter. In response to specific questions, Mrs. Penn said that she was born in Tennessee in 1940, that her father had worked at odd jobs and her mother had worked as a housekeeper, and that they were poor. Her parents had three girls; Mrs. Penn was the youngest.

285

286

B e y o n d the T reat m e n t Ma n u al s

When Mrs. Penn was 14 years old, her mother died of tuberculosis, and shortly thereafter, her father took his daughters to Los Angeles to live closer to relatives. Mrs. Penn graduated from high school a year early because she was such a good student. She married the year of her graduation, but her husband died unexpectedly of a medical problem (she was unclear of what) 2 months before Janet was born. Mrs. Penn then moved back into her father’s home and, with the help of her sisters, managed to care for Janet and work full time for an office-cleaning business, where she met her second husband. With him, Mrs. Penn had a daughter, Laura. When Laura began school, Mrs. Penn obtained a job as a receptionist at a branch of the Department of Health and Social Services, where she was promoted to secretary, then administrative assistant, and worked until her retirement at age 65. She and her second husband had been married for almost 45 years when he died of a heart attack. Mrs. Penn’s sisters were both living in another state, and Mrs. Penn talked to them about twice a month, but she never initiated the contact—they always called her. The chronological ordering of Mrs. Penn’s story was provided by the order of Robert’s questions. Robert noticed that the only date Mrs. Penn gave was her birth year. When tactfully pressed about the years of her high school graduation; the births of her children, grandchildren, and great-grandchildren; and her first and second marriages, Mrs. Penn gave general or vague answers such as “sometime in the ‘50s” or “oh, too long ago.” Considering her exceptional high school performance and successful work history, Robert hypothesized that these were all pieces of information she should know. During the interview with Mrs. Penn, Robert drew a timeline containing the significant events in the lives of Mrs. Penn and her family (see Figure 12.1). He later filled in the dates Janet provided and, above the line, wrote in some sociocultural influences and events that had occurred during Mrs. Penn’s lifetime. The latter included segregation, World War II, school desegregation, the civil rights movement, the assassination of Martin Luther King Jr., the Watts riots and later violence related to the Rodney King incident in Los Angeles (their home), the election of Barack Obama as president, and the recent increased media coverage of police shootings of young African American men. Additional recent events of particular relevance to Mrs. Penn and the family included the wars in Iraq and Afghanistan (as her grandsons were considering enlisting), challenges to Social Security and public employee pension plans (the source of her income), and changes in Medicare (her health insurance). Despite the hardships related to the time period in which Mrs. Penn had lived, she showed no emotion when talking about her life. Robert hypothesized that Mrs. Penn’s unemotional presentation was due to some stoicism or resignation in her approach to life. When he asked if she felt sad about some of the events in her life, she said, “I learned early on that life is hard, and you better not get too happy, or you’ll just get

Figure 12.1 School desegregation WWII

Civil Rights Antiwar Act protests

War ends

1940–44 1945 1954

1964 1958 1961 1962

1940

1957

Born

HS graduation; married Mom died; family moved to LA

World Trade Center towers destroyed

Watts riots (LA)

Remarried

1st husband died; Janet born

Laura born

Dr. M.L. King assassinated

1965

LA riots

1968 1977

1992 1980

1982 1986

Changes in Medicare; War in Iraq

U.S. invasion of Iraq 2001

1996

Began Daughters Father Laura’s twins work grown and died born at DSHS left home 1st grandchild born

2003

Obama elected

Media coverage: police harassment/ shootings of African American men

2008

2014

2005 2006

2011 2013

2nd husband died Retired

CVA, moves to Janet’s

1st greatgrandchild born

Mrs. Penn’s Sociocultural Timeline. Pulling It All Together 287

288

B e y o n d the T reat m e n t Ma n u al s

slapped down.” When Robert asked if she had “ever thought of ending it all,” she said that she had thought about it after her mother died but not since, because it was against her beliefs. (See Hinrichsen, 2006, regarding how, as a result of discrimination and oppression over a lifetime, some older people of color learn early on that their choices are limited, resulting in “a diminished sense of control and mastery in later life” [p. 31].) Subsequently, in the interview with Mrs. Penn’s daughter, Janet talked about feeling overwhelmed by her responsibilities: I get home from work, the phone’s ringing, dinner needs fixing, my daughter’s at work, my granddaughter wants help with her homework, and [husband] Jim wants me to listen to him, then on top of it, when she goes to visit [sister] Laura for the weekend, Laura lets her do whatever she wants—doesn’t make her take a bath and lets her eat sweets, knowing she has diabetes—and all Mother can say when she gets home is what a good time she had at Laura’s and how much she wishes she could stay there longer.

At the end of these individual meetings, Robert met and talked with Janet and Mrs. Penn together about his beginning understanding of their situation. He began by explaining how, to understand what was going on with an individual, he considered the person’s childhood experiences, along with the stressors in their life, and the supports and strengths they had. He added that in their situation, he was also trying to understand and be helpful to the family. He summarized that it sounded like Mrs. Penn had seen some pretty hard times as a child and as an adult, and summarized the most recent stressors she and Janet had described, including the stroke, followed by Mrs. Penn’s loss of her own home and previous independence, the move to Janet’s home, Mrs. Penn’s loss of daily contact with friends and church, and the ongoing medical challenges of diabetes. As he noted, however, he also saw many strengths, including Mrs. Penn’s successful work history, their close family connections and concern for one another, their hard work, and their faith. He refrained from making any diagnosis at this point, and instead noted that one of the questions that he still had concerned Mrs. Penn’s memory difficulties. He explained that the difficulties Janet described, along with Mrs. Penn’s inability to recall some of the things he had asked her about, suggested the need for further evaluation. He said that a medical examination and a neuropsychological assessment would help to clarify whether there was a significant memory problem that needed to be addressed. He explained what a neuropsychological assessment involves and added that sometimes what appears to be a memory problem may be something else—for example, focusing too much on one’s memory, feeling depressed or worried, or just not seeing the point in remembering some things. Robert went on to say that he was also concerned about how tired Janet seemed, at which point Janet’s eyes filled with tears. From his

Pulling It All Together

previous experience working with caregivers, and his personal experience watching his mother take care of his grandfather, he was aware of the pressures on caregivers, particularly the difficulties faced by daughters caring for their aging parents. He said that he felt concerned that Janet was trying to do too much. Out of respect for Janet and the family’s preference that Mrs. Penn live with the family, he did not bring up assisted living, but he did mention the possibility of an in-home health aide for Mrs. Penn. He also mentioned a caregivers support group, but after Janet responded that it would just be one more thing to do, he didn’t press the idea. He also suggested that they might want to look as a family at some ways to lessen Janet’s load. Both Mrs. Penn and Janet seemed open to this, so he suggested that they schedule a meeting in 2 weeks to discuss the results of Mrs. Penn’s medical exam and neuropsychological assessment and then, afterward, set up a family meeting. Janet agreed, and Mrs. Penn nodded that she would participate.

Case Formulation and Diagnosis Mrs. Penn’s medical examination included blood work (which was within expected ranges given her diabetes), and an MRI (magnetic resonance imaging) of her brain, which showed some slight changes related to cerebro­vascular disease. The neuropsychological assessment showed mild impairments in concentration, short-term memory, insight, judgment, and initiation. Mrs. Penn’s overall functioning, however, was moderately impaired compared with her prestroke baseline, during which time she was retired but ran her own household and maintained a moderately active social life. Robert was aware that in older adults, particularly those with major medical problems (e.g., diabetes), depression can bring on or exacerbate existing cognitive deficits. He hypothesized that Mrs. Penn’s symptoms of apathy and decreased activity, along with the cognitive impairments and flattened/depressed mood, could be due to the cerebro­ vascular accident (CVA; or stroke) alone, but the symptoms also could be due to depression or to a combination of these factors. He hypothesized that her noncompliance with diet and medication recommendations was secondary to preexisting personality tendencies, possibly exacerbated by her cognitive impairment and/or depression. Because the cognitive deficits met criteria for a neurocognitive disorder, Robert diagnosed a major vascular neurocognitive disorder (major because although the neuropsychological assessment showed mild deficits and the MRI showed slight changes, her daily functioning was significantly impaired—e.g., she did not pay her own bills or manage her

289

290

B e y o n d the T reat m e n t Ma n u al s

own medications, and her self-care had deteriorated). In addition to the major vascular neurocognitive disorder, Robert diagnosed Mrs. Penn with a major depressive disorder on the basis of the family’s report that her poor self-care and apathetic behavior had begun or increased in the past few months and of his recognition that depression can cause the kind of concentration and memory problems she was having. Robert was aware that depression should not be diagnosed if the symptoms are related to a medical condition, however, the relationship in this case was not clear and, with her fragile health status, it was a greater risk to not treat her for depression (American Psychological Association [APA], 2004; Friedhoff & National Institute of Health Consensus Development Panel on Depression in Late Life, 1992). It seemed prudent to see whether counseling, family interventions, and antidepressant medication could lift the depression, in which case the cognitive impairments might improve, but if they did not, at least Mrs. Penn might feel better. During the second assessment meeting with Mrs. Penn and Janet, Robert recommended that Mrs. Penn begin antidepressant medication again and return weekly for half-hour meetings for the next 6 months. Although he was pessimistic about whether Mrs. Penn would comply with the medication recommendation (given her history of noncompliance with antidepressants and her diet), he hoped that closer monitoring through counseling sessions might reinforce its importance. At the same time, he felt a positive connection with Mrs. Penn, who seemed, even with her subdued manner, to enjoy the extra attention. Robert

EXHIBIT 12.1 ADDRESSING Framework for Mrs. Penn Age and generational influences: Grew up as an African American in the South (Tennessee); then at 14 years old moved to Los Angeles; experienced severe poverty and oppressive conditions; attended segregated schools. Developmental or other Disability: Experienced a cerebrovascular accident 2 years ago, with recovery except for residual left leg weakness and possible cognitive impairments. Religion and spiritual orientation: Both parents were Christian; active member of Baptist church until the stroke and subsequent move to Janet’s house. Ethnic and racial identity: Both parents African American. Socioeconomic status: Grew up in poverty, first in Tennessee then Los Angeles, California; with her second husband, had a lower-middle-class income; currently living on middle-class family income, including own pension and Social Security. Sexual orientation: Probably heterosexual, although not specifically asked. Indigenous heritage: None. National origin: Born and grew up in the United States; English is first language. Gender: Woman; youngest child in a family of three daughters; mother died when Mrs. Penn was 14; married twice, two daughters; role as the family’s grandmother involved “active authority” (therapist’s words) before the stroke and move to Janet’s, but not since.

Pulling It All Together

expected that as their rapport continued to grow, she might benefit from talking about her life, her current difficulties, and her strengths. (See Exhibits 12.1 and 12.2 for cultural profiles of Mrs. Penn and her family.)

INDIVIDUAL THERAPY WITH MRS. PENN Robert had recently learned about a therapeutic approach known as life review therapy through which older clients are helped to look back on their lives, remember, and talk about events and relationships (Lewis & Butler, 1974). One goal of this reminiscing is for clients to become more accepting of their decisions because the choices they made in the past led to the experiences that have shaped who they are in the present. The process of integrating one’s past experiences with the present can be facilitated by creating a book filled with photographs, drawings, news clippings, pressed flowers, writings, and poems, along with any other forms of documentation that the client considers meaningful (Butler, Lewis, & Sunderland, 1998). Robert was interested in trying this collaborative intervention with Mrs. Penn (Exhibit 12.2). He believed that it would provide some structure to his sessions with her, and he saw it as a way to affirm her life. He also saw the benefits to her family, for whom this documentation

EXHIBIT 12.2 ADDRESSING Framework for Mrs. Penn’s Family Age and generational influences: Fourth-generation African American family; lifetime spans 1940 to present (see Figure 12.1 for a timeline of sociocultural influences). Developmental or other Disability: Only family member with disability is Mrs. Penn (left-leg weakness and cognitive impairments). Religion and spiritual orientation: Christian family orientation but not all members practicing; Mrs. Penn grew up and brought up her daughters in a nondenominational African American church; as adults, she and Janet belong to a Baptist church. Ethnic and racial identity: Everyone identifies as Black or African American except the twins who at times also identify as biracial or multiracial (their father was Latino and White). Socioeconomic status: Current household is middle class with four incomes: Janet’s, Jim’s, Clarisse’s, and Mrs. Penn’s pension and Social Security income; Laura and her children are low income and live in subsidized housing. Sexual orientation: Adults are heterosexual. Indigenous heritage: American Indian grandfather on Jim’s side of the family, but little connection to this heritage. National origin: All born and reared in United States; English is their first language. Gender: Household includes three adult women, one adult man, and a girl; extended family includes Mrs. Penn’s daughter Laura and her two boys and Mrs. Penn’s two sisters; gender roles are relatively fluid—Jim shares cleaning responsibilities with Janet and their daughter and watches his granddaughter when the women go out; Laura expects her boys to help with dinner, cleaning, and laundry; the women all work outside the home.

291

292

B e y o n d the T reat m e n t Ma n u al s

might provide a deeper appreciation of Mrs. Penn and a reminder of their family’s history to pass on to younger generations. Mrs. Penn and Janet appeared only mildly interested in the idea but said they would be willing to try it. Over the next few weeks, Mrs. Penn did engage in the verbal review of her life. However, she never brought in pictures or any other mementos, despite Robert’s reminders. After 4 weeks, Robert realized that Mrs. Penn either did not want to or simply could not do such a project, given her cognitive deficits and apathy, and expecting Janet to bring in items would just add to Janet’s workload. Recognizing that the impetus for the project was coming from his assumption that the family would value it as much as he did, Robert let go of the documentation piece of this particular intervention. He continued the life review process verbally with Mrs. Penn, whose mood seemed to lift slightly by the end of the second month (possibly also because of the antidepressant, which she was taking more regularly). No improvement occurred, however, in her resigned attitude, her activity level, or her memory difficulties. Robert now believed that these problems were attributable to an inseparable combination of previous personality tendencies, stressful life events, and mild dementia related to the stroke.

INTERGENERATIONAL FAMILY THERAPY Recognizing that Janet’s needs had not yet been addressed, Robert worked with her to schedule and invite all members of the family to the family meeting they had discussed. This meeting turned into three sessions attended by Mrs. Penn; Janet and her husband, Jim; their daughter Clarisse; Clarisse’s daughter; Mrs. Penn’s daughter Laura; and Laura’s twin 22-year-old sons. Mrs. Penn’s sisters couldn’t attend, but Janet and Laura both promised to talk with them about the sessions. During the meeting, Robert used a flipchart and with the help of the family, drew a genogram (see Figure 12.2), which then led to a discussion of their relationships to Mrs. Penn and Janet. (For more on genograms with detailed cultural notations, see Comas-Díaz, 2012.) The family members took turns expressing their concern about Mrs. Penn and Janet, but the support for Janet was particularly striking, as her family sympathetically noted that “she tries to take on everything.” Each person subsequently volunteered for a small task that Janet previously had assumed (e.g., taking Mrs. Penn to have her eyes and glasses checked, picking up medications at the pharmacy, making sure that there were fresh vegetables cut up for snacks). Robert was impressed by the family’s willingness to “come through” for Janet, and his statements to this effect clearly pleased the family.

Pulling It All Together

Figure 12.2 d. 1982

d. 1958

d. 2006 b. 1940

m. 1957

Mrs. P

m. 1961

b. 1962 Jim

d. 1954

Janet

Laura b. 1958

Clarisse b. 1986

Jevon

Jaydee

b. 1996 (Twins)

Kishana b. 2011

Genogram: Mrs. Penn and Family.

Edith

Martha

293

294

B e y o n d the T reat m e n t Ma n u al s

One deeply meaningful experience occurred for Janet during the second session, when Laura explained her lesser involvement in Mrs. Penn’s care: When Mother’s with me, all she talks about is how responsible Janet is, how Janet takes such good care of her, and she doesn’t know what she would do without her, so I just figured Janet didn’t need my help. I know Janet gets pissed that I let her eat candy and not take baths, but I want Mother to be happy when she’s at our place too.

Janet was clearly surprised by this revelation, which indicated that Mrs. Penn was saying things to one about the other that made both Laura and Janet feel as though they could never do enough. Janet then shared how their mother referred to Laura as “her baby,” talked about how nice Laura was to her, and said, “Laura lets me eat what I want.” At this point, Mrs. Penn appeared uncomfortable, but she could not or would not engage in a discussion of her behavior. The shared information clearly decreased the tension between Laura and Janet. Later, Janet reported that she and Laura had begun talking on the telephone more often. She described their conversations about Mrs. Penn as having shifted to “comparing notes” instead of competing. The improvement in their relationship was a significant move forward in the family’s overall functioning. Unfortunately, the family’s practical support for Janet lasted only about two months, after which family members, with the exception of her husband, Jim, began forgetting their commitments or simply began letting Janet take on the tasks again. Rather than lament the “irresponsibility” of her family members, Robert chose to reframe the situation more positively. In an individual meeting with Janet, he told her that although it seemed difficult for the family to maintain their extra efforts, it was good to know that they could be there for her in a crisis, as they had clearly demonstrated. But now it was up to Janet, who admitted to being more responsible than was always necessary, to figure out a way to take on less in her day-to-day life. Recognizing Janet’s time and financial constraints, Robert recommended that he and Janet meet individually for eight sessions to talk about her needs during the 45 minutes following his 30-minute sessions with Mrs. Penn. Because meeting with Janet on this subject could ethically be framed as part of helping Mrs. Penn, her time could be billed under Mrs. Penn’s insurance.

CULTURALLY RESPONSIVE COGNITIVE BEHAVIOR THERAPY WITH JANET Two main themes emerged in therapy with Janet. The first concerned her tendency to “take on too much.” Janet came to understand her behavior in the context of her own upbringing; her mother and father

Pulling It All Together

had worked hard and expected her to share in household responsibilities, including the care of her younger sister. Janet and Robert also discussed how her tendencies were reinforced as an adult—for example, at work. As the only African American woman in her office, she knew that she was often seen, as she put it, “as the representative Black woman.” She stated that she had had to work twice as hard as her White counterparts to reach and keep her managerial position. Robert listened and affirmed her experiences. When he was sure that Janet felt heard and validated, he began asking her questions about the standards she set for herself. Janet said that she felt she “always had to be responsible and hard-working to avoid disappointing people.” In response to Robert’s questions, Janet began to recognize how the perfectionistic nature of this belief increased her feelings of anxiety and guilt and led her to consistently put her own needs last. Robert pointed out that if she did not take care of herself by setting limits and engaging in self-care activities, she could become so physically ill that she could not take care of her mother. With some suggestions from Robert, Janet began to change her self-talk, for example, reminding herself, “I need to take care of myself so that I can take care of my family.” Also, when in doubt about what she should expect of herself, she began asking herself whether she would expect the same thing of her daughter Clarisse, and the answer was usually no. A second theme involved Janet’s sense of herself as a spiritual person. She told Robert that during the past few years she’d become so busy that it was easier to sleep on Sundays than go to church, and she no longer prayed regularly. Using cognitive behavioral strategies, Janet began using self-talk to decrease the guilt she felt, reminding herself that she was doing her best and God knew her heart. But Robert helped her go a bit further by asking her the following questions about her spirituality: ❚❚ ❚❚

❚❚

What are your three greatest sources of strength? When you want to feel comforted, where do you go, or whom do you see? How would you describe the purpose of your life? (D. S. Smith, 1995, p. 179)

These questions led Janet to talk about what her “soul needed,” which included quiet time in a park or by some trees and starting to pray again. She also said that she would like to find a book from which she could read an inspiring idea every morning. She had done this in the past and had liked carrying the hopeful idea or thought with her throughout the day. Over the next few weeks, Janet talked with Robert about the importance of these needs and how she might begin to meet them. With his encouragement, she began attending church again, taking her mother with her, and the two of them would go to the park for a little while afterward. Janet also began getting up half an hour earlier to read one passage

295

296

B e y o n d the T reat m e n t Ma n u al s

a day from a prayer book. At the end of 3 months, her schedule had not changed dramatically, and although she recognized that Mrs. Penn was not going to change, she felt more in control. During their last session, Robert told her that he would be available in the future if “something more came up” and she, Mrs. Penn, or any other family members wanted to come in again. He added that they could come in for a one-time or occasional “booster sessions” or whatever might be helpful.

Conclusion As the situation of Mrs. Penn and her family illustrates, culturally responsive therapy can be a complex endeavor. Robert’s personal knowledge of African American culture and his professional experience with older adults, including those with disabilities, enabled him to establish a respectful therapeutic alliance, ask relevant questions, and obtain the necessary information to understand Mrs. Penn, Janet, and their family in a holistic way. In turn, his assessment and diagnosis laid the groundwork for culturally responsive interventions. His familiarity with different theories and therapies enabled him to consider a range of approaches that might work (i.e., life review, cognitive behavioral and family systems therapies, exploration of early childhood experiences that shaped beliefs and behavior, and attention to spirituality and faith). His collaborative and flexible approach facilitated therapy, particularly when something did not work, for example, his willingness to let go of the documentation piece of the life review therapy with Mrs. Penn. Although workplace and insurance requirements necessitated the identification of one patient, Robert went beyond this narrow focus to conceptualize the case as involving the whole family, situated in a particular cultural and historical context. This included validation of the oppression Mrs. Penn has experienced over a lifetime, and experiences of racism and sexism reported by Janet. At the same time, he encouraged each member to recognize what actions they could take to improve their situation. In sum, Robert’s assessment, diagnosis, and interventions were culturally responsive and, even more important, helpful.

