1. Cultural Issues in Clinical Psychology
Chapter 4
Cultural Issues in Clinical Psychology

2. The U.S. Population
The U. S. population is increasingly diverse, particularly in certain areas/cities
20% of U. S. schoolchildren speak a language other than English at home
In Miami, Detroit, and Washington DC, a single ethnic minority group represents over half of the population
In a single decade (1990–2000), the Asian American/Pacific Islander population and the Latino/Latina/Hispanic population each grew by about 50%. In 2000, there were 28 million first-generation immigrants in the United States, representing about 10% of the entire U.S. population.

3. Cultural Issues (cont.)
As stated by McGoldrick, Giordano, and Garcia-Preto (2005), “[we] must incorporate cultural acknowledgment into our theories and into our therapies, so that clients not of the dominant culture will not have to feel lost, displaced, or mystified”

4. Multiculturalism as the “Fourth Force”
Some argue that multiculturalism is the defining issue of the current generation of psychology
Defining paradigms of previous generations have included
Psychoanalysis (1st)
Behaviorism (2nd)
Humanism/person-centered (3rd)
Multiculturalism can enhance any of previous “forces”

5. Culture and Clients
Culture shapes how clients understand their problems
Questions to assess client understanding:
What do you call your problem (illness, distress)?
What do you think your problem does to you?
What do you think the natural cause of your problem is?
How do you think this problem should be treated?
Who else (e.g., family, religious leaders) do you turn to for help?
Culture shapes the way that the client understands the very problem for which he or she is seeking help. It is this understanding—this worldview, applied to psychological problems—that the therapist should appreciate as he or she devises an approach to helping the client.

6. Recent Professional Efforts to Emphasize Issues of Culture
Journals and books on cultural topics
New APA divisions
Division 35—Society for the Psychology of Women
Division 36—Psychology of Religion
Division 44—Society for the Psychological Study of Lesbian, Gay, and Bisexual Issues
Division 45—Society for the Study of Ethnic Minority Issues
Division 51—Society for the Psychological Study of Men and Masculinity
See Table 4.1 Scholarly Journals Relevant to Multicultural Issues in Clinical Psychology.

7. Recent Professional Efforts to Emphasize Issues of Culture (cont.)
Revisions to APA ethical code
Competence
Discrimination
Interpreting Assessment Results
Others
APA Accreditation Standards
See Table 4.2 Selected Excerpts From the American Psychological Association’s (2002) Ethical Principles of Psychologists and Code of Conduct Relating to Multiculturalism.

8. Recent Professional Efforts to Emphasize Issues of Culture (cont.)
DSM efforts toward multiculturalism
Text describing cultural variations of disorders
General guidance for cultural competence
“Outline for Cultural Formulation”
“Cultural Formulation Interview”
Cultural concepts of distress glossary
Nine terms that represent psychological problems in various cultures
Some related to DSM disorders; others unique
Exs. Taijin kyofusho, susto, maladi moun
DSM-5 state in the Introduction that “key aspects of culture relevant to diagnostic classification and assessment have been considered in the development of DSM-5.”
“Outline for Cultural Formulation” instructs clinicians in various aspects of culture to assess in clients, such as cultural identity, cultural conceptualization of distress, and cultural features of the relationship with the mental health professional. “Cultural Formulation Interview” is a series of 16 specific questions that can guide a clinician toward a culturally informed interview.
Taijin kyofusho – a person anxiously avoids interpersonal situations because he believes that his appearance, actions, or odor will offend other people (found in Japanese and some other cultures)
Sutso – a frightening event is thought to cause the soul to leave the body, resulting in depressive symptoms (found in some Hispanic cultures)
Maladi moun – one person can “send” psychological problems like depression and psychosis to another, usually as a result of envy or hatred toward the other person’s success (found in some Haitian communities)

9. Recent Professional Efforts to Emphasize Issues of Culture (cont.)
Revisions of prominent assessment methods
MMPI-2
Wechsler intelligence tests

10. Cultural Competence
The counselor’s acquisition of awareness, knowledge, and skills needed to function effectively in a pluralistic democratic society
3 main components:
Awareness
Knowledge
Skills

11. Cultural Competence: Self-Awareness
Learning about one’s own culture
Values, assumptions, biases
By doing so, become less egocentric
Realize that differences are not deficiencies
Psychologists will inevitably encounter clients whose cultural background differs—sometimes slightly, sometimes considerably—from their own.

12. Cultural Competence: Knowledge of Diverse Cultures
Can gain knowledge by
Reading, especially regarding history
Direct experiences
Relationships with people of various cultures
Asking client to explain cultural meaning (to a limited extent)
Remember that there are exceptions to cultural trends
Metaphor—Asian men tend to be relatively short, but Yao Ming is 7’ 6”
See Box 4.1 Considering Culture.

13. Cultural Competence: Knowledge of Diverse Cultures (cont.)
Acculturation
Response to new cultural environment
Balance between adopting new and retaining original culture
Specific strategies:
Assimilation (high new, low original)
Separation (low new, high original)
Marginalization (low new and original)
Integration (high new and original)

14. Cultural Competence: Culturally Appropriate Clinical Skills
Techniques should be consistent with the values and life experiences of each client
“Talk therapy” may work better for some cultural groups than for others
Some cultural groups may respond more positively to “action” than “insight”
Some clients may respond much more positively to action-oriented therapies with a short-term focus. Common features of traditional psychotherapy, including verbal self-disclosure of personal problems and 50-minute sessions in an office building, may not be entirely compatible with clients from certain cultural backgrounds.

15. Cultural Competence: Culturally Appropriate Clinical Skills (cont.)
Microaggressions
Comments or actions made in cultural context that (often unintentionally) convey negative beliefs
Can suggest dominance and cause marginalization or invalidation
Psychologists can avoid by examining their own beliefs

16. Cultural Adaptation
Modifying treatments with empirical evidence for members of a cultural group

17. Etic vs. Emic Perspective
Emphasizes similarities between all people
Assumes universality
Downplays culture-based differences
Emic
Emphasizes culture-specific norms
Appreciate clients in the context of their own culture

18. Tripartite Model of Personal Identity
Three levels of identity
Individual level
Every person is totally unique
Group level
Every person is like some others
Universal level
Every person is like all others
Clinical psychologists can recognize all three levels for any client

19. What Constitutes a Culture?
Narrow vs. broad definitions
Some argue that ethnicity and race are the defining characteristics of culture
Others argue that many other variables can define a culture, such as
Socioeconomic status
Religion
Gender
Age
Geography/region
Political affiliation
Disability status
Those who argue for a more narrow definition of culture typically point to ethnicity and race as the defining cultural characteristics. Some argue that culture can be defined by a much broader range of variables, including any and all potentially salient ethnographic, demographic, status, or affiliation identities.

20. Interacting Cultural Variables
Multiple cultural factors can combine to create a unique culture for a particular individual
Two people of the same ethnicity can differ on many other variables, and can have very different life experiences as a result

21. Training Psychologists in Cultural Issues
Educational alternatives
Courses
Readings
Real-world experiences
Recruit and retain diverse students and faculty
Encourage cultural self-knowledge, curiosity, and humility

22. Measuring the Outcome of Culture-Based Training Efforts
Many questions remain
How can we measure a baseline of cultural competence?
How can we measure change after training?
Whose opinion should we seek? Psychologist, client, supervisor, others?
How can we infer cause?
At the moment, measuring the outcome of culture-based efforts is at a very early stage of empirical investigation.