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Introduction. The U.S. population is more diverse than ever before. The demographic changes have significant implications for our profession. The U.S. Census Bureau (2008) announced that racial/ethnic minorities who consist of one third of the U.S. population will make up the majority of the U.S. population by the year 2042, 8 years sooner than previously thought..
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1. Ethical Considerations in a Multicultural World Melba J. T. Vasquez, Ph.D., ABPP
Austin, Tx.
melvasquez@aol.com
512-329-8000x5
3. APA Members Practicing with Underserved Populations 86% of APA Members reported that they practice with Racial/Ethnic Minorities!
Cultural competence in our modern mental health care environment requires far more knowledge and sophistication on the part of the professional, and is becoming part of the mainstream fundamental knowledge and skill set required for effective practice.
4. Cultural Competence Awareness of the role of counseling professionals in their work with those different from them.
The quality of the alliance between psychotherapist and the client of color should be a key area of examination
5. Cultural Competence Racial and ethnic diversity among clients/patients presents challenges for all psychotherapists and counselors, without exception, and these challenges are often subconscious (Greenwald & Banaji, 1995; Vasquez, 2007a, 2007b).
Multicultural competency, and diversity training in general, should be more incorporated into the fabric of training programs, continuing education, and lifelong learning for mental health professionals.
6. Ethical Responsibilities We tend to relate most easily, in our lives, as well as in our practices, to those most similar to us, including in regard to the major variables of gender, ethnicity, and social class.
Our profession has developed ethical imperatives that underlie the importance of multicultural competence in psychotherapy with members of racial/ethnic minority groups, including immigrant and international groups, as well as with members of other diverse groups such as gender, age, religion, sexual orientation, etc.
7. Ethical Responsibilities To practice ethically requires awareness, sensitivity, and empathy for the client as an individual, including knowledge of and attention to the clients cultural values, beliefs, norms, and behaviors.
The APA Ethical Principles of Psychologists and Code of Conduct requires that psychologists respect the dignity and worth of each individual, that we not engage in unfair, discriminatory and harassing or demeaning behaviors and that we maintain knowledge about the groups with whom we work.
8. APA Ethics Code Standard 2.01 (b) Where scientific or professional knowledge in the discipline of psychology stablishes than an understanding of factors associated with age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation or supervision necessary to ensure the competence of their services, or they make appropriate referrals, except as provided in Standard 2.02, Providing Services in Emergencies. (APA, pp 1063-1064).
9. Relevant Guidelines Guidelines on Multicultural Education, Training, Research, Practice and Organizational Change for Psychologists (APA, 2003b);
Guidelines for Psychological Practice With Girls and Women (APA, 2007);
Guidelines for Psychotherapy With Lesbian, Gay, and Bisexual Clients (APA, 2000); and
Guidelines for Psychological Practice With Older Adults (APA, 2003a).
10. Cultural Competence (Tseng and Streltzer, 2004) cultural sensitivity, an awareness and appreciation of human cultural diversity.
cultural knowledge, the factual understanding of basic anthropological knowledge about cultural variation.
cultural empathy, the ability to connect emotionally with the patients cultural perspective.
cultural guidance involves assessing whether and how a patients problems are related to cultural factors and experiences and suggesting therapeutic interventions that are based on cultural insight.
11. Addressing Variations in People (L. Buetler, 2009) 1) One must know what the relevant variation is among people,
2) one must know that it is in fact relevant---it matters, and
3) one must be able to measure that variation in a reasonably reliable way.
12. Cultural Competence Involves: a) the ability to recognize and understand the dynamic interplay between the heritage and adaptation dimensions of culture in shaping human behavior;
b) the ability to use the knowledge acquired about an individuals heritage and adaptational challenges to maximize the effectiveness of assessment, diagnosis, and treatment; and
c) internalization (i.e. incorporation into ones clinical problem-solving repertoire) of this process of recognition, acquisition, and use of cultural dynamics so that it can be routinely applied to diverse groups. (Whaley & Davis, 2007, p. 565)
13. Purpose of Presentation To provide an evidence-based analysis of how psychologists in practice may unintentionally interfere with development of quality alliances with culturally different clients or patients, and thus contribute to the barriers to effective multicultural counseling and psychotherapy.
14. Multicultural Guidelines Principles from the APA Multicultural Guidelines (2003) will be applied in suggesting strategies to reduce bias, and to develop culturally appropriate skills in psychological practice.
Guideline 5 of the Multicultural Guidelines states that, Psychologists are encouraged to apply culturally appropriate skills in clinical and other applied psychological practices (APA, 2003, p. 390).