Practice Robert worked with Mrs. Penn and her family from his own unique cultural identity and context—that of a young, biracial, heterosexual man of African American and Anglo Christian heritage who had no

Pulling It All Together

personal history of disability. If you were to work with this family, you would meet them with your own unique cultural identity and context. Keeping in mind your own ADDRESSING profile, write a brief paragraph describing how your work with this family might differ because of who you are. For example, if you are not African American, what kind of information might you need to obtain either outside the session or from your clients regarding cultural influences? If you are younger or older than Robert, how might your age influence your interactions with this family? If you, for example, have a visible physical disability, or identify as Muslim, or grew up in poverty, or identify as gay, how might these differences influence (or not) your work with the family?

Key Ideas

  1. Engage in your own ongoing cultural self-assessment through individually oriented work (introspection, self-questioning, reading, research) and interpersonal learning (community activities, diverse media, relationships, and other experiential learning).   2. Use the ADDRESSING framework to consider the influence of culture and related areas of privilege on your identity, beliefs, and behavior.   3. Use the ADDRESSING framework to consider cultural influences on each client’s identity, beliefs, and behavior.   4. Think critically about your assumptions regarding the diverse meanings of physical gestures, eye contact, and other nonverbal and verbal forms of communication to prevent inaccurate assumptions.   5. Consider the interaction of your own identity and context with that of each client.   6. Seek out and use multiple sources of information regarding clients (with appropriate releases of information).   7. Consider sociocultural historical events that may have affected clients during particular developmental periods in their lives.   8. Deliberately look for culturally related strengths and supports at the individual, interpersonal, and environmental levels.   9. Use a flexible, dynamic, hypothesis-testing approach that includes a clinical interview and select tests that match the referral question and the client’s characteristics, culture, and preferences; following standardized procedures, use the strategy of testing the limits to gain a deeper understanding of the reasons for the client’s performance; and explore possible reasons for a client’s test performance.

297

298

B e y o n d the T reat m e n t Ma n u al s

10. Use standardized tests cautiously with consideration of possible biases in tests, testing procedures, the testing environment, and the tester; always note culturally related limitations and potential biases in your report. 11. Work with cultural consultants and interpreters to develop additional questions that assess skills and knowledge relevant to clients’ experiences and contexts. 12. In making a diagnosis, take into account the client’s conceptualization of the problem and self-care practices, along with (a) the person’s vulnerability to anxiety, depression, anger, or whatever the presenting problem is based on their childhood experiences; (b) past and current stressors, including past traumatic events that may have lingering effects; and (c) supports and strengths. 13. When using the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013), go beyond an individualistic focus to think systemically and consider relational disorders, and cultural and environmental influences. 14. Regarding culturally responsive therapy, keep in mind the APA’s definition of evidence-based practice as the “integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.” 15. Seek out information regarding diverse approaches to health and healing, particularly those preferred in your client’s culture. 16. Whatever your home therapy, consider integrating approaches from other sources, including culturally preferred approaches (e.g., meditation, traditional healers), adaptations of mainstream psychotherapies (e.g., culturally responsive cognitive behavior therapy), expressive and creative arts therapies, and systemslevel interventions. 17. Set goals, develop treatment plans, and choose interventions collaboratively with clients. 18. Use the ADDRESSING framework as a reminder of the various domains in which power differences may exist in couple and family therapy. 19. Keep in mind culturally related expectations regarding medications. 20. When writing your clinical summary and case formulation, remember that it is often the only part of the report that other providers will read. Include (a) the diagnosis with a list of the symptoms justifying it, (b) contributing factors, (c) resilience factors (i.e., strengths and supports), and (d) recommendations. Also, include culturally related limitations and potential biases.

Conclusion Looking to the Future

T

13

he day after I began thinking about this final chapter, I was on a flight to Alaska. As the plane was taking off, I heard an angry voice and leaned forward to see what was going on. In the seats directly in front of me was a couple who appeared to be European American and in their early 60s. Earlier, I had heard them say that this was their first trip to Alaska. The wife was sitting by the window, and her husband was sitting in the middle seat. Next to him in the aisle seat was a stylishly dressed young woman, whom I guessed to be American Indian, from Los Angeles or San Francisco. This woman was angrily saying to the man, “No, that’s wrong. It’s just wrong.” I couldn’t hear the man, but I hypothesized that he had just made some well-intentioned comment about American Indian people that had offended her. They kept talking, and I heard her say something about “fishing rights . . . the American people don’t know what really goes on.” I hypothesized further that she was a newly

http://dx.doi.org/10.1037/14801-013 Addressing Cultural Complexities in Practice: Assessment, Diagnosis, and Therapy, Third Edition, by P. A. Hays Copyright © 2016 by the American Psychological Association. All rights reserved.

299

300

B e y o n d the T r eat m ent Man u als

appointed professor (i.e., not burned out) of American Indian studies at a university in California. At some point, the wife pretended to be taking a nap, but occasionally she would lean forward to add some benign comment like, “Well, you know, there’s just good and bad in all cultures.” What subsequently amazed me about this interaction was not what they were talking about but, rather, that these two people were talking at all. Although I was uncomfortable with the angry tone in the woman’s voice, as the conversation continued I thought to myself, “Why is she putting so much energy into educating this one guy?” After his initial comment, I think I would have said something polite to indicate my disagreement and then started reading a book. But she stayed in there, and so did he, and to his credit, I never heard him get defensive in response to her anger. By the end of the 3-hour flight, something had shifted, and they were laughing and sharing details about their children. When we landed, they gave each other their names, shook hands, and wished each other a good day. While admiring these two people, I thought to myself, yes, this is what it’s all about—that two people who have extremely different upbringings, identities, and views of the world can come together, interact, learn from each other, and even appreciate one another.

A Word About Conflict The difficult thing about the field of multicultural studies (in psychology, counseling, social work, and related disciplines) is the conflict that so commonly arises. Diversity brings multiple perspectives, and multiple perspectives often lead to conflict. I suspect that this is one of the reasons why people who do not specialize in this work tend to avoid the topics of race, ethnicity, and culture. Because one can so easily offend another person even by one’s choice of terms, the simplest solution often appears to be avoidance. But as therapists, we do not have the option of ignoring cultural influences. If we are to work effectively with people of diverse identities, we must learn to deal with difference and conflict in ways that do not simply reinforce dominant power structures but rather empower and show respect for one another. In the preceding chapters, I have explained most of what I know about this work. The only additional point I make is to reiterate the role of mistakes. Just as conflict is inherent in this work, so, too, are mistakes. The challenge for therapists is to be accepting of our fallible selves and others, but at the same time continually to be looking for biases that limit our thinking and work.

Conclusion

Summary of the ADDRESSING Framework A central point to this book is this: To work effectively with people of diverse identities, we must first be willing to critically examine our own value systems, beliefs, and sociocultural contexts. To understand the impact of culture on our clients and in our work, we must also understand the impact of culture on ourselves. The ADDRESSING framework facilitates engagement in the cultural self-assessment process by providing a broad outline of influences and related identities that you can use to explore your own strengths and weaknesses, including potential biases. This self-assessment is facilitated by humility, compassion, and critical-thinking skills. Equally key is an understanding of the relationship of privilege to culture and of the ways in which privilege separates those who hold it from those who do not. The selfknowledge that comes with such learning is essential in understanding the dynamics of therapeutic relationships and in developing the ability to comfortably discuss such dynamics with clients. Although parts of the self-assessment process may occur during sessions with clients, the bulk of this work takes place outside the therapy setting. It involves individually oriented work (e.g., introspection, self-questioning, reading, research, other experiential learning) and learning from people of diverse identities through community activities, reading and listening to diverse media, and relationships. Once engaged in this ongoing self-assessment process, the next step involves learning about and understanding the diverse identities that clients hold. The ADDRESSING framework can be a helpful reminder of influences and identities to be considered, including bicultural and multicultural identities. Although information about the personspecific meanings of identity usually comes from the client, it is the therapist’s responsibility to obtain knowledge outside the therapy setting of the culture-specific meanings of a client’s identity. Knowledge of clients’ salient identities gives clues as to how clients see the world, what they value, how they may behave in certain situations, and how others treat them. Such knowledge contributes to the development of a respectful relationship and positive therapeutic alliance. Critical thinking about your own assumptions is important in this regard, because even if you do not know the specific meanings of clients’ physical gestures, eye contact, nonverbal cues, and other culturally influenced forms of communication, simply staying aware of the diversity of meanings can help you to avoid inaccurate assumptions. Minimizing and explaining professional terminology and questioning

301

302

B e y o n d the T r eat m ent Man u als

the meaning of the terms you and the client use also can decrease misunderstandings. During the assessment, several practical steps can increase understanding and accuracy, including seeking out and using multiple sources of information, considering sociocultural historical events that may have affected clients during particular developmental periods in their lives, and actively looking for culturally related strengths at the individual, interpersonal, and environmental levels. Asking about clients’ conceptualizations of their situations and about health care (including self-care) practices is also helpful. The use of standardized tests for assessment purposes requires careful consideration of biases in the tests themselves, in testing procedures, in the testing environment, and in the tester. Whenever possible, it is helpful to think about clients’ performance ideographically, keeping in mind the difference between academic knowledge and tacit knowledge (i.e., knowledge required in clients’ everyday life functioning), and comparing clients’ test performance against their own past performance rather than against the performance of others. With clients who speak English as a second language, a cultural consultant can be a valuable source of information in the development of questions that tap skills and knowledge relevant to clients’ experiences and contexts. When standardized tests must be used, the relevance of responses will be enhanced by an exploration of the reasons for clients’ poor test performance. In making a culturally responsive diagnosis, it is important to consider (a) the person’s vulnerability to anxiety, depression, anger, or whatever the presenting problem is based on their childhood experiences; (b) past and current stressors, including past traumatic events that may have lingering effects; and (c) strengths and supports. Using these three key components to conceptualize one’s diagnosis facilitates a lay-language summary that most clients will understand. If using the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013), it’s important to go beyond an individualistic focus to think systemically and consider relational disorders, and cultural and environmental influences. In one’s written report, it can be helpful to call attention to cultural influences by adding next to the diagnosis a cultural profile consisting of the ADDRESSING framework. List the acronym vertically, and then next to each letter, write the salient cultural influences and identities for that client. Choosing the most culturally responsive interventions requires familiarity with a broad range of culturally related helping strategies, adaptations of mainstream psychotherapies, expressive and creative arts therapies, and systems-level interventions. The choice of intervention may be facilitated by a broader conceptualization of family, a willingness to see individual members and subsystems of the family on an

Conclusion

as-needed basis, and the collaborative development of goals and treatment plans. When medications are a part of the intervention, remain aware of different cultural expectations regarding the prescription and use of medicines. Throughout one’s work with individuals, couples, families, groups, and institutions, it is important to watch for power differentials between clients and between the client and the therapist. Use the ADDRESSING framework as a reminder of the various domains in which these power differences may occur.

Conclusion I would like to end with a story. My mother grew up during the Great Depression and World War II. Her father was a Presbyterian minister who believed in the equality of human beings and the importance of social responsibility. The family was of Scotch Irish descent; however, my mother believed that this was only part of her heritage. She is tall and has an olive complexion, black hair, high cheekbones, and deepset eyes. One time when she was a child, after going to see a western at the movie theater, she and her father began talking about Indian people, and he said to her, “You know, you have some Indian blood in you.” Another time, when they were living in the southern United States and talking about Black people, her father told her, “You probably have some Negro blood in you, too.” And still another memory she has is of her father coming home from the war, talking about the horrible things being done to Jewish people, and telling her, “You know, your ancestors were also Jewish.” My mother took all of these comments literally (reinforced by an awareness of her appearance), and until her late teens, she truly believed that she was related to all of these groups. When she would see, read, or hear about some injustice that had occurred to someone of these cultures, she felt a strong sense of connection and empathy that has shaped her work and life. And of course, in the broadest sense, my mother is related to all of these groups, as we are all related to one another.

Practice Return to the Practice exercise in Chapter 1 in this volume, for which you wrote a paragraph about your multicultural competence with a minority or dominant group of which you are a member, and then

303

304

B e y o n d the T r eat m ent Man u als

with a minority group of which are not a member. After rereading your writing, reflect on what and how you think of your multicultural competence now regarding each of these groups. Do you feel more or less confident about working with either group? What do you see as your learning edges, that is, areas in which you need to learn more? What do you consider future challenges for you, given your particular identity and context, with these and other groups?

References

AAA Native Arts. (2006). Canadian Indians: Canada First Nations by culture, language, region, status, and providence. Retrieved from http://www.aaanativearts.com/canadian_tribes_AtoZ.htm Abudabbeh, N. (2005). Arab families. In M. McGoldrick, J. Giordano, & N. Garcia-Preto (Eds.), Ethnicity and family therapy (3rd ed., pp. 423–436). New York, NY: Guilford Press. Abudabbeh, N., & Hays, P. A. (2006). Cognitive–behavioral therapy with people of Arab heritage. In P. A. Hays & G. Y. Iwamasa (Eds.), Culturally responsive cognitive–behavioral therapy: Assessment, practice, and supervision (pp. 141–159). Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/11433-006 Achenbach, T. M. (1991). Manual for the Child Behavior Checklist. Burlington: University of Vermont, Department of Psychiatry. Achenbach, T. M., & Rescorla, L. A. (2001). Manual for the ASEBA school-age forms and profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, and Families. Acklin, F., Newman, J., Arbon, V., Trindal, A., Brock, K., Bermingham, M., . . . Koori Elders. (1999). Story-telling: Australian Indigenous women’s means of health promotion. In R. Earnhardt (Ed.), Indigenous education around the world: Workshop papers from the 1996 World Indigenous Peoples 305

306

R eferences

Conference: Education (pp. 1–10). Fairbanks: University of Alaska– Fairbanks, Center for Cross-Cultural Studies. Ahmed, S., & Amer, M. M. (2011). Counseling Muslims: Handbook of mental health issues and interventions. New York, NY: Routledge. Alarcón, R. D. (1997). Personality disorders and culture: Conflict at the boundaries. Transcultural Psychiatry, 34, 453–461. http://dx.doi.org/ 10.1177/136346159703400402 Alarcón, R. D., & Foulks, E. F. (1995). Personality disorders and culture: Contemporary clinical views (Part A). Cultural Diversity and Mental Health, 1, 3–17. http://dx.doi.org/10.1037/1099-9809.1.1.3 Alderson, K. (2013). Counseling LGBTI people. Thousand Oaks, CA: Sage. Ali, S. R., Liu, W. M., & Humedian, M. (2004). Islam 101: Understanding the religion and therapy implications. Professional Psychology: Research and Practice, 35, 635–642. http://dx.doi.org/10.1037/0735-7028.35.6.635 Allen, J. (1998). Personality assessment with American Indians and Alaskan Natives: Instrument considerations and service delivery style. Journal of Personality Assessment, 70, 17–42. http://dx.doi.org/10.1207/ s15327752jpa7001_2 Altman, N. (2007). Toward the acceptance of human similarity and difference. In J. C. Muran (Ed.), Dialogues on difference: Studies of diversity in the therapeutic relationship (pp. 15–25). Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/11500-001 Ameli, R. (2014). 25 lessons in mindfulness: Now time for healthy living. Washington, DC: American Psychological Association. http://dx.doi.org/ 10.1037/14257-000 America after 9/11: Freedom preserved or freedom lost? Hearing before the Committee on the Judiciary, United States Senate, 108th Cong. (2003). Retrieved from http://www.gpo.gov/fdsys/pkg/CHRG-108shrg94064/ pdf/CHRG-108shrg94064.pdf American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association. American Psychological Association. (1996). Violence and the family: Report of the APA Presidential Task Force on Violence and the Family. Washington, DC: Author. American Psychological Association. (2000a). Guidelines for psychotherapy with lesbian, gay, and bisexual clients. American Psychologist, 55, 1440–1451. http://dx.doi.org/10.1037/0003-066X.55.12.1440 American Psychological Association. (2000b). Resolution on poverty and socioeconomic status. Retrieved from http://www.apa.org/about/policy/ poverty-resolution.aspx American Psychological Association. (2004). Guidelines for psychological practice with older adults. American Psychologist, 59, 236–260.

References

American Psychological Association. (2010). 2010 Amendments to the 2002 “Ethical principles of psychologists and code of conduct.” American Psychologist, 65, 493. Washington, DC: Author. http://dx.doi.org/10.1037/ a0020168 American Psychological Association. (2011). Answers to your questions about transgender people, gender identity, and gender expression [Brochure]. Washington, DC: Author. Retrieved from http://www.apa.org/topics/ lgbt/transgender.pdf American Psychological Association. (2012). Guidelines for the assessment of and interventions with persons with disabilities. Washington, DC: Author. Retrieved from http://www.apa.org/pi/disability/resources/ assessment-disabilities.aspx American Psychological Association. (2013). Recognition of psychotherapy effectiveness. Psychotherapy, 50, 102–109. http://dx.doi.org/ 10.1037/a0031817 American Psychological Association Practice Organization. (2014). New member benefit: ICD–10 web-based application. Retrieved from http://www.apapracticecentral.org/update/2014/12-18/memberbenefit.aspx American Psychological Association Presidential Task Force on EvidenceBased Practice. (2006). Evidence-based practice in psychology. American Psychologist, 61, 271–285. http://dx.doi.org/10.1037/0003066X.61.4.271 American Psychological Association, Task Force on Socioeconomic Status. (2007). Report of the APA Task Force on Socioeconomic Status. Retrieved from http://www.apa.org/pi/ses/resources/publications/ task-force-2006.pdf Anderson, E. R., Smith, A. J., & Christophersen, E. R. (2011, January). A creative approach to teaching anxiety management skills in children. Behavior Therapist, 34, 3–7. Andronikof-Sanglade, A. (2000). Use of the Rorschach Comprehensive System in Europe: State of the art. In R. H. Dana (Ed.), Handbook of cross-cultural and multicultural personality assessment (pp. 329–344). Mahwah, NJ: Erlbaum. Anzaldua, G. (1987). Borderlands/La Frontera: The new mestiza. San Francisco, CA: Aunt Lute Books. Aponte, H. J. (1994). Bread and spirit: Therapy with the new poor. New York, NY: Norton. Aravind, V. K., Krishnaram, V. D., & Thasneem, Z. (2012). Boundary crossings and violations in clinical settings. Indian Journal of Psychological Medicine, 34(1), 21–24. http://dx.doi.org/10.4103/0253-7176.96151 Ardila, A. (2001). The manifestation of aphasic symptoms in Spanish. Journal of Neurolinguistics, 14, 337–347. http://dx.doi.org/10.1016/ S0911-6044(01)00022-7

307

308

R eferences

Ardila, A., Rosselli, M., & Puente, A. E. (1994). Neuropsychological evaluation of the Spanish speaker. New York, NY: Plenum Press. http://dx.doi. org/10.1007/978-1-4899-1453-8 Arredondo, P., & Perez, P. (2006). Historical perspectives on the multicultural guidelines and contemporary applications. Professional Psychology: Research and Practice, 37, 1–5. Artman, L. K., & Daniels, J. A. (2010). Disability and psychotherapy practice: Cultural competence and practical tips. Professional Psychology: Research and Practice, 41, 442–448. http://dx.doi.org/10.1037/ a0020864 Assanand, S., Dias, M., Richardson, E., Chambers, N. A., & WaxlerMorrison, N. (2005). People of South Asian descent. In N. WaxlerMorrison, J. M. Anderson, E. Richardson, & N. A. Chambers (Eds.), Cross-cultural caring: A handbook for health professionals (2nd ed., pp. 197–246). Vancouver, Canada: University of British Columbia Press. Atkinson, D., Morten, G., & Sue, D. (Eds.). (1993). Counseling American minorities: A cross-cultural perspective. Dubuque, IA: William C. Brown Communications. Atkinson, D. R., Wampold, B. E., Lowe, S. M., Matthews, L., & Ahn, H. (1998). Asian American preferences for counselor characteristics: Application of the Bradley-Terry-Luce model to paired comparison data. Counseling Psychologist, 26, 101–123. http://dx.doi.org/10.1177/ 0011000098261006 Austin, A., & Craig, S. L. (2015). Transgender affirmative cognitive behavioral therapy: Clinical considerations and applications. Professional Psychology: Research and Practice, 46, 21–29. http://dx.doi.org/10.1037/ a0038642 Ball, A. L. (2014, April 6). Who are you on Facebook now? New York Times, p. 16. Balsam, K. F., Huang, B., Fieland, K. C., Simoni, J. M., & Walters, K. L. (2004). Culture, trauma, and wellness: A comparison of heterosexual and lesbian, gay, bisexual, and two-spirit Native Americans. Cultural Diversity and Ethnic Minority Psychology, 10, 287–301. http://dx.doi. org/10.1037/1099-9809.10.3.287 Balsam, K. F., Martell, C. R., & Safren, S. A. (2006). Affirmative cognitive–behavioral therapy with lesbian, gay, and bisexual people. In P. A. Hays & G. Y. Iwamasa (Eds.), Culturally responsive cognitive– behavioral therapy: Assessment, practice, and supervision (pp. 223–243). Washington, DC: American Psychological Association. http://dx.doi. org/10.1037/11433-010 Barker, C. H., Cook, K. L., & Borrego, J. (2010). Addressing cultural variables in parent training programs with Latino families. Cognitive and Behavioral Practice, 17, 157–166. http://dx.doi.org/10.1016/ j.cbpra.2010.01.002

