1. Culture and Mental Health
Why is multiculturalism good? or
The hidden assumptions about
mental health and its treatment

2. In this lecture… The limitations of the DSM An alternative approach
Cultural Competence
should we focus on race, class, and culture in therapy?
therapist ideology and its implications for psychotherapy
a multicultural orientation

3. The assumptions of the DSM
Four basic psychological paradigms
Psychodynamic
Cognitive-Behavioral
Humanistic
Biological
What assumptions do they share about the etiology of abnormal behavior and mental health problems?

4. The assumptions of the DSM (cont.)
Assumption 1: The problem is in the person (or family)
Assumption 2: The appropriate intervention is to treat the person (or his/her family)
Why might this be problematic?

5. Four steps to “blaming the victim”
William Ryan 1971, 1976
Identify a social problem
Study those affected by the problem to discover how they are different from those who are not affected by the problem.
Define the difference as the cause of the problem itself
Create a humanitarian action (social service) program to correct the differences (from #2)

6. Therapeutic implications of “blaming the victim”
Implication 1: Environmental factors are often ignored or minimized in assessment and treatment
Implication 2: Some individuals are more likely to be negative affected by implication 1 than others
Who is likely to be disproportionally affected?

7. Urie Bronfenbrenner Ecology from Ecos: House (Greek)
Alternative Approach:
Attend to environmental aspects in both assessment and intervention
Often misrepresented
Mesosystem links two microsystems together, either directly or indirectly
Exosystem=setting in which the person does not participate but in which decisions are made that affect individuals interacting with the person
Macrosystem=overarching patterns of culture, politics, and economy
Ecology from Ecos: House (Greek)
Ecology: A House in Biological Terms - A system of interacting organisms

8. Therapeutic implications of ecological model
Psychopathology, even individual psychopathology can only be understood within the context of a person’s family, community, and sociocultural environment. These may differ according to client’s
gender
race/ethnicity/culture/religion
immigration status
sexual orientation
socioeconomic status
Given above, a client’s “psychopathological” behavior:
may be influenced by the therapist’s attitudes regarding client’s demographic characteristics
may not actually violate cultural norms and thus not “pathological”
may be driven by society’s deficits, rather than the client’s
may be treated more appropriately and efficiently through community interventions

9. Cultural Competence What is Cultural Competence?
It’s not easily defined, but what might it entail? What might it NOT entail?

10. The fundamental question vis a vis psychotherapy:
Should we focus on race, ethnicity, and culture in therapy?
Two “good” arguments not to:
We are all fundamentally the same
2. Each of us is a unique person with unique life experiences
On the other hand:
"I don’t see color, I only see children.” What message does this statement send? That there is something wrong with black or brown, that it should not be noticed? I would like to suggest that if one does not see color, then one does not really see children. Children made “invisible” in this manner become hard- pressed to see themselves worthy of notice.” Lisa Delpit

11. Assumptions of multiculturalism
Diversity (of all sorts) is valuable and should be pursued
Group differences should be recognized
Group differences should be respected
Group differences should be valued

12. Three dimensions of cultural competence
(Sue et al., 1998)
Therapist is aware of own assumptions, values, and biases
role that race/ethnicity/culture plays in own life
role that race/ethnicity/culture plays in mental health
role that race/ethnicity/culture plays in psychotherapy
Therapist focuses on understanding the racial ideology and worldview of culturally different clients
how client(s) perceive mental health and psychotherapy
how client(s) perceive the therapist
Therapist develops appropriate counseling strategies and techniques

13. Racial ideology Left Right Where do you think you are?
Theoretical center
Where do you think you are?
Where do you think “liberals” are?
Where do you think “conservatives” are?

14. Racial ideologies Left Right Mainstream U.S. ideology Multicultural
Radical
Liberal
Neo-lib.
Neo-con.
Conservative
Fascist
Racism so deeply embedded in our structures that reform not possible. New structures must be created.
Race is socially constructed. The path to equality is a color-blind society.
Race is socially constructed. The path to equality is race-based remedy
Race is biologically determined and people generally get what they deserve (a just world)
Race is socially constructed. The path to equality is need-based remedy
Since God created racial differences, racial inequality is both normal and desirable, and it is God’s will that the White race be in “control.”