15. Definition of Psychotherapy Psychotherapy is a change process designed to provide symptom relief, personality change, prevention of future symptomatic episodes, and increase the quality of life, including the promotion of adaptive functioning in work and relationships, the ability to make healthy and satisfying life choices, and other goals arrived at in the collaboration between client/patient and psychotherapist (APA Task Force on Evidence-Based Practice, 2006).
16. Effectiveness of Psychotherapy Evidence-based practice in psychology is the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences (APA Task Force, 2006, p. 273 & 284). Psychologists must attend to a range of outcomes that may sometimes suggest one strategy and sometimes another, and they must also attend to the strengths and limitations of available research regarding these different ways of measuring success.
17. Psychotherapy Outcome Studies Generally, treatment is effective
Various psychotherapy treatments intended to be therapeutic are equivalent in terms of the benefits produced; generally, no one treatment seems to be more effective than another.
18. Characteristics of Effective Treatment The patients sense of alliance with the healer, belief in the treatment, and a clear rationale explaining why the client has developed the problems (Lambert, 2004).
Therapists should learn as many approaches as they found congenial and convincing and then select for each patient the therapy that accords, or can be brought to accord, with the patients personal characteristics and view of the problem.
19. Moment by Moment Moment by moment, the therapists position shifts. How the therapist decides to intervene, depends on both what she has come to understand about the patient by virtue of the listening position she has assumed and what she believes the patient most needswhether enhancement of knowledge, a corrective experience, or interactive engagement in relationship. (Stark, 1999, p. 5).
20. The Therapeutic Alliance The therapeutic alliance has been identified as one of the most important of the common factors in therapeutic effectiveness.
It is the quality of involvement between therapist and client or patient, as reflected in their task teamwork and personal rapport, and the therapists contribution to the alliance is an important element of that involvement.
21. The Therapeutic Alliance The ability of the practitioner to tune into the client/patient of color, with cultural sensitivity, cultural knowledge, and cultural empathy, as well as to provide cultural guidance when appropriate, are factors that promote the therapeutic alliance with clients/patients of color (Tseng & Streltzer, 2004; Vasquez, 2007a, 2007b).
22. Barriers to Effective Treatment for Multicultural Clients/Patients Ethnic minority populations underutilize psychotherapy services, and have high rates of dropping out of treatment.
Multiple reasons most likely account for these unfortunate findings, but one possibility may be that many ethnic minority clients do not experience the alliance.
Related causes include cultural misunderstandings and miscommunications between psychotherapists and clients.
23. Barriers to Effective Treatment Clients working with clinicians of similar ethnic backgrounds and languages tend to remain in treatment longer than do clients whose therapists are neither ethnically nor linguistically matched (Sue & Sue, 2003
24. Barriers to Effective Treatment 2005 US Population Census
14.4% Hispanic,
4.3% Asian,
12.8% Black,
1.5% 2 or more races
1.0% American Indian
66.9% Non-Hispanic White 2005 Doctorate Employment Survey
6.2% Hispanic,
6.0% Asian,
4.4% Black,
2.7% 2or more races,
0.4% American Indian,
80.4% White/Non-Hispanic
25. Muticultural Guidelines Psychologists are encouraged to recognize that, as cultural beings, they may hold attitudes and beliefs that can detrimentally influence their perceptions of and interactions with individuals who are ethnically and racially different from themselves (APA, 2003b, p. 382)
26. Threats to the Alliance We all possess unconscious bias.
Our societal structures have compounding effects on our cognitive structures, and ultimately our social attitudes and our beliefs about people. The way society constructs societal representations of groups affects the social order and has tremendous impact on the identities of individuals in various groups, both ethnic minority and White majority. These representations have an impact on judgments, decisions, choices, and behaviors in various implicit ways (Greenwald & Banaji, 1995)
Psychologists may not always be aware of when the potential for developing an effective therapeutic alliance may be compromised.
27. Ethical Responsibilities APA Ethical Standard 3.01 Unfair Discrimination
In their work-related activities, psychologists do not engage in unfair discrimination based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, socioeconomic status, or any bias proscribed by law (APA, 2002, p. 1064).
Ethical Standard 3.03 Other Harassment
psychologists do not knowingly engage in behavior that is harassing or demeaning to persons with whom they interact in their work based on factors such as those persons age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status. (p. 1064)
28. Awareness as Ethical Responsibility Subconsciously, we may be influenced negatively by the fact that a clients identity group is outside of our personal experience, or may treat people on the basis of their identity with lower quality of care without full awareness.