References

Barnett, J. E., Shale, A. J., Elkins, G., & Fisher, W. (2014). Complementary and alternative medicine for psychologists: An essential resource. Washington, DC: American Psychological Association. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York, NY: Guilford Press. Beck, A. T., & Steer, R. A. (1993). Beck Anxiety Inventory manual. San Antonio, TX: Harcourt Brace. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depression Inventory (2nd ed.). San Antonio, TX: Pearson. Beck, J. (2011). Cognitive behavior therapy: Basics and beyond. New York, NY: Guilford Press. Benish, S. G., Quintana, S., & Wampold, B. E. (2011). Culturally adapted psychotherapy and the legitimacy of myth: A direct-comparison metaanalysis. Journal of Counseling Psychology, 58, 279–289. http://dx.doi. org/10.1037/a0023626 Bennett, S. T., Flett, R. A., & Babbage, D. R. (2014). Culturally adapted cognitive behaviour therapy for Ma¯ori with major depression. Cognitive Behaviour Therapist, 7, 1–16. http://dx.doi.org/10.1017/S1754470X 14000233 Ben-Porath, Y. S., & Tellegen, A. (2008). Minnesota Multiphasic Personality Inventory–2 restructured form. Minneapolis: University of Minnesota Press. Bernal, G., & Domenech Rodriguez, M. M. (Eds.). (2012). Cultural adaptations: Tools for evidence-based practice with diverse populations. Washington, DC: American Psychological Association. http://dx.doi. org/10.1037/13752-000 Berry, J. W. (2004). An ecocultural perspective on the development of competence. In R. J. Sternberg & E. L. Grigorenko (Eds.), Culture and competence: Contexts of life success (pp. 3–22). Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/10681-001 Berry, J. W., Poortinga, Y. H., Segall, M. H., & Dasen, P. R. (1992). Crosscultural psychology: Research and applications. New York, NY: Cambridge University Press. Berzoff, J., Flanagan, L. M., & Hertz, P. (2011). Inside out and outside in: Psychodynamic clinical theory and practice in contemporary multicultural contexts (3rd ed.). Lanham, MD: Rowman & Littlefield. Betancourt, H., & Lopez, S. R. (1993). The study of culture, ethnicity, and race in American psychology. American Psychologist, 48, 629–637. http://dx.doi.org/10.1037/0003-066X.48.6.629 Bibb, A., & Casimir, G. J. (1996). Haitian families. In M. McGoldrick, J. Giordano, & J. K. Pearce (Eds.), Ethnicity and family therapy (2nd ed., pp. 86–111). New York, NY: Guilford Press. BigFoot, D. S., & Braden, J. (2007, Winter). Adapting evidence-based treatments for use with American Indian and Native Alaskan children

309

310

R eferences

and youth. Focal Point, 21(1), 19–22. Retrieved from http://www. icctc.org/focus%20article.pdf BigFoot, D. S., & Schmidt, S. R. (2010). Honoring children, mending the circle: Cultural adaptation of TF-CBT for American Indian and Alaska Native children. Journal of Clinical Psychology, 66, 847–856. http:// dx.doi.org/10.1002/jclp.20707 Blood, P., Tuttle, A., & Lakey, G. (1995). Understanding and fighting sexism: A call to men. In M. L. Anderson (Ed.), Race, class and gender: An anthology (pp. 154–161). New York, NY: Wadsworth. Bornstein, D. (2013, November 3). Protecting children from toxic stress. New York Times. p. SR4. Boyd-Franklin, N. (1989). Black families in therapy. New York, NY: Guilford Press. Boyd-Franklin, N. (2003). Black families in therapy (2nd ed.). New York, NY: Guilford Press. Bracken, B. A., & McCallum, R. S. (1998). Universal Nonverbal Intelligence Test. Rolling Meadows, IL: Riverside. Bradford, D. T., & Munoz, A. (1993). Translation in bilingual psychotherapy. Professional Psychology: Research and Practice, 24, 52–61. http:// dx.doi.org/10.1037/0735-7028.24.1.52 Bratton, S. C., Ray, D., Rhine, T., & Jones, L. (2005). The efficacy of play therapy with children: A meta-analytic review of treatment outcomes. Professional Psychology: Research and Practice, 36, 376–390. http:// dx.doi.org/10.1037/0735-7028.36.4.376 Brendtro, L. K., Brokenleg, M., & Van Bockern, S. (1998). Reclaiming youth at risk: Our hope for the future. Bloomington, IN: National Educational Service. Briere, J. N., & Scott, C. (2015). Principles of trauma therapy: A guide to symptoms, evaluation, and treatment. Thousand Oaks, CA: Sage. Bronson, P., & Merryman, A. (2009). NurtureShock. New York, NY: Twelve/ Hachette Book Group. Brookfield, S. (1987). Developing critical thinkers. San Francisco, CA: Jossey-Bass. Brown, L. S. (1990). Taking account of gender in the clinical assessment interview. Professional Psychology: Research and Practice, 21, 12–17. http://dx.doi.org/10.1037/0735-7028.21.1.12 Brown, L. S. (1994). Subversive dialogues. New York, NY: Basic Books. Brown, L. S. (2004). Feminist paradigms of trauma treatment. Psychotherapy: Theory, Research, Practice, Training, 41, 464–471. http://dx.doi. org/10.1037/0033-3204.41.4.464 Brown, L. S. (2008). Cultural competence in trauma therapy: Beyond the flashback. Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/11752-000

References

Brown, L. S., & Ballou, M. (Eds.). (1992). Personality and psychopathology: Feminist reappraisals. New York, NY: Guilford Press. Budge, S. L. (2013). Interpersonal therapy with transgender clients. Psychotherapy, 50, 356–359. http://dx.doi.org/10.1037/a0032194 Bushra, A., Khadivi, A., & Frewat-Nikowitz, S. (2007). History, custom, and the Twin Towers: Challenges in adapting psychotherapy to Middle Eastern culture in the United States. In J. C. Muran (Ed.), Dialogues on difference: Studies of diversity in the therapeutic relationship (pp. 221–235). Washington, DC: American Psychological Association. http://dx.doi. org/10.1037/11500-025 Butcher, J. N., Cabiya, J., Lucio, E., & Garrido, M. (2007). Assessing Hispanic clients using the MMPI–2 and MMPI–A. Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/11585-000 Butcher,J.  N.,Graham,J.  R.,Ben-Porath,Y.  S.,Tellegen,A.,Dahlstrom,W.  G., & Kaemmer, B. (2001). Minnesota Multiphasic Personality Inventory—2 (MMPI–2): Manual for administration, scoring, and interpretation (Rev. ed.). Minneapolis: University of Minnesota Press. Butcher, J. N., Mosch, S. C., Tsai, J., & Nezami, E. (2006). Cross-cultural applications of the MMPI–2. In J. Butcher (Ed.), MMPI–2: A practitioner’s guide (pp. 505–537). Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/11287-018 Butcher, J. N., & Williams, C. L. (2009). Personality assessment with the MMPI–2: Historical roots, international adaptations, and current challenges. Applied Psychology: Health and Well-Being, 1(1), 105–135. http:// dx.doi.org/10.1111/j.1758-0854.2008.01007.x Butcher, J. N., Williams, C. L., Graham, J. R., Archer, R. P., Tellegen, A., Ben-Porath, Y. S., & Kaemmer, B. (1992). Minnesota Multiphasic Personality Inventory—Adolescent (MMPI®–A). Minneapolis: University of Minnesota Press. Butler, R. N., Lewis, M., & Sunderland, T. (1998). Aging and mental health. New York: Allyn & Bacon. Byrne, M., Oakland, T., Leong, F. T. L., Hambleton, R. K., Oakland, T., van de Vijver, F. J. R., . . . Bartram, D. (2009). A critical analysis of cross-cultural research and testing practices: Implications for improved education and training in psychology. Training and Education in Professional Psychology, 3, 94–105. http://dx.doi.org/10.1037/a0014516 Cabral, R. R., & Smith, T. B. (2011). Racial/ethnic matching of clients and therapists in mental health services: A meta-analytic review of preferences, perceptions, and outcomes. Journal of Counseling Psychology, 58, 537–554. http://dx.doi.org/10.1037/a0025266 Cagigas, X. E., & Manly, J. J. (2014). Cultural neuropsychology: The new norm. In M. W. Parsons & T. A. Hammeke (Eds.), Clinical neuro­ psychology: A pocket handbook for assessment (3rd ed., pp. 132–156).

311

312

R eferences

Washington, DC: American Psychological Association. http://dx.doi. org/10.1037/14339-008 Calisch, A. (2003). Multicultural training in art therapy: Past, present, and future. Art Therapy, 20, 11–15. http://dx.doi.org/10.1080/ 07421656.2003.10129632 Cameron, E. (2010). Using the arts as a therapeutic tool for counseling— An Australian Aboriginal perspective. Procedia: Social and Behavioral Sciences, 5, 403–407. http://dx.doi.org/10.1016/j.sbspro.2010.07.112 Campbell, C., Richie, S. D., & Hargrove, D. S. (2003). Poverty and rural mental health. In B. H. Stamm (Ed.), Rural behavioral health care: An interdisciplinary guide (pp. 41–51). Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/10489-003 Cass, V. C. (1979). Homosexual identity formation: A theoretical model. Journal of Homosexuality, 4, 219–235. http://dx.doi.org/10.1300/ J082v04n03_01 Center for Health and Health Care in Schools. (2008). Mental health interpreter training. Washington, DC: Author. Centers for Medicare and Medicaid Services & National Center for Health Statistics. (2010). ICD–10–CM official guidelines for coding and reporting. Washington, DC: Authors. Central Intelligence Agency. (2015). World factbook: Tunisia. Retrieved from https://www.cia.gov/library/publications/the-world-factbook/ geos/ts.html Cervantes, R. C., Padilla, A. M., & Salgado de Snyder, N. (1990). Reliability and validity of the Hispanic Stress Inventory. Hispanic Journal of Behavioral Sciences, 12, 76–82. http://dx.doi.org/10.1177/07399863900121004 Chan, A. S., Shum, D., & Cheung, R. W. Y. (2003). Recent development of cognitive and neuropsychological assessment in Asian countries. Psychological Assessment, 15, 257–267. http://dx.doi.org/10.1037/ 1040-3590.15.3.257 Cheung, S. F., Cheung, F. M., & Fan, W. (2013). From Chinese to CrossCultural Personality Inventory: A combined emic–etic approach to the study of personality in culture. In M. J. Gelfand, C. Chiu, & Y. Hong (Eds.), Advances in culture and psychology: Volume 3 (pp. 117–179). New York, NY: Oxford University Press. Chin, J. L. (1994). Psychodynamic approaches. In L. Comas-Díaz & B. Greene (Eds.), Women of color: Integrating ethnic and gender identities in psychotherapy (pp. 194–222). New York, NY: Guilford Press. Chodron, P. (2000). When things fall apart: Heart advice for difficult times. Boston, MA: Shambala. Chögyam Trungpa Rinpoche. (2014, June 30). Why we meditate. Retrieved from http://www.lionsroar.com/the-view-why-we-meditateyour-guide-to-buddhist-meditationjuly-2014/ Chorpita, B. (2007). Modular cognitive–behavioral therapy for childhood anxiety disorders. New York, NY: Guilford Press.

References

Chung, J. C. (2009). Clinical validity of Fuld Object Memory Evaluation to screen for dementia in a Chinese society. International Journal of Geriatric Psychiatry, 24, 156–162. http://dx.doi.org/10.1002/gps.2085 Chung, R. C. Y., & Bemak, F. (2011). Social justice counseling: The next steps beyond multiculturalism. Thousand Oaks, CA: Sage. Civil Liberties Act of 1988, Pub. L. 100-383, Title I, August 10, 1988, 102 Stat. 904, 50a U.S.C. § 1989b et seq. Civil Rights Act of 1964, Pub. L. 88-352, 78 Stat. 241. Clay, R. A. (2014). New ways to protect kids. Monitor on Psychology, 45(7), 31–33. CNN World. (2013). Haiti earthquake fast facts. Retrieved from http:// www.cnn.com/2013/12/12/world/haiti-earthquake-fast-facts/ Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., . . . Zucker, K. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. International Journal of Transgenderism, 13, 165–232. http://dx.doi.org/ 10.1080/15532739.2011.700873 Comas-Díaz, L. (2001). Hispanics, Latinos, or Americanos: The evolution of identity. Cultural Diversity and Ethnic Minority Psychology, 7, 115–120. http://dx.doi.org/10.1037/1099-9809.7.2.115 Comas-Díaz, L. (2007). Commentary: Freud, Jung, or Fanon? The racial other on the couch. In C. Muran (Ed.), Dialogues on difference: Studies of diversity in the therapeutic relationship (pp. 35–39). Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/11500-003 Comas-Díaz, L. (2012). Multicultural care: A clinician’s guide to cultural competence. Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/13491-000 Comas-Díaz, L., & Duncan, J. W. (1985). The cultural context: A factor in assertiveness training with mainland Puerto Rican women. Psychology of Women Quarterly, 9, 463–476. http://dx.doi.org/10.1111/ j.1471-6402.1985.tb00896.x Comas-Díaz, L., & Greene, B. (Eds.). (1994). Women of color: Integrating ethnic and gender identities in psychotherapy. New York, NY: Guilford Press. Cooper, C. C., & Gottlieb, M. C. (2000). Ethical issues with managed care: Challenges facing counseling psychology. Counseling Psychologist, 28, 179–236. http://dx.doi.org/10.1177/0011000000282001 Cordes, C. C., Cameron, R. P., Mona, L. R., Syme, M. L., & Coble-Temple, A. (in press). Perspectives on disability within integrated healthcare. In L. A. Suzuki, M. Casas, C. Alexander, & M. Jackson (Eds.), Handbook of multicultural counseling (4th ed.). Thousand Oaks, CA: Sage. Costantino, G., Flanagan, R., & Malgady, R. (1995). The history of the Rorschach: Overcoming bias in multicultural projective assessment. Rorschachiana, 20, 148–171. http://dx.doi.org/10.1027/1192-5604.20.1.148 Costantino, G., & Malgady, R. G. (2000). Multicultural and cross-cultural utility of the TEMAS (Tell-Me-A-Story) Test. In R.  H. Dana (Ed.), Handbook

313

314

R eferences

of cross-cultural and multicultural personality assessment (pp. 481–513). Mahwah, NJ: Erlbaum. Costantino, G., Malgady, R. G., & Rogler, L. H. (1988). TEMAS (Tell-MeA-Story) manual. Los Angeles, CA: Western Psychological Services. Costantino, G., Malgady, R., & Vasquez, C. (1981). A comparison of the Murray-TAT and a new Thematic Apperception Test for urban Hispanic children. Hispanic Journal of Behavioral Sciences, 3, 291–300. Craig, S. L., McInroy, L., Alloggia, R., & McCready, L. (2014). Like picking up a seed, but you haven’t planted it: Queer youth analyze the It Gets Better Project. International Journal of Child, Youth, and Family Studies, 1, 204–219. Crane, L. S. (2013). Multiracial daughters of Asian immigrants: Identity and agency. Women & Therapy, 36, 268–285. http://dx.doi.org/10.1080/ 02703149.2013.797776 Criddle, J. (1992). Bamboo and butterflies: From refugee to citizen. Dixon, CA: East/West Bridge. Cross, T. L. (2003). Culture as a resource for mental health. Cultural Diversity and Ethnic Minority Psychology, 9, 354–359. http://dx.doi. org/10.1037/1099-9809.9.4.354 Cross, W. E. (1991). Shades of Black: Diversity in African American identity. Philadelphia, PA: Temple University Press. Croteau, J. M. (1999). One struggle through individualism: Toward an antiracist White racial identity. Journal of Counseling & Development, 77, 30–32. http://dx.doi.org/10.1002/j.1556-6676.1999.tb02411.x Cruikshank, J. (1990). Life lived like a story: Life stories of three Yukon Native elders. Lincoln: University of Nebraska Press. Cuéllar, I. (1998). Cross-cultural clinical psychological assessment of Hispanic Americans. Journal of Personality Assessment, 70, 71–86. http:// dx.doi.org/10.1207/s15327752jpa7001_5 Cuéllar, I. (2000). Acculturation as a moderator of personality and psychological assessment. In R. H. Dana (Ed.), Handbook of cross-cultural and multicultural personality assessment (pp. 113–129). Mahwah, NJ: Erlbaum. Dana, R. H. (1998). Cultural identity assessment of culturally diverse groups: 1997. Journal of Personality Assessment, 70, 1–16. http://dx.doi. org/10.1207/s15327752jpa7001_1 Dana, R. H. (1999). Cross-cultural–multicultural use of the Thematic Apperception Test. In L. Geiser & M. I. Stein (Eds.), Evocative images: The Thematic Apperception Test and the art of projection (pp. 177–190). Washington, DC: American Psychological Association. http://dx.doi. org/10.1037/10334-013 Dana, R. H. (2000). Culture and methodology in personality assessment. In I. Cuéllar & F. A. Paniagua (Eds.), Handbook of multicultural mental health: Assessment and treatment of diverse populations (pp. 97–120). San Diego, CA: Academic Press. http://dx.doi.org/10.1016/B978012199370-2/50007-9

References

Dang, A., & Vianney, C. (2007). Living in the margins: A national survey of lesbian, gay, bisexual and transgender Asian and Pacific Islander Americans. New York, NY: National Gay & Lesbian Task Force Policy Institute. Dator, J. (1979). The futures of culture or cultures of the future. In A. J. Marsella, R. G. Tharp, & T. J. Ciborowski (Eds.), Perspectives on cross-cultural psychology (pp. 369–388). New York, NY: Academic Press. Davidson, G. (1995). Cognitive assessment of Indigenous Australians: Towards a multiaxial model. Australian Psychologist, 30, 30–34. http:// dx.doi.org/10.1080/00050069508259601 Davis, D. M., & Hayes, J. A. (2012). What are the benefits of mindfulness? Monitor on Psychology, 43, 64. Davis, H. (1993). Counselling parents of children with chronic illness or disability. Leicester, England: British Psychological Society. Department of Disability Services, Columbus State Community College, & Murray, A. (2015). Fast facts for faculty: Sign language interpreting in the classroom. Retrieved from http://ada.osu.edu/resources/fastfacts/ Sign_Language_Interpreting_in_the_Classroom.htm deShazer, S. (1985). Keys to solution in brief therapy. New York, NY: Norton. Diener, E., Oishi, S., & Lucas, R. E. (2003). Personality, culture, and subjective well-being: Emotional and cognitive evaluations of life. Annual Review of Psychology, 54, 403–425. http://dx.doi.org/10.1146/ annurev.psych.54.101601.145056 Dimaggio, G., & Lysaker, P. H. (2014). Supporters of a single orientation may do less for science and the health of patients than integrationists: A reply to Govrin (2014). Journal of Psychotherapy Integration, 24, 91–94. http://dx.doi.org/10.1037/a0036996 Dolan, Y. M. (1991). Resolving sexual abuse. New York, NY: Norton. Dowd, E. T. (2003). Cultural differences in cognitive therapy. Behavior Therapist, 26, 247–249. Downes, L. (2013, March 2). A word gone wrong. New York Times, p. SR10. Retrieved from http://www.nytimes.com/2013/03/03/ opinion/sunday/a-word-gone-wrong.html Downing, N. E., & Roush, K. L. (1985). From passive acceptance to active commitment: A model of feminist identity development of women. Counseling Psychologist, 13, 695–709. http://dx.doi.org/10.1177/ 0011000085134013 Droby, R. M. (2000). With the wind and the waves: A guide for non-Native mental health professionals working with Alaska Native communities. Nome, AK: Norton Sound Health Corporation, Behavioral Health Services. Duffy, F. F., West, J. C., Wilk, J., Narrow, W. E., Hales, D., Thompson, J., . . . Manderscheid, R. W. (2004). Mental health practitioners and trainees. In R. W. Manderscheid & M. J. Henderson (Eds.), Mental health, United States, 2002 (pp. 327–368; DHHS Publication No. SMA 04-3938).