15. Racial Ideologies (samples)
Neo-Conservative:
“My proposal for dealing with the racial issue in social welfare is to repeal every bit of legislation and reverse every court decision that in any way requires, recommends, or awards differential treatment according to race…We may argue about the appropriate limits of government intervention in trying to enforce the ideal, but at least it should be possible to identity the ideal: Race is not a morally admissible reason for treating one person differently from another. Period.”
Charles Murray, “Losing Ground: American Social Policy, ”
Liberal:
“A profound difference separates governmental actions that themselves are racist and governmental actions that seek to remedy the effects or prior racism or to prevent neutral government activity from perpetuating the effects of such racism.”
Supreme Court Justice, Thurgood Marshall

16. The culturally competent therapist (cont.)
Is cognizant of cultural explanations of phenomena
The behaviors displayed may not be considered maladaptive or abnormal in the other culture.
There may be a cultural explanation for the client’s experiences
Experience of racism and prejudice may account for certain beliefs/behaviors
Talking to a therapist is a very “cultural” experience that may take considerable adjustment and trust-building for some clients.
Avoids oversimplified cultural explanations
For example, the idea of collectivism vs. individualism is a broad dichotomy. In reality, these differences lie on a continuum…with not only variation between cultural groups but also within cultural groups.

17. The culturally competent therapist (cont.)
Avoids making assumptions
Each client is an individual, not a stereotype. Be careful about what you think you know about a person given their cultural background
All cultural “facts” should be treated as hypotheses
Do not prejudge which aspects of a client's cultural history, values, and lifestyle are relevant to your work with the client.
A person’s racial, ethnic, and even cultural background does not necessarily tell us anything important in and of themselves.
Do not assume that client values either cultural assimilation or maintenance of traditional cultural beliefs/practices. Acculturation preferences should be assessed
Experiences of prejudice/discrimination may or may not be salient for the client. Racial and/or ethnic identity should be assessed.
Acculturation: Psychosocial change that occurs when a group or individual comes into continuous first-hand contact w/ another culture

18. The culturally competent therapist (cont.)
Works with a multicultural orientation
Recognizes that culture is there and values cultural differences
Understands that cultural differences can trigger important discussions that not only have therapeutic benefit but also educate both client and therapist and, in so doing, break down stereotypes
Looks for personal and cultural strengths and tailors intervention so that is consistent with client’s cultural values and strengths
Seeks to assist the client in identifying areas that create social or psychological conflict related to bi-culturalism and seeks to reduce dissonance in those areas
Is prepared to deal with situations when the client’s culture seriously clashes with the values/beliefs of the therapist (cultural relativism)
Fowers & Richardson (1996) assert that the therapist can choose to reject the questionable behaviors of the other culture. However, this is contingent upon the therapist first having an accurate and relatively complete perspective on the client’s culture, from that culture’s own point of view.

19. Legitimate criticism of Multiculturalism
Conservative
Multiculturalism is a form of cultural relativism, and some cultural practices are morally repugnant
Multiculturalism is a rejection of majority culture
Multiculturalism encourages cultural separatism
Neo-Conservative
We are really all fundamentally the same
We all fundamentally different
Liberal
Multiculturalism is a form of cultural relativism, and some cultural practices are morally repugnant (same as conservatives)
Multiculturalism is a rejection of majority culture (same as conserv.)
Radical
Multiculturalism does not acknowledge power dynamics
True multiculturalism is unattainable because of power differential
Multiculturalism may threaten the “authenticity” of a group through contact with other cultures.

20. An example from the past
Earlier in the course we saw Gina – an African American woman – interact with two White male therapists.
Would the therapist have been more effective in this particular case if he had paid more attention to Gina’s cultural identity and background?
If so, what might a therapist do to display appropriate cultural competence?

21. Cultural Competence Continuum
Cultural Destructiveness
Cultural differences are seen as problematic. Goal of therapy is to eliminate cultural differences.
Cultural Incapacity
Although they do not intentionally seek to cause harm, individuals in this stage believe in the superiority of their own racial or ethnic group and assume a paternalistic posture toward “lesser” groups.
Cultural Blindness
Color or culture is assumed to make no difference and all people are assumed to be fundamentally the same.
Cultural Pre-competence
Weaknesses in working with various cultures are acknowledged and some effort made to improve services to diverse populations.
Cultural Competence
Cultural differences are accepted and respected. Therapists engage in continuing cultural self-assessment.
Cultural Proficiency
Culturally proficient individuals prioritize cultural competency in their clinical work, research, teaching, etc.