29. Threats to the Alliance Categorization: Constructive and Destructive Strategy
We/they dichotomy
People in our in-groups are more highly valued, more trusted, and engender greater cooperation as opposed to competition.
On the other hand, people in our out-groups are implicitly conceptualized as they, and these categorizations affect behavior. We tend to treat out-group members as objects, in insensitive ways. At minimum, people in our out-groups are ignored or neglected; behaviors can extend to the point of engaging in abusive and genocidal activities
30. In Group, Out Group Reverend Jeremiah Wright = Angry Black Man = Out Group
Attempts made to associate Barack Obama with Reverend Jeremiah Wright, thus part of the Out Group.
31. Threats to the Alliance For most psychologists and mother mainstream health providers, individuals in racial/ethnic minority groups are in an out-group, simply by virtue of being different.
32. Threats to the Alliance Contemporary racism among Whites is subtle, often unintentional, and unconscious. Many Whites often give off negative body language (less eye contact, voice tone not as warm or natural) in response to those different from themselves. Whites who demonstrate these behaviors report not being aware of this.
Members of ethnic minority groups are aware in those studies that examine these interactions (Dovidio, et al, 2002).
33. Multiculturalism vs. Color Blindness Paradoxically, emphasizing minimization of group differences reinforces majority dominance and minority marginalization.
Multiculturalism may promote inclusive behaviors and policies.
Minorities are vigilant to inclusion-related cues and that color blindness may signal bias.
Poor diversity climates cost and positive diversity climates benefit both minorities and organizations.
34. Threats to the Alliance Micro-aggression is a term coined to convey power dynamics in interactions in cross-cultural encounters that convey attitudes of dominance superiority and denigration; that a person with privilege is better than the person of color.
35. Examples of Microaggressions
36. Examples of Microaggressions
37. Threats to the Alliance We must examine to what degree microaggressions occur for any psychotherapist with those different from them by virtue of differences based on any factor that is negatively socially constructed without privilege in society.
The nature of the role of psychotherapist confers power that can be beneficial in facilitating constructive change (Sue & Sue, 2003). Historically, power has been a factor in cross-cultural encounters (Fouad & Arredondo, 2007; Sue & Sue, 2003).
Only 6.5% of the U.S. population holds masters degrees and only 1.17% holds doctorate degrees. (U.S. Census Bureau, 2003)
38. Missed Empathic Opportunities Nelson and Baumgarte (2004) demonstrated that individuals experience less emotional and cognitive empathy for a target experiencing distress stemming from an incident reflecting unfamiliar cultural norms and that this reduction of empathy is mediated by a lack of perspective taking on the part of the observer.
Comas-Díaz contends that these missed empathetic opportunities may be more frequent when clinicians work with those different from themselves based on a variety of cultural identities.
39. Threats to the Alliance Steels stereotyped threat research indicates that when ethnic minorities are asked to perform on a task where ethnic minorities stereotypically underperform, they end up underperforming.
Ethnic minority clients may be particularly sensitive to the experiences of negative judgment, rejection, and criticalness on the part of White therapists, without the White therapist being aware of this.
Because of a history of oppressive and rejecting experiences, many, if not most ethnic minorities are easily shamed.
Therapist may not always know when they convey negative judgments in body language, including facial expressions, voice tone and eye contact.
40. Neurobiology Siegel (2003) described how our experiences shape brain structure, which shapes brain function, which creates the mind. Both implicit and explicit memory results in the creation of particular circuits of the brain responsible for generating emotions, behavioral responses, perception, and the encoding of bodily sensations
41. Neurobiology This integrating part of the brain continues to develop throughout the life span, so we continue to have the possibility for growth and change. Siegel (2003) believes that conscious awareness and continued reflection of unresolved issues can change emotions, behaviors, bodily sensations, perceptual interpretations, and the bias of those mental models. This is an important aspect of the change process.
42. Neurobiology Many racial/ethnic minority clients may have developed brain structures to easily perceive biased behaviors.
Practitioners (not just White therapists) may have developed brain structures resulting in biases obtained from the society in which we grew, developed, and live.
43. Threats to the Alliance Eberhardt (2005) indicated that Whites exhibit more positive evaluation bias (greater amygdala response habituation) to in-group White faces than to out-group Black faces. Blacks exhibit a more positive evaluation bias to Blacks than Whites do. in ways never before thought possible.
The implication of these studies is that even psychotherapists may exhibit unintentional bias in their work with clients or patients who are culturally different from them.
44. Threats to the Alliance Seigel (1999) believes that implicit recollections without explicit processing may be the source of the experience of flashbacks or serve as the origin of rigid implicit mental models that may, for example, block a therapists ability to remain flexible and attuned to the minority client.