315

316

R eferences

Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. Duffy, M. (1986). The techniques and contexts of multigenerational therapy. In T. Brink (Ed.), Clinical gerontology: A guide to assessment and interventions (pp. 347–362). New York, NY: Haworth Press. Dulicai, D., & Berger, M. R. (2005). Global dance/movement therapy growth and development. Arts in Psychotherapy, 32, 205–216. Dunn, D. S., & Andrews, E. E. (2015). Person-first and identity-first language: Developing psychologists’ cultural competence using disability language. American Psychologist, 70, 255–264. http://dx.doi. org/10.1037/a0038636 Dwairy, M. (2006). Counseling and psychotherapy with Arabs and Muslims: A culturally sensitive approach. New York, NY: Teachers College Press. Ecklund, K. (2012). Intersectionality of identity in children: A case study. Professional Psychology: Research and Practice, 43, 256–264. http://dx.doi. org/10.1037/a0028654 Eisman, E. J., Dies, R. R., Finn, S. E., Eyde, L. D., Kay, G. G., Kubiszyn, T. W., . . . Moreland, K. L. (2000). Problems and limitations in using psychological assessment in the contemporary health care delivery system. Professional Psychology: Research and Practice, 31, 131–140. http://dx.doi. org/10.1037/0735-7028.31.2.131 Elbulok-Charcape, M. M., Rabin, L. A., Spadaccini, A. T., & Barr, W. B. (2014). Trends in the neuropsychological assessment of ethnic/racial minorities: A survey of clinical neuropsychologists in the United States and Canada. Cultural Diversity and Ethnic Minority Psychology, 20, 353–361. http://dx.doi.org/10.1037/a0035023 Ellis, A. (1997). Using rational emotive behavior therapy techniques to cope with disability. Professional Psychology: Research and Practice, 28, 17–22. Ephraim, D. (2000). Culturally relevant research and practice with the Rorschach Comprehensive System. In R. H. Dana (Ed.), Handbook of cross-cultural and multicultural personality assessment (pp. 303–328). Mahwah, NJ: Erlbaum. Erickson, C. D., & Al-Timimi, N. R. (2001). Providing mental health services to Arab Americans: Recommendations and considerations. Cultural Diversity and Ethnic Minority Psychology, 7, 308–327. Erickson-Schroth, L. (Ed.). (2014). Trans bodies, trans selves: A resource for the transgender community. New York, NY: Oxford University Press. Escobar, J. I., Burnam, A., Karno, M., Forsythe, A., Landsverk, J., & Golding, J. M. (1986). Use of the Mini-Mental State Examination (MMSE) in a community population of mixed ethnicity: Cultural and linguistic artifacts. Journal of Nervous and Mental Disease, 174, 607–614. http://dx.doi.org/10.1097/00005053-198610000-00005

References

Exner, J. E., Jr. (1993). The Rorschach: A comprehensive system: Vol. I. Basic foundations (3rd ed.). New York, NY: Wiley. Fadiman, A. (1997). The spirit catches you and you fall down. New York, NY: Farrar, Straus & Giroux. Falicov, C. J. (2014). Latino families in therapy (2nd ed.). New York, NY: Guilford Press. Farley, N. (1992). Same-sex domestic violence. In S. H. Dworkin & F. J. Gutierrez (Eds.), Counseling gay men and lesbians: Journey to the end of the rainbow (pp. 231–244). Alexandria, VA: American Counseling Association. Fiore, J., Coppel, D. B., Becker, J., & Cox, G. B. (1986). Social support as a multifaceted concept: Examination of important dimensions for adjustment. American Journal of Community Psychology, 14, 93–111. http://dx.doi.org/10.1007/BF00923252 Fiske, S. T. (1993). Controlling other people: The impact of power on stereotyping. American Psychologist, 48, 621–628. http://dx.doi.org/ 10.1037/0003-066X.48.6.621 Flanagan, R., & Di Giuseppe, R. (1999). Critical review of the TEMAS: A step within the development of thematic apperception instruments. Psychology in the Schools, 36, 21–30. http://dx.doi.org/10.1002/ (SICI)1520-6807(199901)36:13.0.CO;2-L Fleras, A. (2011). Unequal relations: An introduction to race, ethnic, and Aboriginal dynamics in Canada (7th ed.). Toronto, Ontario, Canada: Pearson Education Canada. Folstein, M. F., & Folstein, S. E. (2010). Mini-Mental State Examination, 2nd edition (MMSE-2). Lutz, FL: Psychological Assessment Resources. Frager, R., & Fadiman, J. (1998). Personality and personal growth. New York, NY: Longman. Friedhoff, A. J., & the National Institute of Health Consensus Development Panel on Depression in Late Life. (1992). NIH consensus conference. Diagnosis and treatment of depression in late life. Journal of the American Medical Association, 268, 1018–1024. http://dx.doi. org/10.1001/jama.1992.03490080092032 Fukuyama, M. A., & Sevig, T. D. (1999). Integrating spirituality into multicultural counseling. Thousand Oaks, CA: Sage. Fuld, P. A. (1977). Fuld Object-Memory Evaluation. Wood Dale, IL: Stoelting. Fuld, P. A., Muramoto, O., Blau, A., Westbrook, L., & Katzman, R. (1988). Cross-cultural and multi-ethnic dementia evaluation by mental status and memory testing. Cortex, 24, 511–519. http://dx.doi.org/10.1016/ S0010-9452(88)80045-5 Gaines, E. J. (1997). A lesson before dying. New York, NY: Vintage Books. Gaines, S. O., & Reed, E. S. (1995). Prejudice: From Allport to DuBois. American Psychologist, 50, 96–103. http://dx.doi.org/10.1037/0003066X.50.2.96

317

318

References

Gallagher, D., & Thompson, L. W. (1981). Depression in the elderly: A behavioral treatment manual. Los Angeles: University of Southern California Press. Gallardo, M. E. (2010). Advancing clinical and contextual practice: Working with the Latina/o community. Professional Psychology: Research and Practice, 41, 508–510. http://dx.doi.org/10.1037/a0021689 Gallardo, M. E. (2014). Developing cultural humility: Embracing race, privilege and power. Thousand Oaks, CA: Sage. Garrido, M., & Velasquez, R. (2006). Interpretation of Latino/Latina MMPI–2 profiles: Review and application of empirical findings and cultural–linguistic considerations. In J. Butcher (Ed.), MMPI–2: A practitioner’s guide (pp. 477–504). Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/11287-017 Gates, H. L., Jr. (2011). Black in Latin America. New York: New York University Press. Gatz, M. (1994). Application of assessment to therapy and intervention with older adults. In M. Storandt & G. R. VandenBos (Eds.), Neuropsychological assessment of dementia and depression in older adults: A clinician’s guide (pp. 155–176). Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/10157-008 Gaughen, K. J. S., & Gaughen, D. K. (1996). The Native Hawaiian (Kanaka Maoli) client. In P. B. Pedersen & D. C. Locke (Eds.), Cultural and diversity issues in counseling (pp. 33–36). Greensboro: School of Education, University of North Carolina at Greensboro. (ERIC Document Reproduction Service No. ED400486) Geisinger, K. F. (Ed.). (1992). Psychological testing of Hispanics. Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/ 10115-000 Gibbons, K. (1998). Ellen Foster. New York, NY: McMillan. Gil, E. (Ed.). (2006). Cultural issues in play therapy. New York, NY: Guilford Press. GLAAD. (2014). Tips for allies of transgender people. Retrieved from http:// www.glaad.org/transgender/allies Gleave, D., Chambers, N. A., & Manes, A. S. (2005). People of Central American descent. In N. Waxler-Morrison, J. M. Anderson, E. Richardson, & N. A. Chambers (Eds.), Cross-cultural caring: A handbook for health professionals (2nd ed., pp. 11–58). Vancouver, Canada: University of British Columbia Press. Glickman, N. S. (2009). Adapting best practices in CBT for Deaf and hearing persons with language and learning challenges. Journal of Psychotherapy Integration, 19, 354–384. http://dx.doi.org/10.1037/a0017969 Gonzalez, A., & Zimbardo, P. G. (1985, May). Time in perspective: The time sense we learn early affects how we do our jobs and enjoy our pleasures. Psychology Today, 19, 21–26.

References

Good, B. J. (1996). Culture and DSM–IV: Diagnosis, knowledge and power. Culture, Medicine and Psychiatry, 20, 127–132. http://dx.doi.org/10.1007/ BF00115857 Goode-Cross, D. J. (2011). Same difference: Black therapists’ experience of same-race therapeutic dyads. Professional Psychology: Research and Practice, 42, 368–374. http://dx.doi.org/10.1037/a0025520 Goodheart, C. (2014). A primer for ICD–10 users: Psychological and behavioral conditions. Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/14379-000 Govrin, A. (2014). The vices and virtues of monolithic thought in the evolution of psychotherapy. Journal of Psychotherapy Integration, 24, 79–90. http://dx.doi.org/10.1037/a0035972 Graham, J. (1990). MMPI–2: Assessing personality and psychopathology. New York, NY: Oxford University Press. Graham, J. R., Archer, R. P., Tellegen, A., Ben-Porath, Y. S., & Kaemmer, B. (2006). Minnesota Multiphasic Personality Inventory—Adolescent (MMPI–A): Manual supplement. Minneapolis: University of Minnesota Press. Grant, J. (2014). How big is the LGBT community? Why can’t I find this number? Washington, DC: National Gay and Lesbian Task Force. Retrieved from http://www.theTaskForce.org/static_html/downloads/release_ materials/tf_lgbt_community.pdf Greenberg, S., & Motenko, A. K. (1994). Women growing older: Partnerships for change. In M. P. Mirken (Ed.), Women in context (pp. 96–117). New York, NY: Guilford Press. Greenberger, D., & Padesky, C. A. (1995). Mind over mood: Change how you feel by changing the way you think. New York, NY: Guilford Press. Greene, B. (1994). Lesbian women of color: Triple jeopardy. In L. Comas-Díaz & B. Greene (Eds.), Women of color: Integrating ethnic and gender identities in psychotherapy (pp. 389–427). New York, NY: Guilford Press. Greenwald, A. G., & Banaji, M. R. (1995). Implicit social cognition: Attitudes, self-esteem, and stereotypes. Psychological Review, 102, 4–27. http://dx.doi.org/10.1037/0033-295X.102.1.4 Grier, W., & Cobbs, P. (1968). Black rage. New York, NY: Basic Books. Griffin-Pierce, T. (1997). “When I am lonely the mountains call me”: The impact of sacred geography on Navajo psychological well being. American Indian and Alaska Native Mental Health Research, 7, 1–10. http://dx.doi.org/10.5820/aian.0703.1997.1 Guthman, D., & Sandberg, K. A. (2002). Dual relationships in the Deaf community: When dual relationships are unavoidable and essential. In A. A. Lazarus & O. Zur (Eds.), Dual relationships and psychotherapy (pp. 287–297). New York, NY: Springer. Gutierrez, F. J., & Dworkin, S. H. (1992). Gay, lesbian, and African American: Managing the integration of identities. In S. H. Dworkin

319

320

R eferences

& F. J. Gutierrez (Eds.), Counseling gay men and lesbians: Journey to the end of the rainbow (pp. 141–156). Alexandria, VA: American Counseling Association. Haldeman, D. C. (2010). Life with the Village People: A psychologist in the LGBT community. Professional Psychology: Research and Practice, 41, 507–508. http://dx.doi.org/10.1037/a0021689 Haley, J. (1963). Strategies of psychotherapy. New York, NY: Grune & Stratton. http://dx.doi.org/10.1037/14324-000 Hall, C. C. I. (2003). Not just Black and White: Interracial relationships and multicultural individuals. In J. S. Mio & G. Y. Iwamasa (Eds.), Culturally diverse mental health (pp. 231–248). New York, NY: Brunner-Routledge. Hall, E. T. (1966). The hidden dimension. New York, NY: Doubleday. Hall, G. C. N., Bansal, A., & Lopez, I. R. (1999). Ethnicity and psychopathology: A meta-analytic review of 31 years of comparative MMPI/ MMPI–2 research. Psychological Assessment, 11, 186–197. http://dx.doi. org/10.1037/1040-3590.11.2.186 Hammill, D. D., Pearson, N. A., & Wiederholt, J. L. (2009). Comprehensive Test of Nonverbal Intelligence (2nd ed.). Austin, TX: Pro-Ed. Hammond, L. C., & Gantt, L. (1998). Using art in counseling: Ethical considerations. Journal of Counseling & Development, 76, 271–276. http:// dx.doi.org/10.1002/j.1556-6676.1998.tb02542.x Hanh, T. N. (1992). Touching peace: Practicing the art of mindful living. Berkeley, CA: Parallax Press. Harowski, K., Turner, A., LeVine, E., Schank, J. A., & Leichter, J. (2006). From our community to yours: Rural best perspectives on psychology practice, training, and advocacy. Professional Psychology: Research and Practice, 37, 158–164. http://dx.doi.org/10.1037/0735-7028.37.2.158 Harvard Program in Refugee Trauma. (2004). Measuring trauma, measuring torture: Instructions and guidance on the utilization of the Harvard Program in Refugee Trauma’s versions of the Hopkins Symptom Checklist–25 (HSCL-25) and the Harvard Trauma Questionnaire (HTQ). Cambridge, MA: Author. Hayes, S., & Smith, S. (2005). Get out of your mind and into your life: The new acceptance and commitment therapy. Oakland, CA: New Harbinger. Hays, P. A. (1996). Culturally responsive assessment with diverse older clients. Professional Psychology: Research and Practice, 27, 188–193. http:// dx.doi.org/10.1037/0735-7028.27.2.188 Hays, P.  A. (2006). Cognitive–behavioral therapy with Alaska Native people. In P. A. Hays & G. Y. Iwamasa (Eds.), Culturally responsive cognitive– behavioral therapy: Assessment, practice, and supervision (pp. 47–71). Washington, DC: American Psychological Association. http://dx.doi. org/10.1037/11433-002 Hays, P. A. (2007). Commentary: A strengths-based approach to psychotherapy with Middle Eastern people. In J. C. Muran (Ed.), Dialogues on

References

difference: Studies of diversity in the therapeutic relationship (pp. 243–250). Washington, DC: American Psychological Association. http://dx.doi. org/10.1037/11500-027 Hays, P. A. (2008). Addressing cultural complexities in practice: Assessment, diagnosis, and therapy (2nd ed.). Washington, DC: American Psychological Association. Hays, P. A. (2009). Integrating evidence-based practice, cognitive– behavior therapy, and multicultural therapy: Ten steps for culturally competent practice. Professional Psychology: Research and Practice, 40, 354–360. http://dx.doi.org/10.1037/a0016250 Hays, P. A. (2012). Culturally responsive cognitive–behavioral therapy in practice: Series V—Multicultural counseling [DVD]. Washington, DC: American Psychological Association. Hays, P. A. (2013). Connecting across cultures: The helper’s toolkit. Thousand Oaks, CA: Sage. Hays, P. A. (2014). Creating well-being: Four steps to a happier, healthier life. Washington, DC: American Psychological Association. http:// dx.doi.org/10.1037/14317-000 Hays, P. A. (2015). Culturally responsive cognitive behavioral therapy over time: Psychotherapy in six sessions [DVD]. Washington, DC: American Psychological Association. Hays, P. A., & Iwamasa, G. Y. (Eds.). (2006). Culturally responsive cognitive– behavioral therapy: Assessment, practice, and supervision. Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/ 11433-000 Hays, P. A., & Zouari, J. (1995). Stress, coping, and mental health among rural, village, and urban women in Tunisia. International Journal of Psychology, 30, 69–90. http://dx.doi.org/10.1080/00207599508246974 Health Insurance Portability and Accountability Act of 1996, Pub. L. 104-191, 110 Stat. 1936. Helms, J. E. (1995). An update of Helms’s White and people of color racial identity models. In J. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural counseling (pp. 181–198). Thousand Oaks, CA: Sage. Herman, J. (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5, 377–391. http:// dx.doi.org/10.1002/jts.2490050305 Herman, J. (1997). Trauma and recovery. New York, NY: Basic Books. Herring, R. (1999). Counseling with Native American Indians and Alaskan Natives. Thousand Oaks, CA: Sage. Hertzberg, J. F. (1990). Feminist psychotherapy and diversity: Treatment considerations from a self psychology perspective. In L. S. Brown & M. P. P. Root (Eds.), Diversity and complexity in feminist therapy (pp. 275–297). Binghamton, NY: Haworth Press. http://dx.doi. org/10.1300/J015V09N03_03

321

322

R eferences

Hill, J. S., Pace, T. M., & Robbins, R. R. (2010). The colonizing personality assessment and honoring Indigenous voices: A critical examination of the MMPI–2. Professional Psychology: Research and Practice, 16, 16–25. http://dx.doi.org/10.1037/a0016110 Hilsenroth, M. (Ed.). (2014). Relational foundations of psychotherapy [Special section]. Psychotherapy, 51(3). Hinrichsen, G. A. (2006). Why multicultural issues matter for practitioners working with older adults. Professional Psychology: Research and Practice, 37, 29–35. http://dx.doi.org/10.1037/0735-7028.37.1.29 Hinshaw, S., & Scheffler, R. (2014). The ADHD explosion: Myths, medication, money, and today’s push for performance. New York, NY: Oxford University Press. His Holiness the Dalai Lama. (2003). A simple path: Basic Buddhist teachings. New York, NY: Thorsons/HarperCollins. His Holiness the Dalai Lama, & Cutler, H. C. (1999). The art of happiness: A handbook for living. New York, NY: Riverhead Books. Hiscox, A. R., & Calisch, A. C. (Eds.). (1998). Tapestry of cultural issues in art therapy. Philadelphia, PA: Jessica Kingsley. Ho, C. K. (1990). An analysis of domestic violence in Asian American communities: A multicultural approach to counseling. In L. S. Brown & M. P. P. Root (Eds.), Diversity and complexity in feminist therapy (pp. 129–150). Binghamton, NY: Haworth Press. http://dx.doi.org/ 10.1300/J015v09n01_08 Hogan, L. (1995). Solar storms. New York, NY: Scribner. Hong, G. K. (1988). A general family practitioner approach for Asian American mental health services. Professional Psychology: Research and Practice, 19, 600–605. http://dx.doi.org/10.1037/0735-7028.19.6.600 hooks, b. (1998). Feminism: A transformational politic. In P. S. Rothenberg (Ed.), Race, class, and gender in the United States (pp. 579–586). New York, NY: St. Martin’s Press. Hopson, R. E. (1996). The 12-step program. In E. P. Shafranske (Ed.), Religion and the clinical practice of psychology (pp. 533–558). Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/ 10199-020 Hoshino, J. (2003). Multicultural art therapy with families. In C. Malchiodi (Ed.), Clinical handbook of art therapy (pp. 375–386). New York, NY: Guilford Press. Huey, S. J., Jr., Tilley, J. L., Jones, E. O., & Smith, C. A. (2014). The contribution of cultural competence to evidence-based care for ethnically diverse populations. Annual Review of Clinical Psychology, 10, 305–338. http://dx.doi.org/10.1146/annurev-clinpsy-032813-153729 Hulnick, M. R., & Hulnick, H. R. (1989). Life’s challenges: Curse or opportunity? Counseling families of persons with disabilities. Journal of Counseling & Development, 68, 166–170. http://dx.doi.org/10.1002/ j.1556-6676.1989.tb01350.x

References

Inman, A. G., Tummala-Narra, P., Kaduvettoor-Davidson, A., Alvarez, A. N., & Yeh, C. J. (2015). Perceptions of race-based discrimination among first-generation Asian Indians in the United States. Counseling Psychologist, 43, 217–247. http://dx.doi.org/10.1177/0011000014566992 Irish, D. P., Lundquist, K. P., & Nelsen, V. J. (1993). Ethnic variations in dying, death, and grief: Diversity in universality. Washington, DC: Taylor & Francis. Itai, G., & McRae, C. (1994). Counseling older Japanese American clients: An overview and observations. Journal of Counseling & Development, 72, 373–377. http://dx.doi.org/10.1002/j.1556-6676.1994.tb00952.x Ivey, A. E., Ivey, M. B., & Simek-Morgan, L. (1993). Counseling and psychotherapy: A multicultural perspective. Needham Heights, MA: Simon & Shuster. Iwamasa, G. Y., Hsia, C., & Hinton, D. (2006). Cognitive–behavioral therapy with Asian Americans. In P. A. Hays & G. Y. Iwamasa (Eds.), Culturally responsive cognitive–behavioral therapy: Assessment, practice, and supervision (pp. 117–140). Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/11433-005 Jamil, O. B., Harper, G. W., Fernandez, M. I., & Adolescent Trials Network for HIV/AIDS Interventions. (2009). Sexual and ethnic identity development among gay–bisexual–questioning (GBQ) male ethnic minority adolescents. Cultural Diversity and Ethnic Minority Psychology, 15, 203–214. http://dx.doi.org/10.1037/a0014795 Jewell, D. A. (1989). Cultural and ethnic issues. In S. Wetzler & M. M. Katz (Eds.), Contemporary approaches to psychological assessment (pp. 299–309). New York, NY: Brunner/Mazel. Jilek, W. G. (1994). Traditional healing in the prevention and treatment of alcohol and drug abuse. Transcultural Psychiatric Research Review, 31, 219–258. http://dx.doi.org/10.1177/136346159403100301 Jones, J. T., Pelham, B. W., Carvallo, M., & Mirenberg, M. C. (2004). How do I love thee? Let me count the Js: Implicit egotism and interpersonal attraction. Journal of Personality and Social Psychology, 87, 665–683. http://dx.doi.org/10.1037/0022-3514.87.5.665 Jones, R. L. (Ed.). (1996). Handbook of tests and measurements for Black populations. Hampton, VA: Cobb & Henry. Jorm, A. F., & Jacomb, P. A. (1989). The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): Socio-demographic correlates, reliability, validity and some norms. Psychological Medicine, 19, 1015–1022. http://dx.doi.org/10.1017/S0033291700005742 Judd, T. (2014). The psychologist’s second language skills. Unpublished manuscript. Judd, T., Capetillo, D., Carrión-Baralt, J., Mármol, L. M., MiguelMontes, L. S., Navarrete, M. G., . . . the NAN Policy and Planning Committee. (2009). Professional considerations for improving the neuropsychological evaluation of Hispanics: A National Academy of

323

324

R eferences

Neuropsychology education paper. Archives of Clinical Neuropsychology, 24, 127–135. http://dx.doi.org/10.1093/arclin/acp016 Judd, T., & DeBoard, R. (2010). Assessment of linguistic minorities. National Academy of Neuropsychology Bulletin, 25(1), 6–9. Kabat-Zinn, J. (2005). Wherever you go, there you are: Mindfulness meditation in everyday life. New York, NY: Hyperion. Kahn, R. L., Goldfarb, A. I., Pollack, M., & Peck, A. (1960). Brief objective measures for the determination of mental status in the aged. American Journal of Psychiatry, 117, 326–328. http://dx.doi.org/10.1176/ ajp.117.4.326 Kaplan, M. (1983). A woman’s view of DSM–III. American Psychologist, 38, 786–792. http://dx.doi.org/10.1037/0003-066X.38.7.786 Kaplan, S. L. (2011, June 19). U.S. children misdiagnosed with bipolar disorder. Newsweek. Retrieved from http://www.newsweek.com/ us-children-misdiagnosed-bipolar-disorder-67871 Kaslow, F. W. (1993). Relational diagnosis: An idea whose time has come? Family Process, 32, 255–259. http://dx.doi.org/10.1111/j.1545-5300. 1993.00255.x Kathuria, R., & Serpell, R. (1998). Standardization of the Panga Munthu test: A nonverbal cognitive test developed in Zambia. Journal of Negro Education, 67, 228–241. http://dx.doi.org/10.2307/2668192 Kaufert, J. M., & Shapiro, E. (1996). Cultural, linguistic and contextual factors in validating the Mental Status Questionnaire: The experience of Aboriginal elders in Manitoba. Transcultural Psychiatric Research Review, 33, 277–296. http://dx.doi.org/10.1177/ 136346159603300302 Kaufman, A. S., & Kaufman, N. L. (2004). Kaufman Assessment Battery for Children (2nd ed.). Circle Pines, MN: American Guidance Service. Kelland, D. Z., Lewis, R., & Gurevitch, D. (1992). Evaluation of the Repeatable Cognitive–Perceptual–Motor Battery: Reliability, validity and sensitivity to diazepam [Abstract]. Journal of Clinical and Experimental Neuropsychology, 14, 65. Kelly, S. (2006). Cognitive–behavioral therapy with African Americans. In P. A. Hays & G. Y. Iwamasa (Eds.), Culturally responsive cognitive– behavioral therapy: Assessment, practice, and supervision (pp. 97–116). Washington, DC: American Psychological Association. http://dx.doi. org/10.1037/11433-004 Kemp, N. T., & Mallinckrodt, B. (1996). Impact of professional training on case conceptualization of clients with a disability. Professional Psychology: Research and Practice, 27, 378–385. http://dx.doi.org/10.1037/ 0735-7028.27.4.378 Kertész, R. (2002). Dual relationships in psychotherapy in Latin America. In A. A. Lazarus & O. Zur (Eds.), Dual relationships and psychotherapy (pp. 329–334). New York, NY: Springer.

