Melba J. T. Vasquez, Ph.D., ABPP Austin, Tx. firstname.lastname@example.org 512-329-8000x5
The U.S. population is more diverse than ever before. The demographic changes have significant implications for our profession.
Culture is a complex whole that includes knowledge, beliefs, art, architecture, language, morals, laws, customs, and other capabilities and habits acquired by members of a society (Vontress, 2008). The term “multicultural” is broadly defined to include various strands of one’s identities.
In psychotherapy practice, regardless of theoretical orientation, culture influences the experiences of distress, dysfunction, strength and resilience.
Cultural competence requires appropriate awareness, knowledge and skills about the intersectionality of the many strands of identities, including race and ethnicity, sex and gender, social class (including education), sexual orientation, heritage or national origin, immigration experiences, abilities and disabilities, religion and spirituality, age, language, body type, location or geography.
Awareness – of human cultural diversity; one’s own identity; values associated with traditional psychology; tendency to engage in insidious bias and microaggressions. Knowledge –factual understanding of basic knowledge about cultural variation, avoid stereotyping; impact of oppression. Skill – ability to connect emotionally with the client’s cultural perspective, using strategies that result in effective outcome.
Cultural competence in our modern mental health care environment requires more knowledge, awareness and skill—a level of sophistication on the part of the professional-- required for effective practice.
To practice ethically requires awareness, sensitivity, and empathy for the client as an individual, including knowledge of and attention to the client’s 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.
Guidelines on Multicultural Education, Training, Research, Practice and Organizational Change for Psychologists (APA, 2003); Guidelines for Psychological Practice With Girls and Women (APA, 2007); Guidelines for Psychotherapy With Lesbian, Gay, and Bisexual Clients (APA, 2011); Guidelines for Psychological Practice With Older Adults (APA, 2004); Guidelines for Assessment of and Intervention with Persons with Disabilities (APA, 2011). www.apa.org
Racism, discrimination and bias waste incredible human resources for society. To be deprived of a positive sense of self- worth and self-respect is to be dehumanized, and may lead to profound loneliness, shame, depression, anxiety; optimism and hope are difficult to retain (Jones, 2015).
Eberhardt’s (2014) brain imaging technology – demonstrates how unconscious racial stereotypes criminalize African Americans and other dark skinned persons.
600 lynchings of Mexicans and Mexican- Americans between the years of 1846 and 1925. Reasons such as “acting uppity,” taking jobs away from Anglos, making advances toward Anglo women, cheating at cards, practicing “Witchcraft,” refusing to leave land that Whites coveted, acting “too Mexican;” Mexican women may also be lynched if they resisted the sexual advances of Anglo men.
Making English the official language of the U.S.; forcing immigrants to assimilate to the dominant Anglo culture; ending bilingual school opportunities and enforce English-only speaking at jobs, businesses, etc. Such movements facilitate children to reject their own culture, acquire English, and forget their native language. These actions have consequence, like social distress, depression, and crime These actions are an implicit form of lynching.
We tend to relate most easily to those most similar to us, including in regard to the major variables of gender, ethnicity, ability and social class.
“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.
Ascription of Intelligence Alien in One’s Own Land Assumption of Inferiority Assumption of Criminal Status Assumption of Universal Experience Second Class Citizenship Exoticization/Objectification/Tokeniszation
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 master’s degrees and only less than one percent holds doctorate degrees (U.S. Census Bureau, 2010).
Make a list of your identities What is a microaggression you have experienced as a result of one of your identities? What is a privilege you experience as a result of one of your identities?
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 (although specific problems/individuals respond to some treatments better than others). Rigorous clinical trails show a large effect size (.80), which means that the average treated person fares better than 80% of those untreated.
The patient’s 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 patient’s personal characteristics and view of the problem.
Moment by moment, the therapist’s 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 needs—whether enhancement of knowledge, a corrective experience, or interactive engagement in relationship.” (Stark, 1999, p. 5).
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; the therapist’s contribution to the alliance is an important element of that involvement.
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).
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.
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).
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… in various implicit ways (Greenwald & Banaji, 1995). Mental health providers may not always be aware of when the potential for developing an effective therapeutic alliance may be compromised.
Subconsciously, we may be influenced negatively by the fact that a client’s 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.
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.
For most psychologists and other mainstream health providers, individuals in racial/ethnic minority groups are in an “out-group,” simply by virtue of being different.
Contemporary racism among Whites is subtle, often unintentional, and unconscious. Whites who demonstrate these behaviors report not being aware of this. Many/most members of ethnic minority groups are aware in those studies that examine these interactions (Dovidio, et al, 2002).
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.
Counselor expectations produced different behaviors in counselors, with different results of randomly assigned patients. How we DO THERAPY matters. Making people feel bad doesn’t help them to change. Hire staff based on and train staff in the skill of accurate empathy.
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.
Steele’s “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. Therapists may not always know when they convey negative judgments in body language, including facial expressions, voice tone and eye contact.
One develops a nonracist identity by first acknowledging that one’s racism exists. 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 (Green, 2007).
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 successes, accurate interpretation, facilitating the expression of affect, and attending to the patient’s experience were also found to contribute positively to 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).
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 one’s reactions to clients.
Identify areas of strength and resilience. Emphasize the empowerment of individuals and work toward the increased quality of life for all people. Latinas have the highest life expectancy rate than any other group in this country (84 years, 2.7 years longer than white and 5.8 years longer than African-American women). Latinos have a life expectancy of 79.7 years, 2.4 years longer than white and 7.3 years longer than African- American men (MacArthur Foundation Research Network on Aging Society, 2012; Centers for Disease Control, 2010).
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.
Cultural adaptation brings together the best of the multicultural and evidence based movements in the service of offering psychological treatments that are based on the best available research and that consider culture and context in a thoughtful, documented, and systemic way (Bernal & Domenech Rodriguez, 2012).
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.
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 one’s health, in some ways. In addition, the burdens of poverty and discrimination result in effects that are not always mediated by resilience.
American Psychological Association (2012). Ethnic and Racial Disparities in Education: Psychology’s Contributions to Understanding and Reducing Disparities. Washington, DC: American Psychological Association. Available at http://www.apa.org/ed/resources/racial- disparities.aspx
American Psychological Association, 2012. Pathways to a Better America: Preventing Discrimination and Promoting Diversity. Washington, DC: APA. Available at http://www.apa.org/pubs/info/reports/promoti ng-diversity.aspx
American Psychological Association. (2012a). Crossroads: The Psychology of Immigration in the New Century. Washington, DC: American Psychological Association. Available at http://www.apa.org/topics/immigration/rep ort.aspx
Every year since 1990, approximately one million new immigrants have entered the United States. 17 million (43%) of the foreign-born currently living in the U.S. are naturalized 11 million (28%) are authorized non-citizens 11 million (28%) (CBO, 2011) are undocumented.
On balance, there is a general consensus that immigration benefits the U.S. economy (Griswold, 2009; Schumacher-Matos, 2011).
“Well, I came to America because I heard the streets were paved with gold. When I got here, I found out three things: first, the streets weren’t paved with gold; second, they weren’t paved at all; third, I was expected to pave them.” Old Italian story
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).
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.
Life Transitional Events Self-Disclosure Giving and Receiving Gifts Nonsexual Touch and Other Expressions of Care
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.
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.
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.
I recommend approaching those different from us with curiosity, interest and openness.