Eberhardt (2005) is optimistic in believing that seeing pictures of the brain may lead people to understand that their own race-based perceptions have the capacity to change and shape who they are themselves in ways never before thought possible.
45. Reduction of Bias One develops a nonracist identity by first acknowledging that ones racism exists.
Green (2007) suggested that most people do not want to be considered racist or biased in any way, but they spend more of their time seeking to avoid those labels rather than exploring their behavior and the ways that they benefit from or have participated in systems of interrelated privilege and oppression, intended or not.
46. Developing the Alliance Personal attributes found to contribute positively to the alliance include being flexible, honest, respectful, trustworthy, confident, warm, interested, and open.
Techniques such as exploration, reflection, noting past therapy success, accurate interpretation, facilitating the expression of affect, and attending to the patients experience were also found to contribute positively to the alliance.
47. Developing the Alliance Factors and issues must be continuously assessed, as cultural groups vary, and as individuals within those groups are heterogeneous, based on acculturation, language, generational status, and other related factors (APA, 2003).
48. Multicultural Guidelines The first and most critical is awareness of those attitudes. The second and third strategies are effort and practice in changing the automatically favorable perceptions of in-group members and negative perceptions of out-group members.
How this change occurs has been the subject of many years of empirical effort, with varying degrees of support (Hewstone, Rubin, & Willis, 2002).
49. Reduction of Bias (cont.) Increased contact.
Change the perception of us vs. them to we, or recategorizing the out-group as members of the in-group.
Increase tolerance and trust of those different from oneself.
Develop continuous consciousness to ones reactions to clients.
50. Developing the Alliance Cultural mutuality, as defined by the APA Guidelines for Providers of Psychological Services to Ethnic, Linguistic, and Culturally Diverse Populations (1990) describes, in part, the importance of relating to clients of color, women, and other oppressed groups in a respectful, connecting manner based on our knowledge of clients culture and also tuning in to aspects of the clients needs that our therapeutic processes may help.
51. Developing Awareness of Ones Values Use of a cultural genogram for clinicians to learn about their own unique values, transmitted through their families and experiences, as well as learn better how to assess those values for their clients, especially clients who are different from them.
This tool is a didactic-experiential training tool to promote awareness of how the family is the principal mode by which people learn and develop an understanding about their cultures and ethnicities.
52. Reduction of Bias (cont.) Identify areas of strength and resilience.
Emphasize the empowerment of individuals and work toward the increased quality of life for all people.
Plant and Sachs-Ericsson (2004) found that interpersonal functioning protected against depressive symptoms for Latinos and other minorities to a greater extent than for non-Latino Whites.
The Latino cultural value of familismo, which implies an emphasis on strong family relationships, may foster positive social support that protects individuals against depression, even in the face of substantial environmental risk.
The Hispanic/Latino/a Paradox (Palloni & Morenoff, 2001) is a phenomenon termed to describe unique resilience to the usual negative health outcomes of poverty and other psychosocial challenges.
53. Multicultural Guideline 2 Psychologists are encouraged to recognize the importance of multicultural sensitivity/responsiveness to, knowledge of, and understanding about ethnically and racially different individuals (APA, 2003, p. 385).
54. Developing the Alliance The challenge in learning about cultural groups is to avoid stereotyping; rather, the knowledge is to be used to assess the degree of application of various cultural values, behaviors and expectations.
Comas-Diaz (2006) suggested that while the therapeutic relationship requires special attention in multicultural dyads, clinicians need to tailor the relationship to the clients interpersonal and developmental needs.
55. Cultural Adaptations of Evidence-Based Practice Traditional, empirically supported treatments and adapted interventions are effective with racial/ethnic minorities.
Whaley and Davis (2007) suggested that the impact of culture may be most important during the process of therapeutic engagement, rather than the outcome; that is, a change in the approach to service, whether in content, language, or approach, may be necessary to engage and retain the client in treatment.
56. Knowledge of Racial/Ethnic Populations Marginalized groups continue to face formidable economic and social barriers in this country .
8% of non-Latino Whites live in poverty, but 14% of Cuban Americans, 27% of Mexican Americans, and 31% of Puerto Ricans live in poverty.
Only 56% of Latinos/as have graduated from high school, compared with 83% of the total population (U.S. Department of Health & Human Services, 2001).
57. Knowledge of Racial/Ethnic Populations Individuals of low socioeconomic status are more likely than individuals of high socioeconomic status to become depressed and experience persistent depressive symptoms (Lorant et al., 2003).