References

Kessler, L. E., & Waehler, C. A. (2005). Addressing multiple relationships between clients and therapists in lesbian, gay, bisexual, transgender communities. Professional Psychology: Research and Practice, 36, 66–72. http://dx.doi.org/10.1037/0735-7028.36.1.66 Kim, B. L. C. (1996). Korean families. In M. McGoldrick, J. Giordano, & J. K. Pearce (Eds.), Ethnicity and family therapy (2nd ed., pp. 281–294). New York, NY: Guilford Press. Kim, B. L. C. (1998). Marriages of Asian women and American military men. In M. McGoldrick (Ed.), Re-visioning family therapy (pp. 309–319). New York, NY: Guilford Press. Kim, B. S. K. (1996). The Korean Americans. In P. B. Pedersen & D. C. Locke (Eds.), Cultural and diversity issues in counseling (pp. 47–50). Greensboro: School of Education, University of North Carolina at Greensboro. (ERIC Document Reproduction Service No. ED400486) Kim, B. S. K., Ng, G. F., & Ahn, A. J. (2005). Effects of client expectation for counseling success, client–counselor worldview match, and client adherence to Asian and European American cultural values on counseling process with Asian Americans. Journal of Counseling Psychology, 52, 67–76. http://dx.doi.org/10.1037/0022-0167.52.1.67 Kim, S. C. (1985). Family therapy for Asian Americans: A strategic structural framework. Psychotherapy: Theory, Research, Practice, Training, 22, 342–348. http://dx.doi.org/10.1037/h0085513 Kim, W. J., Kim, L. I., & Rue, D. S. (1997). Korean American children. In G. Johnson-Powell & J. Yamamoto (Eds.), Transcultural child development: Psychological assessment and treatment (pp. 182–207). New York, NY: Wiley. Kim-Ju, G. M., & Liem, R. (2003). Ethnic self-awareness as a function of ethnic group status, group composition, and ethnic identity orientation. Cultural Diversity and Ethnic Minority Psychology, 9, 289–302. http:// dx.doi.org/10.1037/1099-9809.9.3.289 Kimmel, M. S., & Messner, M. (Eds.). (1992). Men’s lives. New York, NY: Macmillan. Kinzie, J. D., Manson, S. M., Vinh, D. T., Tolan, N. T., Anh, B., & Pho, T. N. (1982). Development and validation of a Vietnamese-language depression rating scale. American Journal of Psychiatry, 139, 1276–1281. http://dx.doi.org/10.1176/ajp.139.10.1276 Kirmayer, L. J. (1998). Editorial: The fate of culture and DSM–IV. Transcultural Psychiatry, 35, 339–342. http://dx.doi.org/10.1177/ 136346159803500301 Kirwan Institute. (2014). State of the science: Implicit bias review. Retrieved from http://kirwaninstitute.osu.edu/wp-content/uploads/2014/03/ 2014-implicit-bias.pdf Kisiel, C., Conradi, L., Fehrenbach, T., Torgersen, E., & Briggs, E. C. (2014). Assessing the effects of trauma in children and adolescents in

325

326

References

practice settings. Child and Adolescent Psychiatric Clinics of North America, 23, 223–242, vii. http://dx.doi.org/10.1016/j.chc.2013.12.007 Kivel, P. (2002). Uprooting racism. Gabriola Island, British Columbia, Canada: New Society Publishers. Kluckhohn, P., & Strodtbeck, F. (1961). Variations in value orientations. Evanston, IL: Row, Peterson. Kosmin, B. A., & Keysar, A. (2009). American Religious Identification Survey (ARIS 2008): Summary report, March 2009. Hartford, CT: Trinity College. Retrieved from http://commons.trincoll.edu/aris/files/2011/08/ARIS_ Report_2008.pdf Kubiszyn, T. W., Meyer, G. J., Finn, S. E., Eyde, L. D., Kay, G. G., Moreland, K. L., . . . Eisman, E. J. (2000). Empirical support for psychological assessment in clinical health care settings. Professional Psychology: Research and Practice, 31, 119–130. http://dx.doi.org/10.1037/0735-7028.31.2.119 LaFromboise, T. D., & Rowe, W. (1983). Skills training for bicultural competence: Rationale and application. Journal of Counseling Psychology, 30, 589–595. http://dx.doi.org/10.1037/0022-0167.30.4.589 Lai, M. C., & Yue, K. M. K. (1990). The Chinese. In N. Waxler-Morrison, J. M. Anderson, & E. Richardson (Eds.), Cross-cultural caring: A handbook for health professionals in Western Canada (pp. 68–90). Vancouver, Canada: University of British Columbia Press. La Roche, M. J. (2013). Cultural psychotherapy: Methods, theories, and practice. Thousand Oaks, CA: Sage. La Roche, M. J., D’Angelo, E., Gualdron, L., & Leavell, J. (2006). Culturally sensitive guided imagery for allocentric Latinos: A pilot study. Psychotherapy: Theory, Research, Practice, Training, 43, 555–560. http:// dx.doi.org/10.1037/0033-3204.43.4.555 Larry P. v. Riles, 495 F.Supp. 926, 987 (N.D.Cal. 1979). La Rue, A., Romero, L.  J., Ortiz, I. E., Liang, H. C., & Lindeman, R.  D. (1999). Neuropsychological performance of Hispanic and non-Hispanic older adults: An epidemiologic survey. Clinical Neuropsychologist, 13, 474–486. http://dx.doi.org/10.1076/1385-4046(199911)13:04;1-Y;FT474 Laska, K. M., Gurman, A. S., & Wampold, B. E. (2014). Expanding the lens of evidence-based practice in psychotherapy: A common factors perspective. Psychotherapy, 51, 467–481. http://dx.doi.org/10.1037/ a0034332 Lau, A. S. (2012). Reflections on adapting parent training for Chinese immigrants: Blind alleys, thoroughfares, and test drives. In G. Bernal & M. M. Domenech Rodriguez (Eds.), Cultural adaptations: Tools for evidence-based practice with diverse populations (pp. 133–156). Washington, DC: American Psychological Association. Lau, A. W., & Kinoshita, L. M. (2006). Cognitive–behavioral therapy with culturally diverse older adults. In P. A. Hays & G. Y. Iwamasa (Eds.), Culturally responsive cognitive–behavioral therapy: Assessment, practice, and

References

supervision (pp. 179–197). Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/11433-008 Leigh, I. W. (2003). Deaf: Moving from hearing loss to diversity. In J. S. Mio & G. Y. Iwamasa (Eds.), Culturally diverse mental health (pp. 323–339). New York, NY: Brunner-Routledge. Leigh, I. W., Corbett, C. A., Gutman, V., & Morere, D. A. (1996). Providing psychological services to Deaf individuals: A response to new perceptions of diversity. Professional Psychology: Research and Practice, 27, 364–371. http://dx.doi.org/10.1037/0735-7028.27.4.364 Lemma, A. (2000). Humour on the couch. Philadelphia, PA: Whurr. Leonard, T., Aung, L., Bronson, M., Dunn, A. R., & Thomas, B. (2013). Review & update regarding the assessment of African American children. CASP Today, 63(1), 7–17. Lewis, J. A., Dana, R. Q., & Blevins, G. A. (1994). Substance abuse counseling: An individualized approach. Pacific Grove, CA: Brooks/Cole. Lewis, M. I., & Butler, R. N. (1974). Life-review therapy. Putting memories to work in individual and group psychotherapy. Geriatrics, 29, 165–173. Lewis-Fernández, R. (1996). Cultural formulation of psychiatric diagnosis. Culture, Medicine and Psychiatry, 20, 133–144. Lezak, M. (1995). Neuropsychological assessment. New York, NY: Oxford University Press. Lindsey, M. L. (1998). Culturally competent assessment of African American clients. Journal of Personality Assessment, 70, 43–53. http:// dx.doi.org/10.1207/s15327752jpa7001_3 Linehan, M. (2014). DBT® skills training manual (2nd ed.). New York, NY: Guilford Press. Liu, W. M. (2011). Social class and classism in the helping professions. Thousand Oaks, CA: Sage. Livanis, A., & Tryon, G. S. (2010). The development of the Adolescent Nervios Scale: Preliminary findings. Professional Psychology: Research and Practice, 16, 9–15. Locke, D. C., & Kiselica, M. S. (1999). Pedagogy of possibilities: Teaching about racism in multicultural counseling courses. Journal of Counseling & Development, 77, 80–86. http://dx.doi.org/10.1002/j.1556-6676.1999. tb02424.x Lohman, D. F., & Hagen, E. P. (2001). Cognitive Abilities Test (Form 6). Itasca, IL: Riverside Publishing. López, S. R., Grover, K. P., Holland, D., Johnson, M. J., Kain, C. D., Kanel, K., . . . Rhyne, M. C. (1989). Development of culturally sensitive psychotherapists. Professional Psychology: Research and Practice, 20, 369–376. http://dx.doi.org/10.1037/0735-7028.20.6.369 Lott, B. (2002). Cognitive and behavioral distancing from the poor. American Psychologist, 57, 100–110. http://dx.doi.org/10.1037/0003-066X.57.2.100 Lott, B. (2012). The social psychology of class and classism. American Psychologist, 67, 650–658. http://dx.doi.org/10.1037/a0029369

327

328

R eferences

Lott, B., & Bullock, H. E. (2001). Where are the poor? Journal of Social Issues, 57, 189–206. http://dx.doi.org/10.1111/0022-4537.00208 Lovinger, R. (1996). Considering the religious dimension in assessment and treatment. In E. P. Shafranske (Ed.), Religion and the clinical practice of psychology (pp. 327–364). Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/10199-012 Lyubomirsky, S. (2007). The how of happiness: A scientific approach of getting the life you want. New York, NY: Penguin. Maguen, S., Shipherd, J. C., & Harris, H. N. (2005). Providing culturally sensitive care for transgender patients. Cognitive and Behavioral Practice, 12, 479–490. http://dx.doi.org/10.1016/S1077-7229(05)80075-6 Magyar-Moe, J. L. (2009). Therapist’s guide to positive psychological interventions. New York, NY: Academic Press. Magyar-Moe, J. L., Pedrotti, J. T., Edwards, L. M., Ford, A. I., Petersen, S. E., Rasmussen, H. N., & Ryder, J. A. (2005). Perceptions of multi­ cultural training in predoctoral internship programs: A survey of interns and training directors. Professional Psychology: Research and Practice, 36, 446–450. http://dx.doi.org/10.1037/0735-7028.36.4.446 Mahrer, A. R., & Gervaise, P. A. (1994). What strong laughter in psychotherapy is and how it works. In H. Strean (Ed.), The use of humor in psychotherapy (pp. 209–222). Northvale, NJ: Aronson. Maj, M., D’Elia, L., Satz, P., Janssen, R., Zaudig, M., Uchiyama, C., . . . the World Health Organization, Division of Mental Health/Global Programme on AIDS. (1993). Evaluation of two new neuropsychological tests designed to minimize cultural bias in the assessment of HIV-1 seropositive persons: A WHO study. Archives of Clinical Neuropsychology, 8, 123–135. http://dx.doi.org/10.1016/0887-6177(93)90030-5 Malchiodi, C. A. (Ed.). (2005). Expressive therapies. New York, NY: Guilford Press. Manson, S., & Kleinman, A. (1998). DSM–IV, culture and mood dis­ orders: A critical reflection on recent practice. Transcultural Psychiatry, 35, 377–386. http://dx.doi.org/10.1177/136346159803500304 Maramba, G. G., & Hall, G. C. (2002). Meta-analyses of ethnic match as a predictor of dropout, utilization, and level of functioning. Cultural Diversity and Ethnic Minority Psychology, 8, 290–297. Marsella, A. J., & Kaplan, A. (2002). Cultural considerations for understanding, assessing, and treating depressive experience and disorder. In M. Reinecke & M. Davison (Eds.), Comparative treatments of depression (pp. 47–78). New York, NY: Springer. Marsella, A. J., & Yamada, A. M. (2000). Culture and mental health: An introduction and overview of foundations, concepts, and issues. In I. Cuéllar & F. Paniagua (Eds.), The handbook of multicultural mental health: Assessment and treatment of diverse populations (pp. 3–24). New York, NY: Academic Press. http://dx.doi.org/10.1016/B978-012199370-2/ 50002-X

References

Martin, A. (1982). Some issues in the treatment of gay and lesbian patients. Psychotherapy: Theory, Research, Practice, Training, 19, 341–348. http://dx.doi.org/10.1037/h0088445 Mast, B. T., Fitzgerald, J., Steinberg, J., MacNeill, S. E., & Lichtenberg, P. A. (2001). Effective screening for Alzheimer’s disease among older African Americans. Clinical Neuropsychologist, 15, 196–202. http://dx.doi. org/10.1076/clin.15.2.196.1892 Matheson, L. (1986). If you are not an Indian, how do you treat an Indian? In H. P. Lefley & P. Pedersen (Eds.), Cross-cultural training for mental health professionals (pp. 115–130). Springfield, IL: Charles C Thomas. Matsui, W. T. (1996). Japanese families. In M. McGoldrick, J. Giordano, & J. K. Pearce (Eds.), Ethnicity and family therapy (2nd ed., pp. 268–280). New York, NY: Guilford Press. Matthews, C. R., & Lease, S. H. (2000). Focus on lesbian, gay, and bisexual families. In R. M. Perez, K. A. DeBord, & K. J. Bieschke (Eds.), Handbook of counseling and psychotherapy with lesbian, gay, and bisexual clients (pp. 249–273). Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/10339-011 McCarn, S. R., & Fassinger, R. E. (1996). Revising sexual minority identity formation: A new model of lesbian identity and its implications for counseling and research. Counseling Psychologist, 24, 508–534. http:// dx.doi.org/10.1177/0011000096243011 McClanahan, A. J. (1986). Our stories, our lives. Anchorage, AK: Cook Inlet Region. McFarr, L., Brown, L.  A., Holler, R., Jackson, L., Morgan, W., & Ramirez, U. (2014). Cognitive behavioral therapies in Southern California. Behavior Therapist, 37, 117–121. McGoldrick, M. (1998). Introduction. In M. McGoldrick (Ed.), Re-visioning family therapy: Race, culture, and gender in clinical practice (pp. 3–19). New York, NY: Guilford Press. McGoldrick, M., Giordano, J., & Garcia-Preto, N. (Eds.). (2005). Ethnicity and family therapy (3rd ed.). New York, NY: Guilford Press. McIntosh, P. (1998). White privilege and male privilege: A personal account of coming to see correspondence through work in women’s studies. In M. L. Anderson & P. H. Collins (Eds.), Race, class and gender: An anthology (pp. 94–105). New York, NY: Wadsworth. Mejias, N. J., Gill, C. J., & Shpigelman, C.-N. (2014). Influence of a support group for young women with disabilities on sense of belonging. Journal of Counseling Psychology, 61, 208–220. http://dx.doi.org/10.1037/ a0035462 Menos, J. (2005). Haitian families. In M. McGoldrick, J. Giordano, & N. Garcia-Preto (Eds.), Ethnicity and family therapy (3rd ed., pp. 127–137). New York, NY: Guilford Press. Meyer, G. J., & Archer, R. P. (2001). The hard science of Rorschach research: What do we know and where do we go? Psychological

329

330

R eferences

Assessment, 13, 486–502. http://dx.doi.org/10.1037/1040-3590. 13.4.486 Meyers, L. (2006). Psychologists and psychotropic medication. Monitor on Psychology, 37, 46–47. http://dx.doi.org/10.1037/e512802006-025 Miller, M. J., Yang, M., Lim, R. H., Hui, K., Choi, N. Y., Fan, X., . . . Blackmon, S. (2013). A test of the domain-specific acculturation strategy hypothesis. Cultural Diversity & Ethnic Minority Psychology, 19, 1–12. Minton, B. A., & Soule, S. (1990). Two Eskimo villages assess mental health strengths and needs. American Indian and Alaska Native Mental Health Research, 4, 7–24. http://dx.doi.org/10.5820/aian.0402.1990.7 Minuchin, P., Colapinto, J., & Minuchin, S. (2007). Working with families of the poor. New York, NY: Guilford Press. Minuchin, S. (1974). Family and family therapy. Cambridge, MA: Harvard University Press. Mistry, R. (2001). A fine balance. New York, NY: Vintage Books. Mohatt, N. V., Fok, C. C. T., Burket, R., Henry, D., & Allen, J. (2011). Assessment of awareness of connectedness as a culturally-based protective factor for Alaska native youth. Cultural Diversity and Ethnic Minority Psychology, 17, 444–455. http://dx.doi.org/10.1037/a0025456 Mona, L. (2013, July). Promoting sexual health among women with disabilities. Paper presented at the meeting of the American Psychological Association, Honolulu, HI. Mona, L. R., Romesser-Scehnet, J. M., Cameron, R. P., & Cardenas, V. (2006). Cognitive–behavioral therapy and people with disabilities. In P. A. Hays & G. Y. Iwamasa (Eds.), Culturally responsive cognitive– behavioral therapy: Assessment, practice, and supervision (pp. 199–222). Washington, DC: American Psychological Association. http://dx.doi. org/10.1037/11433-009 Monnot, M. J., Quirk, S. W., Hoerger, M., & Brewer, L. (2009). Racial bias in personality assessment: Using the MMPI–2 to predict psychiatric diagnoses of African American and Caucasian chemical dependency inpatients. Psychological Assessment, 21, 137–151. http://dx.doi. org/10.1037/a0015316 Moore Hines, P., & Boyd-Franklin, N. (1996). African American families. In M. McGoldrick, J. Giordano, & J. K. Pearce (Eds.), Ethnicity and family therapy (2nd ed., pp. 66–84). New York, NY: Guilford Press. Morales, P. (1999). The impact of cultural differences in psychotherapy with older clients: Sensitive issues and strategies. In M. Duffy (Ed.), Handbook of counseling and psychotherapy with older adults (pp. 132–153). New York, NY: Wiley. Morere, D. A., & Allen, T. E. (Eds.). (2012). Assessing literacy in Deaf individuals: Neurocognitive measurement and predictors. New York, NY: Springer.

References

Morey, L. (2007). Personality Assessment Inventory professional manual. Lutz, FL: Psychological Assessment Resources. Morris, E. (2000). Assessment practices with African Americans: Combining standard assessment measures within an Africentric orientation. In R. H. Dana (Ed.), Handbook of cross-cultural and multicultural personality assessment (pp. 573–604). Mahwah, NJ: Erlbaum. Muecke, M. A. (1983a). Caring for Southeast Asian refugee patients in the USA. American Journal of Public Health, 73, 431–438. http://dx.doi. org/10.2105/AJPH.73.4.431 Muecke, M. A. (1983b). In search of healers: Southeast Asian refugees in the American health care system. Western Journal of Medicine, 139, 835–840. Mungas, D., Reed, B. R., Haan, M. N., & González, H. (2005). Spanish and English neuropsychological assessment scales: Relationship to demographics, language, cognition, and independent function. Neuro­ psychology, 19, 466–475. http://dx.doi.org/10.1037/0894-4105.19.4.466 Muñoz, R. F., & Mendelson, T. (2005). Toward evidence-based interventions for diverse populations: The San Francisco General Hospital prevention and treatment manuals. Journal of Consulting and Clinical Psychology, 73, 790–799. http://dx.doi.org/10.1037/0022-006X.73.5.790 Murgatroyd, W. (1996). Counseling Buddhist clients. In P. B. Pedersen & C. Locke (Eds.), Cultural and diversity issues in counseling (pp. 69–72). Greensboro: School of Education, University of North Carolina at Greensboro. (ERIC Document Reproduction Service No. ED400486) Murray, H. A. (1943). The Thematic Apperception Test. Cambridge, MA: Harvard University Press. Nabors, N. A., Evans, J. D., & Strickland, T. L. (2000). Neuropsychological assessment and intervention with African Americans. In E. FletcherJanzen, T. L. Strickland, & C. R. Reynolds (Eds.), Handbook of crosscultural neuropsychology (pp. 31–42). New York, NY: Kluwer Academic/ Plenum. http://dx.doi.org/10.1007/978-1-4615-4219-3_3 Nakamura, N., Chan, E., & Fischer, B. (2013). “Hard to crack”: Experiences of community integration among first- and second-generation Asian MSM in Canada. Cultural Diversity and Ethnic Minority Psychology, 19, 248–256. http://dx.doi.org/10.1037/a0032943 National Association of Social Workers. (2007). Indicators for the achievement of NASW standards for cultural competence in social work practice. Retrieved from http://www.naswdc.org/practice/standards/ NASWCulturalStandardsIndicators2006.pdf National Center for Telehealth & Technology. (n.d.). Virtual Hope Box. Retrieved from http://www.t2health.dcoe.mil/apps/virtual-hope-box National Child Traumatic Stress Network, Core Curriculum on Childhood Trauma Task Force. (2012). The 12 core concepts: Concepts for understanding traumatic stress responses in children and families. Retrieved from

331

332

R eferences

http://www.nctsnet.org/resources/audiences/parents-caregivers/ what-is-cts/12-core-concepts National Council on Interpreting in Health Care. (2005). National standards of practice for interpreting in health care. Santa Rosa, CA: Author. Retrieved from http://www.ncihc.org/assets/documents/publications/ NCIHC%20National%20Standards%20of%20Practice.pdf Newton, N. A., & Jacobowitz, J. (1999). Transferential and countertransferential processes in therapy with older adults. In M. Duffy (Ed.), Handbook of counseling and psychotherapy with older adults (pp. 21–40). New York, NY: Wiley. Nichols, D. S., Padilla, J., & Gomez-Maqueo, E. L. (2000). Issues in the cross-cultural adaptation and use of the MMPI–2. In R. H. Dana (Ed.), Handbook of cross-cultural and multicultural personality assessment (pp. 247–266). Mahwah, NJ: Erlbaum. Nicolas, G., DeSilva, A. M., Grey, K. S., & Gonzalez-Eastep, D. (2006). Using a multicultural lens to understand illness among Haitians living in America. Professional Psychology: Research and Practice, 37, 702–707. http://dx.doi.org/10.1037/0735-7028.37.6.702 Nicolas, G., & JeanBaptiste, V. (2001). Experiences of women on public assistance. Journal of Social Issues, 57, 299–309. http://dx.doi.org/ 10.1111/0022-4537.00214 Niemeyer, G. J. (2013, August 2). Understanding the DSM–5: Problems and prospects in the diagnostic revisions. Continuing education workshop presented at the meeting of the American Psychological Association, Honolulu, HI. Norcross, J. C., & Lambert, M. J. (2011). Evidence-based therapy. In J. C. Norcross (Ed.), Psychotherapy relationships that work (2nd ed., pp. 2–24). New York, NY: Oxford University Press. Norcross, J. C., & Wampold, B. E. (2011). Evidence-based therapy relationships: Research conclusions and clinical practices. Psychotherapy, 48, 98–102. http://dx.doi.org/10.1037/a0022161 Norris, F. H., & Alegria, M. (2006). Promoting disaster recovery in ethnicminority individuals and communities. In E. C. Ritchie, P. J. Watson, & M. J. Friedman (Eds.), Interventions following mass violence and disasters (pp. 319–342). New York, NY: Guilford Press. Novotney, A. (2014, April). Is it really ADHD? Monitor on Psychology, pp. 28–31. O’Brien, S. (2010, April 2–3). Survival skills beat high scores [Letter to the editor]. Alaska Dispatch News. Retrieved from http://www.adn. com/article/20100402/letters-editor-4310 O’Connor, K. (2005). Addressing diversity issues in play therapy. Professional Psychology: Research and Practice, 36, 566–573. Okazaki, S., & Tanaka-Matsumi, J. (2006). Cultural considerations in cognitive–behavioral assessment. In P. A. Hays & G. Y. Iwamasa (Eds.), Culturally responsive cognitive–behavioral therapy: Assessment, practice, and

References

supervision (pp. 247–266). Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/11433-011 Olkin, R. (1999). What psychotherapists should know about disability. New York, NY: Guilford Press. Olkin, R. (2002). Could you hold the door for me? Including disability in diversity. Cultural Diversity and Ethnic Minority Psychology, 8, 130–137. http://dx.doi.org/10.1037/1099-9809.8.2.130 Organista, K. C. (2006). Cognitive–behavioral therapy with Latinos and Latinas. In P. A. Hays & G. Y. Iwamasa (Eds.), Culturally responsive cognitive–behavioral therapy: Assessment, practice, and supervision (pp. 73–96). Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/11433-003 Organista, K. C. (2007). Commentary: The need to explicate culturally competent approaches with Latino clients. In C. Muran (Ed.), Dialogues on difference: Studies of diversity in the therapeutic relationship (pp. 168–175). Washington, DC: American Psychological Association. http://dx.doi. org/10.1037/11500-018 Pace, T. M., Robbins, R. R., Choney, S. K., Hill, J. S., Lacey, K., & Blair, G. (2006). A cultural-contextual perspective on the validity of the MMPI–2 with American Indians. Cultural Diversity and Ethnic Minority Psychology, 12, 320–333. http://dx.doi.org/10.1037/1099-9809.12.2.320 Pan, D., Huey, S. J., Jr., & Hernandez, D. (2011). Culturally adapted versus standard exposure treatment for phobic Asian Americans: Treatment efficacy, moderators, and predictors. Cultural Diversity and Ethnic Minority Psychology, 17, 11–22. http://dx.doi.org/10.1037/a0022534 Paniagua, F. A. (1998). Assessing and treating culturally diverse clients (2nd ed.). Thousand Oaks, CA: Sage. Paniagua, F. A. (2005). Assessing and treating culturally diverse clients (3rd ed.). Thousand Oaks, CA: Sage. http://dx.doi.org/10.4135/9781483329093 Paradis, C. M., Cukor, D., & Friedman, S. (2006). Cognitive–behavioral therapy with Orthodox Jews. In P. A. Hays & G. Y. Iwamasa (Eds.), Culturally responsive cognitive–behavioral therapy: Assessment, practice, and supervision (pp. 161–175). Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/11433-007 Parsons, M. W., & Hammeke, T. A. (Eds.). (2014). Clinical psychology: A pocket handbook for assessment (3rd ed.). Washington, DC: American Psychological Association. Patient Protection and Affordable Care Act, Pub. L. 111-148, § 3502, 124 Stat. 119, 124 (2010). Payne, R. K. (2013). A framework for understanding poverty: A cognitive approach (5th ed.). Highlands, TX: aha! Process. Pedersen, P. (1987). Ten frequent assumptions of cultural bias in counseling. Journal of Multicultural Counseling and Development, 15, 16–24. http://dx.doi.org/10.1002/j.2161-1912.1987.tb00374.x

333

334

R eferences

Pérez-Arce, P., & Puente, A. E. (1996). Neuropsychological assessment of ethnic minorities: The case of Hispanics living in North America. In R. J. Sbordone & C. J. Long (Eds.), Ecological validity of neuropsychological testing (pp. 283–300). Delray Beach, FL: GR Press/St. Lucie Press. Pérez Foster, R. (1996). What is the multicultural perspective for psychoanalysis? In R. Pérez Foster, M. Moskowitz, & R. A. Javier (Eds.), Reaching across boundaries of culture and class: Widening the scope of psychotherapy (pp. 3–20). Northvale, NJ: Aronson. Peterson, C. (2008, August 18). 20th anniversary of the Civil Liberties Act: Japanese internment during World War II. Retrieved from http://www. civilrights.org/resources/features/018-civil-liberties-act.html Petrik, A. M., Kazantzis, N., & Hofmann, S. G. (2013). Distinguishing integrative from eclectic practice in cognitive behavioral therapies. Psychotherapy, 50, 392–397. http://dx.doi.org/10.1037/a0032412 Phinney, J. S. (1996). When we talk about American ethnic groups, what do we mean? American Psychologist, 51, 918–927. http://dx.doi. org/10.1037/0003-066X.51.9.918 Piercy, F., Soekandar, A., & Limansubroto, C. D. M. (1996). Indonesian families. In M. McGoldrick, J. Giordano, & J. K. Pearce (Eds.), Ethnicity and family therapy (2nd ed., pp. 333–346). New York, NY: Guilford Press. Piff, P. K., Stancato, D. M., Côté, S., Mendoza-Denton, R., & Keltner, D. (2012). Higher social class predicts increased unethical behavior. Proceedings of the National Academy of Sciences, 109, 4086–4091. http://dx.doi. org/10.1073/pnas.1118373109 Pires, A. A. (2000). National norms for the Rorschach normative study in Portugal. In R. H. Dana (Ed.), Handbook of cross-cultural and multicultural personality assessment (pp. 366–392). Mahwah, NJ: Erlbaum. Pollard, R. Q., Jr. (1996). Professional psychology and Deaf people: The emergence of a discipline. American Psychologist, 51, 389–396. http:// dx.doi.org/10.1037/0003-066X.51.4.389 Poortinga, Y. H., & Van de Vijver, F. J. R. (2004). Cultures and cognition: Performance differences and invariant structures. In R. J. Sternberg & E. L. Grigorenko (Eds.), Culture and competence: Contexts of life success (pp. 139–162). Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/10681-006 Pope, M. (1995). The “salad bowl” is big enough for us all: An argument for the inclusion of lesbians and gay men in any definition of multiculturalism. Journal of Counseling & Development, 73, 301–304. http:// dx.doi.org/10.1002/j.1556-6676.1995.tb01752.x Prigatano, G. P., Gupta, S., & Gale, S. (2007). Fuld Object Memory Evaluation adapted for school-age children. Developmental Neuropsychology, 32, 757–768. http://dx.doi.org/10.1080/87565640701539469 Pukui, M. K., Haertig, E. W., & Lee, C. A. (1972). NanalKeKumu [Look to the source] (Vol. 1). Honolulu, HI: Queen Lili’uokalani Children’s Center.

References

Quiñones, M. E. (2007). Reply: Are we bridging the gap yet? A work in progress. In J. C. Muran (Ed.), Dialogues on difference: Studies of diversity in the therapeutic relationship (pp. 181–184). Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/11500-020 Rao, K. R. (1988). Psychology of transcendence: A study in early Buddhistic psychology. In A. C. Paranjpe, D. Y. F. Ho, & R. W. Richer (Eds.), Asian contributions to psychology (pp. 123–148). New York, NY: Praeger. Rastogi, M., & Wampler, K. S. (1998). Couples and family therapy with Indian families: Some structural and intergenerational considerations. In U. P. Gielen & A. L. Comunian (Eds.), The family and family therapy in international perspective (pp. 257–274). Milan, Italy: Edizioni Lint Trieste. Ready, R. E., & Veague, H. B. (2014). Training in psychological assessment: Current practices of clinical psychology programs. Professional Psychology: Research and Practice, 45, 278–282. http://dx.doi.org/10.1037/a0037439 Reed, G., Khoury, B., & Evans, S. (2013, August). Global field studies of WHL’s ICD–9–11: Preliminary results. Presentation at the meeting of the American Psychological Association, Honolulu, HI. Reesman, J.  H., Day, L.  A., Szymanski, C.  A., Hughes-Wheatland, R., Witkin, G. A., Kalback, S. R., & Brice, P. J. (2014). Review of intellectual assessment measures for children who are deaf or hard of hearing. Rehabilitation Psychology, 59, 99–106. http://dx.doi.org/10.1037/a0035829 Reitan, R. M. (1958). Validity of the Trail Making Test as an indicator of organic brain damage. Perceptual and Motor Skills, 8, 271–276. Reynolds, C. (Ed.). (2001). Special series on the utility of the Rorschach for clinical assessment [Special section]. Psychological Assessment, 13(4). Reynolds, D. K. (1980). The quiet therapies: Japanese pathways to personal growth. Honolulu, HI: University of Hawaii Press. Rezentes, W. C., III. (1996). Ka Lama Kukui Hawaiian psychology: An introduction. Honolulu, HI: A’ali’i Books. Richards, P. S., & Bergin, A. E. (2014). Handbook of psychotherapy and religious diversity (2nd ed.). Washington, DC: American Psychological Association. Ridley, C. R., Liddle, M. C., Hill, C. L., & Li, L. C. (2001). Ethical decisionmaking in multicultural counseling. In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural counseling (2nd ed., pp. 165–188). Thousand Oaks, CA: Sage. Robinson, T. L. (1999). The intersections of dominant discourses across race, gender, and other identities. Journal of Counseling & Development, 77, 73–79. http://dx.doi.org/10.1002/j.1556-6676.1999.tb02423.x Robinson, T. L., & Howard-Hamilton, M. F. (2000). The convergence of race, ethnicity, and gender: Multiple identities in counseling. Columbus, OH: Merrill/Prentice-Hall. Rogler, L. H. (1999). Methodological sources of cultural insensitivity in mental health research. American Psychologist, 54, 424–433. http:// dx.doi.org/10.1037/0003-066X.54.6.424

335

336

R eferences

Rogler, L. H. (2002). Historical generations and psychology: The case of the Great Depression and World War II. American Psychologist, 57, 1013–1023. http://dx.doi.org/10.1037/0003-066X.57.12.1013 Roid, G. H. (2003). Stanford–Binet Intelligence Scales (5th ed.). Rolling Meadows, IL: Riverside Publishing. Roid, G. H., Miller, L. J., Pomplun, M., & Koch, C. (2013). Leiter International Performance Scale (3rd ed.). Wood Dale, IL: Stoelting. Roopnarine, J., Johnson, J., & Hooper, F. (Eds.). (1994). Children’s play in diverse cultures. Albany: State University of New York Press. Root, M. P. P. (1992). Reconstructing the impact of trauma on personality. In L. S. Brown & M. Ballou (Eds.), Personality and psychopathology: Feminist reappraisals (pp. 229–265). New York, NY: Guilford Press. Root, M. P. P. (1996). The multiracial experience: Racial borders as a significant frontier in race relations. In M. P. P. Root (Ed.), The multiracial experience: Racial borders as the new frontier (pp. xiii–xxviii). Thousand Oaks, CA: Sage. http://dx.doi.org/10.4135/9781483327433 Rosa’s Law, Pub. L. 111-256, 124 Stat. 2643, 2644 and 2645 (2010). Rosenfelt, S., & Estes, L. (Producers), & Eyre, C. (Director). (1998). Smoke signals [Motion picture]. United States: Miramax. Roy, A. L., & Raver, C. C. (2014). Are all risks equal? Early experiences of poverty-related risk and children’s functioning. Journal of Family Psychology, 28, 391–400. http://dx.doi.org/10.1037/a0036683 Royce-Davis, J. (2000). The influence of spirituality on community participation and belonging: Christina’s story. Counseling and Values, 44, 135–142. http://dx.doi.org/10.1002/j.2161-007X.2000.tb00165.x Roysircar, G., Arredondo, P., Fuertes, J. N., Ponterotto, J. D., & Toporek, R. L. (2003). Multicultural counseling competencies. Alexandria, VA: Association of Multicultural Counseling and Development/American Counseling Association. Sáez, P. A., Bender, H. A., Barr, W. B., Rivera Mindt, M., Morrison, C. E., Hassenstab, J., . . . Vazquez, B. (2014). The impact of education and acculturation on nonverbal neuropsychological test performance among Latino/a patients with epilepsy. Applied Neuropsychology Adult, 21, 108–119. Sáez, P. A., & Judd, T. (2014, August). Competent, confident, ethical neuropsychological testing and evaluation of Spanish speakers. Continuing education workshop presented at the meeting of the American Psychological Association, Washington, DC. Saéz-Santiago, E., Bernal, G., Reyes-Rodríguez, M. L., & Bonilla-Silva, K. (2012). Development and cultural adaptation of the Taller de Educación Psicológica para Padres y Madres (TEPSI): Psychoeducation for parents of Latino/a adolescents with depression. In G. Bernal & M. M. Domenech Rodríguez (Eds.), Cultural adaptations: Tools for

References

evidence-based practice with diverse populations (pp. 91–112). Washington, DC: American Psychological Association. Samuda, R. J. (1998). Psychological testing of American minorities: Issues and consequences. Thousand Oaks, CA: Sage. Sanders, K., Brockway, J. A., Ellis, B., Cotton, E. M., & Bredin, J. (1999). Enhancing mental health climates in hospitals and nursing homes: Collaboration strategies for medical and mental health staff. In M. Duffy (Ed.), Handbook of counseling and psychotherapy with older adults (pp. 335–349). New York, NY: Wiley. Sang, B. E. (1992). Counseling and psychotherapy with midlife and older lesbians. In S. H. Dworkin & F. J. Gutierrez (Eds.), Counseling gay men and lesbians: Journey to the end of the rainbow (pp. 35–48). Alexandria, VA: American Counseling Association. Santiago-Rivera, A., & Altarriba, J. (2002). The role of language in therapy with the Spanish–English bilingual client. Professional Psychology: Research and Practice, 33, 30–38. http://dx.doi.org/10.1037/ 0735-7028.33.1.30 Santiago-Rivera, A., Arredondo, P., & Gallardo-Cooper, M. (2002). Counseling Latinos and la familia: A guide for practitioners. Thousand Oaks, CA: Sage. Scarbrough, J. W. (2001). Welfare mothers’ reflections on personal responsibility. Journal of Social Issues, 57, 261–276. http://dx.doi.org/ 10.1111/0022-4537.00212 Schank, J. A. (2010). Challenges and benefits of ethical small-community practice. Professional Psychology: Research and Practice, 41, 502–505. http:// dx.doi.org/10.1037/a0021689 Schank, J. A., & Skovholt, T. M. (2006). Ethical practice in small communities: Challenges and rewards for psychologists. Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/11379-000 Schoonmaker, C. V. (1993). Aging lesbians: Bearing the burden of triple shame. Women & Therapy, 14, 21–31. http://dx.doi.org/10.1300/ J015v14n01_03 Schrank, F. A., Mather, N., & McGrew, K. S. (2014). Woodcock–Johnson IV Tests of Achievement. Rolling Meadows, IL: Riverside. Schulman, M. (2014, January 10). Generation LGBTQIA. New York Times, pp. E1–E8. Segal, Z. V., Williams, M. G., & Teasdale, J. D. (2012). Mindfulnessbased cognitive therapy for depression (2nd ed.). New York, NY: Guilford Press. Sehgal, R., Saules, K., Young, A., Grey, M. J., Gillem, A. R., Nabors, N. A., . . . Jefferson, S. (2011). Practicing what we know: Multi­cultural counseling competence among clinical psychology trainees and experienced multicultural psychologists. Cultural Diversity and Ethnic Minority Psychology, 17, 1–10. http://dx.doi.org/10.1037/a0021667

337

338

R eferences

Serpell, R., & Haynes, B. P. (2004). The cultural practice of intelligence testing: Problems of international export. In R. J. Sternberg & E. L. Grigorenko (Eds.), Culture and competence: Contexts of life success (pp. 163–185). Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/10681-007 Shapiro, E. R. (1995). Grief in family and cultural context: Learning from Latino families. Cultural Diversity and Mental Health, 1, 159–176. http://dx.doi.org/10.1037/1099-9809.1.2.159 Sheikh, J. I., & Yesavage, J. A. (1986). Geriatric Depression Scale (GDS): Recent evidence and development of a shorter version. In T. L. Brink (Ed.), Clinical gerontology: A guide to assessment and intervention (pp. 165–173). New York, NY: Haworth Press. Sherman, J. W., Stroessner, S. J., Conrey, F. R., & Azam, O. A. (2005). Prejudice and stereotype maintenance processes: Attention, attribution, and individuation. Journal of Personality and Social Psychology, 89, 607–622. http://dx.doi.org/10.1037/0022-3514.89.4.607 Shweder, R. A., & Bourne, E. J. (1989). Does the concept of the person vary cross-culturally? In A. J. Marsella & G. M. White (Eds.), Cultural conceptions of mental health and therapy (pp. 97–140). Dordrecht, Holland: D. Reidel. Sims, J. M. (1996). The use of voice for assessment and intervention in couples therapy. Women & Therapy, 19, 61–77. http://dx.doi.org/10.1300/ J015v19n03_07 Smedley, A., & Smedley, B. D. (2005). Race as biology is fiction, racism as a social problem is real: Anthropological and historical perspectives on the social construction of race. American Psychologist, 60, 16–26. http://dx.doi.org/10.1037/0003-066X.60.1.16 Smith, A. (1997). Cultural diversity and the coming-out process. In B. Greene (Ed.), Ethnic and cultural diversity among lesbian and gay men (pp. 279–300). Thousand Oaks, CA: Sage. Smith, D. S. (1995). Exploring the religious-spiritual needs of the dying. In M. T. Burke & J. G. Miranti (Eds.), Counseling: The spiritual dimension (pp. 177–182). Alexandria, VA: American Counseling Association. Smith, H. (1991). The world’s religions. New York, NY: HarperCollins. Smith, H. (2009). The world’s religions. New York, NY: HarperOne. Smith, L. (2005). Psychotherapy, classism, and the poor: Conspicuous by their absence. American Psychologist, 60, 687–696. http://dx.doi. org/10.1037/0003-066X.60.7.687 Smith, T. B., Domenech Rodríguez, M., & Bernal, G. (2011). Culture. Journal of Clinical Psychology, 67, 166–175. http://dx.doi.org/10.1002/ jclp.20757 Snow, K. (2006). A few words about people first language. Retrieved from https://www.disabilityisnatural.com/images/PDF/pfl-sh09.pdf Snowden, L. R., Masland, M., & Guerrero, R. (2007). Federal civil rights policy and mental health treatment access for persons with limited