Lack of access to critical economic and social resources is stressful, and depression often develops in the context of psychosocial stress (Willkinson, 1997).
Racism and discrimination, unfair treatment, and negative external judgments about ones worth have deleterious effects on both physical and psychological health (Clark, Anderson, Clark, & Williams, 1999).
58. Knowledge of Racial/Ethnic Populations Plant and Sachs-Ericsson (2004) found that interpersonal functioning protected against depressive symptoms for Latinos and other minorities to a greater extent than for non-Latino Whites.
It is important to note that this resilience may decrease as individuals acculturate in the United States.
Acculturation is apparently bad for ones health, in some ways. In addition, the burdens of poverty and discrimination result in effects that are not always mediated by resilience.
59. Intersection of Oppressive Factors Gender, age, sexual orientation, disability, religion/spiritual orientation, educational attainment and experiences, and socioeconomic factors are examples of other dimensions of identity that enhance or detract from ones identity, and influence the way we relate to our clients.
60. Intersection of Oppressive Factors When individuals have multiple identities, some of those identities or characteristics may place them in privileged groups, whereas, simultaneously, others may place them in disparaged groups.
Many people of color have additional aspects of identity that intersect with racial/ethnic identity to form multiple oppressions.
61. Intersection of Oppressive Factors The commitment to provide services to those with whom we experience differences requires cognitive complexity, increased attention, and management of anxiety.
It is also important to know when to refer, because we will not be likely to provide services without ill effects of bias and the ensuing distance, anxiety, empathic failures, and so on.
62. Developing the Alliance Not only must we possess sophisticated and ongoing self-awareness, we must continuously evaluate our theories, assumptions, practices, and clinical skills to correctly apply culturally resonant interventions to accommodate the needs of the wide variety of clients with whom we work.
63. Reduction of Bias (cont.) Attend to the clients experience of oppression.
Assist clients in determining whether a problem stems from institutional or societal racism (or other prejudice) or individual bias in others so that the client does not inappropriately personalize problems (Helms & Cook, 1999).
Help clients recognize the cognitive and affective motivational processes involved in determining whether they are targets of prejudice.
64. Unique Issues of Assessment Cultural factors for assessment may include relevant generational history (e.g., number of generations in the country, manner of coming to the country); citizenship or residency status (e.g., number of years in the country, parental history of migration, refugee flight, or immigration); fluency in standard English or other language; extent of family support or disintegration of family; availability of community resources; level of education, change in social status as a result of coming to this country (for immigrant or refugee); work history, and level of stress related to acculturation and/or oppression (APA, 2003).
65. Boundary Crossings vs. Boundary Violations Boundary crossings refer to any activity that moves therapists away from a strictly neutral position with their patients. This activity may be helpful or harmful. A boundary violation is a harmful boundary crossing.
Sometimes maintaining strict boundaries does more harm than engaging in a humane, genuine, authentic manner that is culturally congruent.
66. Special Issues for Practitioners of Color Many of my clients of color choose to come to see me because of my ethnic identity.
Other people of color, with internalized racism, might choose to avoid seeing someone like me.
Many of my White clients have to go through some process of cognitive dissonance to assume my competency, because if they grew up in this society, people from my ethnic background are not assumed to be competent.
67. Special Issues for Practitioners of Color A basic task for ethical practice is to remember the humanity of those with whom we work (Pope & Vasquez, 2006).
Comas-Díaz and Jacobsen (1995) address the interracial dyad involving a therapist of color and a White patient, and they provide a dynamic analysis of the contradictions, such as significance of power reversal and transferential and countertransferential reactions.
Opportunity for therapists of color to acquire a perspective from White patients and witness the reality experienced by their majority group patients.
Alternatively, White patients can benefit from the contributions of the therapist of color, who has experience in overcoming the odds of achieving success. Both clients and therapists can thus heal and become more empowered.
68. Differences The Multicultural Guidelines ask us to acknowledge differences and, even if they make us uncomfortable, to be respectful about the differences.
We have all had experiences in which our critical, negative judgments and perceptions were misplaced, inappropriate, and unfounded.
We must be cautious as to whether such stances are ever legitimate in the psychotherapy room. If so, I suggest that we must refer.
69. Reduction of Bias We can rewire our circuitry through explicit processing of our biases, immersion with different groups and individuals, readings, training and practice in behaving in ways to change our subconscious perceptions in the psychotherapeutic process (stay attune to clients, demonstrating cultural empathy, being respectful to worldviews).
We can change our neural pathways developed through negative biases and stereotypes in society (Siegle, 1999, Eberhardt, 2005).
I recommend approaching those different from us with curiosity, interest and openness.