References

English proficiency. American Psychologist, 62, 109–117. http://dx.doi. org/10.1037/0003-066X.62.2.109 Solomon, A. (2014, August 5). Notes an on exorcism [Audio podcast]. Retrieved from http://themoth.org/posts/stories/notes-on-anexorcism Sommers-Flanagan, J., & Sommers-Flanagan, R. (2007). Tough kids, cool counseling: User-friendly approaches with challenging youths. Alexandria, VA: American Counseling Association. Sommers-Flanagan, J., & Sommers-Flanagan, R. (2014). Clinical interviewing (5th ed.). Hoboken, NJ: Wiley. Spickard, P. R. (1992). The illogic of American racial categories. In M. P. P. Root (Ed.), Racially mixed people in America (pp. 12–23). Newbury Park, CA: Sage. Statistics Canada. (2014). 2011 National Household Survey: Data tables. Retrieved from http://www12.statcan.gc.ca/nhs-enm/2011/dp-pd/ dt-td/Rp-eng.cfm?LANG=E&APATH=3&DETAIL=0&DIM=0&FL=A& FREE=0&GC=0&GID=0&GK=0&GRP=1&PID=105396&PRID=0&PTY PE=105277&S=0&SHOWALL=0&SUB=0&Temporal=2013&THEME= 95&VID=0&VNAMEE=&VNAMEF= Steinmetz, K. (2014, June 9). America’s transition. Time, 183(22), 38–46. Stepakoff, S., Hubbard, J., Katoh, M., Falk, E., Mikulu, J. B., Nkhoma, P., & Omagwa, Y. (2006). Trauma healing in refugee camps in Guinea: A psychosocial program for Liberian and Sierra Leonean survivors of torture and war. American Psychologist, 61, 921–932. http://dx.doi. org/10.1037/0003-066X.61.8.921 Sternberg, R. J., & Grigorenko, E. L. (2004). Why cultural psychology is necessary and not just nice: The example of the study of intelligence. In R. J. Sternberg & E. L. Grigorenko (Eds.), Culture and competence: Contexts of life success (pp. 207–223). Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/10681-009 Sternberg, R. J., Grigorenko, E. L., & Kidd, K. K. (2005). Intelligence, race, and genetics. American Psychologist, 60, 46–59. http://dx.doi.org/ 10.1037/0003-066X.60.1.46 Sternberg, R. J., Wagner, R. K., & Okagaki, L. (1993). Practical intelligence: The nature and role of tacit knowledge in work and at school. In H. Reese & J. Puckett (Eds.), Advances in life span development (pp. 205–227). Hillsdale, NJ: Erlbaum. Sternberg, R. J., Wagner, R. K., Williams, W. M., & Horvath, J. A. (1995). Testing common sense. American Psychologist, 50, 912–927. http://dx.doi. org/10.1037/0003-066X.50.11.912 Stock, C., Mares, S., & Robinson, G. (2012). Telling and re-telling stories: The use of narrative and drawing in a group intervention with parents and children in a remote Aboriginal community. Australian and New Zealand Journal of Family Therapy, 33, 157–170. http://dx.doi. org/10.1017/aft.2012.17

339

340

R eferences

Straussner, S. L. A. (Ed.). (2001). Ethnocultural factors in substance abuse treatment. New York, NY: Guilford Press. Struwe, G. (1994). Training health and medical professionals to care for refugees: Issues and methods. In A. J. Marsella, T. Bornemann, S. Ekblad, & J. Orley (Eds.), Amidst peril and pain: The mental health and well-being of the world’s refugees (pp. 311–324). Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/10147-016 Sue, D. W. (2013). Race talk: The psychology of racial dialogues. American Psychologist, 68, 663—672. http://dx.doi.org/10.1037/a0033681 Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M. B., Nadal, K. L., & Esquilin, M. E. (2007). Racial microaggressions in everyday life: Implications for clinical practice. American Psychologist, 62, 271–286. http://dx.doi.org/10.1037/0003-066X.62.4.271 Sue, D. W., & Sue, D. (1999). Counseling the culturally different (3rd ed.). New York, NY: Wiley. Sue, D. W., & Sue, D. (2003). Counseling the culturally different (4th ed.). New York, NY: Wiley. Sue, S. (1998). In search of cultural competence in psychotherapy and counseling. American Psychologist, 53, 440–448. http://dx.doi.org/10.1037/ 0003-066X.53.4.440 Sundberg, N. D., & Sue, D. (1989). Research and research hypotheses about effectiveness in intercultural counseling. In P. B. Pedersen, J. G. Draguns, W. J. Lonner, & J. E. Trimble (Eds.), Counseling across cultures (pp. 355–370). Honolulu: University of Hawaii Press. Sussman, N. M., & Rosenfeld, H. M. (1982). Influence of culture, language, and sex on conversational distance. Journal of Personality and Social Psychology, 42, 66–74. http://dx.doi.org/10.1037/0022-3514.42.1.66 Sutherland, P., Moodley, R., & Chevannes, B. (2013). Caribbean healing traditions: Implications for health and mental health. New York, NY: Routledge. Sutton, C. T., & Broken Nose, M. A. (1996). American Indian families: An overview. In M. McGoldrick, J. Giordano, & J. K. Pearce (Eds.), Ethnicity and family therapy (2nd ed., pp. 31–44). New York, NY: Guilford Press. Sutton, J. P. (2002). Music, music therapy, and trauma: International perspectives. London, England: Jessica Kingsley. Suzuki, L. A., & Kugler, J. F. (1995). Intelligence and personality assessment. In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural counseling (pp. 493–515). Thousand Oaks, CA: Sage. Swinomish Tribal Community. (1991). A gathering of wisdoms: Tribal mental health: A cultural perspective. LaConnor, WA: Author. Takaki, R. (1993). A different mirror: A history of multicultural America (Reissue ed.). Boston, MA: Little, Brown/Bay Back Books. Takaki, R. (2008). A different mirror: A history of multicultural America (Rev. ed.). Boston, MA: Bay Back Books.

References

Tewari, N., Inman, A. G., & Sandhu, D. S. (2003). South Asian Americans: Culture, concerns, and therapeutic strategies. In J. S. Mio & G. Y. Iwamasa (Eds.), Culturally diverse mental health (pp. 191–209). New York, NY: Brunner-Routledge. Thoma, B. C., & Huebner, D. M. (2013). Health consequences of racist and anti-gay discrimination for multiple minority adolescents. Cultural Diversity and Ethnic Minority Psychology, 19, 404–413. http://dx.doi. org/10.1037/a0031739 Thomas, A., & Sillen, S. (1972). Racism and psychiatry. Toronto, Ontario, Canada: Citadel Press. Tirado, L. (2013, November 11). This is why poor people’s bad decisions make perfect sense. Retrieved from http://www.huffingtonpost. com/linda-tirado/why-poor-peoples-bad-decisions-make-perfectsense_b_4326233.html The top 10: The most influential therapists of the past quarter-century. (2007, March/April). Psychotherapy Networker, 31(2). Retrieved from http://www.psychotherapynetworker.org/magazine/recentissues/ 2007-marapr/item/219-the-top-10 Troiden, R. R. (1979). Becoming homosexual: A model of gay identity acquisition. Psychiatry: Journal for the Study of Interpersonal Processes, 42, 362–373. Tropp, L. R., & Mallett, R. (Eds.). (2011). Moving beyond prejudice reduction: Pathways to positive intergroup relations. Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/12319-000 Tsemberis, S. J., & Orfanos, S. D. (1996). Greek families. In M. McGoldrick, J. Giordano, & J. K. Pearce (Eds.), Ethnicity and family therapy (2nd ed., pp. 517–529). New York, NY: Guilford Press. Tseng, W. (1999). Culture and psychotherapy: Review and practical guidelines. Transcultural Psychiatry, 36, 131–179. http://dx.doi.org/ 10.1177/136346159903600201 Tulkin, S. R., & Stock, W. (2004). A model for predoctoral psychopharmacology training: Shaping a new frontier in clinical psychology. Professional Psychology: Research and Practice, 35, 151–157. http:// dx.doi.org/10.1037/0735-7028.35.2.151 Tummala-Narra, P. (2007). Skin color and the therapeutic relationship. Psychoanalytic Psychology, 24, 255–270. http://dx.doi.org/10.1037/07369735.24.2.255 Tummala-Narra, P. (2016). Psychoanalytic theory and cultural competence in psychotherapy. Washington, DC: American Psychological Association. Tummala-Narra, P., Sathasivam-Rueckert, N., & Sundaram, S. (2013). Voices of older Asian Indian immigrants: Mental health implications. Professional Psychology: Research and Practice, 44, 1–10. http://dx.doi. org/10.1037/a0027809 Tummala-Narra, P., Singer, R., Li, Z., Esposito, J., & Ash, S. E. (2012). Individual and systemic factors and clinicians’ self-perceived cultural

341

342

R eferences

competence. Professional Psychology: Research and Practice, 43, 165–174. http://dx.doi.org/10.1037/a0025783 Ulysse, G. A. (2013, January 9). How Voudon became “voodoo” and Vodou. Huffington Post. Retrieved from http://www.huffingtonpost. com/gina-athena-ulysse/vodoun-voodoo_b_2413249.html U.S. Census Bureau. (2010). Older Americans month: May 2010. Retrieved from http://www.census.gov/newsroom/releases/archives/facts_ for_features_special_editions/cb10-ff06.html U.S. Census Bureau. (2011). 2010 census shows America’s diversity (American Community Survey). Retrieved from http://www.census.gov/ newsroom/releases/archives/2010_census/cb11-cn125.html U.S. Census Bureau. (2012, July 25). Nearly 1 in 5 people have a disability in the U.S., Census Bureau reports. Retrieved from http://www.census. gov/newsroom/releases/archives/miscellaneous/cb12-134.html U.S. Census Bureau. (2014). 2010 census shows interracial and interethnic married couples grew by 28 percent over decade. Retrieved from http://www. census.gov/newsroom/releases/archives/2010_census/cb12-68.html U.S. Department of the Interior Indian Affairs. (2014). Tribal directory. Retrieved from http://www.bia.gov/WhoWeAre/BIA/OIS/ TribalGovernmentServices/TribalDirectory/ Üstün, T. B., Kostanjsek, N., Chatterji, S., & Rehm, J. (2010). Measuring health and disability: Manual for WHO Disability Assessment Schedule (WHODAS 2.0). Geneva, Switzerland: World Health Organization. Uzzell, B. P., Ponton, M., & Ardila, A. (Eds.). (2007). International handbook of cross-cultural neuropsychology. Mahwah, NJ: Erlbaum. Van Fleet, R. (2013). Filial therapy: Strengthening parent–child relationships through play (3rd ed.). Sarasota, FL: Professional Resource Press. Vasquez, M. (2007). Cultural difference and the therapeutic alliance: An evidence-based analysis. American Psychologist, 62, 878–885. http:// dx.doi.org/10.1037/a0003-066X.62.8.878 Vasquez, M. J. T. (2012). Psychology and social justice: Why we do what we do. American Psychologist, 67, 337–346. http://dx.doi.org/10.1037/ a0029232 Vernon, M. (2006). The APA and deafness. American Psychologist, 61, 816–824. http://dx.doi.org/10.1037/0003-066X.61.8.816 Vinet, E. V. (2000). The Rorschach Comprehensive System in Ibero­ america. In R. H. Dana (Ed.), Handbook of cross-cultural and multicultural personality assessment (pp. 345–366). Mahwah, NJ: Erlbaum. Vontress, C. E., Johnson, J. A., & Epp, L. R. (1999). Cross-cultural counseling: A casebook. Alexandria, VA: American Counseling Association. Wade, J. C. (1998). Male reference group identity dependence: A theory of male of identity. Counseling Psychologist, 26, 349–383. http://dx.doi. org/10.1177/0011000098263001 Wagner, A. P. (2005). Worried no more: Help and hope for anxious children (2nd ed.). Apex, NC: Lighthouse Press.

References

Wagner, A. P. (2008, May/June). The worry hill: A child-friendly approach to OCD. Psychotherapy Networker, 32(3), 63–68. Walker, K. L., & Chestnut, D. (2003). The role of ethnocultural variables in response to terrorism. Cultural Diversity and Ethnic Minority Psychology, 9, 251–262. http://dx.doi.org/10.1037/1099-9809.9.3.251 Wang, V. O., & Sue, S. (2005). In the eye of the storm: Race and genomics in research and practice. American Psychologist, 60, 37–45. http://dx.doi. org/10.1037/0003-066X.60.1.37 Warne, R. T., Yoon, M., & Price, C. J. (2014). Exploring the various interpretations of “test bias.” Cultural Diversity and Ethnic Minority Psychology, 20, 570–582. http://dx.doi.org/10.1037/a0036503 Washington, B. (2012). Coyote thoughts: A Native explains mental health. Retrieved from http://coyotethoughts.com/The_Story.html Watt, S. K. (1999). The story between the lines: A thematic discussion of the experience of racism. Journal of Counseling & Development, 77, 54–61. http://dx.doi.org/10.1002/j.1556-6676.1999.tb02420.x Watters, E. (2010). Crazy like us: The globalization of the American psyche. New York, NY: Free Press. Waxler-Morrison, N., Anderson, J. M., Richardson, E., & Chambers, N. A. (Eds.). (2005). Cross-cultural caring: A handbook for health professionals (2nd ed.). Vancouver, Canada: University of British Columbia Press. Weaver, H. N. (2001). Native Americans and substance abuse. In S. L. A. Straussner (Ed.), Ethnocultural factors in substance abuse treatment (pp. 77–96). New York, NY: Guilford Press. Wechsler, D. (2003). Wechsler Intelligence Scale for Children (4th ed.). San Antonio, TX: Psychological Corporation. Wechsler, D. (2009a). Wechsler Individual Achievement Test (3rd ed.). San Antonio, TX: Psychological Corporation. Wechsler, D. (2009b). Wechsler Memory Scale (4th ed.). San Antonio, TX: Psychological Corporation. Wechsler, D. (2011). Wechsler Adult Intelligence Scale (4th ed.). New York, NY: Psychological Corporation. Weeber, J. E. (1999). What can I know of racism? Journal of Counseling and Development, 77, 20–23. http://dx.doi.org/10.1002/j.1556-6676.1999. tb02407.x Weisman, A., Feldman, G., Gruman, C., Rosenberg, R., Chamorro, R., & Belozersky, I. (2005). Improving mental health services for Latino and Asian immigrant elders. Professional Psychology: Research and Practice, 36, 642–648. http://dx.doi.org/10.1037/0735-7028.36.6.642 Weiss, J. C. (1999). The role of art therapy in aiding older clients with life transitions. In M. Duffy (Ed.), Handbook of counseling and psychotherapy with older adults (pp. 182–196). New York, NY: Wiley. Wenzel, A. (2013). Strategic decision making in cognitive behavioral therapy. Washington, DC: American Psychological Association. http://dx.doi. org/10.1037/14188-000

343

344

R eferences

Westbrooks, K. (1995). Functional low-income families. New York, NY: Vantage Press. Westermeyer, J. (1987). Cultural factors in clinical assessment. Journal of Consulting and Clinical Psychology, 55, 471–478. http://dx.doi. org/10.1037/0022-006X.55.4.471 Westermeyer, J., & Janca, A. (1997). Language, culture, and psycho­ pathology: Conceptual and methodological issues. Transcultural Psychiatry, 34, 291–311. http://dx.doi.org/10.1177/136346159703400301 Wiarda, N. R., McMinn, M. R., Peterson, M. A., & Gregor, J. A. (2014). Use of technology for note taking and therapeutic alliance. Psychotherapy, 51, 443–446. http://dx.doi.org/10.1037/a0035075 Wight, V. R., Chau, M., & Arantani, Y. (2010). Who are America’s poor? The official story. New York, NY: National Center for Children in Poverty. Wijeyesinghe, C. L. (2001). Racial identity and multiracial people: An alternative paradigm. In C. L. Wijeyesinghe & B. W. Jackson, III (Eds.), New perspectives on racial identity development: A theoretical and practical anthology (pp. 243–270). New York: New York University Press. Wilgosh, L., & Gibson, J. T. (1994). Cross-national perspectives on the role of assessment in counseling: A preliminary report. International Journal for the Advancement of Counselling, 17, 59–70. http://dx.doi.org/10.1007/ BF01407926 Williams, C. B. (1999). Claiming a biracial identity: Resisting social constructions of race and culture. Journal of Counseling & Development, 77, 32–35. http://dx.doi.org/10.1002/j.1556-6676.1999.tb02412.x Williams, C. R., & Abeles, N. (2004). Issues and implications of Deaf culture in therapy. Professional Psychology: Research and Practice, 35, 643–648. http://dx.doi.org/10.1037/0735-7028.35.6.643 Wilson, J. A. B., & Schild, S. (2014). Provision of mental health care services to Deaf individuals using telehealth. Professional Psychology: Research and Practice, 45, 324–331. http://dx.doi.org/10.1037/a0036811 Wolfe, B. E. (2014). Book review of Psychotherapy Integration by George Stricker. Psychotherapy Bulletin, 49(2), 66–67. Wong, T. M., Strickland, T. L., Fletcher-Janzen, E., Ardila, A., & Reynolds, C. R. (2000). Theoretical and practical issues in the neuropsychological assessment and treatment of culturally dissimilar patients. In E. Fletcher-Janzen, T. L. Strickland, & C. R. Reynolds (Eds.), Handbook of cross-cultural neuropsychology (pp. 3–18). New York, NY: Kluwer Academic/ Plenum. http://dx.doi.org/10.1007/978-1-4615-4219-3_1 Wood, P. S., & Mallinckrodt, B. (1990). Culturally sensitive assertiveness training for ethnic minority clients. Professional Psychology: Research and Practice, 21, 5–11. http://dx.doi.org/10.1037/0735-7028.21.1.5 Words Between the Spaces. (2009, December 21). Voodoo vs Vodou [Web log post]. Retrieved from http://www.wordsbetween.com/2009/ 12/voodoo-vs-vodoun.html

References

World Almanac Education Group. (2007). The World Almanac 2007. New York, NY: Author. World Health Organization. (1992a). The ICD–10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. Geneva, Switzerland: Author. World Health Organization. (1992b). International statistical classification of diseases and related health problems (10th ed., Vol. 1). Geneva, Switzerland: Author. Wylie, M. S. (2014, March/April). The book we love to hate: Why DSM–5 makes nobody happy. Psychotherapy Networker, 38(2), 28–49. Yabusaki, A. S. (2010). Clinical supervision: Dialogues on diversity. Training and Education in Professional Psychology, 4, 55–61. http://dx.doi. org/10.1037/a0017378 Yassuda, M. S., Diniz, B. S. O., Flaks, M. K., Viola, L. F., Pereira, F. S., Nunes, P. V., & Forlenza, O. V. (2009). Neuropsychological pro­file of Brazilian older adults with heterogeneous educational backgrounds. Archives of Clinical Neuropsychology, 24, 71–79. http://dx.doi.org/10.1093/ arclin/acp009 Yeh, C. J., Inman, A. C., Kim, A. B., & Okubo, Y. (2006). Asian American families’ collectivistic coping strategies in response to 9/11. Cultural Diversity and Ethnic Minority Psychology, 12, 134–148. http://dx.doi. org/10.1037/1099-9809.12.1.134 Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Huang, V., Adey, M., & Leirer, V. O. (1982–1983). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17, 37–49. http://dx.doi.org/10.1016/0022-3956(82)90033-4 Zinn, H. (2005). The people’s history of the United States: 1492–present. New York, NY: HarperPerennial.

345

Index

A Able (website), 55 Aboriginal heritage, 68, 155, 168, 266–267 Academic intelligence, 167 Academic protocol, 65 Acceptance and commitment therapy, 266 Action interventions, 236–239 Active listening, 129 ADDRESSING framework, 7–13 in art therapy, 268 and client identities, 92–95 components of, 7–11 and cultural profiles, 206 and cultural self-assessment, 40, 44, 45, 57, 59 examining power dynamics with, 274–275 interpersonal work in, 12–13 overview, 301–303 personal work in, 11–12 and therapist privilege, 84 ADHD (attention-deficit/hyperactivity disorder), 203 Adolescent Nervios Scale, 166 African Americans ethnic and racial identities of, 68, 82 and paranoid personality disorder, 207 as racial category, 67 and respect, 105–106 and social interaction, 109 stereotypes of, 25, 26

African culture, 161 Age and generational influences diversity in, 7, 8 language for, 71 Alaska Natives and Awareness of Connectedness Scale, 166 common mental health issues of, 142 communication styles of, 132 and culturally responsive cognitive behavior therapy, 248 culturally responsive cognitive behavior therapy with, 250 ethnic identity of, 68–69 and in-session note taking, 116 and respect, 105 testing of, 167–168 Alcoholics Anonymous, 238, 247, 276–277 Alderson, Kevin, 73 Ameli, R., 265 American Indians. See Native Americans/ American Indians American Psychiatric Association, 198 American Psychological Association (APA) and DSM–5, 14 Ethics Code, 113 Office on Socioeconomic Status, 250 Resolution on Psychotherapy Effectiveness, 229–230 Task Force on Evidence-Based Practice, 5, 171, 228

347

348

inde x

American Psychological Association (APA) continued Task Force on Evidence-Based Therapy Relationships, 103 Task Force on Socioeconomic Status, 84 and testing, 165 American Psychological Association Practice Organization (APAPO), 197 American Religious Identification Survey, 64 American Sign Language (ASL), 151, 173–174. See also Deaf communities Anxiety Remote Control intervention, 248 Anzaldua, G., 81 APA. See American Psychological Association APAPO (American Psychological Association Practice Organization), 197 Aphasia, 165 Aponte, H. J., 84 Arab cultures beliefs about medication in, 278 physical space in, 115 respect in, 105–106 Archer, R. P., 185 Ardila, A., 168 Art therapy, 266–269 Asian Americans action interventions with, 237 and domestic violence, 274 ethnic identity of, 68 family therapy with, 270 feminist therapy with, 272–273 and medication, 278 and respect, 106 and theories of health, 141 ASL (American Sign Language), 151, 173–174. See also Deaf communities Assertiveness skills, 237 Assessment. See Culturally responsive assessment; Testing Assumptions, about client identities, 90, 92 Ataque de nervios, 201–202 Attention-deficit/hyperactivity disorder (ADHD), 203 “Attitude of gratitude” exercise, 245 Awareness of Connectedness Scale, 166 B Babbage, D. R., 246–247 Balsam, K. F., 147 Beck Depression Inventory, 163 Bemak, F., 279 Bennett, S. T., 246–247 Bergin, A. E., 138, 262 Bias, 22–27 approaches to, 22–24 language-centered, 266 and power, 24–27 in testing, 163–167 Bicultural competence, 237

Biracial identity, 75, 81 Bisexual populations. See LGBTQIA populations Black pride movement, 67 Boundary crossings, 112 Boundary violations, 112 Brazil, 66 Bronson, P., 65 Brown, L. S., 88, 142, 145, 146, 272 Buddhism, 31, 237, 243, 266. See also Mindfulness meditation C Cagigas, X. E., 165, 179 Canada, 68, 88 Casual register (communication), 132 CBT, 110. See also Culturally responsive cognitive behavior therapy Central Americans, 278 Chicanos and Chicanas, 69. See also Latino and Hispanic Americans Child Behavior Checklist, 185–186 Children assessment of, 133 cognitive restructuring techniques for, 247–250 play therapy for, 268–269 psychological research on, 70 Chinese immigrants, 238 Chorpita, B., 250 Chung, R. C. Y., 279 Civil Rights Act of 1964, 148 CLASS action interventions, 236, 238 Classism, 84 Client identities, 79–99 ADDRESSING framework for assessment of, 92–95 complexities of, 80–82 hypotheses and questions about, 90–92 learning about, 85–90 for people with disabilities, 83–84, 86–87 person-specific meanings of, 95–97 research on, 82–84 with sexual orientation and gender, 83–84, 87–90, 92 Cognitive Abilities Test, 164 Cognitive behavior therapy, 110. See also Culturally responsive cognitive behavior therapy Cognitive restructuring. See Culturally responsive cognitive behavior therapy Color blindness, 65–66 Color Trails Test, 179 Comas-Díaz, L., 69, 116 Communication in individualistic cultures, 107 nonverbal, 114–116 registers of, 132 teaching skills for, 237–238 in therapeutic alliance, 106–109

Index

Compassion effects of, 27 obstacles to, 31–33 “Compassion voice” exercise, 243–244 Complex trauma, 142 Complexity, 6–7 Comprehensive Test of Nonverbal Intelligence, 162 Computers, 116 Confidentiality, 150–151, 206, 275–276 Conflict, 300 Conflict resolution, 237 Corbett, C. A., 173 Countertransference, 120 Couples therapy, 270–275 Courage, 28 “Coyote thoughts” metaphor, 247 CR-CBT, Culturally–responsive cognitive behavior therapy. See Culturally responsive cognitive behavior therapy Creative arts therapies, 266–269 Critical thinking, 27–31 Cross Cultural Health Care Program, 148 Cross-Cultural Personality Assessment Inventory, 186 Cross-cultural psychology, 4 Croteau, J. M., 26 Cuéllar, I., 166, 181 Cukor, D., 133, 275–276 Cultural Competence in Trauma Therapy: Beyond the Flashback (L. S. Brown), 142 Culturally responsive assessment, 127–160. See also Diagnosis; Testing; Treatment planning case example, 284–289 clarifying expectations in, 130–131 in cognitive behavior therapy, 232 errors of omission and commission in, 157 gathering information in, 131–133 personal histories in, 136–142 strengths and supports in, 129–130, 152–155, 159–160 systems orientation for, 133–136 of trauma, 142–147 of unusual perceptions and experiences, 152–157 working with interpreters in, 147–152 wrapping up initial session for, 157–159 Culturally responsive cognitive behavior therapy (CR-CBT), 227–255 and assumptions about CBT, 230 case conceptualization in, 231–232 case examples, 251–254, 294–296 clarifying external vs. internal sources of stress in, 232–235 homework in, 251 as integrative approach, 229–230 strategies for engaging clients in, 242–250 treatment plans in, 235–242 Cultural profiles, 206–207

Cultural self-assessment, 37–60 case example, 45–54 examination of sociocultural contexts in, 56–59 of privilege, 40, 44–45, 59 and seeking new and diverse information, 55–56 of your own heritage, 40–44 Curanderismo, 260 D Dalai Lama, 31 D’Angelo, E., 248 Davidson, G., 168 Davis, D. M., 106 Deaf communities, 112, 148, 173, 250 Deboard, R., 170–171 Defensiveness, 33–36, 65–66 Democracy, 26 Dependent personality disorder, 207–208 Descriptive stereotypes, 25 Desire, 32–33 Developmental disabilities, 7–9 Diagnosis, 195–223 case examples, 209–221, 289–291 and cultural profiles, 206–207 definitions of, 196–197 with Diagnostic and Statistical Manual of Mental Disorders, 196–205 giving explanations of, 208–209 with International Classification of Diseases, 196–198 of personality disorders, 207–208 systematic thinking for, 205–206 Diagnostic and Statistical Manual of Mental Disorders (DSM) considerations with, 302 Cultural Concepts of Distress in, 235 diagnosis with, 197–205 influence of, 14 intellectual disability in, 64 Diagnostic inflation, 198, 202–204 Dialectical behavior therapy, 266 Disabilities and 2010 Census, 64 and assessment, 133 cultural conceptualizations of, 140 developmental, 7–9 diversity in, 7–9 identities of clients with, 83–84, 86–87 and informed consent, 130 language for, 71–72 and nonverbal communication, 114, 115 prescriptive stereotypes with, 25 and time orientation, 117–118 Diversity, 3–14 and ADDRESSING framework. See ADDRESSING framework components of, 7–11 exercises for addressing, 6–7

349

350

inde x

Diversity continued history of approaches to, 4–5 and multicultural competence, 5–6 and quality, 5–6 Domestic violence, 274 Duffy, F. F., 270 Dworkin, S. H., 275 E Eastern Woodland Oklahoma tribe, 183–184 EBPP (evidence-based practice in psychology), 5, 228 Egalitarianism, 104 Egoism, 32–33 Elders, 71, 105, 132 Emotions, 235 Empirically supported treatments (ESTs), 227–228 Environmental conditions, 153, 154 Environmental cues, 116–117 Errors of omission and commission, 157 ESTs (Empirically supported treatments), 227–228 Ethical boundaries, 112–118 Ethnicity and racial identity diversity in, 8–10 language for, 66–69 of therapists and patients, 121–122 Evidence-based practice in psychology (EBPP), 5, 228 Expectations, in psychotherapy, 130–131 Expressive and creative arts therapies, 266–269 Exxon Valdez oil spill, 142 Eye contact, 115 F Falicov, C. J., 278 Family therapy, 135, 270, 292–294 Farley, N., 274 Fear, 32 Feminist therapy, 4, 111, 272–273 Ferguson, Karen, 131 Fernando, Gaithri, 143 Fieland, K. C., 147 First Nations, The, 68 Fletcher-Janzen, E., 168 Flett, R. A., 246–247 FOME (Fuld Object Memory Evaluation), 174–175 Formalismo, 105 Formal register (communication), 132 Frances, Allen, 202 Friedman, S., 133, 275–276 Fuld Object Memory Evaluation (FOME), 174–175 G Gallardo, M. E., 113 Gantt, L., 268 Garcia-Preto, N., 67–68 Gates, H. L., Jr., 66 Gay populations. See LGBTQIA populations Gender. See also LGBTQIA populations in client identity, 83–84, 87–90, 92 diversity in, 8, 10

of interpreters, 150 sexual orientation vs., 73 Gender dysphoria, 204 Gender identity disorder (GID), 204 Genderqueer and gender-nonconforming identities, 74 Generational influences diversity in, 7, 8 language for, 71 Genetics, 67 Geriatric Depression Scale, 181 Geropsychology, 4 GID (gender identity disorder), 204 Gift giving, 115–116 Giordano, J., 67–68 Glickman, N. S., 250 Globalization, 4 Goodheart, C., 197 Griffin-Pierce, T., 155 Grigorenko, E. L., 67 Group therapy, 238, 275–276 “Growth opportunity” exercise, 246 Gualdron, L., 248 Gutierrez, F. J., 275 Gutman, V., 173 H Haitian populations, 92–97 Hammond, L. C., 268 Handbook of Psychotherapy and Religious Diversity (P. S. Richards and A. E. Bergin), 138, 262 Handbook of Tests and Measurements for Black Populations, 166 Handshakes, 114 Harvard Program in Refugee Trauma, 147 Haynes, B. P., 168 Hays, P. A., 8, 43, 236, 239, 264 Healing cards, 266–267 Health Insurance Portability and Accountability Act, 206 Helpfulness, 241 Herman, J., 277 Hernandez, D., 236 Herring, R., 268 Heterosexism, 73, 88 Hispanic Americans. See Latino and Hispanic Americans Hispanic Neuropsychological Society (HNS), 181 Hispanic Stress Inventory, 166 HNS. See Hispanic Neuropsychological Society Homework, 251 Homosexuality, 73 Ho’oponopono, 260–261 Huang, B., 147 Huey, S. J., Jr., 236 Hulnick, H. R., 32 Hulnick, M. R., 32

Index

Humility, 27–31 Humor, 35–36 Hypotheses about client identities, 90–92 Hypothesis-testing approach, 179

Kinoshita, L. M., 238 Kirmayer, L. J., 205 Kleinman, A., 173 Kluckhohn, P., 117

I ICD. See International Classification of Diseases Ignorance, 32 Indian Child Welfare Association (ICWA), 127 Indigenous and traditional practices, 259–266 based on religion, 261–262 mindfulness meditation, 262–266 in Rwanda, 259–260 types of, 260–261 Indigenous heritage in Canada, 68 diversity in, 8, 10 and respect, 105 and time orientation, 117 Individualistic cultures, 107 Informed consent, 130 Integrated care, 140 Integrative approaches, 229–230 Intellectual Developmental Disorder, 64 Intellectual disability, 9, 64 Intelligence, 67, 161, 167–171 International Classification of Diseases (ICD) diagnosis with, 196–198 as influence in current mental health field, 14 intellectual disability in, 64 International Journal of Neuropsychology, 181 International Neuropsychological Society, 164, 181 International Test Commission, 181 Interpersonal supports, 153, 154 Interpreters, 147–152 Intersectionality, 81 Intersex people, 10, 72. See also LGBTQIA populations Inuit, 68 Islam, 70, 74, 260. See also Muslims

L La Roche, M. J., 248 LaFromboise, T. D., 237 Language, 63–77 for age, 71 challenging complexities with, 74–76 for culture, 69–70 for difficult dialogues, 64–66 for disabilities, 71–72 effects of, 63–64 for ethnicity, 67–69 for LGBTQ populations, 72–74 for race, 66–67 and terminology around “minority,” 70–71 Larry P. v. Riles, 164 Latino and Hispanic Americans and culturally responsive cognitive behavior therapy, 247–248 ethnic identity of, 68, 69 and personalismo, 109 physical space in, 115 and respect, 105–106 time orientations of, 117 values of, 237–238 Lau, A. W., 238 Leavell, J., 248 Leigh, I. W., 173 Leiter International Performance Scale, 164 LEP (limited English proficiency), 162 LGBTQIA (lesbian, gay, bisexual, transgender, queer, intersex, ally or asexual) populations and 2010 Census, 64 diversity with, 10 early therapies focusing on, 4 language for, 72–74 and multiple relationships, 112–113 power dynamics in, 274 resources for, 55–56 Limited English proficiency (LEP), 162 “Looking for suffering” exercise, 244 López, S. R., 16, 17 Lyubomirsky, S., 245

J Japanese populations, 115, 137–138, 262 Judd, T., 170–171 Judgmentalism, 243 K K-ABC (Kaufman Assessment Battery), 162 Kaplan, A., 260 Kaplan, M., 207 Kaplan, Stuart L., 203 Kathuria, R., 166 Kaufman Assessment Battery (K-ABC), 162 Kelly, S., 234 Kemp, N. T., 157 Kessler, L. E., 113 Kidd, K. K., 67 Kim, B. L. C., 272–273 Kim, S. C., 135, 270

M Magic Three-Step intervention, 249 Malchiodi, C. A., 267 Mallinckrodt, B., 157, 253 Manly, J. J., 165, 179 Manson, S., 173 Maori people, 246–247 Marsella, A. J., 260 Matheson, L., 105 McGoldrick, M., 67–68

351

352

inde x

McIntosh, P., 154 MCT (Multicultural therapy), 231 Meaningful access, 148 Medication, 277–279 Men in Recovery groups, 277 Men who have sex with men (MSM), 73, 88 Mendelson, T., 246 Mental retardation. See Intellectual disability Mental status evaluations, 171–175 Meritocracy, 26 Merryman, A., 65 “Metaphors and sayings” exercise, 246–247 Métis people, 68 Meyer, G. J., 185 Microaggressions, 63–64 Mindfulness, 34–36 Mindfulness-based cognitive therapy, 266 Mindfulness meditation, 262–266 Mini-Mental State Examination (MMSE), 172 Minnesota Multiphasic Personality Inventory (MMPI), 163, 182–184 Minorities ethnic, 68, 112 microaggressions directed toward, 63–64 as term, 70–71 MMSE (Mini-Mental State Examination), 172 Modular Cognitive-Behavioral Therapy for Childhood Anxiety Disorders (B. Chorpita), 250 Mona, L., 86 Morere, D. A., 173 “Most generous interpretation” intervention, 244–245 Mouth Magazine, 55 MSM (men who have sex with men), 73, 88 Muecke, M. A., 140 Multicultural counseling, 4 Multicultural therapy (MCT), 231 Multiple relationships, 112–114 Muñoz, R. F., 246 Muslims ethnic identities of, 69–70 terminology of, 74 N Narcotics Anonymous, 238, 276–277 National Academy of Neuropsychology, 165, 181 National Assessment of Educational Progress, 164 National Association of Women, 56 National Center for Interpretation, 148 National Council on Interpreting in Health Care, 148 National Institute of Mental Health, 199 National LGBTQ Task Force, 55–56 National origin, 8, 10 Native Americans/American Indians Alcoholics Anonymous groups for, 277 culturally responsive cognitive behavior therapy with, 247, 250 ethnic identity of, 68

and in-session note taking, 116 mental status evaluations of, 171 nonverbal communication of, 114 and respect, 105 and social skills, 237 therapeutic support for, 240 and two-spirit identity, 73, 147 Native Hawaiians, 260–261 Navajo populations, 155 Neuropsychological testing, 168, 177–181 Nhat Hanh, Thich, 34, 242, 262, 265 Niemayer, G. J., 198 Nondisabled people, 72 Nonverbal communication, 114–116 Note taking, 116 O O’Connor, K., 269 Olkin, R., 86, 115 Organista, K. C., 237 Orthodox Jewish clients, 237, 276 P Pace, T. M., 183 Pain aversion, 32 Pan, D., 236 Panga Munthu Test, 166 Paradis, C. M., 133, 275–276 Paranoid personality disorder, 207 Parents, Families, and Friends of Lesbians and Gays, 56 Patanjali, 31 Payne, R., 132 Peer support groups, 276 People without disabilities, 72 Perez Foster, R., 120 Performance-based tests, 184–186 Personal histories of clients, 136–142 Personalismo, 103, 109 Personality assessment, 181–186 Personality disorders, 181–182, 207–208 Phinney, J. S., 69 Play therapy, 268–269 Politeness protocol, 65 Positive psychology, 14 Posttraumatic stress disorder (PTSD), 142, 143 Poverty, 143, 203–204 Power dynamics, 24–27, 58, 63 Practical intelligence, 167 Premature cognitive restructuring, 234 Prescriptive stereotypes, 25 Privilege in language choices, 63 socioeconomic, 84 systems of, 26–27 and unethical behavior, 27 Projective tests, 184–186 Psychoanalytic/psychodynamic therapies, 110

Index

Psychodynamic therapy, 230 Psychometric Toolkit Project, 174 PTSD (Posttraumatic stress disorder), 142, 143 R Racism power dynamics in, 26 validating client reports of, 234 RAIN approach to mindfulness, 265 Randomized controlled studies (RCTs), 227–228 Rational emotive behavior therapy (REBT), 240–241 RCS (Rorschach Comprehensive System), 185 REBT (rational emotive behavior therapy), 240–241 Reclaiming of derogatory terms, 75 Reesman, J. H., 174 Relational disorders, 205–206 Relationships, 56–59 Religion and spirituality on 2010 Census, 64 asking questions about, 133 common elements of, 27 diversity in, 8, 9 indigenous and traditional practices based on, 261–262 and psychology, 154 Respect (Respeto), 103, 104–106, 237 Restandardization (testing), 165 Reynolds, C. R., 168 Richards, P. S., 138, 262 Root, M. P. P., 81, 144 Rorschach Comprehensive System (RCS), 185 Rowe, W., 237 Rural communities, 112, 155, 167 Rwanda, 259–260 S Samyojana (mindfulness concept), 34 Schank, J. A., 114 Self-care activities, 238 Self-disclosure, 110–112 Serpell, R., 166, 168 SES. See Socioeconomic status Sexism, 26. See also Feminist therapy Sexual abuse, 144 Sexual health, 86 Sexual orientation client identities with, 87–90 diversity in, 8, 10 gender vs., 73 Sexual preference, 73 Shame, 145 Shenjing shuairuo, 202 Simoni, J. M., 147 Skills learning, 237 Skovholt, T. M., 114 SLD (specific learning disability), 162 Smith, H., 27, 138, 262 Smoke Signals (film), 261

Snow, K., 72 Social class, 84 Social engagement and support, 238 Social justice interventions, 279 Sociocultural contexts, 56–59 Socioeconomic status (SES) diversity in, 8, 10 identities with, 84 Solomon, Andrew, 259–260 Southwest Plains Oklahoma tribe, 184 Specific learning disability (SLD), 162 Spirituality. See Religion and spirituality Stanford–Binet Intelligence Scales, 164 Steinmetz, K., 73 Stephen, John Franklin, 63, 64 Stereotypes, 23–25, 98 Sternberg, R. J., 67 Storytelling interventions, 261, 267 Stress, 232–235, 263 Strickland, T. L., 168 Strodtbeck, F., 117 Substance abuse treatment, 276–277 Sue, D. W., 65 Suffering, 244, 262 Sympatía, 237 Systems-level interventions, 279 T Tacit knowledge, 167 Taijin kyofusho, 201–202 Takaki, R., 138 TAT (Thematic Apperception Test), 184–185 Technology, 4 Tell-Me-a-Story (TEMAS) test, 185 Terminology. See Language Testing, 161–193 biases in, 163–167 case examples, 175–177, 186–191 complexity of, 162 considerations with, 302 of intellectual abilities, 167–171 of mental status, 171–175 neuropsychological, 168, 177–181 personality, 181–186 Testing the limits, 167, 179–180 Thematic Apperception Test (TAT), 184–185 Therapeutic alliance, 101–122 case example, 101–103 communication in, 106–109 effects of, 103–104 and ethical boundaries, 112–118 human connection in, 109–110 interactions in, 118–120 respect in, 104–106 and therapist–client ethnicity match, 121–122 and therapist self-disclosure, 110–112 Therapeutic relationships, 230

353

354

inde x

Therapist knowledge and qualities, 19–37 bias in, 22–27 case example, 20–22 compassion, 27, 31–33 defensiveness, 33–36 humility and critical thinking, 27–31 mindfulness, 34–35 and power dynamics, 24–27 sense of humor, 35–36 Time orientations, 117–118 Tirado, L., 79, 80 Traditional practices. See Indigenous and traditional practices Trail Making Test, 179 Transcultural psychiatry, 4 Transdiscrimination, 235 Transference, 118–120 Transgender people, 73–74. See also LGBTQIA populations and coming-out process, 89 in culturally responsive cognitive behavior therapy, 234–235 and diagnosis, 204–205 as gender identity, 10 Transsexual people, 10, 74 Trauma, 142–147, 250 Trauma-focused cognitive behavior therapy, 250 Tunisian women, 29–30 Two-spirit identity (Native American culture), 73, 147 U Unequal Relations: An Introduction to Race, Ethnic, and Aboriginal Dynamics in Canada (A. Fleras), 138 Universal Nonverbal Intelligence Test, 162

V “Values compass” exercise, 246 Vietnamese Depression Scale, 166 Violence, domestic, 274 Visual Language and Visual Learning Center, 174 Vodou rituals, 94–95 W Waehler, C. A., 113 Wagner, M. P., 250 Walters, K. L., 147 Wechsler Adult Intelligence Scale, 163, 180 Wechsler Intelligence Scale for Children, 162, 163 Weeber, J. E., 141 Westermeyer, J., 155 Wijeyesinghe, C. L., 81 Williams, C. B., 33, 75 “Wise elder” intervention, 245 Women for Sobriety groups, 277 Women who have sex with women (WSW), 73 Wong, T. M., 168 Wood, P. S., 253 Woodcock–Johnson Tests of Achievement, 163 World Professional Association for Transgender Health, 205 The World’s Religions (H. Smith), 138, 262 Worry Hill intervention, 249–250 WSW (women who have sex with women), 73 Y Yup’ik people, 114 Z Zinn, H., 138

About the Author

Pamela A. Hays, PhD, received her doctorate in clinical psychology from the University of Hawaii and completed a National Institute of Mental Health postdoctoral fellowship at the University of Rochester School of Medicine. She was on the graduate psychology faculty of Antioch University in Seattle, Washington, for 11 years, and in 2000, returned to her hometown on the Kenai Peninsula in Alaska, where she has worked in community mental health for the Kenaitze Tribe’s Dena’ina Wellness Center, in private practice, and served on the Board of the Alaska State Psychological Association. Her research has included work with Tunisian women in North Africa and with Vietnamese, Lao, and Cambodian people in the U.S. She is the author of Connecting Across Cultures: The Helper’s Toolkit and Creating Well-Being: Four Steps to a Happier, Healthier Life; coeditor of the book Culturally Responsive Cognitive–Behavioral Therapy: Assessment, Practice, and Supervision; and coauthor of the forthcoming book (with video series) Cognitive Behavioral Therapy Techniques and Strategies. Dr. Hays’s work with clients is featured in several APAproduced DVDs, and she provides consultation and teaches workshops internationally. For more information on Dr. Hays’s clinical practice, publications, videos, and workshops, visit her website (http://www.drpamelahays.com).

355